Weight Bearing After a Periarticular Fracture: What is the Evidence?

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Key points

  • There is some evidence that patients autoregulate weight bearing based on the amount of fracture healing.

  • Current methods of evaluating weight-bearing status are unreliable.

  • Patient compliance with existing weight-bearing restrictions is poor.

  • Studies of early weight bearing for acetabular, tibial plateau, tibial plafond, ankle, and calcaneus fractures demonstrate no increased risk for loss of reduction or nonunion compared with restricted weight bearing.

  • Early weight bearing may return patients to

Effects of restricted weight bearing

Weight-bearing restrictions can impart a significant physiologic toll on patients. In healthy patients, restricted weight bearing

  • Results in a 4-fold increase in the energy expended for ambulation, when compared with full weight bearing, as measured by the physiologic cost index3

  • Alters gait mechanics4

  • Shifts the weight distribution from the forefoot and hallux to the heel4

Despite concerns for the increased risk of venous thromboembolism following surgery and restricted weight bearing, available

Weight bearing after fracture

Clinicians routinely prescribe partial weight bearing for a lower extremity fracture in an attempt to produce an optimal mechanical environment at various stages of fracture healing. Partial weight bearing involves a gradual increase in the amount of weight that is placed on the affected limb. The partial-weight-bearing recommendation for patients varies based on the type of fracture, the extent of the injury, and the discretion of the clinician. For periarticular fractures, the standard

Patient compliance

Available data suggests patient compliance with physician restrictions on weight bearing is poor.11, 12, 13, 14, 15 Standard clinical techniques to monitor weight-bearing compliance include the use of bathroom scales and a therapist estimating the load with palpation or observation. The scale has been shown to be effective; however, this is only useful for standing but not ambulation.16, 17 Both palpation and observation by a therapist have proven to be unreliable, regardless of the therapist’s

Acetabular fracture

Malreduction after an acetabular fracture has been shown to be associated with poor patient outcome and development of posttraumatic arthritis.22, 23 Given the potential consequences of fixation failure with subsequent loss of reduction, few studies have been performed permitting early weight bearing after acetabular fracture.

Mouhsine and colleagues24 allowed elderly patients (mean 81 years of age) with column, transverse, or T-type fractures fixed percutaneously to begin unrestricted weight

Tibial plateau fracture

The knee joint experiences forces between 220% and 350% of a person’s body weight during normal daily activities.29 A 3-mm step-off in the tibial plateau can increase the cartilage contact stresses by 75%, thus raising concerns that loss of reduction could lead to worse patient outcomes.30 However, the tibial plateau has been shown to tolerate some malreduction without change in outcome.31, 32

Segal and colleagues33 reported on a consecutive series of 86 lateral tibial plateau fractures treated

Tibial plafond fracture

Tibial plafond fractures are associated with high rates of posttraumatic arthritis.39, 40 A 2-mm malreduction of the tibial plafond can result in a nearly 200% elevation in surrounding contact pressures.41 Given the concern of loss of reduction and the potential development of posttraumatic osteoarthritis, there is limited literature evaluating early weight bearing after tibial plafond fractures.42

In a series of 26 patients with AO type C plafond fractures treated with dynamic external fixator

Ankle fracture

The best available evidence for weight bearing after periarticular lower extremity fractures is found in the literature on ankle fractures. A Cochrane meta-analysis of early versus late weight bearing after ankle fractures showed no difference between the groups in range of motion, functional scores, or radiographic outcomes at 1 year after the injury.50 This analysis was based on 3 studies that directly compared early and late weight bearing after ankle fractures without other confounding

Calcaneus fracture

In patients with a calcaneal fracture with significant soft tissue compromise, external fixation offers the ability to minimize further damage to the surrounding soft tissue envelope. Ali and colleagues64 used an Ilizarov external fixator on displaced calcaneal fractures in 25 patients (10 Sanders type II, 9 type III, and 6 type IV). Partial weight bearing was encouraged 3 weeks postoperatively. There were no reported revision surgeries, and 68% excellent or good outcomes according to the

Summary

Despite their willingness to comply, patients often do not follow weight-bearing restrictions. Based on the few laboratory-based studies available, patients seem to advance their weight bearing as fracture healing progresses. The evidence available for early weight bearing following fixation of acetabular, tibial plateau, tibial plafond, ankle, and calcaneus fractures suggests that patients are not at a higher risk of loss of fixation as compared with patients with restricted weight bearing.

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