Early mobilisation and weight-bearing as tolerated after hip fracture surgery among older adults in China and similar countries: barriers and strategies

Key Points

• Editorial to accompany Barriers and facilitators to early mobilisation and weight-bearing as tolerated after hip fracture surgery among older adults in Saudi Arabia: a qualitative study.

• Early mobilisation and weight-bearing as tolerated after hip fracture surgery is not widely adopted in China and similar countries (such as India and Saudi Arabia).

• The acceptance by patients and families, as well as the type of surgery, are two key factors in determining weight-bearing prescriptions.

• Multidisciplinary co-management, standardised guidelines, legal protections for practitioners and patient education are essential.

• Adopting a gradual transition approach based on individualised strategy may help securely expand early mobilisation and WBAT practices.

Introduction

Hip fractures are a major public health issue, especially in societies with an increasing ageing population [1]. The medical community in North America and Europe has long recommended immediate weight-bearing as tolerated (WBAT, up to the full body weight based on patient’s comfort) after hip fracture surgery [2, 3]. This practice aims to prevent complications arising from prolonged bed rest, such as decreased mobility, increased mortality, delirium, infection, thromboembolism, and pneumonia.

In an analysis of 4918 hip fracture patients in the USA, 3668 (74.58%) were allowed to WBAT on the first postoperative day (POD 1) [4]. However, immediate WBAT after hip fracture surgery is not the preferred choice among Chinese practitioners. In a multicentre study conducted in Beijing, only 19.9% out of 961 patients receiving usual care after hip fracture surgery were allowed WBAT on the POD 1 [5]. Even in the Beijing Jishuitan Hospital, considered one of the best orthopaedic hospitals in China, only 43.5% of 1110 patients were allowed WBAT on POD 1 [5]. Additionally, for hip fractures treated with internal fixation surgery (sliding hip screw, intramedullary nail and others), the initiation of WBAT is often delayed until even 3 to 5 months after surgery [6–8].

Outside of China, similar practices are observed in another populous country, India. In a study conducted in Meerut, a northern city in India, involving 35 hip fracture patients, WBAT was initiated 8 to 12 weeks postoperatively [9]. In Indore, a central Indian city, a study with 60 patients started with toe-touch weight bearing in the first postoperative week, followed by partial weight bearing, but there was no clear timeline for the initiation of WBAT [10]. In Hyderabad, a southern city in India, a study of 99 patients found that weight bearing began at 3 to 6 weeks post-surgery [11].

Through qualitative semi-structured interviews with orthopaedic surgeons and physiotherapists in Saudi Arabia, Turabi et al. [12] identified the barriers and facilitators to implementing early mobilisation and WBAT after hip fracture surgery in older adults. In this qualitative study, some participants indicated that the recognition and acceptance by patients and their family members is a key factor in prescribing weight-bearing protocols. They noted that fear of further injury can significantly impact a patient’s adherence to weight-bearing prescriptions. Some participants also emphasised that the type of surgery or implant is also a key factor in determining weight-bearing prescriptions, as their understanding was that different implants offered varying levels of mechanical integrity and could impact patient recovery differently.

As part of the Chinese orthogeriatric community, we recognize that our practices are similarly influenced by these factors. In this editorial, we elucidate these barriers and facilitators in our own clinical settings and propose our suggestions. Our goal is to improve the postoperative care plans for older adults undergoing hip fracture surgery in China, India, Saudi Arabia and other countries with similar circumstances.

Insufficient recognition and acceptance by patients and family members

The traumatic incidence of hip fractures ignites fear-avoidance behaviours in patients and family members. While family members are motivated by genuine concern and overprotectiveness, they may also unintentionally intensify these apprehensions [12]. Practitioners in Saudi Arabia expressed hesitation to advance early mobilisation and WBAT, deeming caution a necessity to avoid being accountable if mechanical failures (such as implant cut-out, implant breakage, loss of fixation, etc.) occurred.

The situation in China is similar, where the doctor-patient relationship is not particularly good [13, 14]. Some patients and family members fear or reject early mobilisation and WBAT protocols by doctors. In this context, if doctors continue to implement early mobilisation and WBAT, the occurrence of mechanical failure or reoperations could be attributed to poor surgical quality or misjudged early mobilisation strategies. This frequently leads to patient-doctor conflicts and medical malpractice lawsuits [13, 14]. To mitigate these issues, some Chinese practitioners tend to recommend a cautious mobilisation protocol (partial weight-bearing or non-weight-bearing) until radiographs indicate evident signs of fracture healing [6–8]. As a result, Chinese patients do experience fewer mechanical failure where the implant cut-out rate is <2.5% [6–8] while it is reported to be ~5% to 6% in the USA [15]. Nonetheless, this excessive focus on mechanical failure has led to an oversight of adverse events caused by restricted weight-bearing (RWB). Particularly under the conservative mobilisation protocols set by practitioners, older patients tend to perceive adverse events such as delirium, thromboembolism and pneumonia as inevitable risks that must be endured for the sake of fracture healing.

The adverse events caused by RWB should draw attention from both practitioners and patients [16]. In the aforementioned analysis of 4918 hip fracture patients in the USA, the 30-day mortality rate in the WBAT group (3.19%) was significantly lower than that in the RWB group (5.52%) (P < .001) [4]. Similarly, in the previously mentioned multicenter study in Beijing, Jishuitan Hospital (with 43.5% of patients on WBAT by POD 1) had an in-hospital mortality rate of 0.1% and a 1-year mortality rate of 7.3%, which were significantly lower than the in-hospital mortality rate of 1.7% and 1-year mortality rate of 12.3% in other hospitals in Beijing (with only 19.9% of patients on WBAT by POD 1) (P < .0001 and P = .01, respectively).

Greater caution with internal fixation surgery than hip replacement

Weight-bearing prescriptions in Saudi Arabia are also based on the type of surgery or implant [12]. Similarly, Chinese practitioners’ caution primarily pertains to internal fixation surgery rather than hip replacement surgery. There are reasons behind the formation of these concerns.

In Western countries where immediate WBAT is widely recommended, the reoperation rate for internal fixation surgery is substantially higher than that for hip replacement surgery. In a multicentre, randomised controlled trial (RCT) conducted in Western countries involving 1079 patients; the reoperation rate of internal fixation surgery for hip fractures was reported to be as high as 21.0% [17]. Notably, another multicentre RCT in the Western setting, conducted by Fernandez et al. [18], reported a low reoperation rate of only 1.8% (22 out of 1225) for hip replacement surgery with immediate WBAT, in stark contrast to the aforementioned 21.0% associated with internal fixation surgery [17].

The distinction between hip replacement and internal fixation lies in the immediate post-surgical stability. The hip prosthesis (hemi or total hip arthroplasty) is designed to achieve immediate primary stability without the need for fracture healing while internal fixation only provides provisional stability until fracture healing occurs. Fracture healing can take several months, and it is influenced by numerous patient- and fracture-related factors [19]. Although internal fixation implants can provide provisional fracture stability, secondary displacement of the fracture fragments during early mobilisation can still occur. Factors such as poor bone quality (common in geriatric hip fractures), comminuted fracture, poor fracture reduction quality, and suboptimal implant placement can potentially lead to mechanical failure and reoperation [15, 20].

Overcoming the barriers

Based on the insights from the literature [12, 16], the following three strategies are summarised: First, to make early mobilisation and WBAT safer for patients, orthogeriatric co-management within the multidisciplinary team is necessary. Robust perioperative care and planning by the multidisciplinary team can help overcome barriers such as hypotension, inadequate pain control, delirium, and the risk of falling again [16]. Second, practitioners need support from standardised guidelines and senior leadership [12]. If early mobilisation and WBAT prescriptions follow standardised guidelines, yet mechanical failure still occurs, practitioners should receive greater legal protection. Third, to help patients and family engage in more proactive rehabilitation, practitioners can educate them with the development of culturally appropriate education strategies [12]. Some patients and families believe that rest and immobilisation are needed after an injury or fracture. Therefore, it is important to educate them about the convincing evidence of the harm caused by prolonged immobilisation and the literature supporting the benefits of early mobilisation.

Fourth, we recommend using a gradual transition approach to promote early mobilisation and WBAT. By evaluating factors like each patient’s bone quality, fracture geometry, fracture reduction quality, implant type, and implant placement, practitioners can select patients with a relatively lower risk of mechanical failure. These selected patients can then be given an individualised strategy for early mobilisation and WBAT post-surgery. If this gradual transition approach proves effective, expanding early mobilisation and WBAT to a broader range of patients will become more feasible.

In China and other countries with similar circumstances (such as India and Saudi Arabia), by effectively implementing the above four strategies, we believe practitioners can transform the current inadequate state of early mobilisation and WBAT after hip fracture surgery, thereby paving the way for better outcomes, improved quality of life, and a brighter future for older adults.

Acknowledgements

Not applicable.

Declaration of Conflicts of Interest

None.

Declaration of Sources of Funding

This work was supported by the National Natural Science Foundation of China (Grant No. 81772323), and the Shanghai Science and Technology Commission (Grant No. 23ZR1459300).

References