Impact of Postoperative Weight-Bearing Protocols on Prognosis in Geriatric Hip Fracture Patients: A Systematic Review and Meta-Analysis

Background: Clinical controversy persists regarding the optimal weight-bearing strategy for elderly patients following hip fractures. Whilst early unrestricted weight-bearing may improve functional outcome and reduce the risk of bed-related complications, concerns about implant stability and failure often lead clinicians to adopt restricted weight-bearing protocols. To address this, we conducted a systematic review and meta-analysis to identify the effects of unrestricted weight-bearing compared with restricted weight-bearing on clinical outcomes in this patient population. We hypothesized that unrestricted weight-bearing may be associated with lower all-cause mortality without increasing postoperative complications, reoperation rates or length of hospital stay (LOS). Methods: This systematic review was conducted based on a study protocol registered on the PROSPERO platform and reported strictly in accordance with the PRISMA guidelines. We included clinical studies involving patients aged ≥65 years with hip fractures undergoing surgical treatment that directly compared the effects of different postoperative weight-bearing strategies on outcomes. Patients were further classified into unrestricted and restricted weight-bearing groups according to the postoperative weight-bearing protocols reported in each study. The primary outcome was all-cause mortality. Secondary outcomes included postoperative complications, reoperation rates, and LOS. A random-effects model was used for meta-analysis. Dichotomous variables were expressed as risk ratios (RRs), continuous variables as mean differences (MDs), and study heterogeneity was assessed using the I2 statistic. The certainty of evidence of each outcome was assessed by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: Ten studies (one randomized controlled trial and nine cohort studies) were included with 5806 patients in total. Extra-capsular fractures (intertrochanteric/subtrochanteric fractures) were the most common, with 3694 patients, followed by femoral neck fractures, with 1929 patients. Unrestricted weight-bearing was significantly associated with lower long-term mortality compared with restricted weight-bearing (RR = 0.67, 95% CI 0.51–0.88, p = 0.004, I2 = 34%; 95% PI 0.52–0.83), with an absolute risk difference of −0.10%. Short-term mortality did not differ significantly in the primary analysis (RR = 0.58, 95% CI 0.14–2.34, p = 0.44, I2 = 70%; 95% PI 0.00–126.98). Furthermore, the corresponding absolute risk difference was only −0.03%. No significant differences were observed for short-term complications, long-term complications, reoperation risk, or LOS between the two groups (all p > 0.05). GRADE assessment showed low certainty of evidence for long-term mortality and short-term complications, and very low certainty of evidence for the remaining outcomes. Conclusions: This meta-analysis suggests that unrestricted weight-bearing may be a feasible postoperative rehabilitation approach in selected patients. However, the results should be interpreted with caution. Further well-designed prospective studies are required to confirm these findings.