Both TKA and THA, which were once managed with inpatient admission of days to more than one week, have been safely transitioned to outpatient or overnight procedures [9]. This is but one example of the benefits of accelerated rehabilitation. Compelling evidence exists that early motion is less restrictive and generally leads to the same or often better outcomes following elbow injuries and surgery [13], Achilles’ tendon ruptures treated either operatively or nonoperatively [1, 2], and proximal humerus fractures [5]. The obvious retort or rebuttal is that early motion may lead to complications, implying that we, as surgeons, would rather treat (or more commonly ignore and write off to a natural sequelae) a stiff, healed injury than a reinjury or treatment complication. But is it really true that early motion leads to increased complications? The answer seems simply to be “no.” While this is not an all-encompassing review article, there are many (many) studies demonstrating that early motion is beneficial, whereas I did not find any recent articles suggesting that early motion was harmful or associated with inferior outcomes. The same can be said for early, permissive weightbearing on many fractures. Early weightbearing appears to be safe, resulting in no increase in complications such as loss of fixation or articular collapse, and yield equivalent or better patient-reported outcomes for everything from ankle fractures [11], to tibial plateau fractures [3], to geriatric hip fractures [7, 8]. Taking a closer look at the latter case of hip fractures, patients older than 65 years of age generally have worse mobility scores in the setting of (attempted) weightbearing restrictions [8], worse outcomes (including mortality) without early mobilization and weightbearing [7], and are unable to follow weightbearing restrictions even when they are imposed or recommended [4, 8]. All of this raises the question: If our patients want to move and are better for it, why are we so slow to adapt and let them? There is evidence suggesting that is exactly what we are doing for both motion and weightbearing. One survey study noted that nearly 40% of low-volume surgeons (and over 20% of high-volume surgeons) still delayed weightbearing after ACL reconstruction, with very similar proportions for delays in permitting full ROM [6]. Another survey of 702 surgeons from both the Orthopaedic Trauma Association and American Orthopaedic Foot & Ankle Society reported wide ranges in time to full weightbearing following ankle fractures [12]. And Ottesen et al. [7] reported that at least 25% of patients with hip fractures were placed on restricted weightbearing status after surgery. I am not at all criticizing the flood of recent studies seeking to demonstrate the equivalence or benefit of early mobilization and/or weightbearing. Rather, I would argue that we need more of them. The ankle fracture survey cited above concluded that there was “reluctance of many practicing surgeons to adopt some of the more aggressive mobilization protocols,” but conceded “there is very little objective guidance for what is most appropriate” [12], although the latter situation has since improved [11]. And one systematic review of pelvic fractures concluded: “A review of postoperative weightbearing regimens reveals a nonexistent scientific evidence base from which to make recommendations” [10]. Still, we can infer a lot from recently published studies and at the very least adapt our own clinical practices to match the existing evidence. Next, (as I am fond of explaining to my patients) making a patient “permissive weightbearing” or “weightbearing as tolerated” does not mean those patients will be able to immediately tolerate full weightbearing. On the contrary, there is evidence that patients will auto-regulate and adapt their weightbearing to match their injury and healing, such as patients with more severe tibial plateau fractures taking longer to achieve full weightbearing than their less severe counterparts [3]. But discrepancies such as this should make us more, not less, comfortable letting our patients attempt do more, sooner. Finally, there are certainly injuries, such as articular, osteoporotic lower extremity fractures in patients with diabetes or neuropathic joints of the ankle and hindfoot, for which surgeons are understandably hesitant to be too aggressive and for which (surprise!) there is to my knowledge no evidence in favor of immediate mobilization and unrestricted weightbearing. And then there are injuries, such as pelvic fractures, for which there is, indeed, a dearth of evidence to guide as and requiring further study. So it seems like we need more research to guide us and help us migrate away from the AO’s “magical 10 to 12 week” timeline for healing, as my colleague Robert O’Toole MD sarcastically likes to call it. But for many injuries, orthopaedic procedures, and fractures, we need to heed the evidence that already exists. Our patients want to move and we have demonstrated that they are better for it when they do. Let’s move with them.
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Aug 14, 2024
Jiangmei Xu + 7
