Abstract
Background:
The functional recovery of unstable pelvic ring injuries patients relies heavily on their ability to mobilize post-operatively and immobility is associated with a multitude of negative outcomes. The purpose of this study was to examine the restricted (NWB) and unrestricted (WB) immediate postoperative weight bearing protocols for patients who have undergone unstable pelvic ring injury fixation and evaluate trends in postoperative outcomes.
Methods:
A retrospective review of medical charts and radiographs were performed on adult patients from 1/2012 through 6/2022 at a level one trauma center. Outcomes examined time to fracture healing, time to full weight bearing, postoperative complications, and reoperation between groups.
Results:
151 patients (50 females, 101 males) met the eligibility criteria. Eighty-six patients (mean age 46 years, 71% men) were designated NWB group, and 65 patients (mean age 46 years, 62% men) were designated WB group. The most common injury mechanism was motor vehicle collision (MVC) (n=60, 40%) followed by fall from height (n=29, 19%). The most common injury patterns were lateral compression (n=87, 58%), followed by anteroposterior compression (n=47, 31%) and vertical shear (n=17, 11%). 54 (36%) patients who had postoperative complications with seven (5%) patients having both fracture-related and no-fracture-related complications noted. The NWB group had a mean fracture healing time of 17 weeks, 14 fracture related complications, 21 nonfracture related complications, 23 reoperations, and a mean full weight bearing time of 12 weeks. The WB group had a mean fracture healing time of 16 weeks, 14 fracture related complications, 13 non-fracture related complications, 15 reoperations, and a mean full weight bearing time of nine weeks. The mean duration of the initial weight bearing restriction for the NWB group was 9.7±3.4 weeks. No statistically significant difference found between these two groups (healing time: p=0.73; fracture related complication: p=0.41; non-fracture related complication: p=0.38; reoperation: p=0.61; full weight bearing time: p=0.73).
Conclusion:
This study shows unrestricted postoperative weight bearing protocols achieved similar postoperative outcomes as restricted postoperative weight bearing protocols. The choice of restricted or unrestricted postoperative weight bearing protocols after surgical treated unstable pelvic ring injuries patients could not significantly affect the postoperative outcomes.
Level of Evidence: IV
Keywords: weight bearing, pelvic, injuries, outcome measures, complications
Introduction
Unstable pelvic ring injuries typically result from high-energy mechanisms and often require operative fixation.1'4 Due to the high-energy nature of these injuries, patients often sustain multiple orthopedic and non-orthopedic injuries.5,6 The functional recovery of these patients relies heavily on their ability to mobilize post-operatively, and immobility is associated with a multitude of negative outcomes including pulmonary compromise, venous thromboembolism, pressure sores, and deconditioning.7,8 Postoperative or post-injury weight bearing restrictions are often determined by expert opinion of the degree to which patients can mobilize after traumatic injuries, and more conservative weight bearing restrictions may limit the patient’s and therapist’s options for safely participating in physical and occupational therapy. Often, these weight bearing restrictions are generated by the discretion of the orthopedic team based on a patient’s injuries. Such restrictions aimed to maximize patient mobilization while preventing loss of reduction and subsequent reoperation.
Several studies examined weight bearing restrictions after lower extremity fracture fixation.9–11 However, very few studies examined the evidence base for weight bearing restrictions after pelvic ring injuries. Notably, a meta-analysis in 2019 found that there was a paucity of evidence to support weight bearing recommendations following pelvic ring fixation with only one prior study evaluating weight bearing as a specific aim.2,12 Bellabarba et al. observed fourteen patients with displaced, vertically stable, lateral compression injuries of the pelvis, and their results showed that a mean time to full weight bearing without the need for assistive devices was twelve days (range, 3-18 days), and mean healing time was 8.2 weeks (range, 7-12 weeks).2 Surgeon recommendations for these types of injuries run the gamut from complete non-weight bearing for 6-12 weeks to immediate partial weight bearing to early full weight bearing. Currently, very little evidence is available to guide these recommendations. A study by Marchand et al. found no difference in construct failure or fracture union in patients allowed to fully weight bear before or after eight weeks post-operatively for unstable pelvic ring injuries.10 However, the overall body of evidence investigating weight bearing restrictions after these types of injuries remains extremely sparse, and there is little to guide clinicians besides dogma and surgeon opinion. The purpose of this study was to examine the restricted and unrestricted postoperative weight bearing protocols for patients who have undergone unstable pelvic ring injury fixation and evaluate trends in postoperative outcomes, including time to fracture healing, time to full weight bearing, the incidence of postoperative complications, and reoperation rates associated with weight bearing restrictions.
Methods:
The study was approved by the Institutional Review Board (STUDY00003046). A retrospective review was conducted of the medical charts and radiographic studies of a consecutive series of adult patients (age > 18 years at the time of injury) with unstable pelvic ring injuries at a single institution in the Midwest region.
The medical codes utilized to identify potential subjects were Current Procedural Terminology (CPT) codes 27216, 27217, and 27218. The inclusion criteria consisted of subjects who had undergone operative repair of unstable pelvic ring injuries from January 2012 through June 2022, and patients with less than 11 weeks of follow-up (as some patients showed up early for their 3-month follow up visit) were excluded from the study.
Patient demographic details, mechanism of injury, pelvic ring injury patterns, weight bearing restriction status, length of orthopedic surgery follow-up, time to radiographic fracture healing, postoperative complications, and reoperations were recorded. Pelvic ring injury patterns were classified using the Young and Burgess classification system of pelvic ring injuries: anteroposterior compression (APC), lateral compression (LC), and vertical shear (VS).4,13,14 Postoperative complications included fracture-related complications (hardware breakage or failure, loss of reduction on radiographs, nonunion, or malunion) and non-fracture-related complications (postoperative development of venous thromboembolism (VTE), deep or superficial infection). Planned reoperations, such as external fixator removal, were not considered reoperation surgery for the purpose of this study.
Postoperative lower extremity weight bearing status as instructed by the operating or managing physician following pelvic fixation was recorded, both in the immediate post operative period and in the subsequent follow-up period. Postoperative weight bearing status was categorized into two groups: non-weight (NWB) and weight bearing (WB) groups. The NWB group included patients with toe touch weight bearing (also referred to as touch down or flat foot) and patients with restricted weight bearing either on the bilateral lower extremities or on a unilateral lower extremity. The WB group included patients with partial weight bearing on the affected side of which was defined as allowing 14 - 23 kg (30 - 50 lbs) weight bearing, and patients with weight bearing as tolerated. The duration of the initial weight bearing advancement for the NWB group was recorded as was the time to full weight bearing.
Descriptive statistics of mean, standard deviation, and range were determined for subject demographic variables and patient outcomes. Frequencies and percentages for other variables were determined. A two-tailed t-test method with equal variances assumed was used to compare notable effects among age, BMI, follow-up period, time to fracture healing, and time to full weight bearing between the two groups. The Pearson Chisquare method was used among gender, injury mechanism, injury pattern, complications, and reoperation. All statistical testing methods used were performed using IBM SPSS Statistics software (Version 24.0.0.0; IBM), and the statistically significant relationships were defined as those with a p-value less than 0.05.
Results:
Two hundred eighty-three patients who underwent operative repair pelvic ring injuries were identified. After excluding patients with incomplete data or inadequate follow up 151 patients (50 females, 101 males) were included in this study. There were 86 patients (mean age 46 years, 71% men) were designated NWB group, and 65 patients (mean age 46 years, 62% men) were designated WB group (Table 1). The overall mean age was 46 ± 17 years (range, 18 to 79 years), the overall mean BMI was 30.2 ± 7.2 kg/m2 (range, 18.5 to 62.7 kg/m2), and the mean length of follow-up was 51 ± 73 weeks (range, 11 to 493 weeks) (Table 1). These were not significantly different between these two groups (age: p = 0.84; BMI: p = 0.28; follow-up: p = 0.94).
Table 1.
Patient Demographics
| Variable | NWB Group (n = 86) | WB Group (n = 65) | p-value | |
| Gender | Female | 25 (29%) | 25 (38%) | 0.23 |
| Male | 61 (71%) | 40 (62%) | ||
| Age (years) (mean ± SD, range) | 46 ± 17 (18 - 78) | 46 ± 17 (18 - 79) | 0.84 | |
| BMI (kg/m2) (mean ± SD, range) | 30.4 ± 6.9 (19.8 - 47.7) | 28.7 ± 5.0 (18.5 - 40.2) | 0.28 | |
| Length of follow-up (weeks) (mean ± SD, range) | 50.4 ± 69.8 (10.7 - 493) | 51.4 ± 76.8 (11.1 - 481) | 0.94 | |
*Note: NWB: non-weight bearing group; WB: weight bearing group; BMI: body mass index; SD: standard deviation.
The most common injury mechanism was motor vehicle collision (MVC) (n = 60, 40%) followed by fall from height (n = 29, 19%). Other injury mechanisms included pedestrian versus vehicle (n = 19, 13%), equestrian (n = 14, 9%), crush injury (n = 14, 9%), motorcycle crash (n = 12, 8%), and others (n = 3, 2%) (Table 2). There was no statistically significant difference detected between these two groups (p = 0.83).
Table 2.
Mechanism of Injury for Each Group
| Injury Mechanism | NWB Group (n = 86) | WB Group (n = 65) | Overall (n = 151) |
| Motor vehicle collision (MVC) | 36 | 24 | 60 (40%) |
| Fall from height | 14 | 15 | 29 (19%) |
| Pedestrian versus vehicle | 12 | 7 | 19 (13%) |
| Equestrian | 7 | 7 | 14 (9%) |
| Crush injury | 8 | 6 | 14 (9%) |
| Motorcycle crash | 8 | 4 | 12 (8%) |
| Others | 1 | 2 | 3 (2%) |
*Note: NWB: non-weight bearing group; WB: weight bearing group.
The most common injury patterns were LC (n = 87, 58%), followed by APC (n = 47, 31%) and VS (n = 17, 11%) (Table 3). For the NWB group, there were 27 (31%) patients sustained APC injury pattern, 47 (55%) patients sustained LC injury pattern, and 12 (14%) patients sustained VS injury pattern. For the WB group, there were 20 (31%) patients sustained APC injury pattern, 40 (62%) patients sustained LC injury pattern, and five (8%) patients sustained VS injury pattern (Table 3). There was no statistically significant difference detected between these two groups (p = 0.45).
Table 3.
Injury Patterns for Each Group
| NWB Group (n = 86) | WB Group (n = 65) | Overall (n = 151) | |
| Anteroposterior compression (APC) | 27 | 20 | 47 (31%) |
| APC2 | 26 | 19 | |
| APC3 | 1 | 1 | |
| Lateral compression (LC) | 47 | 40 | 87 (58%) |
| LC1 | 19 | 14 | |
| LC2 | 24 | 22 | |
| LC3 | 4 | 4 | |
| Vertical shear | 12 | 5 | 17 (11%) |
*Note: NWB: non-weight bearing group; WB: weight bearing group; APC2: pubic symphysis diastasis > 2.5 cm, disruption of the anterior sacroiliac ligaments, and rotational instability. APC3: pubic symphysis diastasis > 2.5 cm, disruption of both anterior and posterior sacroiliac ligaments, leading to both rotational and vertical instability. LC1: involves a fracture of the sacrum, potentially with a crescent-shaped fracture. LC2: characterized by a crescent-shaped fracture of the pelvic ring. LC3: injury with one side of the pelvis compressed and the other side opened, also known as a "windswept pelvis".
There was a total of 54 (36%) patients who had postoperative complications with seven (5%) patients having both fracture-related and no-fracture-related complications noted in this study (Table 4). For fracture related complications in the NWB group, there were seven (8%) patients who sustained hardware failure, four (5%) patients had loss of fracture reduction, and three (3%) patients had nonunion. For fracture related complications in the WB group, there were ten (15%) patients who sustained hardware failure, two (3%) patients had loss of fracture reduction, and two (3%) patients had nonunion. No cases of malunion were noted for both groups. For non-fracture related complications in the NWB group, there were ten (12%) patients who had postoperative VTE, and 11 (13%) patients had infection (superficial: eight patients; deep: three patients). For non-fracture related complications in the WB group, there were eight (12%) patients who had postoperative VTE, and five (8%) patients had infection (superficial: three patients; deep: two patients). Statistically, no significant differences were detected in both fracture and non-fracture related complications between these two groups (Table 4).
Table 4.
Comparison of Fracture and Non-Fracture Related Complications and Reoperation Rates for Each Group
| Complications | NWB Group (n = 86) | WB Group (n = 65) | p-value | |
| Fracture Related | Hardware Failure | 7 | 10 | 0.16 |
| Loss of Reduction | 4 | 2 | 0.62 | |
| Nonunion | 3 | 2 | 0.89 | |
| Malunion | - | - | - | |
| Total | 14 | 14 | 0.41 | |
| Non-Fracture Related | Postoperative VTE | 10 | 8 | 0.90 |
| Superficial Infection | 8 | 3 | 0.27 | |
| Deep Infection | 3 | 2 | 0.89 | |
| Total | 21 | 13 | 0.38 | |
| Reoperation | 23 | 15 | 0.61 | |
| Time to fracture healing (weeks) (mean ± SD, range) | 17 ± 9 (10 - 68) | 16 ± 7 (7 - 60) | 0.73 | |
*Note: NWB: non-weight bearing; WB: weight bearing; VTE: venous thromboembolism; SD: standard deviation.
Thirty-eight of the 151 patients underwent reoperation and thus resulted in an overall reoperation rates of 25%. The WB group had slightly lower reoperation rates compared to the NWB group (WB: 23% [15/65 cases]; NWB: 27% [23/86 cases]), but statistically there was no significant difference detected between these two groups (p = 0.61) (Table 4).
The mean radiographic fracture healing time was 16.3 ± 8.2 weeks (range, 7.3 - 68.0 weeks) with nine patients that had no fracture healing observed. The NWB group had a mean radiographic fracture healing time of 16.5 ± 9.1 weeks (range, 9.6 - 68.0 weeks) with five non-healing, whereas the WB group had 16.0 ± 6.8 weeks (range, 7.3 - 59.6 weeks) with four non-healing. Statistically, there was no difference detected between these two groups (p = 0.73, Table 4).
The mean duration of the initial weight bearing restriction for the NWB group was 9.7 ± 3.4 weeks (range, 3.9 - 21.7 weeks). On average, there were slightly shorter mean full weight bearing periods observed in the WB group compared to the NWB groups (WB: 12 ± 5 weeks; NWB: 9 ± 4 weeks; p = 0.73, Table 5). Statistically, there was no difference detected between these two groups.
Table 5.
Duration of Weight Bearing Advancement and Full Weight Bearing for Each Group
| NWB Group (n = 86) | WB Group (n = 65) | p-value | |
| Time to Initial Weight Bearing Advancement (Weeks) (mean ± SD, range) | 97 ± 3.4 (3.9 - 21.7) | - | - |
| Time to Full Weight Bearing (Weeks) (mean ± SD, range) | 12.1 ± 4.7 (5.1 - 44.7) | 8.9 ± 3.8 (3.9 - 26.3) | 0.73 |
*Note: NWB: non-weight bearing; WB: weight bearing; SD: standard deviation.
Discussion
Unstable pelvic ring injuries can be challenging to treat, both surgically and post-surgically. There is little data to guide weight bearing restrictions in the immediate postoperative period or the advancement of weight bearing postoperatively. The present study is the first case series study to date that assess the trend and the impact of immediate postoperative weight bearing status on complications, reoperation rates, time to fracture healing, and time to full weight bearing for patients who operatively treated unstable pelvic ring injuries. This study found that with surgical fixation, patients who designated immediate postoperative weight bearing (WB group) had similar fracture healing time and similar incidence of postoperative complications, but slightly shorter mean time to full weight bearing periods, and slightly lower reoperation rates compared to the restricted postoperative weight bearing group (NWB group).
The literature regarding postoperative WB protocols and pelvic ring injuries is currently limited.11,12,15 Rickman et al. performed a systematic review of literature from 1990 to 2016 specifically related to patient weightbearing protocols after pelvic fracture surgery, and they revealed a nonexistent scientific evidence base from which to make recommendations to guide postoperative management.12 No study has fully evaluated the possible effects that varying weight bearing restrictions may have on the postoperative complication rate of operatively treated pelvic ring injuries. Schildhauer et al. reported on a series of 34 patients with vertically unstable sacral fractures managed with triangular osteosynthesis.16 Immediate WB was allowed in 19 patients and three (16%) postoperative complications were observed. Bellabarba et al. observed 14 immediate WB patients with type B lateral compression pelvic ring injuries, and they noted six (43%) postoperative complications (infection: three patients, nerve palsy: one patient, pin tract abscess: one patient, choric low-back pain: one patient).2 Tornetta et al. reported on 29 patients with rotationally unstable pelvic injuries managed with symphyseal plating and immediate WB, noted seven (24%) postoperative complications (plate failures: four patients; loss of reduction: three patients).17 Poole et al. reviewed 53 patients with type B lateral compression pelvic ring injuries with 28 patients were allowed to immediately weight bear as tolerated postoperatively, and their results showed five (18%) of the 28 patients had postoperative complications (loss of reduction: one patient, hardware failure: four patients).9 In the present study, 65 patients were allowed immediate weight bearing (WB group) and noted similar postoperative complication rates of 37% (n = 24) (hardware failure: nine patients, loss of reduction: two patients; nonunion: one patients; VTE: six patients; infection: three patients; VTE + infection: one patient; nonunion + infection: one patient; VTE + hardware failure: one patient). This postoperative complication results were comparable to the restricted weight bearing patient group (NWB group) with 35% complication rates (n = 30) (hardware failure: six patients; loss of reduction: two patients; nonunion: one patient; VTE: seven patients; infection: nine patients; VTE + nonunion: two patients; loss of reduction + infection: two patient; VTE + hardware failure: one patient).
Weight bearing restrictions that severely limit a patient’s mobility and ability to perform activities of daily living can present significant challenges to patient’s postoperative recoveries. Patients routinely exceed WB restrictions despite believing themselves to have been compliant with physician-directed WB protocols.15,18-22 Early WB or weight bearing as tolerated may improve patient’s function and return to work, decreasing the overall economic burden of injury.11 This, however, must be balanced against the risk of allowing patients to bear weight too soon, else resulting in loss of reduction or complications and subsequent reoperation. Marchand et al. compared 286 patients following pelvic fracture fixation from 2006-2015 with early (<8 weeks) and late (>8 weeks) time to full WB, and their results revealed no difference in implant failure, malunion, or early loss of reduction between the two groups.10 Poole et al. presented a cohort of type B pelvic fracture patients some of whom were allowed immediate unrestricted weight bearing after fixation without an increase in loss of reduction or reoperation.9 The results of this study support the same theory that more permissive weight bearing could allow patients to be more independent in the initial postoperative period. In part, this conclusion could certainly be confounded by the severity of these patients’ initial injuries and any associated injuries. Several studies have demonstrated the influence of injury patterns on postoperative complication rate.23–26 However, this trend may bear further investigation.
This study has several limitations to recognize. This was a single-institution, retrospective chart review study that introduced the possibility of selection and/ or observation bias, as it was neither randomized nor blinded. The information in this study is limited to the specified time within a single hospital. A small sample size made applying tests of significance to many of the variables difficult. The low number of cases included was unfortunately unavoidable due to multiple factors including the relative rarity of pelvic ring injuries and a high rate of follow-up loss. While patients with less than three months follow-up were excluded from this study, the lengths and thoroughness of follow-up for the included patients remained highly variable. Additionally, patients may have sought care at other institutions postoperatively, the outcomes of which would not have been registered in this study. This could have falsely decreased the number of postoperative failures, reoperation surgeries, or other complications recorded.
In conclusion, this study shows unrestricted postoperative weight bearing protocols achieved similar postoperative outcomes as restricted postoperative weight bearing protocols. The choice of restricted or unrestricted postoperative weight bearing protocols after surgical treated unstable pelvic ring injuries patients could not significantly affect the postoperative outcomes. However, clinicians should implement proper patient selection and recognize the potential benefits and drawbacks of each weight bearing status when treating unstable pelvic ring injuries to reduce the risk of complications, maximize the odds of healing, and facilitate patient’s functional rehabilitation potential.
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