Post-operative weight-bearing practices following lower limb fracture surgery: A National multidisciplinary survey of concordance with AO foundation guidelines.

Abstract

Post-operative weight-bearing (WB) prescription is the principal tool for regulating fracture mechanical environment. Low adherence to AO Foundation guidelines is documented across settings, yet the occupational, age-related, and semantic determinants of non-concordance in a multidisciplinary trauma workforce remain poorly characterised. A national cross-sectional survey was administered electronically to 79 Israeli clinicians (orthopaedic specialists n = 44, trauma specialists n = 16, residents n = 13, rehabilitation team n = 6) between December 2022 and March 2023. Four standardised clinical vignettes (AO 43A2, 43C1, 43B1 distal tibia; B-type pelvic ring fracture) were used to assess AO-concordant WB responses. Multivariable binary logistic regression, chi-square and Fisher's exact tests were performed. Per-case AO concordance ranged from 25.3% (AO 43C1, complete articular) to 73.4% (B-type pelvic fracture); only 10.1% were concordant across all four cases. Trauma specialists demonstrated a statistically significant bimodal pattern: lowest concordance on the simple extra-articular C1 vignette (12.5% vs 44.4% non-trauma; Fisher p = 0.022), driven by paradoxical over-restriction (50.0% chose NWB-6 weeks vs 22.2%; p = 0.057), yet highest concordance on the complex pelvic fracture C4 (81.2%). WB escalation philosophy differed significantly by occupation (χ² = 82.2, df = 60, p = 0.030). Age > 67 years was the sole independent predictor of non-concordance on NWB protocols (OR = 0.11, 95% CI 0.02-0.66, p = 0.015). 'Partial weight-bearing' was interpreted as 8.9-25.3% of body weight across respondents. AO WB guideline concordance is low, case-specific, and shaped by occupational philosophy rather than seniority. Trauma specialists display a coherent case-selective approach that diverges from guidelines for simple fractures but converges for complex ones. Adopting the 2024 BOAST qualitative WB framework eliminates dangerous partial WB interpretation heterogeneity at no cost. Senior practitioners' mentorship role makes collaborative guideline engagement more effective than corrective approaches.