Effectiveness of early weight-bearing rehabilitation protocols on outcomes after surgical fixation of pelvic and acetabular fractures: A systematic review

Abstract

Optimal postoperative weight-bearing management following surgical fixation of pelvic and acetabular fractures remains incompletely defined. Prolonged restriction carries well-recognized risks of immobility-related morbidity, yet the safety and efficacy of early weight bearing (EWB) after screw-based constructs have not been rigorously synthesized. This review evaluates the available evidence on fixation stability, functional recovery, and complication rates following explicitly prescribed EWB protocols after surgical fixation of pelvic and acetabular fractures using screw-dominant or minimally invasive stabilization constructs. A systematic review was conducted in accordance with PRISMA 2020 guidelines. Eligible studies included adult patients who underwent screw-dominant or minimally invasive surgical fixation for pelvic or acetabular fractures and whose postoperative protocol explicitly prescribed EWB initiation within two weeks of surgery. Studies prescribing restricted or delayed weight bearing as the primary protocol were excluded. Methodological quality was appraised using the Methodological Index for Non-Randomized Studies (MINORS). Electronic databases (PubMed, Scopus, the Cochrane Library, and Google Scholar) were systematically searched as of December 2025. Six studies encompassing 297 patients met the final eligibility criteria. The evidence base consisted predominantly of retrospective case series, with one comparative cohort study identified. Across the included studies, catastrophic fixation failure was uncommon in carefully selected patients receiving EWB, and the included studies did not consistently demonstrate increased rates of loss of reduction. Functional recovery was generally favorable, and complication rates were low. Substantial heterogeneity across fracture morphology, fixation techniques, and EWB definitions precluded meta-analysis. Current literature on EWB following pelvic and acetabular fixation consists predominantly of low-level retrospective evidence subject to meaningful selection bias. While EWB appears feasible and catastrophic fixation failure was uncommon in these highly selected cohorts, the absence of high-quality comparative trials precludes confirmation of its widespread safety. EWB should currently be regarded as a feasibility concept applicable to carefully selected patients with stable fixation, rather than a routine recommendation. Prospective randomized trials are needed to establish definitive guidance.