Which patients need to toe off after femur fracture surgery?

Toe-Off Requirements After Femur Fracture Surgery

All patients with femur fractures should be encouraged to toe-off and begin weight bearing as soon as possible after surgery to improve functional outcomes and reduce complications. 1, 2

Factors Determining Toe-Off Timing

• Immediate weight bearing after femur fracture fixation with statically locked intramedullary nails is safe and effective, even for patients with comminuted fractures 2
• Patients with adequate fixation strength (particularly those with two distal locking screws in intramedullary nails) can safely begin toe-off and weight bearing immediately 2
• Early mobilization and weight bearing help reduce the risk of thromboembolism, which has a clinical prevalence of 1-3% for DVTs and 0.5-3% for PEs in hip fracture patients 3

Patient-Specific Considerations

• The time to full weight-bearing should be based on:
  • Cortical contact of major bone fragments 4
  • Presence of bridging callus on radiographs 4
  • Extent of other injuries to the ipsilateral lower extremity 4
• Patients with multiple injuries may particularly benefit from early toe-off and weight bearing to:
  • Improve participation in physical therapy 2
  • Potentially decrease hospital stay duration 2
  • Reduce need for prolonged inpatient rehabilitation 2

Fixation Method Considerations

• Patients with statically locked intramedullary nails with high fatigue strength (particularly those with two distal locking screws) can safely begin immediate weight bearing 2
• Static interlocking of intramedullary nails does not appreciably inhibit fracture healing, making early toe-off safe 4
• Patients who had external fixation converted to intramedullary nailing can also safely begin early weight bearing once the definitive fixation is in place 5

Rehabilitation Protocol

• Intervention should focus on immediate weight bearing and early progression of strengthening to address impairments in range of motion, knee extensor and hip abductor strength 1
• Early rehabilitation with immediate weight bearing following surgical fixation may result in:
  • Earlier resolution of impairments and functional limitations 1
  • Decreased overall disability 1
  • Faster return to work and normal activities 1

Special Considerations for Elderly Patients

• Elderly patients with hip fractures particularly benefit from early toe-off and mobilization to:
  • Reduce risk of pressure sores 3
  • Prevent deep vein thrombosis 3
  • Minimize risk of postoperative cognitive dysfunction 6
  • Improve overall rehabilitation outcomes 3

Common Pitfalls to Avoid

• Delaying weight bearing unnecessarily can lead to:
  • Increased risk of thromboembolism 3
  • Prolonged hospital stays 3
  • Poorer functional outcomes 1
• Failure to recognize fixation strength can lead to either:
  • Overly cautious weight bearing restrictions that delay recovery 2
  • Premature full weight bearing on inadequate fixation 7