Surgeon-directed weight-bearing strategies after intramedullary fixation of extracapsular hip fractures: Impact of medical complexity on functional recovery

Background Postoperative weight-bearing after hip fracture fixation remains controversial in elderly patients. Although early mobilization is widely recommended, rehabilitation practices vary, and evidence from non-Western healthcare systems is limited. Conventional analyses often rely on dichotomous outcomes and may not adequately reflect differences in the trajectory of postoperative recovery. This study compared recovery trajectories following early and delayed weight-bearing rehabilitation after hip fracture fixation. Methods This retrospective cohort study included patients aged ≥65 years who underwent intramedullary fixation for proximal hip fractures between 2017 and 2025 at a tertiary public hospital within a middle Eastern public healthcare system. Patients were classified according to documented postoperative weight-bearing protocol. Fractures were classified according to the AO Foundation/Orthopaedic Trauma Association fracture classification system and stratified as stable (31-A1) and unstable (31-A2/A3, 32-A/B) patterns. Subgroup analyses were performed to evaluate the interaction between American Society of Anesthesiologists (ASA) class (as a marker of perioperative medical complexity), fracture stability, and weight-bearing protocol. Recovery trajectory was evaluated using 6-month Harris Hip Score (HHS) distribution and EQ-5D domain outcomes. Postoperative complications, readmissions, and mortality were recorded. For cases requiring reoperation, indication, timing of revision procedure, and postoperative course were documented to enhance clinical interpretability. Multivariable logistic regression assessed factors associated with favorable functional recovery. Results Of 155 eligible patients (77 early, 78 delayed weight bearing), 109 completed 6-month follow-up. Differences in HHS category distribution (p = .0025) and multiple EQ-5D domains were observed between rehabilitation strategies, while complication rates, reoperations, readmissions, and mortality did not differ significantly between groups. Among patients classified as ASA III–IV, delayed weight-bearing was not associated with lower complication or mortality rates, while functional recovery remained more favorable with early weight-bearing. Conclusion Postoperative weight-bearing strategy influences the trajectory of functional recovery after hip fracture fixation without increasing short-term adverse events, supporting an evidence-informed and individualized approach to postoperative weight-bearing prescription following intramedullary fixation in elderly patients.