Tibial shaft fractures represent a substantial proportion of long bone injuries encountered in orthopaedic practice, with an incidence of approximately 15 per 100,000 person-years. Intramedullary nailing (IMN) has become the standard of care for displaced diaphyseal fractures due to its biomechanical advantages & ability to preserve soft tissue integrity[1].

Fractures of the tibial shaft are among the most common long bone injuries encountered in orthopedic practice, accounting for a significant proportion of trauma-related hospital admissions worldwide. These fractures typically result from high-energy trauma such as road traffic accidents, falls, or sports-related injuries, though low-energy mechanisms are also common in elderly or osteoporotic individuals [2]. The tibia’s subcutaneous anatomical location & its limited soft-tissue envelope make it highly vulnerable to both open fractures & complications such as infection & delayed union [3-4].

Postoperative rehabilitation is critical for optimal recovery. Traditional protocols often restrict weight-bearing until radiographic evidence of callus to prevent implant failure or nonunion[5]. However, several biomechanical & clinical studies suggest that controlled early loading may stimulate osteogenesis & improve muscle strength, joint mobility, & overall function[6-7].

Despite increasing interest in early weight-bearing (EWB), clinical adoption remains inconsistent due to concerns regarding fracture displacement, delayed union, & hardware failure. There is a need for well-designed prospective studies comparing functional outcomes & complication profiles between early versus delayed weight-bearing (DWB) after IMN of tibial shaft fractures[8-9].

The aim of this study was to compare EWB & DWB protocols in terms of functional outcomes, time to union, return to work, & complications in a cohort of 120 patients treated with tibial IMN.

Study Design & Participants This prospective cohort study was conducted at a Tertiary Trauma Center for 01 Year. Inclusion criteria were adults aged 18–65 years with isolated closed or Gustilo I–II open tibial shaft fractures treated by reamed IMN within 48 hours of injury. Exclusion criteria included pathological fractures, segmental bone loss >2 cm, neurovascular injury requiring repair, polytrauma (Injury Severity Score >16), & inability to follow rehabilitation protocols. Ethical Considerations The study protocol was approved by the Institutional Ethics Committee. Informed written consent was obtained from all participants. Operative Procedure All surgeries were performed under fluoroscopic guidance by experienced orthopaedic trauma surgeons using standard reamed tibial IMN techniques with locked nails. Perioperative antibiotics & thromboprophylaxis were administered according to institutional protocols. Weight-Bearing Protocols Patients were nonrandomly assigned to: ● EWB group (n=60): Partial weight-bearing (20–30% body weight) initiated within 2 weeks postoperatively, progressing to full weight-bearing as tolerated by 6–8 weeks. ● DWB group (n=60): Non-weight-bearing until radiographic evidence of bridging callus on three cortices (typically 6–8 weeks), then progressive weight-bearing. Weight-bearing status was enforced with assistive devices & physiotherapy supervision. Outcome Measures Primary outcome was functional status measured using the Lower Extremity Functional Scale (LEFS) at 3, 6, & 12 months. Secondary outcomes included time to radiographic union (defined as bridging callus on three cortices & clinical absence of pain at fracture site), time to full weight-bearing, return to work, & complications (nonunion, delayed union, malunion, implant failure, infection). Statistical Analysis Data were analyzed using SPSS v26. Continuous variables were compared using Student’s t-test or Mann–Whitney U test. Categorical data were analyzed using Chi-square or Fisher’s exact test. A p-value <0.05 was considered statistically significant.

Patient Demographics

Of 120 patients, the mean age was 38.2±12.5 years (range 18–64). Males constituted 72% of the cohort. Baseline characteristics including fracture classification, comorbidities, & mechanism of injury were similar between groups.

Table 1: Baseline Demographics & Injury Characteristics

RTA: road traffic accident; DM: diabetes mellitus; HTN: hypertension.

Functional Outcomes

LEFS scores were similar preoperatively. At 3 & 6 months, the EWB group demonstrated significantly better functional outcomes.

Table 2: LEFS Scores over time

At 12 months, both groups achieved similar functional status, though EWB trended higher.

Fracture Healing & Return to Function

The mean time to radiographic union was significantly shorter in the EWB group (14.9±3.2 weeks) compared to DWB (16.8±3.6 weeks) (p=0.04). The proportion of patients achieving union by 20 weeks was higher in EWB but did not reach statistical significance.

Table 3: Union & Functional Timelines

Complications

Overall complication rates were similar between groups. Nonunion occurred in 4 patients in EWB & 6 in DWB (p=0.51). Implant failure occurred in one patient per group. There were no deep infections.

Table 4: Complications

This prospective study of 120 patients undergoing IMN for tibial shaft fractures demonstrates that early weight-bearing (EWB) results in improved early functional outcomes, faster progression to full weight-bearing, & shorter time to radiographic union compared to delayed weight-bearing (DWB), without increasing the risk of nonunion, implant failure, or other complications[10].

Functional Recovery

Patients in the EWB group achieved significantly higher LEFS scores at 3 & 6 months, indicating quicker restoration of function. Early mobilization may promote muscle strength, proprioception, & joint range of motion, contributing to enhanced early recovery. These findings align with previous smaller studies showing functional advantages with early loading protocols after lower extremity fracture fixation[11-12].

By 12 months, functional outcomes converged between groups but remained numerically higher with EWB. Long-term function may be less influenced by early loading, whereas short-to-mid-term outcomes appear more sensitive to early rehabilitation strategies[13-14].

Fracture Healing

EWB was associated with a statistically significant reduction in time to radiographic union (mean 14.9 vs 16.8 weeks). Mechanistically, controlled weight-bearing can stimulate mechanotransduction pathways that enhance callus formation & bone remodeling.18 Although some clinicians fear that early loading may compromise fracture stability, careful progression under supervised protocols appears safe in appropriately selected patients[15].

The proportion of patients achieving union by 20 weeks was higher in EWB, though the difference was not statistically significant, perhaps due to sample size. Nonunion rates were low & comparable between groups[16].

Patients in the EWB cohort returned to work significantly earlier (mean 10.4 vs 15.2 weeks). Faster return to productivity has important implications for socioeconomic welfare, particularly in working-age populations.

Complications

The overall complication profile was similar between EWB & DWB groups. Rates of nonunion, delayed union, malunion, & implant issues did not differ significantly, suggesting that early weight-bearing, when implemented judiciously, does not increase risk.

Clinical Implications

These results support adoption of early weight-bearing protocols after IMN for tibial shaft fractures in patients without contraindications (e.g., unstable fracture patterns requiring protection, poor bone quality, or inability to comply with supervised rehabilitation). Early loading can be integrated with physiotherapy to promote faster functional recovery & earlier return to daily activities.

Limitations

Limitations include nonrandomized group allocation owing to surgeon preference, which may introduce selection bias. Weight-bearing progression was partly patient-dependent, though standardized guidance was provided. Future randomized controlled trials with blinding & objective load-monitoring tools may strengthen evidence.

Early weight-bearing following intramedullary nailing of tibial shaft fractures confers significant early functional benefits, reduces time to full weight-bearing & radiographic union, & enables earlier return to work without increasing complications. These findings support a paradigm shift toward early mobilization protocols in appropriately selected patients.

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