Ankle fractures of the geriatric patient: a narrative review

Optimizing medial malleolar fixation: Two bicortical screws improve stability in osteoporotic and healthy bone models

INTRODUCTION

Medial malleolar fractures are a common orthopedic injury, especially in osteoporotic bone. These fractures present unique challenges due to fragile tissues and reduced bone density, increasing the risk of fixation failure. This study aims to compare the biomechanical performance of single versus double bicortical screws in medial malleolar fractures in both healthy and osteoporotic bone.

DESIGN

Biomechanical study.

METHODS

Using fourth-generation composite Sawbones models, 32 tibias (16 osteoporotic, 16 healthy) were divided into four groups: one or two bicortical screws in either bone type. Fractures were simulated, and fixation was achieved in a lag-by-technique fashion. Specimens were subject to axial compression until failure, measuring load-to-failure and stiffness. Statistical analysis compared performance across groups.

RESULTS

Constructs with two bicortical screws demonstrated significantly higher load-to-failure in both healthy (mean: 1747 N vs. 1090 N, p = 0.02) and osteoporotic bone (mean: 935 N vs. 509 N, p = 0.01). Stiffness was also greater in two-screw constructs, though not statistically significant. We used a two-tailed t-test to compare the means of the two groups, with a p-value of <0.05, which is considered statistically significant. Osteoporotic bone exhibited lower overall performance than healthy bone, but the two-screw configuration partially mitigated these disadvantages.

CONCLUSION

Our study demonstrates that two bicortical screws provide superior biomechanical stability compared to one screw, particularly in osteoporotic bone. These findings underscore the importance of optimizing fixation strategies for osteoporotic fractures. While prior studies found minimal differences between single and double-screw constructs, our use of bicortical screws highlights their advantage in load distribution and resistance to failure. Implementing these findings in clinical practice could potentially reduce the risk of fixation failure and improve outcomes for patients with osteoporotic fractures.

The impact of surgical timing in ankle fracture on postoperative wound complications: a critical 24-hour cutoff point through systematic review and meta-analysis

BACKGROUND

Ankle fractures are among the most prevalent injuries in the general population, and the timing of surgical fixation may influence postoperative wound complications. This systematic review and meta-analysis investigated the impact of surgical timing on postoperative wound complications, specifically investigating the significance of a 24-hour cutoff point.

MATERIALS AND METHODS

The comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, Web of Science, and Cochrane databases. Research evaluating and comparing clinical outcomes following ankle fracture treatment between early versus delayed surgical fixation groups, specifically using a 24-hour cutoff point, were reviewed. Evaluated data for the meta-analysis included total wound complications: divided into major and minor wound complications, length of stay, and other complications such as fixation failure.

RESULTS

A total of eight studies were included in this systematic review and meta-analysis. In total, 1,183 patients were analyzed, with 572 in the early fixation group and 611 in the delayed fixation group. Compared to the delayed fixation group, the early fixation group significantly reduced total wound complications and length of stay, with a relative ratio of 0.37 (95% CI, 0.22 to 0.60) and - 0.88 (95% CI, -1.07 to -0.70), respectively. When analyzed as separate groups of major and minor wound complications, there was a trend showing lower rate of major and minor wound complication in the early fixation group than the delayed fixation group, but without reaching statistically significant differences.

CONCLUSIONS

Based on our review, early surgical intervention within the first 24 h may be considered to minimize the risk of postoperative wound complications and reduce the length of stay in ankle fractures.

LEVEL OF EVIDENCE

Level 3.

Open Reduction and Internal Fixation vs Primary Tibiotalocalcaneal Hindfoot Nailing for Ankle Fractures in Elderly Patients: A Systematic Review and Meta-analysis

BACKGROUND

Current literature lacks comprehensive information comparing primary tibiotalocalcaneal (TTC) hindfoot nailing and open reduction internal fixation (ORIF) in the ankle fractures in the elderly population. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of 2 surgical techniques, primary TTC nailing and ORIF, for ankle fractures in the elderly.

METHODS

Our comprehensive literature review adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and used databases including PubMed, Embase, Web of Science, and the Cochrane Library. Data investigated in this study included total infection, deep infection, superficial infection, hardware problems such as painful hardware, and hardware protrusion/pullout, nonunion/delayed union, reoperation, length of stay, and return to preoperative mobility level.

RESULTS

Total 5 studies were included in this study. In aggregate, 127 patients (42.9%) underwent TTC nailing, whereas 169/296 patients (57.1%) underwent ORIF. A lower rate of superficial infection was reported for the TTC nailing group: 2.1% (2/95) in TTC nailing vs 10.2% (14/137) in ORIF, with a relative ratio of 0.26 (95% CI, 0.08-0.85). The other outcome measures were not significantly different between groups.

CONCLUSION

Based on our review of these studies that reported mostly early follow-up data, it appears that primary TTC nailing may be a viable alternative to ORIF for ankle fracture fixation in the elderly population. However, these findings should be interpreted cautiously because of heterogeneity across the included studies.

Screw and absorbable suture tension band technique for geriatric weber type A lateral malleolus fractures

Purpose

The optimal method of internal fixation for ankle fractures in geriatric patients remains debated. This study aims to assess the efficacy of the screw and absorbable suture self-compression tension band technique in treating Weber Type A lateral malleolus fractures in geriatric patients.

Methods

Clinical data were analyzed from 31 geriatric patients with Weber Type A lateral malleolus fractures treated between March 2018 and June 2022. All patients underwent fixation with two screws combined with an absorbable suture self-compression tension band. The cohort comprised 18 males and 13 females, with a mean age of 65.6 ± 7.3 years. The study recorded operative time, intraoperative blood loss, fracture healing time, and postoperative complications. Outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) for pain, and ankle range of motion (ROM).

Results

Of the 31 patients, 30 achieved primary wound healing. Follow-up periods ranged from 12 to 36 months (mean: 19.5 months). The average operative time was 44.7 ± 13.6 min, with slightly longer times for patients with additional injuries. Fracture healing time ranged from 8 to 16 weeks (mean: 12.1 weeks), with no cases of delayed healing or non-union, and no instances of fixation loosening or failure. Postoperative complications included one cases of superficial infection, one case of numbness, one case of foreign body sensation, and one case of prolonged pain. At the final follow-up, the mean AOFAS score was 89.8 ± 6.2, with VAS scores of 0 in 18 cases, 1 in 11 cases, and 2 in 2 cases. The average ROM was 65.4° ± 4.3°, resulting in a clinical satisfaction rate of 87.1 %.

Conclusion

The use of screws combined with an absorbable suture self-compression tension band for treating Weber Type A lateral malleolus fractures in geriatric patients is straightforward, effective, and warrants broader adoption.

Distal Femoral Nail as a Cost-Effective Alternative to Tibiotalocalcaneal Nail for Ankle Fracture Non-Union in an Elderly Patient: A Case Report

Introduction

Ankle fracture non-union in elderly patients is challenging due to osteoporotic bone, comorbidities, and risks associated with open reduction and internal fixation (ORIF). Tibiotalocalcaneal (TTC) nail fixation enables early weight-bearing but is costly and not widely available in resource-limited settings.

Case Report

We present an 83-year-old male with a painful, deformed left ankle and non-union of a bimalleolar fracture treated conservatively. Comorbidities included diabetes mellitus and hypertension. Due to fragile skin and high ORIF-associated risks, a distal femoral nail (DFN) was used as a substitute for a TTC nail. A minimally invasive technique was performed, including joint preparation and medial malleolar bone grafting. Weight-bearing was initiated postoperatively.

Conclusion

DFN offered comparable fixation with reduced cost and acceptable complications. This case highlights DFN's utility as a TTC nail substitute in elderly patients, ensuring stability, early mobilization, and functional recovery in low-resource settings.

The clinical frailty scale is associated with an increased risk of postoperative complications and the development of post-traumatic osteoarthritis in elderly patients with trimalleolar ankle fractures - a retrospective study

BACKGROUND

The Clinical Frailty Scale (CFS) is a tool to assess the overall health of older adults. There are few reports of CFS and prognosis of ankle fracture. The objective of this study was to determine the predictive power of the CFS for adverse clinical and radiographic outcomes after surgery in elderly patients with trimalleolar fractures.

METHOD

All patients aged 65 and older underwent open reduction and internal fixation for trimalleolar fractures between January 2015 to January 2023 were selected. Follow-up time was at least 1 year. Patients with post-traumatic osteoarthritis, bone tumors, bone infection, and other diseases before surgery were excluded. According to the CFS score, the patients were divided into three groups: not frail, vulnerable, and frail. Multivariate logistic regression analysis was used to evaluate the effect of the clinical frailty scale on postoperative complications.

RESULT

Excluding 3 cases of death during the follow-up process, and 4 cases lost to follow-up, the study included a total of 146 patients, who were grouped based on their degree of frailty: the Healthy Group (CFS = 1-3, n = 69), the Vulnerable Group (CFS = 4, n = 50), and the Frail Group (CFS = 5-9, n = 47). In comparison with the not frail group, frail (CFS 5-9) emerged as an independent predictor of any complications (OR = 6.90, CI: 1.43-11.56, P = 0.009), adverse discharge destination (OR = 7.53, CI: 2.06-77.50, P = 0.006), and post-traumatic osteoarthritis (OR = 8.90, CI: 1.94-24.66, P = 0.003).

CONCLUSIONS

The frailty assessed by the CFS is associated with adverse discharge destination, any complications, and post-traumatic osteoarthritis in elderly patients undergoing open reduction and internal fixation for trimalleolar fractures.

Functional Outcomes After Nonoperative Management in Older Adult Low-Energy Stable and Unstable Ankle Fractures: A Retrospective Review of 158 Patients

Background

There is ongoing debate regarding the optimal management of older adult ankle fractures. The purpose of this study was to describe baseline characteristics and functional outcomes including complications in older adult patients receiving nonoperative treatment for low-energy ankle fracture and compare the outcomes of those with unstable vs stable fracture patterns.

Methods

Patients aged ≥65 from January 2012 to March 2019 that sustained an ankle fracture were identified. Those who had surgical treatment, age <65, high-energy trauma, bilateral ankle fractures, and patients without adequate follow-up (minimum 12 weeks) were excluded. Baseline demographics, injury characteristics, Charlson Comorbidity Index (CCI) score, and functioning regarding ambulatory status, living environment, and assistance personnel in the household were collected for all patients. The primary outcome of interest was retention of baseline ambulation, living environment, and assistance requirements at follow-up (>12 weeks). Pain improvement, radiographic changes, and adverse clinical events were also assessed.

Results

A total of 158 patients were included with an average follow-up timeframe of 41.6 weeks. Eighty-six percent of patients (n = 136) retained their ambulatory status at long-term follow up. Most patients retained the same living environment (n = 145, 91.8%). Thirty-five patients (22.2%) required additional assistance long-term. Approximately 67.1% of the entire cohort retained all three functional metrics. Patients who experienced functional decline were older (77.8 vs 71.6, P < 0.001), had higher CCI (3.2 vs 1.6, P < 0.001), had a diagnosis of dementia or cognitive impairment (36.5% vs 3.8%, P < 0.001), had lower baseline functional status (ambulation, living environment, and assistance required; all P < 0.001), and had an unstable fracture pattern (P = 0.003).

Conclusions

Understanding the functional outcomes of non-operative treatment in geriatric ankle fracture cases can contribute to a shared decision-making among healthcare providers, patients, and families.

Modern anatomical locking plates are associated with increased postoperative wound complications and unplanned surgical revisions compared to standard tubular plates in the management of unstable ankle fractures: a comparative cohort study in 595 patients

BACKGROUND

The clinical benefit of locking plates in distal fibula fractures has not yet been proven. In addition, the risk of wound complications appears to be higher than with conventional tubular plates. We hypothesize that the benefits of locking plates in terms of biomechanical properties are outweighed by a higher risk of wound complications.

METHODS

We conducted a retrospective review of fibula fractures treated by osteosynthesis with either a conventional one-third tubular plate or an anatomically shaped locking plate from January 1, 2015 to December 31, 2021. We recorded baseline data and relevant comorbidities and defined the need for revision surgery due to wound-related or mechanical complications as primary endpoints.

RESULTS

A total of 595 out of 727 patients were eligible for our study. Of these 595 fractures, 526 were fixed with a one-third tubular plate, 69 with a locking plate. Revision surgery was required in 54 patients, in 51 cases due to wound complications. Three patients required revision surgery for mechanical reasons and all of them were younger than 40 years of age, have not been diagnosed with osteoporosis, but experienced complex fracture types. As the third tubular plate and locking plate groups differed in terms of age and comorbidities, we performed a 2:1 matching based on age and gender, leaving data from 138 patients receiving a third tubular plate. While the two groups were comparable in many aspects, the rate of wound complications was significantly higher in the locking plate group. Although the locking plate group had a higher percentage of diabetes mellitus, there was no correlation between this comorbidity and the higher revision rate in this group.

CONCLUSIONS

Our data do not support the general use of locking plates in the treatment of distal fibular fractures. The risk of mechanical complications in osteoporotic ankle fractures seems to be overrated, as there were no mechanical revisions in the osteoporotic subgroup. The rate of wound-related revision surgery was significantly higher after the use of locking plates. This might be attributed to the greater thickness of locking plates.

Advancing fracture management: the role of minimally invasive osteosynthesis in orthopedic trauma care

PURPOSE

Minimally Invasive Osteosynthesis (MIO) developed to be a key technique in orthopedic trauma surgery, offering a less invasive alternative for managing fractures in various anatomical regions. However, standardized guidelines for its application are lacking. This study aims to establish comprehensive principles for MIO to guide surgeons in treating different types of fractures and its locations.

METHODS

A retrospective analysis including 57 fractures in 53 patients was conducted. All patients were treated with MIO. Study range - March 2017 to January 2022 at a Level-I trauma university hospital. The analysis covered various fracture types, focusing on surgical approaches, reduction techniques, plate insertion methods, and its outcomes. The efficacy and safety of MIO was evaluated by analyzing complications, fracture healing time, and necessary revision surgeries.

RESULTS

MIO is a versatile and effective fracture treatment that minimized soft tissue damage and ensured stable osteosynthetic results. Articular fractures typically used a "one way up" plate insertion technique, while non-articular fractures applied an "inside-up-and-down" approach. Low complication rates confirmed the safety and efficiency of MIO.

CONCLUSION

This research established generalized principles for MIO, offering a systematic approach that can be applied for various fracture types and its locations, by overall enhancing the surgical efficiency as well as patient recovery, without compromising outcomes.

LEVEL OF EVIDENCE

This study is classified as Level III evidence according to "The Oxford 2011 Levels of Evidence".

Evaluating Fibular Intramedullary Nails vs Traditional Plating in Geriatric Ankle Fractures: A 12-Year Single-Center Retrospective Study

BACKGROUND

This study evaluates the outcomes of fibular intramedullary nails (IMNs) compared to traditional plates and screws (PS) in the surgical treatment of unstable ankle injuries in patients aged ≥65 years.

METHOD

We conducted a retrospective study involving 32 elderly patients with unstable ankle fractures treated with IMNs from 2010 to 2022. A comparison was made with 125 case-control patients treated with PS during the same period. Outcomes compared included postoperative wound and nonwound complications, surgical reduction, union rates, implant removal rates, and the Olerud Molander Ankle Score (OMAS) at a minimum follow-up of 2 years.

RESULTS

The IMN group had a higher incidence of high-energy injuries, open fractures, concomitant surgery, and perioperative transfusion requirements than the PS group. Additionally, the IMN group developed fewer wound-related (3.1% vs 20% in the PS group, P = .043) and non-wound-related complications (18.8% vs 39.2% in the PS group, P = .030). Both groups had similar initial weightbearing restrictions, fracture union times, mean OMAS scores, rates of malunion or nonunion, and delayed implant removal times. Notably, there were significant differences in the quality and adequacy of mortise alignment between the groups (good: 53.1% in IMN group vs 79.2% in PS group, fair: 46.9% in IMN group vs 20.8% in PS group, P = .006).

CONCLUSION

Although the IMN group had an inferior outcome in the quality and adequacy of mortise reduction compared with the PS group, elderly patients with ankle fractures treated with IMN showed comparable functional outcomes to those treated with PS but with lower complication rates. Future research in this area will provide vital information for developing optimal treatment strategies, thereby improving the overall care of elderly patients with ankle fractures.

Open ankle fractures in the elderly: predisposing factors and the associated mortality

The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle fractures in the elderly population. This is a retrospective case-control study of 1,045 patients aged 65 years and older, with ankle fractures undergoing surgical fixation between 2010 and 2020 at three medical centers (Levels 1-2). A logistic regression analysis was used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality attributable to open versus closed ankle fractures. There were 128 (12.2%) patients with open ankle fractures. Patients with open ankle fractures were more likely to be older, to be active smokers (OR = 1.7, p = 0.049), and tended to have a higher number of medical comorbidities including hypertension (OR = 2, p = 0.006) and chronic kidney disease (OR = 2.9, p = 0.005). Open ankle fractures were, independently of comorbid conditions and age, associated with higher risk of mortality (HR = 1.7, p = 0.03).

Bone Fracture Healing under the Intervention of a Stretchable Ultrasound Array

Ultrasound treatment has been recognized as an effective and noninvasive approach to promote fracture healing. However, traditional rigid ultrasound probe is bulky, requiring cumbersome manual operations and inducing unfavorable side effects when functioning, which precludes the wide application of ultrasound in bone fracture healing. Here, we report a stretchable ultrasound array for bone fracture healing, which features high-performance 1-3 piezoelectric composites as transducers, stretchable multilayered serpentine metal films in a bridge-island pattern as electrical interconnects, soft elastomeric membranes as encapsulations, and polydimethylsiloxane (PDMS) with low curing agent ratio as adhesive layers. The resulting ultrasound array offers the benefits of large stretchability for easy skin integration and effective affecting region for simple skin alignment with good electromechanical performance. Experimental investigations of the stretchable ultrasound array on the delayed union model in femoral shafts of rats show that the callus growth is more active in the second week of treatment and the fracture site is completely osseous healed in the sixth week of treatment. Various bone quality indicators (e.g., bone modulus, bone mineral density, bone tissue/total tissue volume, and trabecular bone thickness) could be enhanced with the intervention of a stretchable ultrasound array. Histological and immunohistochemical examinations indicate that ultrasound promotes osteoblast differentiation, bone formation, and remodeling by promoting the expression of osteopontin (OPN) and runt-related transcription factor 2 (RUNX2). This work provides an effective tool for bone fracture healing in a simple and convenient manner and creates engineering opportunities for applying ultrasound in medical applications.

Analysis of Operated Ankle Fractures in Elderly Patients: Are They All Osteoporotic?

Background: Osteoporosis represents a global problem, which involves high risks of disability and death due to the consequences of fragility fractures. The aim of our study is to verify what type of relationship there is between ankle fractures and osteoporosis. Specifically, we aim to understand how the clinical and anamnestic characteristics of patients, along with the radiographic features of these fractures, may contribute to considering them as osteoporotic fractures. Methods: The study group includes 51 consecutive patients aged 60 years or older operated for ankle fracture from May to October 2022. The fractures were divided into uni-, bi-, or trimalleolar based on the plain X-rays. All patients underwent femoral and vertebral bone mineralometry by DXA associated with the FRAX questionnaire. Results: Ankle fractures in the elderly were associated with reduced BMD (76.5% of the total patients examined, 83.8% considering only women) and low-energy traumas (82%). Furthermore, these fractures present features of increased complexity as bone mass decreases. Conclusions: Ankle fractures in the elderly exhibit characteristics that suggest a relationship with bone fragility. For these reasons, it might be advisable to initiate a comprehensive fracture risk assessment in elderly patients who experience an ankle fracture. These fractures should not be underrated, and antiresorptive therapy must always be taken into consideration when selecting patients at risk.

[Effectiveness comparison of a new hook-shaped anatomical locking plate and conventional anatomical locking plate in treatment of Danis-Weber type A lateral malleolus fractures]

Objective

To investigate the effectiveness of a new hook-shaped anatomical locking plate in the treatment of Danis-Weber type A lateral malleolus fractures.

Methods

A retrospective analysis was performed on the clinical data of 45 patients with Danis-Weber type A lateral malleolus fractures who met the selection criteria between November 2020 and November 2022. According to the surgical methods, they were divided into the observation group (treated with the new hook-shaped anatomical locking plate, 23 cases) and the control group (treated with the conventional lateral malleolus anatomical locking plate, 22 cases). There was no significant difference in baseline data such as gender, age, cause of injury, Danis-Weber type of fracture, time from injury to operation, and combined ligament injury between the two groups ( P>0.05). The operation time, partial weight-bearing time, return to work time, and postoperative complications were recorded and compared between the two groups. The function and pain of ankle joint were evaluated by the range of motion of ankle dorsiflexion, plantarflexion, varus, valgus, and visual analogue scale (VAS) score at 1 and 3 months after operation, and at last follow-up, and the American Orthopaedic Foot and Ankle Society (AOFAS) score at 3 months after operation and at last follow-up.

Results

All patients were followed up 10-18 months (mean, 15.1 months). There was no significant difference in operation time between the two groups ( P>0.05); the postoperative partial weight-bearing time and return to work time of the observation group were significantly earlier than those of the control group ( P<0.05). During the follow-up, there was 1 case of joint stiffness in the observation group, and 1 case of joint surface displacement, 1 case of joint stiffness, and 1 case of traumatic arthritis in the control group. There was no significant difference in the incidences of complications between the two groups ( P>0.05). With the extension of time after operation, the range of motion of ankle dorsiflexion, plantarflexion, varus, valgus, and VAS score of the two groups gradually improved, and there were significant differences between different time points ( P<0.05); At 1 and 3 months after operation, the above indexes in the observation group were significantly better than those in the control group ( P<0.05), and there was no significant difference between the two groups at last follow-up ( P>0.05). The difference of AOFAS score between the last follow-up and 3 months after operation in the observation group was significantly better than that in the control group ( P<0.05).

Conclusion

Compared with the conventional lateral malleolus anatomical locking plate, the new hook-shaped anatomical locking plate has a more reliable fixation effect in the treatment of Danis-Weber type A lateral malleolus fracture, which is conducive to early functional exercise of the ankle joint, so that patients can bear weight earlier and return to work earlier, and the operation time is not significantly prolonged, and the effectiveness is satisfactory.

The role of Ottawa ankle rules in geriatric emergency department visits

BACKGROUND

Ankle injuries are a common reason for visits to the emergency department (ED). An effective diagnosis and treatment process is crucial for the swift recovery of patients and for alleviating congestion in EDs. This study aims to evaluate the adequacy and effectiveness of the Ottawa Ankle Rules (OAR) in geriatric patients presenting to the emergency department (ED).

METHODS

Between February 2022 and November 2022, 160 patients aged 65 and older (118 women, 42 men) who presented to the ED with isolated ankle injuries were included in the study. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the OAR.

RESULTS

The study found fractures in 37.5% of patients. The sensitivity of the OAR was 98.33%, the specificity was 86%, the negative predictive value was 98.85%, and the positive predictive value was 80.82%.

CONCLUSION

This study demonstrates that the OAR is highly sensitive in the geriatric population but shows some limitations in terms of specificity and positive predictive value. These results support the effectiveness of using the OAR in evaluating ankle injuries in the geriatric population but also highlight the need for cautious application due to the potential for false-positive outcomes.

Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures

PURPOSE OF REVIEW

The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities.

RECENT FINDINGS

There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.