Weight-Bearing and Mobilisation after Hip Fracture Surgery in Older Adults: A Mixed-Methods Exploration of Practices and Experiences within Saudi Arabia

Abstract

Abstract Background Hip fractures in older adults are a growing global health issue, with incidence increasing as populations age. Clinical guidelines recommend unrestricted weight-bearing and early mobilisation to improve outcomes. The extent to which these practices vary globally is unknown, as are barriers and facilitators to their implementation. Moreover, clinicians’, patients’, and carers’ perspectives on these practices are largely unexplored, particularly in non-Western contexts. Understanding how these evidence-based practices are delivered and experienced is essential to address unwarranted variation from guideline recommendations.

Aims This thesis aimed to develop a practice-relevant understanding of postoperative weight-bearing and mobilisation after hip fracture surgery in Saudi Arabia, situated in relation to reported international practice.

Methods This thesis used a mixed-methods design within a Thesis Incorporating Publications format. Four independent studies were undertaken: (1) A scoping review of published and unpublished sources, synthesising barriers and facilitators to weight-bearing into patient, process (surgical and non-surgical), and structural categories. (2) An international cross-sectional survey using a self-administered questionnaire distributed to multidisciplinary healthcare clinicians via professional organisations (e.g., Fragility Fracture Network), social media, and snowball sampling. (3) Qualitative semi-structured interviews with clinicians (orthopaedic surgeons and physiotherapists) from government hospitals in Saudi Arabia. (4) Qualitative semi-structured interviews with patients who received care in the Saudi Arabian healthcare system and/or their carers. The integration of the findings occurred at the interpretation level in the discussion chapter through narrative weaving.

Results The scoping review (n=69 studies) identified 47 barriers and facilitators grouped into patient-, process-, and structure-related barriers/facilitators. Barriers included pre- and postoperative delirium, systemic sepsis, and structural constraints such as staffing shortages, whereas facilitators included early surgery, multidisciplinary care, and intramedullary fixation. The international cross-sectional study (n=389) showed that most respondents were orthopaedic surgeons (36.1%) or physical therapists (30.3%), worked in acute teaching hospitals (60.2%), followed by acute non-teaching hospitals (13.9%). Unrestricted weight-bearing was prescribed by 73.5% overall and was more common in high-income countries (86.3%) than low- and middle-income countries (41%). Early mobilisation was prescribed by 72.5% overall and was more common in high-income countries (79.1%) than low- and middle-income countries (56.3%). Overall, 50.4% reported achieving unrestricted weight-bearing 76-100% of the time, and 38.3% reported achieving early mobilisation 76-100% of the time. Structural barriers were reported more frequently in low- and middle-income countries, highlighting global disparities in implementation. The qualitative interviews with clinicians (n=20) showed strong support for unrestricted weight-bearing and early mobilisation. However, implementation varied and was influenced by surgery type, local protocols, and clinician training. Interdisciplinary collaboration was deemed essential, and patient and family buy-in was identified as crucial due to fear of injury affecting adherence. Clinicians also highlighted the lack of standardised protocols and the need for routine audits to improve practices and outcomes. The qualitative interviews with patients and carers (n=25) found that participants valued unrestricted weight-bearing and early mobilisation if prescribed by clinicians. Their experiences highlighted inconsistencies in clinical instructions and understanding, with implementation influenced by communication clarity, perceptions of safety, and physical or psychological conditions. Carers identified falls as barriers to mobilisation and supported the process by encouraging patients, adapting instructions, and ensuring continuity of care. Integrated findings across the four studies developed a practice-relevant understanding of postoperative weight-bearing and mobilisation after hip fracture surgery in Saudi Arabia, interpreted in relation to reported international practice. Five interpretive intersections were identified: terminology, protocols, professional roles and autonomy, structural conditions, and carer involvement, with communication playing an important role in how postoperative instructions were explained, understood, and implemented in practice.

Conclusion This thesis demonstrates that despite guideline endorsement, unrestricted weight-bearing and early mobilisation after hip fracture surgery are inconsistently implemented, shaped by systemic, organisational, and relational factors rather than clinical considerations alone. Integrating international perspectives with in-depth insights from Saudi Arabia highlights the influence of local conventions, professional hierarchies, and the critical yet under-recognised role of informal carers. Addressing these challenges requires shared terminology, standardised protocols, interdisciplinary collaboration, and structured support for carers. These findings advance understanding of implementation barriers and inform strategies to embed best practices into routine care globally. This thesis contributes to the field by moving beyond identifying variation to exploring its underlying causes and offering practical strategies for improvement.