Proefschrift

Chapter 9 124 One could argue that if a patient is physically and mentally ready to safely bear weight on the affected leg/side, and given that improvend motion is beneficial for bone healing, why should we clinicians slow down the weight bearing process by prohibiting the patient to gradually increase weight bearing at a faster yet safe pace sooner? 9 A number of disadvantages of restricted weight bearing are known.10 First and foremost bed rest and wearing a cast are associated with an evident and timedependent reduction in bone and muscle mass, atrophy of tendons as well as vascular disturbances and skin changes. In near to zero gravity situations such as a six month journey to the International Space Station (ISS) will render nearly 10% loss in skeletal mass in a healthy astronaut, which will take years to recover. These numbers are close to those seen in long term immobilized limbs. Other main disadvantages associated with prolonged immobilization and bed rest are cardiovascular effects, especially in the elderly, such as reduced plasma volume, increased venous compliance and reduced cardiac output. Despite the willingness to comply, patients often do not follow the restrictions in weight bearing and advance their weight bearing as fracture healing progresses. In the elderly population there is a higher incidence of postoperative delirium and a significant prevalence of cognitive impairment, leading to the question of how well this patient population can follow instructions, restricting their rehabilitation. In one study a postoperative compliance rate to a non- or partial weight bearing regimen of up to 37.5% was found. Moreover, most patients were not able to adhere to the loading limitation protocol, even a few days after surgery and even if the patients were trained by a physiotherapist, based upon cognitive impairments.11 Moreover, according to a recent systematic review12 only a few rehabilitation protocols aimed at surgically treated trauma patients with peri-and intra-articular fractures of the lower extremities have been found in the literature, often lacking information about the exact therapeutic strategy and scientific evidence on which the content of described rehabilitation programmes were based. In view of this lack of evidence, many orthopaedic and trauma surgeons tend to advise conservatively in regards to weight bearing in rehabilitation, and hold on to the prevailing dogmas, i.e. recommending time-contingent progression of weight bearing, while physiotherapists and rehabilitation physicians had the tendency to follow a more progressive approach towards fracture weight bearing. Besides, even with specific advice from specialists, as previously mentioned patients may not always be committed to complying with nonweight bearing advice.13,14 Furthermore, the lack of individual feedback on the actual weight bearing status causes great differences in weight bearing when the patient is advised restricted weight bearing.14-16 These circumstances give rise to a wide range of weight bearing patterns and inconsistent aftercare treatment.17, 18

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