Proefschrift

General discussion 125 In the Netherlands we have found that even when choosing the time period of restricted weight bearing after surgically treated tibial plateau fractures, the vast majority of the responding orthopedic and trauma surgeons deviated from their own institutional guidelines and AO-guidelines, based on their own clinical experience and gut feeling and based on the prevailing currents trends. Although not all surgeons may be aware of these current guidelines, more likely, the surgeons act on their own clinical experience when choosing the aftercare trajectory. A study by Thewlis et al.19 demonstrated that postoperative permissive weight bearing is safe, with no radiographic fracture reduction and migration in any patient after 52 weeks. Nevertheless, other key endpoints such as Activities of Daily Living and complications such as non-union, avascular necrosis, infection, but also quality of life outcomes and cost-effectiveness have not been comprehensively presented in the literature to our knowledge at the time of commencement of the individual studies reported in this thesis. Therefore, the aim of this thesis was to further study the use and effectiveness of permissive weight bearing in comparison to the currently adopted restricted weight bearing regimens.20 Our hypothesis was that the permissive weight bearing protocol is beneficial and has potential to be implemented in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities.20 In our research we were able to present a permissive weight bearing aftercare protocol which could serve as a general reference framework and a starting point for discussion on the systematic optimization of allied health aftercare in surgically treated patients with fractures of the lower extremities, rather than as a library of predefined standard solutions (‘cookbook’). In the studies that followed, all major 'International Classification of Functioning, Disability and Health' (ICF) domains have been addressed when comparing permissive weight bearing with restricted weight bearing. Back to back with the publication of the permissive weight bearing aftercare protocol the first experience in 150 surgically treated trauma patients with peri- and/or intra-articular fractures of the pelvis and lower extremities with this aftercare protocol was presented in this thesis. This pilot study found that 52% of the patients with surgically stabilized (peri)- or intra-articular fractures using a PWB regime according to the in-house PROMETHEUS aftercare protocol were able to walk with full weight bearing within 12 weeks, indicating a mean shortening of 4 weeks compared to the current non-weight bearing guidelines. The total complication rate with permissive weight bearing was 10.0%, which were lower compared to current non-weight bearing guidelins.21

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