Proefschrift

Chapter 5 64 From a clinical point of view, the PROMETHEUS framework has been designed to be able to systematically, transparently, and falsifiably plan, implement and evaluate/measure patient-tailored allied health aftercare for surgically treated patients with fractures of the pelvis and the lower extremities, starting from the post-surgery phase and extending to the full weight bearing phase and into activities of daily living. The protocol also facilitates the systematic collection of clinically relevant data (clinimetrics) that may guide the gradual (rather than stepwise) progression of the dosage of weight bearing and therapy (based on the patient’s current clinical manifestations), as well as assessing complications or their prevention, and facilitating the setting of realistic rehabilitation aims. Initially, the patient’s characteristics, potential predictors of fracture consolidation and risks of complications are identified. During the protocolized treatment process, clinical symptoms are screened at the beginning of each therapy session, using the checklist to establish to what level weight bearing and therapy intensity may proceed. It also identifies early warning signs as to possible complications like failures of the osteosynthesis material, bone alignment problems, non-unions, or infections. Data regarding treatment aims, means used, dosage, milestones achieved at the ICF activity level, etc. are recorded systematically. The more scientifically relevant reason for developing a systematic and comprehensive protocol was the fact that, despite major improvements in surgical treatment and osteosynthesis materials, rehabilitation aftercare after surgical treatment of fractures has remained almost unchanged over the last six decades. The PROMETHEUS protocol has been developed in close cooperation between rehabilitation specialists, allied health staff and trauma surgeons. It should serve as a general reference framework and starting point for a discussion of the systematic optimization of allied health aftercare in patients with surgically treated fractures, rather than as a library of predefined standard solutions.17 It is widely assumed by surgeons that the fixation of pelvic and lower extremity fractures should not be absolutely rigid when physiological forces act on the bones during early weight bearing.18 One of the key objections to allowing early weight bearing is the possibility of fracture displacement.19 On the other hand, various authors, including those of more recent randomized controlled trials, have stated that weight bearing does not pose an undue risk of complications or produce poorer outcomes than non-weight bearing protocols.20 These two statements are contradictory and require further evaluation. To our knowledge there have been no studies on early PWB and its complications during rehabilitation from (peri)- or intra-articular fractures of the pelvis and lower extremities treated with internal fixation. Recent literature has reported composite

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