Proefschrift

A protocol for permissive weight bearing during allied health therapy in pelvic and the lower extremities fractures 65 postoperative complication rates of up to 37% (range 0.7%-37%).21-30 A comparison of our complication data with published data based on applying the current guidelines shows comparable rates of complication for all our groups treated with the PWB protocol.21-30 To our knowledge, no study has found any difference in fracture displacement or healing between early and late weight bearing regimes using radio-isometric analysis. One study of ankle fractures did find a small (0.4 mm) widening of the talar mortise, but this had no clinical or functional significance.31 The participants of the study had stable, anatomically adequate fixation of the distal fibula and/or medial malleolus prior to being included in the trials. Recent studies on early weight bearing of surgically treated fractures of the ankle joint showed good outcome and even a lower rate of plate removal.31,32 In one radiostereometric study with fractures of the tibial plateau, the mean cranio-caudal migration of the fracture fragments at one year after the start of early weight bearing was insignificantly -0.34 mm (-1.64 to 1.51).33 This case series showed that in the Schatzker type II fractures that were investigated, internal fixation with subchondral screws and a buttress plate provided enough stability to allow postoperative permissive weight bearing, without harmful consequences.33 While a certain minimum level of loading is required to elicit micro-movements between adjacent bony fracture components, stimulating the biological processes that enhance fracture consolidation and minimizing the effects of immobilization,4,8 both over- and underloading may lead to prolonged and complicated recovery. While instructions for rehabilitation given to patients may be clear, patient compliance with a non-weight bearing or limited weight bearing regime has been found to be poor.34,35 A number of studies found that patients had actually exceeded the prescribed amount of partial weight bearing even though their self-reported compliance was high.35,36 For example, Braun et al used for their study a continuously measuring pedobarography insole to measure the weight bearing in trauma patient with fractures of the lower extremities. The study showed that, despite physical therapy training, weight-bearing compliance to recommended limits was low.36 Overall, despite their willingness to comply, patients often do not adhere to the suggested restrictions on weight bearing and increase their weight bearing as fracture healing progresses. To optimize recovery with a minimal complication rate, we recommend a treatment that is near the upper boundary of the therapeutic bandwidth, yet safe enough to avoid overloading, and this treatment is a key component of our PROMETHEUS protocol.

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