Proefschrift

Chapter 6 78 During normal daily activities the knee joint experiences forces between 220% and 350% of a person’s body weight. As even a 3-mm step-off in the tibial plateau can ŝŶĐƌĞĂƐĞ ƚŚĞ ĐĂƌƚŝůĂŐĞ ĐŽŶƚĂĐƚ ƐƚƌĞƐƐĞƐ ďLJ ϳϱй͕ ĐŽŶĐĞƌŶƐ ĂƌĞ ƌĂŝƐĞĚ ƚŚĂƚ ůŽƐƐ ŽĨ reduction could lead to worse patient outcomes, even in case of non-weight bearing.Ϯϰ On the other hand, it is often stated that early weight bearing does not pose an undue risk of complications or worse patient outcomes compared to a non-weight bearing protocol, as reported in a recent randomized controlled trial dealing with fractures of the ankle joint.25 These two statements are contradictory and require further elaboration. Our study adds evidence in favor of regimens with earlier than standard postoperative weight bearing protocols and shows that there is no significant difference in quality of life, pain or complications compared to RWB. One of the key objections against early weight bearing is the possibility of fracture displacement.26 In one radiostereometric study at one year after early weight bearing of fractures of the tibial plateau, the mean craniocaudal migration of the fracture fragments was -Ϭ͘ϯϰ ŵŵ ;-ϭ͘ϲϰ to 1.51).Ϯϳ This case series has shown that, in the Schatzker type II fractures investigated, internal fixation with subchondral screws and a buttress plate provided adequate stability to allow immediate post-operative partial weight-bearing, without harmful consequences. Longer term outcomes have as well been described in the literature, with more favorable results for PWB. In a prospective, multicenter randomized trial involving ďŝĐŽŶĚLJůĂƌ ƚŝďŝĂů ƉůĂƚĞĂƵ ĨƌĂĐƚƵƌĞƐ͕ Ă ŐƌŽƵƉ ŽĨ ϰϯ ƉĂƚŝĞŶƚƐ ƵŶĚĞƌǁĞŶƚ ĨŝdžĂƚion with external ring fixation and were permitted to bear full weight, while a group of ϰϬ patients underwent open reduction and internal fixation with restricted weight bearing.8 At a minimum 2-year follow-up, there was no difference in reoperations, articular incongruity, or development of radiographic signs of osteoarthritis between the two groups. In line with this study, our study found that there were no significant differences in pain or reoperations (removal of osteosynthesis material or implants of total knee prostheses). Interestingly, removal of osteosynthesis material in the PWB ŐƌŽƵƉ ǁĂƐ ůŽǁĞƌ ƚŚĂŶ ŝŶ Zt ŐƌŽƵƉ͕ ŝ͘Ğ͘ ϮϮ͘ϲй ǀĞƌƐƵƐ ϰϬ͘Ϭй͕ ƌĞƐƉĞĐƚŝǀĞůLJ͘ According to recent literature, a composite postoperative complication rate of up ƚŽ Ϯϳй ŚĂƐ been reported in tibial plateau fractures.ϳ-ϭϰ Comparing our complication data with data published in recent literature, we found decreased rates of postoperative complication in tibial plateau fractures treated by means of a PWB protocol, despite the fact that more severe fractures were found in our PWB ƉŽƉƵůĂƚŝŽŶ͘ dŚĞ ůĂƚƚĞƌ ĐŽƵůĚ ďĞ ĂŶ ĞdžƉůĂŶĂƚŝŽŶ ĨŽƌ ƚŚĞ ĨĂĐƚ ƚŚĂƚ ƚŚĞ ŽƚŚĞƌ ϰϭ͘ϵй ŽĨ ƚŚĞ PWB population did not reach full weight bearing within 12 weeks, which might be due to a high comorbidity rate of our PWB population. Nevertheless, the average time to full weight bearing was significantly lower in the PWB group than the RWB group.

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