Proefschrift

Chapter 7 94 and our study provides evidence in favor of regimes with early weight bearing instead of the standard non-weight-bearing protocols. According to recent literature, a composite postoperative complications rate of up to 27% has been found in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities.7-11 Comparison of our complication rates with data published in recent literature shows that we found lower rates of postoperative complication in these patients when they were treated with the PWB regimen. Over- and under-loading may lead to prolonged and complicated recovery.2 A certain minimum level of loading is required to elicit micro-movements between adjacent bony fracture components, stimulating biological processes that are converted into cellular signals initiating bone remodeling.27,30 This process is described in the literature as the mechanotransduction in bone. Mechanotransduction is continuously present and enables the bone to resist the mechanical impacts caused by daily activities.30 To optimize recovery with the lowest number of complications and better patients’ self-perceived outcome levels, one should apply a treatment that approaches the upper limit of the therapeutic bandwidth regarding weight bearing, yet is safe enough to avoid complications due to overloading. This is the case with the PWB protocol.2 Our study, the first large-scale prospective multicenter cohort study comparing PWB with RWB, adds evidence in support of the use of PWB in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities. This means that our study contests the paradigm of the current RWB guidelines, which have remained unchanged for 60 years. The time has now come to renew the current guidelines in accordance with the most recent evidence. When interpreting our data, some limitations have to be considered. Due to practical reasons, this study featured a non-randomized groups design. However, patients were included to the PWB and RWB groups consecutively to avoid selection bias. There were differences regarding the patients’ comorbidities and the different hospitals in which the patients were treated. Our statistical analyses took these issues into consideration, thus correcting the presented results for the confounding influence that these factors may have had on the study results. Surgeon-oriented functional outcome scores (e.g., the function of a knee or ankle joint) were not taken into account. No radiological assessment was used to assess the alignment of the fractures. Further data are needed on the cost-effectiveness, radiological assessment, and longterm patient-reported outcome of the PWB strategy.

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