Journal of Rehabilitation Medicine 51-4inkOmslag | Page 61

Permissive weight-bearing in surgically treated fractures
Table IV. Number of fractures and types of complications
Pelvic/ acetabular
fractures ( n  =  76) Distal femur
fractures ( n  =  42) Tibial plateau
( n  =  31) Distal tibia/ankle Foot fractures
fractures ( n  =  31) ( n  =  21) Total complications, n 3 7 3 1 1 15
% per no. fractures, (%) (3.9) (16.7) (6.5) (3.2) (4.8) (7.5)
(4.7) (1.3) (0.7) (0.7) (10.0)
% per no. (n  = 150) patients, (%) (2.0)
Type of complication, n
295
Total no. fractures
( n  =  201)
Non-union 1 3 1 0 0 5
Infection 2 1 1 0 0 4
Removal OSM 0 0 1 1 1 3
Avascular necrosis 0 1 0 0 0 1
Periprosthetic fracture 0 1 0 0 0 1
Implant failure 0 1 0 0 0 1
No.: number of.
DISCUSSION
This pilot study found that 52% of the patients with
surgically stabilized (peri)- or intra-articular fractu-
res using a PWB regime according to our in-house
PROMETHEUS protocol were able to walk with full
weight-bearing within 12 weeks, indicating a mean
shortening of 4 weeks compared with the current
AO guidelines (2). The total complication rate with
permissive weight-bearing was 10.0%. The fact that
approximately half of the patients in our study did not
reach full weight-bearing within 12 weeks might be
due to hospitalization delay and the high comorbidity
rate in our sample.
From a clinical point of view, the PROMETHEUS
framework has been designed to be able to systema-
tically, 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 faci-
litating the setting of realistic rehabilitation aims. Ini-
tially, 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, such as 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 deve-
loping a systematic and comprehensive protocol was
the fact that, despite major improvements in surgical
treatment and osteosynthesis materials, rehabilita-
tion aftercare after surgical treatment of fractures has
remained almost unchanged over the last 6 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 al-
lied 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 2 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 postoperative com-
plication 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
J Rehabil Med 51, 2019