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clinical or functional significance (31). The participants
in 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 1
year after the start of early weight-bearing was insigni-
ficant –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
post-operative 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, stimu-
lating the biological processes that enhance fracture
consolidation and minimizing the effects of immobi-
lization (4, 8), both over- and under-loading 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 ex-
ample, Braun et al. used for their study a continuously
measuring pedobarography insole to measure weight-
bearing in trauma patients with fractures of the lower
extremities. The study showed that, despite physical
therapy training, weight-bearing compliance to recom-
mended limits was low (36). Overall, despite their wil-
lingness 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 up-
per boundary of the therapeutic bandwidth, yet safe
enough to avoid overloading, and this treatment is a
key component of our PROMETHEUS protocol.
The lack of evidence on aftercare protocols and on
permissive weight-bearing was the reason for desig-
ning the PROMETHEUS protocol. In this study a
description of a comprehensive protocol for permissive
weight-bearing has been presented, together with data
on both time to full weight-bearing and the number
of complications in patients with surgically treated
fractures of the pelvis and lower extremities. This
pilot study is quintessential for estimating the sample
size in future prospective trials and for gaining insight
into the heterogeneity that exists within and between
www.medicaljournals.se/jrm
different kind of fractures of the lower extremity with
regard to time to full weight-bearing and number of
complications. However, limitations of the current
study include the retrospective nature of the study
and, due to this retrospection, not taking into account
surgeon-oriented functional outcome scores (e.g. knee
function) or generic patient satisfaction scores. Further-
more, no radiological controls have been performed
to investigate the alignment of the fractures and the
fracture healing. Another limitation of the study is the
lack of monitoring patient compliance.
To mitigate the aforementioned limitations, and to
determine whether a PWB protocol results in more
favourable process outcomes and patient outcomes,
requires further research to establish the added value
in terms of effectiveness and cost-effectiveness. To that
aim, we have started a prospective cohort study with a
control group, also including patient-reported outcome
measures to cover the appropriate ICF levels (37).
Conclusion
The PROMETHEUS protocol is a patient-tailored
permissive weight-bearing protocol. Given the low
complication rate, the protocol might be beneficial to
implement in the treatment of trauma patients with
surgically treated articular or (peri)- or intra-articular
fractures of the pelvis and lower extremities.
The authors have no conflicts of interest to declare.
REFERENCES
1. AO Foundation. 2014. Available from: www.aofounda-
tion.org.
2. Ruedi TP, Buckley RE, Moran CG. AO principles of fracture
management. Third edition. New York. Thieme; 2018.
3. Gray FB, Gray C, McClanahan JW. Assessing the accuracy
of partial weight-bearing instruction. Am J Orthop (Belle
Mead NJ) 1998; 27: 558–560.
4. Hurkmans HL, Bussmann JB, Selles RW, Benda E, Stam HJ,
Verhaar JA. The difference between actual and prescribed
weight bearing of total hip patients with a trochanteric
osteotomy: long-term vertical force measurements inside
and outside the hospital. Arch Phys Med Rehabil 2007;
88: 200–206.
5. Tveit M, Kärrholm J. Low effectiveness of prescribed
partial weight bearing. Continuous recording of vertical
loads using a new pressure-sensitive insole. J Rehabil
Med 2001; 33: 42–46.
6. Muller ME, Allgower M, Schneider R, Willenegger H. Manual
of internal fixation techniques. Berlin: Springer; 1977.
7. Wheeless CR. Wheeless’ textbook of orthopaedics. Dur-
ham, NC: Duke University Medical Center’s Division of
Orthopaedic Surgery, and Data Trace Internet Publishing;
2014. Available from: http://www.wheelessonline.com.
8. de Morree JJ. Dynamiek van het menselijk bindweefsel.
[Dynamics of human connective tissue.] Houten, The
Netherlands: Bohn Stafleu van Loghum; 2009.
9. Magee DJ, Zachazewski JE, Quillen WS. Scientific founda-
tions and principles of practice in musculoskeletal rehabi-
litation. St Louis: Saunders Elsevier; 2007.