Three-month results of the effect of Ultrapro or Prolene mesh on post-operative pain and well-being following endoscopic totally extraperitoneal hernia repair (TULP trial).

BACKGROUND: Recurrence rates after inguinal hernia repair have been reduced to a few per cent, since mesh repair has become standard of care. Lightweight meshes reduce post-operative pain and stiffness in open anterior repair, but for endoscopic repair, the discussion about this benefit is ongoing. This study was done to analyse the effects of lightweight mesh versus heavyweight mesh following endoscopic totally extraperitoneal (TEP) hernia repair. METHODS: In a single-centre double-blindly randomized clinical trial, 950 patients with unilateral primary inguinal hernia were randomized to undergo endoscopic TEP using either an Ultrapro(®) or a Prolene(®) mesh. Data were collected by validated questionnaires at day 1, day 7, after 6 weeks and after 3 months, and clinical assessment was performed after 3 months. The presence of groin pain after 3 months, defined as an NRS score >3, was evaluated as the primary outcome measure. Secondary outcomes were foreign body feeling and the impact of pain and foreign body feeling on daily activities. RESULTS: At 3-month follow-up, the incidence of pain (NRS 4-10) was 2 versus 0.9 % in the lightweight and heavyweight mesh group, respectively (p = 0.17). Pain interfered with daily activities in 1.7 % of the lightweight and 1.5 % of heavyweight group. In the lightweight group, 20 % of patients reported a foreign body feeling versus 18 % in the heavyweight group (p = 0.62). No differences between the groups were observed regarding time to return to work, interference with sports and sexual activities, testicular pain and ejaculatory pain. Severe preoperative pain (OR 2.01, 95 % CI 1.21-3.35, p = 0.01) was the only independent predictor of any post-operative pain after 3 months. CONCLUSION: Three months after TEP inguinal repair, there were no significant differences between lightweight and heavyweight mesh use regarding the incidence of pain, foreign body feeling or any other endpoint.

The natural course of chronic exertional compartment syndrome of the lower leg.

PURPOSE: The aim of this study was to investigate the natural course of chronic exertional compartment syndrome (CECS) in the lower leg. METHODS: Twelve military men [mean age 30 (SD 4)] diagnosed with CECS after intracompartmental pressure (ICP) measurements immediately post-exercise in 21 legs, who did not undergo a fasciotomy, were reviewed and participated in a repeat pressure measurement after a mean time of 50 months (SD 15). RESULTS: Sixteen of 21 legs still showed an ICP of 35 mm Hg or more (the cut-off point) at the second visit. All twelve patients still had typical complaints. Mean ICP at index measurement was 58 (SD 15) mm Hg. At the second visit, it was 51 (SD 15) mm Hg. Six patients chose to undergo a subcutaneous fasciotomy, and these six patients all benefited in the short term. CONCLUSION: The natural course of CECS seems to be persistent symptoms over time. LEVEL OF EVIDENCE: Case series with no comparative group, Level IV.

Is there an end of the "learning curve" of endoscopic totally extraperitoneal (TEP) hernia repair?

BACKGROUND: An important challenge of totally extraperitoneal (TEP) hernia repair is the learning curve. The European guidelines suggest that the learning curve ranges between 50 and 100 procedures, with the first 30-50 being critical. Others suggest that optimal outcomes are achieved after 200 or more TEP procedures. METHODS: All TEP repairs performed between 2005 and 2009 were included in this study. The effect of (surgeon) expertise on perioperative complications, conversion to open anterior repair, and operative time was assessed to evaluate the extent of the learning curve of TEP repair. RESULTS: Intraoperative complications occurred in <1 % of the 3,432 patients and postoperative complications were observed in 243 (7 %) patients. With a median follow-up of 2 years after TEP, 19 patients (0.55 %) had a recurrence. During the study period, at the end of which all four surgeons had treated 900-1,000 patients, intraoperative complications and recurrences did not decline. On the other hand, the median operative time decreased from 30 to 20 min (p < 0.001). The conversion rate (1.6-0.2 %, p = 0.018) and postoperative complication rate (11.6-4.2 %, p < 0.001) also declined. The decline was observed for all four surgeons, irrespective of their initial expertise with TEP. The largest decrease in the conversion rate was seen after at least 250 TEP procedures; the postoperative complication rate and operative time showed a linear and significant decline throughout the study period. A more or less "steady state" was observed after approximately 450 procedures per surgeon. CONCLUSIONS: Even after more than 400 individually performed TEP procedures, there is progress in reducing the conversion rate, the incidence of short-term postoperative complications, and operative time, indicating a rather long learning curve.

Feasibility of a smartphone application for inguinal hernia care: a prospective pilot study.

The Inguinal Hernia Application (IHAPP) is designed to overcome current limitations of regular follow-up after inguinal hernia surgery. It has two goals: Minimizing unnecessary healthcare consumption by supplying patient information and facilitating registration of patient-reported outcome measures (PROMs) by offering simple questionnaires. In this study we evaluated the usability and validity of the app. Patients (≥18 years) scheduled for elective hernia repair were assessed for eligibility. Feasibility of the app was evaluated by measuring patient satisfaction about utilization. Validity (internal consistency and convergent validity) was tested by comparing answers in the app to the scores of the standardized EuraHS-Quality of Life instrument. Furthermore, test-retest reliability was analyzed correlating scores obtained at 6 weeks to outcomes after 44 days (6 weeks and 2 days). During a 3-month period, a total of 100 patients were included. Median age was 56 years and 98% were male. Most respondents (68%) valued the application as a supplementary tool to their treatment. The pre-operative information was reported as useful by 77% and the app was regarded user-friendly by 71%. Patient adherence was mediocre, 47% completed all questionnaires during follow-up. Reliability of the app was considered excellent (α > 0.90) and convergent validity was significant (p = 0.01). The same applies to test-retest reliability (p = 0.01). Our results demonstrate the IHAPP is a useful tool for reliable data registration and serves as patient information platform. However, further improvements are necessary to increase patient compliance in recording PROMs.

Athletes treated for inguinal-related groin pain by endoscopic totally extraperitoneal (TEP) repair: long-term benefits of a prospective cohort.

PURPOSE: Inguinal-related groin pain (IRGP) in athletes is a multifactorial condition, posing a therapeutic challenge. If conservative treatment fails, totally extraperitoneal (TEP) repair is effective in pain relief. Because there are only few long-term follow-up results available, this study was designed to evaluate effectiveness of TEP repair in IRGP-patients years after the initial procedure. METHODS: Patients enrolled in the original, prospective cohort study (TEP-ID-study) were subjected to two telephone questionnaires. The TEP-ID-study demonstrated favorable outcomes after TEP repair for IRGP-patients after a median follow-up of 19 months. The questionnaires in the current study assessed different aspects, including, but not limited to pain, recurrence, new groin-related symptoms and physical functioning measured by the Copenhagen Hip and Groin Outcome Score (HAGOS). The primary outcome was pain during exercise on the numeric rating scale (NRS) at very long-term follow-up. RESULTS: Out of 32 male participants in the TEP-ID-study, 28 patients (88%) were available with a median follow-up of 83 months (range: 69-95). Seventy-five percent of athletes were pain free during exercise (p < 0.001). At 83 months follow-up, a median NRS of 0 was observed during exercise (IQR 0-2), which was significantly lower compared to earlier scores (p <0.01). Ten patients (36%) mentioned subjective recurrence of complaints, however, physical functioning improved on all HAGOS subscales (p <0.05). CONCLUSION: This study demonstrates the safety and effectivity of TEP repair in a prospective cohort of IRGP-athletes, for whom conservative treatment had failed, with a follow-up period of over 80 months.

Impairment of sexual activity before and after endoscopic totally extraperitoneal (TEP) hernia repair.

BACKGROUND: In patients with inguinal hernias, sexual activity may be impaired due to hernia-related pain. Surgical repair may improve these complaints but can also lead to similar symptoms as a long-term complication of the operation. Endoscopic hernia repair is associated with less postoperative pain and earlier return to normal activities, but its effect on pain-related sexual function is unknown. In this study, the incidence and effect of pain related to sexual activity are evaluated before and after endoscopic totally extraperitoneal (TEP) hernia repair. METHODS: A hospital-based questionnaire study of pain-related sexual dysfunction was conducted in November 2009 in 500 male patients ≥18 years, who underwent TEP repair of a primary hernia between March 2006 and December 2008. The response rate was 77.2%. RESULTS: Pain of any severity during sexual activity was reported by 124 patients (32.1%) preoperatively and 35 patients (9.1%) postoperatively. Only 2.3% of the 262 patients with no history of preoperative pain experienced moderate to severe (VAS 4-10) pain postoperatively. Pain impaired sexual function in 63 patients (16.3%) preoperatively and in 18 patients (4.7%) postoperatively. The majority of patients who reported pain during sexual activity preoperatively (n = 102, 82.3%) had no pain postoperatively. The frequency of moderate to severe painful sexual activity decreased from 21.2% (preoperatively) to 3.4% after TEP repair (P < 0.001), and the frequency of moderate to severely impaired sexual function decreased from 6.0 to 1.0% (P < 0.001). The preoperative presence of pain during sexual activity and chronic non-hernia-related pain syndromes were predictive for the occurrence of postoperative pain. CONCLUSION: Painful sexual activity, present in one third of patients with inguinal hernias, improved in the majority of patients following TEP hernia repair. Postoperatively, moderate to severe painful sexual activity occurred in 2.3% of the patients with no history of preoperative complaints.

[Bone growth stimulators for fractures; sensible or not?] / Botgroeistimulatoren bij fracturen.

More and more patients with fractures are asking for bone growth stimulators. There are currently 2 types of bone growth stimulators on the market: stimulators using pulsed electromagnetic fields (PEMF) and stimulators using low-intensity pulsed ultrasound (LIPUS). There is insufficient evidence that LIPUS bone growth stimulator treatment is useful in patients with fresh fractures; the effects of LIPUS bone growth stimulation for delayed-union and non-union fractures need more in-depth investigation. There is also insufficient evidence that PEMF bone growth stimulation has beneficial effects on the healing of fresh fractures and delayed-union and non-union fractures. We do not recommend routine use of bone growth stimulators, partly because of the significant costs involved.

Value and patient appreciation of follow-up after endoscopic totally extraperitoneal (TEP) inguinal hernia repair.

PURPOSE: There is some consensus on inguinal hernia surgery follow-up in research settings. However, consensus on regular follow-up is lacking. Therefore, patients and surgeons are unnecessarily burdened and not cost-efficient. Moreover, the purpose of follow-up is barely questioned. This study aims to evaluate follow-up after inguinal hernia repair and determine patient satisfaction. METHODS: This prospective cohort study was executed in a high-volume specialized hernia clinic. All totally extraperitoneal (TEP) repair patients between July and October 2016 were included. Telephone follow-up was performed at 1 day, 6 weeks and 1 year postoperatively. One year postoperatively it was assessed whether patients visited other healthcare organizations, had remaining inguinal complaints, a Post-INguinal-repair-Questionnaire by telephone (PINQ-PHONE) was executed, and appreciation with follow-up was determined. RESULTS: Respectively, 6 weeks and 1 year postoperatively, 138 (79.3%) and 130 (74.7%) of 174 included patients were reached. One year postoperatively 15 patients (11.5%) had remaining inguinal complaints, of which only four patients (3.1%) had not already reported their symptoms. Nineteen patients (14.6%) presented with self-reported complaints between 6 weeks and 1 year, and no patients went to other hospitals. Respectively, 107 (82.3%), 61 (46.9%) and 117 (90.0%) patients considered follow-up useful at 6 weeks, 1 year and in general. One hundred nineteen patients (91.5%) preferred telephone follow-up to outpatient clinic appointments. CONCLUSION: TEP patients value a telephone follow-up time-point, however, long-term follow-up is not considered useful. Patients report postoperative complaints themselves, therefore performing follow-up serves no clinical purpose. The purpose of follow-up is patient satisfaction and registration for quality objectives.

Recurrence after totally extraperitoneal (TEP) inguinal hernia repair: the role of physical examination and ultrasound.

PURPOSE: Physical examination (PE) combined with ultrasound (US) is recommended to confirm a recurrent hernia. However, the evidence is rather weak. The aim of this study was to evaluate PE and appraise the added value of US in alleged recurrent inguinal hernias after totally extraperitoneal (TEP) inguinal hernia repair. METHODS: All adult patients who were re-operated for suspicion of a recurrent hernia after a primary unilateral or bilateral TEP between 2006 and 2017 were identified and investigated retrospectively. Patient characteristics, PE, additional imaging and intra-operative findings were registered. PE outcomes were compared with intra-operative findings to calculate the positive predictive value (PPV) of PE. In case of clinical doubt, the added value of US was evaluated by comparing US findings with the intra-operative findings. RESULTS: A total of 130 patients were re-operated for suspicion of 137 recurrent hernias. In 75 patients, US was performed. PE was positive for an inguinal hernia in 101 groins (73.7%), negative in 30 (21.9%) and inconclusive in 6 (4.4%). PE matched the operative findings in 75.2%. The PPV of diagnosing a recurrent hernia (or lipoma) on PE was 97%. In case of clinical doubt (n = 36), positive US matched the operative findings in 20 cases (87.0%). CONCLUSION: US does not necessarily need to be incorporated in the standard diagnostic workup of a recurrent inguinal hernia. After PE alone, a recurrent hernia (or lipoma) can be diagnosed with a PPV of 97%. Only in case of clinical doubt, US has additional value.

[A man with a painful shoulder and numb hand]. / Een man met een pijnlijke schouder en gevoelloze hand.

A 57-year-old man suffered from an anterior luxation of the left shoulder with a dislocated fracture of the greater humeral tubercle after a fall. His left hand was cold, numb and no arterial pulsations could be detected. After shoulder reposition, the hand became warmer and the numbness disappeared. The next morning, pulsations of the hand were absent again. CT angiography showed a dissection of the axillary artery with thrombosis.

Is young age a risk factor for chronic postoperative inguinal pain after endoscopic totally extraperitoneal (TEP) repair?

PURPOSE: A generally known risk factor for developing chronic postoperative inguinal pain after inguinal hernia repair is young age. However, studies discussing young age as a risk factor are mainly based on open repairs. The aim of this study was to determine if young adults (age 18-30) are also more prone to experience chronic postoperative inguinal pain after totally extraperitoneal (TEP) inguinal hernia repair, compared to older adults (age ≥ 31). METHODS: A prospective study was conducted in a high-volume TEP hernia clinic in 919 patients. Patients were assessed using the Numeric (Pain) Rating Scale, Inguinal Pain Questionnaire and Carolina Comfort Scale preoperatively, at 3 months, 1 year and 2 years after TEP mesh repair. The primary outcome was clinically relevant pain in young adults compared to older adults at 3 months follow-up. Secondary outcomes were pain 1 and 2 years postoperatively, the impact of pain on daily living, foreign body feeling and testicular pain. Furthermore, age categories were analyzed to determine potential age-dependent risk factors. RESULTS: Follow-up was completed in 867 patients. No significant difference was found between young adults and older adults for clinically relevant pain at 3 months follow-up (p = 0.723). At all follow-up time points, no significant differences were found for clinically relevant pain, any pain, mean pain scores, the Inguinal Pain Questionnaire and the Carolina Comfort Scale. The subgroup analyses showed no age-dependent risk factor. CONCLUSIONS: Young age is not associated with a higher risk of chronic postoperative inguinal pain after endoscopic TEP hernia repair.

An 11-year analysis of reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high volume hernia center.

BACKGROUND: Developments in inguinal hernia surgery have substantially lowered recurrence rates, yet recurrences remain an important outcome parameter of inguinal hernia repair. The aim of this study was to analyze the characteristics of all reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high-volume hernia clinic in the Netherlands. METHODS: All groins with recurrence-like symptoms reoperated after previous TEP inguinal hernia repair between January 2006 and December 2016 were analyzed. Patient characteristics, imaging findings, primary hernia type, time to recurrence and recurrence type were assessed. RESULTS: A total of 137 groins were reoperated in 130 patients. The median age at the TEP procedure was 55 years [interquartile range (IQR) 45-64 years]. Fifty-seven groins were initially part of a bilateral procedure (42%). Median time until recurrence was 9 months (IQR 4-26 months). Reoperation findings were a hernia recurrence in 76%, an isolated lipoma in 18%, and no recurrence or lipoma in 6%. The majority of hernias recurred at their initial site (70%), of which the greatest part involved direct hernias. Isolated lipomas were more frequently seen after indirect hernia repair. CONCLUSIONS: Inguinal hernia recurrences were still observed in this high-volume hernia clinic. Recurrences were most frequently seen at their initial hernia site, the majority involving direct hernias. Isolated lipomas presenting as a pseudorecurrence were most frequently seen after correction of indirect hernias. In accordance with the current guidelines, reducing recurrence rates can be achieved by mesh fixation in bilateral, large and direct defects and by thoroughly reducing lipomas.

[Inguinal hernia repair: bringing order to variety]. / Liesbreukchirurgie: orde in verscheidenheid.

- With around 30,000 interventions a year, correction of an inguinal hernia is one of the most commonly performed surgeries in the Netherlands. One would therefore expect the same technique to be used all over the world by now. There are nevertheless different procedures, depending on a patient's age and history, the type of inguinal hernia and the expertise of the surgeon.- When the pathophysiology of an inguinal hernia became clear at the end of the 19th century, Bassini laid the foundation of modern inguinal hernia surgery: reinforcing the posterior wall of the inguinal canal after repositioning the hernial sac with its contents.- Although current surgical treatment still follows this principle, there are now many different techniques for this. Some are named after the 'inventor' of such an operation (Shouldice, Lichtenstein and Stoppa) while others are indicated with an abbreviation (TEP, TAPP, TIPP and TREPP).- In this review article, we describe the surgical techniques currently most common in the Netherlands and bring order to the chaos of proper names and abbreviations.

Differentiation in an inclusive trauma system: allocation of lower extremity fractures.

Background: Implementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system. Methods: This is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands. Results: One thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1 = 417; L2 = 859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (> 1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2). Conclusion: The majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care.

End cap versus no end cap in intramedullary nailing for displaced midshaft clavicle fractures: influence on implant-related irritation.

PURPOSE: Implant-related irritation at the entry site is a known disadvantage of intramedullary nailing for clavicle fractures. The purpose of this study was to compare implant-related irritation rates of intramedullary nailing with or without an end cap for displaced midshaft clavicle fractures. METHODS: Two cohorts of patients treated with intramedullary nailing with or without an end cap were matched and compared. Primary outcome was patient-reported implant-related irritation. Secondary outcome parameters were complications. RESULTS: A total of 34 patients with an end cap were matched with 68 patients without an end cap. There was no difference in implant-related irritation (41 versus 53%, P = 0.26). Significantly more minor revisions were observed in the group without an end cap (15 versus 0%, P = 0.03). For complications requiring major revision surgery, significantly more implant failures were observed in the end cap group (12 versus 2%, P = 0.04). Regardless of their treatment, patients with complex fractures (AO/OTA B2-B3) reported significantly more medial irritation compared to patients with simple fractures (AO/OTA B1)(P = 0.02). CONCLUSION: The use of an end cap after intramedullary nailing for displaced midshaft clavicle fractures did not result in lower patient-reported irritation rates. Although less minor revisions were observed, more major revisions were reported in the end cap group. Based on the results of this study, no end caps should be used after intramedullary nailing for displaced midshaft clavicle fractures. However, careful selection of simple fractures might be effective in reducing implant-related problems after intramedullary nailing.

Predicting suitability of intramedullary fixation for displaced midshaft clavicle fractures.

PURPOSE: Implant-related irritation is a technique-specific complication seen in a substantial number of patients treated with intramedullary nailing for clavicle fractures. The purpose of this study was to identify predictors for developing implant-related irritation in patients with displaced midshaft clavicle fractures treated with elastic stable intramedullary nailing. METHODS: A retrospective analysis of the surgical database in two level 2 trauma centers was performed. Patients who underwent intramedullary nailing for displaced midshaft clavicle fractures between 2005 and 2012 in the first hospital were included. Age, gender, fracture comminution and fracture location were assessed as possible predictors for developing irritation using multivariate logistic regression analysis. These predictors were externally validated using data of patients treated in another hospital. RESULTS: Eighty-one patients were included in initial analysis. In the multivariate analysis, comminuted fractures in comparison to non-comminuted fractures (72 vs. 38%, p = 0.027) and fracture location (p < 0.001) were significantly associated with the development of implant-related irritation. In particular, lateral diaphyseal fractures caused irritation compared to fractures on the medial side of the cut-off point (88 vs. 26%). External validation of these predictors in 48 additional patients treated in another hospital showed a similar predictive value of the model and a good fit. CONCLUSION: Comminuted and lateral diaphyseal fractures were found to be statistically significant and independent predictors for developing implant-related irritation. We, therefore, believe that intramedullary nailing might not be suitable for these types of fractures. Future studies are needed to determine whether alternative surgical techniques or implants would be more suitable for these specific types of fractures.

Athletes with inguinal disruption benefit from endoscopic totally extraperitoneal (TEP) repair.

PURPOSE: Inguinal disruption, a common condition in athletes, is a diagnostic and therapeutic challenge. The aim of this study was to evaluate the effect of endoscopic totally extraperitoneal (TEP) repair in athletes with inguinal disruption, selected through a multidisciplinary, systematic work-up. METHODS: An observational, prospective cohort study was conducted in 32 athletes with inguinal disruption. Athletes were assessed by a sports medicine physician, radiologist and hernia surgeon and underwent subsequent endoscopic TEP repair with placement of polypropylene mesh. The primary outcome was pain reduction during exercise on the numeric rating scale (NRS) 3 months postoperatively. Secondary outcomes were sports resumption, physical functioning and long-term pain intensity. Patients were assessed preoperatively, 3 months postoperatively and after a median follow-up of 19 months. RESULTS: Follow-up was completed in 30 patients (94%). The median pain score decreased from 8 [interquartile range (IQR) 7-8] preoperatively to 2 (IQR 0-5) 3 months postoperatively (p < 0.001). At long-term follow-up, the median pain score was 0 (IQR 0-3) (p < 0.001). At 3 months, 60% of patients were able to complete a full training and match. The median intensity of sport was 50% (IQR 20-70) preoperatively, 95% (IQR 70-100) 3 months postoperatively (p < 0.001), and 100% (IQR 90-100) at long-term follow-up (p < 0.001). The median frequency of sport was 4 (IQR 3-5) times per week before development of symptoms and 3 (IQR 3-4) times per week 3 months postoperatively (p = 0.025). Three months postoperatively, improvement was shown on all physical functioning subscales. CONCLUSIONS: Athletes with inguinal disruption, selected through a multidisciplinary, systematic work-up, benefit from TEP repair.

[Serious foot injury: consider partial amputation designed to preserve leg-length and a weight-bearing stump]. / Ernstig letsel van de voet: overweeg partiële amputatie op maat met behoud van beenlengte en een eindbelastbare stomp.

Three patients with physically demanding jobs, a 25-year-old farmer, a 22-year-old market trader and a 32-year-old house painter, each suffered a traumatic injury of one foot. All three underwent amputation in which part of their foot was salvaged and were able to return to their physically demanding jobs. The first patient underwent a Syme's amputation, the second a Pirogoff's amputation and the third a Chopart's amputation. A partial amputation of the foot has several advantages: patients are able to walk without walking aids, particularly in and around the house, due to the presence of a direct weight-bearing stump. With a prosthesis patients may be able to resume their physically demanding jobs, there are fewer problems of functional restraint of the knee and phantom pain is rare. Although these amputations can be technically demanding, an amputation at this level in young as well as older patients with an adequate blood supply to the hind foot is worthwhile and to be recommended for several reasons.

[Earlier weight-bearing mobilisation after fracture fixation]. / Eerder belast mobiliseren na fractuurfixatie.

Almost all the literature dictates a period of non-weight-bearing after surgical treatment of articular and peri-articular fractures of the pelvis and lower extremities. This is followed by partial weight-bearing which is based on the number of weeks after surgery. However, none of these recommendations are based on evidence. When taking muscle force and gravity into account, non-weight-bearing is actually impossible. In addition, lack of patient compliance, lack of muscle force in the elderly and four-fold energy expenditure make it almost impossible to ensure that patients will adhere to their surgeon's restrictions. Based on our experiences in a large cohort of patients with fractures of the pelvis and lower extremities, we see no drawbacks in permissive weight-bearing and early recovery in most cases. We strongly believe that most patients are able to listen to their body and understand body awareness, while the creation of a safe environment makes more personalised follow-up treatment possible.