I was very impressed by the response to the first journal club paper. This month, I have chosen a paper that is very clinically relevant and addresses a common problem but management is often fraught with controversy. So this month's paper is:
J Bone Joint Surg Br. 2011 Oct;93(10):1362-6.
The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture.
I will pot my assessment in a few days time and would appreciate any input from you guys. Also if you would like to suggest any papers for next month, please go ahead! I would welcome input. FINALLY, I shall be putting up some posts on core training applications soon as well as more MRCS advice...
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APPRAISAL of
The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture.
This retrospective review provides evidence for employing a conservative approach in the management of ruptured tendo Achilles (rtoA) by demonstrating a favourable and acceptable re-rupture rate (2.8%) relative to previous observations. It is important, however, to recognize several important characteristics of the study where such a strategy may provide an acceptable outcome. Some of these are addressed below.
Cohort of patients: the cohort population in this study was carefully selected to include those patients where the ends of the torn tendon were well approximated on palpation in the plantar-flexed position of the foot (some of which were confirmed on ultrasound). As such, this clearly delineates the the cohort of patients most likely to benefit from employing a functional orthosis rather than those with more complex tears.
Considering the assessment of patients selected for conservative management, the primary author was the single evaluating surgeon who selected patients for management via the conservative approach. Although this provides uniformity in the method of selection (albeit clinically, which is subjective), it poses the question whether alternative outcomes may have resulted had several clinicians selected the appropriate cohort of patients for conservative management, perhaps demonstrating the variation in clinicians’ judgement.
Earlier this year, Amlang et al(1) reported a distinct means of integrating clinical and detailed sonographic evaluation to grade the rtoA; the authors demonstrated that combined grading of the rupture will direct management (non-operative or operative) more appropriately. In relation to the current study by Wallace et al, this may translate to selection of rtoA patients based on clinical and sonographic methods to determine which patients are prone to developing a poor outcome (eg. re-rupture), therefore offering an operative approach to tendon repair in selected cases.
In accompaniment with the re-rupture rate the results also indicate that patients underwent 3 months’ physiotherapy post-removal (8 weeks’ duration from “Figure 1”) of pneumatic walker in order to regain function, strength and mobility thus allowing them to return to activity (pre-injury sporting levels) and return to work. In light of this however, the reader will notice that it took approximately 5 months for the patients to acquire this outcome (it is very likely that much variation will exist between the exact duration of time required to return to pre-injury functional levels but such interpretation cannot be inferred from the data provided).
The significance of time duration raises questions concerning the impact of inactivity on patients’ lives for that duration, the economic impact of “time-off-work” for injury for the employer and society (along with its acceptability) and whether use of a more invasive (operative approach) would result in a) earlier recover and mobility of the patient, b) reduced minor and major complications (described in the study) and c) less economic burden to society.
Wallace and colleagues provide a promising approach for the non-operative management of tendo Achilles repair in this large retrospective review. An overall re-rupture rate of 2.8% in the authors’ experience will certainly challenge the orthopaedic community to further evaluate the optimal management of ruptured tendo Achilles. Nonetheless, it may become apparent that individualizing management based upon a derived and validated method of grading the rupture may be the optimal means of managing the injury that led to great Achilles' demise.
Naz
References
(1) Michael H. Amlang, Hans Zwipp, Adina Friedrich, Adam Peaden, Alfred Bunk, and Stefan Rammelt, “Ultrasonographic Classification of Achilles Tendon Ruptures as a Rationale for Individual Treatment Selection,” ISRN Orthopedics, vol. 2011, Article ID 869703, 10 pages, 2011. doi:10.5402/2011/869703
Excellent analysis! I was impressed by the large number of patients and the length of follow up (2 years). However, there are many pitfalls of this paper.
Firstly, it needed a surgical intervention group to compare the two treatment approaches (preferably a RCT). Also, I am not satisfied that they have demonstrated an objective way of selecting patients for conservative management (so perhaps like the paper you suggested, they could have radiologically classified the extent of damage and showed whether conservative management still has superior outcomes for more complex tears. Also, I think that they needed to have used a more objective measure of outcome and also broke down the extent/level of activity patients engaged in pre and post treatment.
All in all, very interesting paper and another strong argument for conservative management despite the shortcomings of the study in terms of robustness.
Amel
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