Pro: Read the Literature: Nonoperative Treatment is the Way to Go! - PowerPoint PPT Presentation

Dalhosie University Halifax Nova Scotia Mark Glazebrook MSc., PhD, MD, FRCS(C), Dip Sports Med Associate Professor Dalhousie University Queen Elizabeth II health sciences Center Halifax, Nova Scotia 4:02 PM Panel: 50-Year-Pld Tennis Player Lunges to Return Serve: The Dreaded Pop Panel Moderator: Richard Ferkel, MD. Pro: Read the Literature: Nonoperative Treatment is the Way to Go! Mark Glazebrook MD PhD MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Mark Glazebrook Disclosure Statement Mark Glazebrook has received something of value in the past 1 year ( ≥ $500.00) or served as a Journal review er from a commercial company or institution related directly or indirectly to the subject of this presentation, as noted below. a = research/institutional support, b = misc. non-income support, c = royalties, d = stock/options, e = consultant/employee f = Journal review er NAME: DISCLOSURE: COMPANY/SOURCE: 1. Glazebrook e Stryker 2. Glazebrook e Wright 3. Glazebrook a,e Ferring Inc. 4. Glazebrook a,e Cartiva Inc 5. Glazebrook f Foot & Ankle International 6. Glazebrook f JBJS(A) 7. Glazebrook f The Bone & Joint Journal 8. Glazebrook f CORR 9. Glazebrook Past BOD Member AOFAS 10. Glazebrook President Elect/BOD Canadian Orthopedics Association (COA) MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Achilles Tendon Rupture: THE PROBLEM Catastrophic event: Achilles Tendon Rupture Consequences: Pain, Inability to bear w eight, Weakness Time aw ay from work and limited athletic activity. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Achilles Tendon Rupture: THE PROBLEM Catastrophic event: Achilles Tendon Rupture Consequences: Pain, Inability to bear w eight, Weakness Time aw ay from work and limited athletic activity. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Diagnostic Imaging • Ultrasound is useful MRI is the gold standard • • Rupture Site: – Myotendinous junction in 12.1 % – Insertion in 4.6 % – Midsubstance 83 % • MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Why do we operate? MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Achilles Rupture: Primary Operative Treatment SUTURES ARE GOOD ! What is the Cost & Benefit of Getting the Sutures across the Rupture Site? Resist Aggressive or reckless Rehab Especially weeks 2-12 MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Achilles Rupture: Primary Operative Treatment SUTURES ARE GOOD ! What is the Cost & Benefit of Getting the Sutures across the Rupture Site? Is the Dissection & Blood Supply Stripping Worth it ??? They will allow Aggressive Re Especially weeks 2-12 Complications Higher ~ 3 x Higher for OR MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Serious Complications Less Frequent but real!! Complication Operative Group (13) Non operative Group (6) Re rupture 2 3 Deep venous thrombosis 1 1 Pain (substantial) 1 Failure to heal (palpable gap) 1 Achilles tendon tethered to skin 1 Hypertrophic scar 1 Superficial infection 4 Deep infection 1 Pulmonary embolus 1 Wound complication 2 (small opening in skin) MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Achilles Tendon Rupture: How do we treat this? MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Hierarchy of Evidence Meta-Analysis Randomized Trials Less Bias Level 1 Prospective Cohort Studies Level 2 Case Control Studies Level 3 Retrospective Case Series Level 4 Opinion Level 5 More Bias Slide Provided by Mohit Bhandari MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Hierarchy of Evidence Meta-Analysis Randomized Trials Less Bias Level 1 Prospective Cohort Studies Level 2 Case Control Studies Level 3 Retrospective Case Series Level 4 Opinion Level 5 More Bias Slide Provided by Mohit Bhandari MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

The Best RCT Achilles Rupture Treatment (True Level I Study) Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation Kevin Willits, MA, MD, FRCSC, Annunziato Amendola, MD, FRCSC, Dianne Bryant, MSc, PhD, Nicholas G. Mohtadi, MD, MSc, FRCSC, J. Robert Giffin, MD, FRCSC, Peter Fowler, MD, FRCSC, Crystal O. Kean, MSc, PhD, and Alexandra Kirkley, MD, MSc, FRCSC THE JOURNAL OF BONE & JOINT SURGERY (A) VOLUME 92-A NUMBER 17 DECEMBER 1, 2010 Investigation performed at the Fowler Kennedy Sport Medicine Clinic, London, Ontario, and the University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results - Demographics • RCT LEVEL I (144 pts 72 Operative and 72 Non Operative) • All patients an accelerated rehabilitation protocol Characteristics Operative Nonoperative (N = 72) (N = 72) Males : females 59:13 59:13 Mean age* (yr) 39.7 ± 11.0 41.1 ± 8.0 Height* (cm) 177.8 ± 13.6 177.3 ± 10.3 Weight* (kg) 88.4 ± 14.2 88.2 ± 17.6 MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results Primary outcome: • NO Significant Difference in Re rupture: – Operative 2 of 72 – Non Operative 3 of 72 MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results Secondary outcome: • NO Difference: Isokinetic strength Clinical Outcome (Leppilahti score) Range of motion Calf circumference (3, 6, 12, 24 mos.) MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results - Complications Complication Operative Group (13) Non operative Group (6) Re rupture 2 3 Deep venous thrombosis 1 1 Pain (substantial) 1 Failure to heal (palpable gap) 1 Achilles tendon tethered to skin 1 Hypertrophic scar 1 Superficial infection 4 Deep infection 1 Pulmonary embolus 1 Wound complication 2 (small opening in skin) MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Serious Complications Less Frequent but real!! Complication Operative Group (13) Non operative Group (6) Re rupture 2 3 Deep venous thrombosis 1 1 Pain (substantial) 1 Failure to heal (palpable gap) 1 Achilles tendon tethered to skin 1 Hypertrophic scar 1 Superficial infection 4 Deep infection 1 Pulmonary embolus 1 Wound complication 2 (small opening in skin) ACHILLES AOFAS SPORTS DR. MARK GLAZEBROOK – Dalhousie Orthopaedics, CDHA, IWK, DGH

CONCLUSION Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation Kevin Willits, MA, MD, FRCSC, Annunziato Amendola, MD, FRCSC, Dianne Bryant, MSc, PhD, Nicholas G. Mohtadi, MD, MSc, FRCSC, J. Robert Giffin, MD, FRCSC, Peter Fowler, MD, FRCSC, Crystal O. Kean, MSc, PhD, and Alexandra Kirkley, MD, MSc, FRCSC JBJS 2010 Conclusion: This study provides Level I Support: 1. Accelerated functional rehabilitation and Non operative treatment for Achilles tendon ruptures. 2. Application of a nonoperative protocol w ill avoid complications MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Most Recent Meta Analysis Operative vs Non-Operative Treatment of Achilles Tendon Ruptures, a Meta-Analysis of Randomized Controlled Trials Alex Soroceanu MD CM MPH, Feroze Sidhwa B.Sc, Shahram Aarabi MD MPH, Annette Kauffman PhD MPH, Mark Glazebrook MD PhD MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Inclusion – Exclusion Criteria • Inclusion criteria : Randomized studies (Level I or II ) Achilles tendon rupture, • comparing surgical intervention Non operative treatment • Exclusion criteria : • • Non-randomized studies, • delayed presentation (beyond three w eeks), • re-ruptures, • duplicate data w as excluded. MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results – All Studies Included MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results – All Studies Included Op vs. Non OP ( NO Functional Rehabilitation) Non op had : 1. Increase Re Rupture 2. Decreased Strength Lower complication rates for Non op Rx 15% MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results – Patient Characteristics Studies WITH Functional Rehabilitation 2010 2007 1997 1995 MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results – Patient Characteristics Studies WITH Functional Rehabilitation Op vs. Non OP (WITH Functional Rehabilitation*) 2010 2007 No Difference in: 1. Re Rupture 2. Strength 1997 3. Calf size 1995 4. Function Lower complication rates for Non op Rx 15% MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

EBM Achilles Rupture RX • Best RCT says: Non-op = Op • Most Recent Meta Analysis Non-op = Op Operative Increased Complications!!!! MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Gap in Knowledge: Why are many surgeons apposed to Non operative Treatment??? MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH