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

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

Sep 26, 2022 159 likes •578 views

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

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Mark Glazebrook

MSc., PhD, MD, FRCS(C), Dip Sports Med

Associate Professor Dalhousie University Queen Elizabeth II health sciences Center Halifax, Nova Scotia

Dalhosie University Halifax Nova Scotia

Pro: Read the Literature: Nonoperative Treatment is the Way to Go! Mark Glazebrook MD PhD

4:02 PM Panel: 50-Year-Pld Tennis Player Lunges to Return Serve: The Dreaded Pop Panel Moderator: Richard Ferkel, MD.

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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)

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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.

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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.

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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 %

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Why do we operate?

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Achilles Rupture: Primary Operative Treatment

What is the Cost & Benefit of Getting the Sutures across the Rupture Site?

SUTURES ARE GOOD ! Resist Aggressive or reckless Rehab Especially weeks 2-12

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Achilles Rupture: Primary Operative Treatment

What is the Cost & Benefit of Getting the Sutures across the Rupture Site?

SUTURES ARE GOOD ! They will allow Aggressive Re Especially weeks 2-12 Is the Dissection & Blood Supply Stripping Worth it ??? Complications Higher ~ 3 x Higher for OR

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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)

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Achilles Tendon Rupture: How do we treat this?

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Hierarchy of Evidence

Randomized Trials Prospective Cohort Studies Retrospective Case Series Case Control Studies Opinion

Level 1 Level 2 Level 3 Level 4 Level 5

Meta-Analysis

Less Bias More Bias

Slide Provided by Mohit Bhandari

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SLIDE 12

MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Hierarchy of Evidence

Randomized Trials Prospective Cohort Studies Retrospective Case Series Case Control Studies Opinion

Level 1 Level 2 Level 3 Level 4 Level 5

Meta-Analysis

Less Bias More Bias

Slide Provided by Mohit Bhandari

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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

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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

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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

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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.)

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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)

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SLIDE 18

ACHILLES AOFAS SPORTS

  • DR. MARK GLAZEBROOK – 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)

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MARK GLAZEBROOK MSc, PhD MD – 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

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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

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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.
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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results – All Studies Included

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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%

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results – Patient Characteristics

2010 2007 1997 1995 Studies WITH Functional Rehabilitation

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Results – Patient Characteristics

2010 2007 1997 1995 Studies WITH Functional Rehabilitation

Op vs. Non OP (WITH Functional Rehabilitation*) No Difference in: 1. Re Rupture 2. Strength 3. Calf size 4. Function Lower complication rates for Non op Rx 15%

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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!!!!

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Gap in Knowledge:

Why are many surgeons apposed to Non operative Treatment???

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Gap in Knowledge:

Why are many surgeons apposed to Non operative Treatment???

Surgeons worry about the Gap…. Willets et al Ignored the Gap!!

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

“Gap” in Knowledge

Reported as 6 CM Gap!!!

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

“Gap” in Knowledge

Reported as 6 CM Gap!!!

MRI OR Finding Next Day MRI OR Finding Next Day

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

What about the Gap?

Prospective study on the clinical outcomes of patients with Non-operative treatment for tendo-achilles ruptures using functional rehabilitation treatment: Closing the “GAP” of knowledge by assessing importance of the Achilles rupture trauma zone Sam C. Roberts, MBChB, FRCSEd (Tr&Orth) 1, Patricia Francis, RN 2, Daniella Rubinger3, Nicole Hughes, MD 4, Gordon Boyd, MD 4, Michael Mitchell 4 MD, Diana Young MD2 Mark A. Glazebrook, MD2.

Submitted for Consideration for Publication JBJS….

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

“Gap” study Results Demographics (N= 68)

Gender Male 54 Female 14 Average age 42.8 (range 17-72) Mechanism of injury Sport 53 Fall from standing height 5 Ascending stairs 3 Gym 1 Lifting/pushing heavy object 2 Dancing 1 Jumping 1 Car detailing 1 Walking 1 Achilles Rupture Trauma Zone length 28.7 mm (range 4.75-90.75mm)

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

“Gap” study Results Demographics

Gender Male 54 Female 14 Average age 42.8 (range 17-72) Mechanism of injury Sport 53 Fall from standing height 5 Ascending stairs 3 Gym 1 Lifting/pushing heavy object 2 Dancing 1 Jumping 1 Car detailing 1 Walking 1 Achilles Rupture Trauma Zone length 28.7 mm (range 4.75-90.75mm)

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

“Gap” study Results

Table 6 – Achilles Rupture Trauma Zone Length Correlations Age Single limb heel raise percentage ATRS SF36 PCS SF36 MCS Achilles Rupture Trauma Zone length Correlation Coefficient

  • 0.071

0.026 0.212 0.202

  • 0.115
  • Significance. (2-

tailed) 0.565 0.835 0.082 0.099 0.351 N 68 68 68 68 68

There was no Correlation with Gap Size and: Strength Function Quality of Life

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

“Gap” study Results

  • 67 patients (1 yaer FU)
  • No loss to follow up
  • Average Gap Size 40mm (range 0. 475 cm – 9.75 cm)

No Correlation betw een Gap size and Clinical Outcome

Table 4 – Patient Demographics

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

“Gap” in Knowledge

  • Is the term “Gap” is a misnomer?
  • We Prefer “Trauma Zone”
  • GAP in Know ledge!!!
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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

MY Approach

  • Patient Eligible for Non Operative If :

– Non Wt. Bearing Plantar flexed cast within 24 hrs – Compliance Likely – Patient Chooses non op after lengthen discussion of Pros & Cons.

  • I tell Patients:

– Suture is GOOD for resisting lengthening with careless or Overzealous Physio – Operative good for Athletes who want to get back to competition weeks not months earlier – Risk of Complications higher in Op but likely minor

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Non-operative treatment for

Achilles Tendon Ruptures

Summary

  • EBM Suggests :
  • Non Operative Treatment w ith FUNCTIONAL REHABALITATION

works. Grade A Support (Level I Studies w ith consistent finding FOR intervention)

  • Complications are higher w ith Operative treatment
  • All patients need to be Informed to consent for Treatment
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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

Non-operative treatment for

Achilles Tendon Ruptures

Summary

Need to CLOSE THE “GAP” IN KNOWLEDGE!!! And Get Into the Trauma Zone…. Let The Patient Choose!!!

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MARK GLAZEBROOK MSc, PhD MD – Dalhousie Orthopaedics, CDHA, IWK, DGH

DalOrtho.ca

Thank You!