Post by beebs on Dec 11, 2012 17:06:15 GMT -5
Thread kicks off with an article comparing surgery and functional rehab.
Achilles Tendon: Nonsurgical Approach Can Match Surgery
Whether surgical or nonsurgical treatment is best for Achilles tendon rupture depends on whether patients undergo early range-of-motion functional rehabilitation, according to a meta-analysis published in the December issue of the Journal of Bone & Joint Surgery. Without that rehabilitation, according to the article, surgery reduces the risk for rerupture by 8.8% over nonsurgical treatment.
Alexandra Soroceanu, MD, MPH, from the Division of Orthaepedic Surgery, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada, and colleagues conducted a meta-analysis of randomized trials that compared surgical and nonsurgical treatment of acute Achilles tendon rupture and assessed the risk for rerupture and other outcomes.
"Surgical options include open, minimally invasive, and percutaneous repair of the tendon," according to the authors. Nonsurgical treatments include casts or special boots with the foot being placed in plantar flexion, which forces movement toward to the sole.
Among 10 trials in which treatment began within 3 weeks of the rupture, the researchers found that the absolute risk difference for rerupture between surgical and nonsurgical treatments was 5.5% in favor of surgery ( P = .002) and that the number of patients needed to treat to prevent a single rerupture was 18. The studies involved 418 surgery patients and 408 nonsurgical patients, mostly men, with a mean age of 39.8 years.
However, the researchers found considerable variation among study results on the basis of whether patients were given functional rehabilitation or were subjected to prolonged immobilization after initial treatment.
After meta-regression analysis, the researchers found that surgery and nonsurgery treatments produced almost equal results in terms of rerupture rates if patients underwent functional rehabilitation with early range-of-motion exercises (absolute risk difference, 1.7%; P = .45). For patients who remained immobile, however, surgery reduced the absolute risk for rerupture by 8.8% ( P = .001) over nonsurgical treatment, and the number needed to treat to prevent a single rerupture fell to 12 patients.
In 4 studies that reported times to return to work, patients who underwent surgery returned to work 19.16 days earlier than nonsurgical patients (95% confidence interval [CI], 3.9 - 34.0; P = .0014). However, in 9 studies reporting other complications, the researchers found that the risk difference was 15.8% ( P = .016) in favor of nonsurgical treatment. Those complications included infections, tendon necrosis, fistulas, nerve damage, and decreased ankle motion.
The researchers found no significant differences in outcomes related to calf circumference, strength, and functional outcomes.
Limitations of the analysis include the small number of studies analyzed and the lack of criteria used to determine time to return to work.
The researchers conclude, "[N]onsurgical treatment represents a reasonable treatment choice at centers that use functional rehabilitation with early range of motion since surgical repair did not decrease the rerupture rate and was associated with a higher rate of other complications.... Nevertheless, given that not all complications are major, some patients and surgeons may consider the increased rate of other complications following surgical treatment to be an acceptable trade-off for the reduced rerupture rate." www.medscape.com/viewarticle/775911?src=nldne