The fact that 12 of the 16 AAOS clinical practice guidelines for treating Achilles tendon ruptures are supported by “weak” or “inconclusive” evidence makes the recent JBJS Reviews article by Guss et al. on this subject all the more welcome.
The most emphatic point made by these authors is that functional rehabilitation protocols with early motion (and an associated shift away from long-term post-injury immobilization) have made a dent in the re-rupture rates historically seen with nonoperative treatment of Achilles tendon injuries, the incidence of which has increased in recent decades. The authors emphasize, however, that the delicate balance between loading and unloading of a healing Achilles tendon remains a rehabilitative challenge, and they encourage further research to identify which patients are more or less likely to experience success with nonoperative management.
The authors note also that the focus of outcomes research of different management methods has shifted from rates of re-rupture and infection to more specific functional measures—and, in some cases, to direct and indirect cost measures. For example, Guss et al. cite one meta-analysis that found that operatively treated patients returned to work almost three weeks earlier than those treated nonoperatively.
The authors also observe that the rate of deep vein thrombosis after Achilles rupture seems to be higher than that seen in other foot/ankle conditions, but they add that the majority of those thrombotic events are “unlikely to be clinically important.” Still, Guss et al. conclude that “prophylactic anticoagulation should be considered for older patients with an Achilles tendon rupture, including those treated nonsurgically.”
Two interesting investigations into lumbar spinal stenosis (LSS) appeared in the general medical literature recently.
—A registry-based observational study of nearly 900 patients in the BMJ found that microdecompression techniques were as effective as open laminectomy in improving disability scores 12 months after surgery. The two techniques yielded similar quality-of-life scores at the one-year point, but the microdecompression patients had shorter hospital stays.
—In Annals of Internal Medicine, a multisite randomized study of 170 patients 50 or older with lumbar spinal stenosis found that those receiving surgical decompression and those receiving physical therapy (2 PT visits per week for six weeks focused on lumbar flexion and general conditioning) had essentially the same functional outcomes at time points ranging from 10 weeks to two years after enrollment. However, 57% of patients assigned to PT crossed over to surgery—some due to high copays for physical therapy, said study co-author Anthony Delitto, PT. In an editorial accompanying the study, JBJS Deputy Editor for Methodology and Biostatistics Jeffrey Katz, MD, concluded, “Because long-term outcomes are similar for both treatments yet short-term risks differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS.”
Fluoroquinolone antibiotics do a great job fighting a broad spectrum of bacteria that cause many respiratory, urogenital, gastrointestinal, and bone and joint infections. However, in 2008, the FDA issued a “black-box warning” about the increased risk of tendinopathies in people taking these drugs, especially those older than 60.
Although rare, when fluoroquinolone-induced tendon ruptures occur, they involve the Achilles tendon 95% of the time. But in the April 8, 2015 edition of JBJS Case Connector, DeWolf et al. describe the case of an 81-year-old man whose sudden inability to extend the metacarpophalangeal joint of his ring finger occurred within one week after he started taking the fluoroquinolone ciprofloxacin for an ear infection.
In the OR, surgeons identified and debrided a ruptured extensor digitorum communis (EDC) tendon and attached it to the EDC of the adjacent middle finger. They found no bony protrusions or synovitis that could have caused tendon erosion, and cultures for bacterial and fungal infections came back negative. Those negative findings, combined with the patient’s medication history and lack of other risk factors such as gout or rheumatoid arthritis, led the authors to postulate with some certainty that ciprofloxacin was the etiological culprit.
DeWolf et al. remind orthopaedists that for general tendinopathy, “the mainstays of treatment include rest, physical therapy, and discontinuation of [any] offending medication.” Ruptured tendons are usually addressed surgically. Although the authors do not report having taken ultrasound images of this patient, they note that “ultrasound provides an inexpensive way to confirm that a tendon has been ruptured and also whether it is a partial or complete rupture.”
Many orthopaedists and primary care clinicians recommend acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line approach for patients with osteoarthritis (OA) or back pain. However, two recent studies call into question how well these pharmacological approaches actually work.
A study employing a new-user design and data from the Osteoarthritis Initiative concluded that short-term use of prescription NSAIDs (such as naproxen, celecoxib, and meloxicam) had no clinical effect in more than 1,800 patients with radiographically confirmed knee osteoarthritis. Long-term use (defined as NSAID use reported at three consecutive annual assessments) was associated with clinically important but not statistically significant improvements in stiffness and function (per WOMAC scales), but not pain. Notably, the rate of NSAID use at all three annual assessments was very low, and the authors concluded that the common discontinuation of NSAID use suggested in this study “call[s] for further understanding of the extent to which potential side effects [of NSAIDs] can be mitigated with gastroprotective agents.”
A meta-analysis of acetaminophen’s effectiveness (13 randomized trials with a total of 5,366 patients) found that the medication did not improve pain, disability, or quality of life for back-pain sufferers, and that its pain-relieving effects in people with knee or hip OA were statistically but not clinically significant. These findings led an editorialist commenting on the meta-analysis to conclude that “the time has come to shift our attention away from tablets as the default option for managing chronic musculoskeletal pain.” As alternatives, he recommended topical NSAIDs, physical therapy, and better coaching on patient self-management. The editorialist also emphasized that these findings should not prompt clinicians to increase prescriptions for opioids.
The April 1, 2015 JBJS features a level II prognostic study that analyzes registry data from 243 patients (mean age: 29) who underwent arthroscopic surgery to correct femoroacetabular impingement (FAI). Almost everyone experienced clinically important and statistically significant post-arthroscopy improvements in patient-reported outcomes. However, those with relative femoral retroversion (<5° anteversion) prior to surgery experienced smaller magnitudes of improvement than those with normal or increased femoral version.
Researchers found no association between the participants’ McKibbin index (calculated from both femoral and acetabular version) and patient-reported outcomes.
According to the authors and to commentator Keith Baumgarten, MD, these results indicate that surgeons should not consider femoral retroversion to be an absolute contraindication to arthroscopic correction of FAI. However, while the findings may help orthopaedists offer prognostic counseling to young and middle-aged adults who are considering arthroscopy for FAI, the authors say the findings “may not be externally valid in adolescents,” who represent a substantial percentage of patients diagnosed with this hip condition.