Ankle Fractures

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Patrick B. -

My non-op and op EBM ortho and sportsmed experts are in fairly strong disagreement with the speakers strong suggestion that Achilles injury is best treated nonop. I think the segment seemed a bit biased for the take home message that it was clear cut to not fix most of these....

Rob O -

Here is the response from Dr. Ramadorai.....

My treatment preferences for Achilles tendon treatment is certainly biased. Every surgeon has his/her protocols based on training and hopefully evidence based medicine. The most recent high quality studies concerning operative vs. nonoperative management of Achilles tendon ruptures shows no significant benefit of surgical management when the appropriate nonoperative protocol is employed so that is my preference. In addition, that is what was favored during my fellowship training. The complications that can arise from operative management (whether it be open or percutaneous) can be catastrophic so unless there is a well done prospective study demonstrating a clear superiority of surgical management, I will continue treating them conservatively. That is certainly not the opinion of every orthopaedic surgeon. I am sure if you sat 20 of us down in a room and asked us our preference you would get a wide variety of responses. Ultimately this podcast is for the emergency room provider and the emphasis should be placed on making the diagnosis and getting the patient properly immobilized with appropriate follow-up. The orthopaedic surgeon can then make the decision concerning operative versus nonoperative management with the patient. Please see the below resources.

Nilsson-Helander K, Silbernagel KG, Thomee R, et al. Acute Achilles
tendon rupture: a randomized, controlled study comparing surgical
and nonsurgical treatments using validated outcome measures. Am
J Sports Med. 2010;38(11):2186-2193.
Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical
versus nonsurgical treatment of acute Achilles tendon rupture:
a meta-analysis of randomized trials. J Bone Joint Surg Am.
Wallace RG, Heyes GJ, Michael AL. The non-operative functional
management of patients with a rupture of the tendo Achillis leads
to low rates of re-rupture. J Bone Joint Surg Br. 2011;93(10):1362-
4. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative
treatment of acute Achilles tendon ruptures: a multicenter randomized
trial using accelerated functional rehabilitation. J Bone Joint
Surg Am. 2010;92(17):2767-2775.

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