Improving clinical procedures with evidence-based medicine

Research backs early functional treatment for acute ankle sprains.

Issue: August 2005

AOA-Huntington Beach, Calif. [icon]

HUNTINGTON BEACH, Calif. — Evidence-based medicine approaches can aid physicians in making tough calls by either supporting clinical practices or dispelling medical myths.

At the 118th Annual Meeting of the American Orthopaedic Association, shoulder and lower extremity experts discussed how this approach supports practices such as autograft choice for ACL reconstruction but disputes the use of corticosteroids for shoulder injuries.

For example, many physicians use corticosteriods when treating rotator cuff tendonitis, but published literature argues against its efficacy, said John E. Kuhn, MD. Kuhn, the chief of shoulder surgery at Vanderbilt Sports Medicine, reviewed nine randomized control trial studies and found that only half reported statistically significant pain relief using injections. Of these, only one study showed clinically significant pain relief or a 30% reduction in pain. “This was pretty surprising to us,” Kuhn said.

Three studies also revealed significant differences in range of motion after injection, but only two were clinically significant. Therefore, Kuhn said that research does not strongly support using injections. “The answer is, for rotator cuff tendinosis, they might help with motion — maybe,” Kuhn said. “They really don’t seem to help with pain,” he said.

Arthroscopic repair

Evidence-based medicine can also help clinicians evaluate the efficacy of new techniques. Kuhn’s examination of three Level I European studies revealed no statistically significant differences in recurrence between arthroscopic and open Bankart repairs. “… the data does suggest that it’s time to switch over and do arthroscopic repairs if that’s something that you’re interested in doing,” he said. But Kuhn cautioned that arthroscopic techniques vary and that successful repair also depends on postoperative rehabilitation.

The conclusions drawn from evidence-based medicine are only as sound as the data — leaving physicians unsure about the best treatment for difficult cases. A literature review comparing open and arthroscopic repair for shoulder instability in contact athletes only generated Level III and IV research. What is more, the data showed similar recurrence rates between techniques, Kuhn said. Instead of providing clear answers, the weak data illustrate the need for further research, he said.

Foot and ankle injuries

“[Corticosteroids] for rotator cuff tendinosis might help with motion — maybe. They really don’t seem to help with pain.”
—John E. Kuhn

In the foot and ankle specialty, using anatomic or non-anatomic reconstruction for chronic ankle instability remains controversial. The three studies available (one Level II and two Level III) provided weak conclusions regarding treatment. Ned Amendola, MD, an orthopedic professor with the University of Iowa, compared studies by Rover Krips, MD, and Bart Cornelis Hendrikus, MD, using anatomic (Brostrom) and non-anatomic (Evans tenodesis) reconstructions. Although Hendrikus reported fewer wound complications with anatomic techniques, Krips found fewer re-operations with the method, Amendola said. “The data were difficult to interpret, but based on this review of this available data, the outcomes were similar,” he said.

Amendola noted similar findings comparing nonoperative and surgical interventions for acute Achilles tendon tears. He found 14 Level I trials but excluded 11 studies for randomization bias. The remaining studies used varying rehab protocols, but he noted more re-ruptures in the nonoperative studies. After pooling the data, he also found a lower complication rate, other than re-ruptures, with nonoperative methods (2%) vs. surgical treatment (34%). However, “the return to function in these three studies was no different,” Amendola said.

Sprains

High-ankle sprains pose many questions for clinicians. Physicians commonly misdiagnose patients because they have normal X-rays but syndesmotic ligament injuries. Physicians also lack a diagnostic test for the condition, Amendola said. Once the injury is spotted, what is the best treatment?

Current English literature only provides Level IV studies, Amendola said. What is more, the studies contained variable sample sizes, outcome measures and injury severity. The literature leads to weak conclusions. “Most of these injuries do get better in the long term but it does raise a number of questions, which [will] probably lead to some research in this area in the future,” Amendola said.

For some questions, evidence-based medicine provides clear-cut answers. A review of nine Level I and II studies showed that early functional treatment for acute ankle sprains was superior to surgery or casting alone, Amendola said. Although the studies used different forms of immobilization and functional treatment, mobility provided better return to sports, he said. “The rate of re-injury was lower with functional treatment; however, the satisfaction with treatment was better with immobilization vs. mobilization,” Amendola said.

Knee injuries

Recent years have seen a shift in autograft choice for ACL reconstruction, with physicians moving from patellar tendon to hamstring grafts. But, Kurt P. Spindler, MD, an associate orthopedic professor at Vanderbilt University Medical School and director of Vanderbilt Sports Medicine, said that a gold standard for reconstruction remains elusive. His review of nine Level I studies only revealed few clinical differences between grafts. “So our hypothesis [is] that autograft choice is not the primary determinant of outcome after ACL reconstruction,” Spindler said. “And we believe that injuries and treatment to the meniscus and the articular cartilage are probably the most important influences on ACL reconstruction techniques and outcomes afterwards,” he said.

Patellar tendon grafts may prove beneficial for less laxity, but studies suggest less kneeling pain and motion loss with hamstring methods. “The caveat is that you can’t choose a hamstring graft because you have a decrease in anterior knee pain,” Spindler said.

Similarly, Spindler said that surgeons can choose either endoscopic or rear- entry ACL reconstruction. He cited Level I studies by Daniel B. O’Neill, MD, Torsten Gerich, MD, and Sveinbjörn Brandsson, MD, which only suggested shorter operating time and better one-hop tests with endoscopic techniques.

Cartilage defects

In patients with smaller femoral defects, evidence-based medicine supports microfracture over autologous chondrocyte use. Spindler cited the work of Gunnar Knutsen, MD, involving 80 patients who received either treatment. A two-year follow up revealed SF-36 improvements in both groups, Spindler said. Yet, the autologous chondrocyte cohort showed a 25% re-operation rate compared to 10% in the microfracture group. “So, it seems clear that, at least approached in this population, it’s probably wise to begin with microfracture first,” Spindler said.

Although evidence-based medicine can aid physicians in making the best practice decisions, Kuhn cautioned against taking research findings at face value. “So when you use an evidence-based medicine approach, you need to be sure that the patients that they’re talking about [in the study] are actually the kind that you see,” he said. “And you have to ask, ‘Can you do this operation?’” he said.

For more information:
Wright RW, Spindler KP, Amendola A, Kuhn JE. Integrating evidence-based medicine into clinical practice. Symposium #1. Presented at the 118th Annual Meeting of the American Orthopaedic Association. June 22-25, 2005. Huntington Beach, Calif.