Many of us were surprised by how cold it was in San Diego this past February. But nobody got an icier reception at the annual meeting of the American Academy of Orthopaedic Surgeons than Alexandra Soroceanu, MD.
Soroceanu, a researcher in the department of orthopaedic surgery at Dalhousie University, was in town to present her group’s meta-analysis showing that since the advent of early-mobilization protocols, rerupture rates for nonoperative treatment of Achilles tendon tears are not significantly different than those for surgical treatment (see “Meta-analysis underscores benefits of early motion after Achilles rupture.”)
This, as you might imagine, did not go over well with the audience of orthopedic surgeons.
The findings aren’t news to some of us. In fact, two more randomized controlled studies that reached similar conclusions were published late last year (see “Achilles rupture redux.”)
But it’s one thing to read about such studies in a journal or online. It’s quite another to be lectured about them in person—by a Canadian, no less. Soroceanu’s presentation ignited one of the more spirited (at times, somewhat mean-spirited) discussions I’ve seen at an AAOS meeting in years.
Audience members hammered her with criticisms and critical questions. How complex was the early mobilization protocol, and wasn’t patient compliance an issue? How could one overlook the fact that surgically treated patients returned to work nearly 20 days sooner than nonsurgically treated patients? (Maybe return to work wasn’t really an issue in Canada, it was suggested.)
A moderator asked audience members if they would choose nonoperative Achilles treatment over surgery for themselves. One or two lonely souls in the audience raised their hands along with Soroceanu. Must be a few Canadians out there, the moderator quipped.
If, like me, you tend to root for the underdog, it was tempting to assume that the surgeons doth protest too much. But being defensive isn’t necessarily the same as being wrong.
A surgeon from Charlotte, NC, took issue with the significantly higher complication rates associated with surgery in the meta-analysis. Maybe in addition to new rehabilitation protocols that lower rerupture rates, he suggested, researchers should also be looking at new minimally invasive surgical techniques that lower complication rates.
Only one randomized controlled trial has compared early-motion nonoperative Achilles treatment with minimally invasive surgery, a 2008 study from the Netherlands published in the American Journal of Sports Medicine. That study, in fact, found that complication rates were higher in the nonoperative group, although the difference was not statistically significant. Rerupture rates were similar in both groups, but patients who did not have surgery took nearly twice as long to return to work.
Clearly more studies of this type, and ultimately a meta-analysis of that group of studies, would provide a better understanding of how the gold standard in surgery stacks up against the gold standard in conservative care.
It’s a good point, and one that advocates of surgery may find tough to swallow.
But that’s not really Alexandra Soroceanu’s fault. Or Canada’s.