JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Riaz J.K. Khan, Dan Fick, Angus Keogh, John Crawford, Tim Brammar, and Martyn Parker
Treatment of Acute Achilles Tendon Ruptures. A Meta-Analysis of Randomized, Controlled Trials
J Bone Joint Surg Am 2005; 87: 2202-2210 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Re: Non-operative treatment of Achilles Tendon Ruptures
Angus R. Keogh, MBBS   (8 March 2006)
[Read Letter to the Editor] Treatment of Acute Achilles Tendon Ruptures
Riaz J.K. Khan, FRCS (Tr&Orth), Dan Fick, MBBS, Angus Keogh, MBBS, John Crawford, FRCS(Tr&Orth), Tim Brammar, FRCS(Tr&Orth), and Martyn Parker, M.D.   (15 February 2006)
[Read Letter to the Editor] Inclusion of Poorly Randomized Studies into Meta-Analysis
Michael H. Dobson, Chinh Nguyen, Consultant Orthopaedic Surgeon   (14 December 2005)
[Read Letter to the Editor] Dr. Khan et al respond to Drs. Dobson and Nguyen
Riaz, J.K. Khan, Martyn Parker, Daniel Fick, Angus Keogh   (14 December 2005)
[Read Letter to the Editor] Non-operative treatment of Achilles Tendon Ruptures
Paul E. Levin   (13 December 2005)

Re: Non-operative treatment of Achilles Tendon Ruptures 8 March 2006
Previous Letter to the Editor Top
Angus R. Keogh, MBBS,
Doctor
Department of Surgery and Pathology, University of Western Australia

Send letter to journal:
Re: Re: Non-operative treatment of Achilles Tendon Ruptures

guskeogh{at}bigpond.net.au Angus R. Keogh, MBBS

We thank Dr. Levin for his encouraging comments. We agree entirely that it would be optimal to have all of the incorporated studies comparing the same non-operative and operative protocols. This is not always possible as there is a wide variation in treatment protocol from centre to centre. However, the figures of the article clearly show statistical homogeneity between studies comparing operative and non-operative treatments and there is a consistent trend towards lower re-rupture rate with operative treatment. Likewise, there is a consistent finding of increased complication rate in the operative group (confidence intervals overlap in all studies). Hence, we disagree that heterogeneity of the method of non-operative or operative treatment substantially compromises the validity and applicability of the conclusions. Statistical heterogeneity can result from treatment diversity but does not necessarily mean that the true treatment effect varies (i.e. every treatment has minor variations, yet the overall effect may be the same).

We agree with Dr. Levin’s method of conservative treatment of Achilles tendon ruptures. This treatment naturally will lead to a rate of re- rupture which, from the meta-analysis, will be greater than that of operative treatment. This rate of rupture is consistent across the three studies examined. The most methodologically sound study(1) showed the greatest benefit.

When a large study directly comparing operative and non-operative treatment is not available it is accepted that meta-analysis is a sound alternative. We agree that a large trial directly comparing treatments would be optimal. However, obtaining a large series of patients with ruptured Achilles tendons, all undergoing the same treatment within a single centre would be difficult.

References:

1. Moller M, Movin T, Granhed H. Lind K, Faxen E, Karlsson J. Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br. 2001;83:843-8.
Treatment of Acute Achilles Tendon Ruptures 15 February 2006
Previous Letter to the Editor Next Letter to the Editor Top
Riaz J.K. Khan, FRCS (Tr&Orth)
1/14-16 Hamersley Street, Cottesloe WA 6011, AUSTRALIA,
Dan Fick, MBBS, Angus Keogh, MBBS, John Crawford, FRCS(Tr&Orth), Tim Brammar, FRCS(Tr&Orth), and Martyn Parker, M.D.

Send letter to journal:
Re: Treatment of Acute Achilles Tendon Ruptures

riazkhan{at}aol.com Riaz J.K. Khan, FRCS (Tr&Orth), et al.

To The Editor:

Our article “Treatment of Acute Achilles Tendon Ruptures. A Meta- Analysis of Randomized, Controlled Trials” (2005;87:2202-10), by Khan et al., was based on a review that was originally published as a Cochrane Review in the Cochrane Library.(1)

It has been brought to my attention that the article was published in the American JBJS without appropriate permission from John Wiley and Sons or acknowledgement of the Cochrane Library. We would like to apologize to both journals and to their readers for this lack of foresight.

Reference:

1. The Cochrane Database of Systematic Reviews, Issue 3, 2004. Chichester, UK: John Wiley and Sons.

Riaz J.K. Khan, FRCS(Tr&Orth) 1/14-16 Hamersley Street Cottesloe WA 6011 Australia

Inclusion of Poorly Randomized Studies into Meta-Analysis 14 December 2005
Next Letter to the Editor Top
Michael H. Dobson,
Orthopaedic SpR
Whittington Hospital, London, ENGLAND,
Chinh Nguyen, Consultant Orthopaedic Surgeon

Send letter to journal:
Re: Inclusion of Poorly Randomized Studies into Meta-Analysis

mdobson30{at}hotmail.com Michael H. Dobson, et al.

To The Editor:

We read with interest the article by Khan, et al, (1) entitled "Treatment of Acute Achilles Tendon Ruptures - A Meta-Analysis of Randomized, Controlled Trials" and we have some concerns regarding the papers that they included in the meta-analysis. The article states that its intention is to provide a meta- analysis of randomized, controlled trials; the authors clearly state their selection criteria and methodology scoring system.

However, we found that four papers (2,3,4,5) scored 0 for method of randomization and were thus recognised to be poorly randomized, if randomized at all. On our review of these papers, we noted that Kerkhoff, et al, (2) clearly state their study was only quasi-randomized and the study by Maffulli, et al, (3) was not randomized for patient selection; treatment selection was only quasi- randomized on the basis of day of attendance.

We feel that the inclusion of these papers into the meta-analysis may invalidate the results as they do not conform to the aims of the article-- a meta-analysis of RANDOMIZED, controlled trials. We would be interested in the reasons the authors have for including these papers in their meta-analysis.

REFERENCES:

1) Khan RJK, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures - a meta-analysis of randomized, controlled trials. J Bone Joint Surg.2005;87:2202-10

2) Kerkhoffs GM, Struijs PA, Raaymakers EL, Marti RK. Functional treatment after surgical repair of acute Achilles tendon rupture:wrap vs walking cast. Arch Orthop Trauma Surg.2002;122:102-5

3)Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med.2003;31:692-700

4) Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon-a prospective randomized controlled study. Foot Ankle Int.2001;22:559-568

5) Nistor l, Surgical and non-surgical treatment of Achilles tendon rupture. a prospective randomized study. J Bone Joint Surg Am.1981;63:394- 9
Dr. Khan et al respond to Drs. Dobson and Nguyen 14 December 2005
Previous Letter to the Editor Next Letter to the Editor Top
Riaz, J.K. Khan,
Orthopaedic Surgeon
University of Western Australia,
Martyn Parker, Daniel Fick, Angus Keogh

Send letter to journal:
Re: Dr. Khan et al respond to Drs. Dobson and Nguyen

riazkhan{at}aol.com Riaz, J.K. Khan, et al.

We thank Drs. Dobson and Nguyen for their letter. The issue they raise is one of semantics. Randomized trials (RCTs) may be blinded (eg with random numbers or sealed identical envelopes) or quasi -randomized (eg by alternation or odd/even numbers). Therefore we believe that our title is not misleading. Moreover, inclusion of such studies is accepted protocol for other evidence-based organisations such as Cochrane.

We have been explicit about inclusion criteria in the methodology section of our paper, stating that we would consider quasi-RCTs and those with inadequate concealment of treatment allocation. We have also been transparent and classified the randomization type in the results section (characteristics of included studies).

It would be ideal to include only pure randomized trials in a meta -analysis. However, in surgery, and orthopaedics in particular, there are regrettably, few such studies. Therefore, to exclude quasi-RCTs would reduce the numbers substantially. Like other researchers, we hope that the number of quasi-randomized trials will continue to decline as researchers use a blinded pure method of randomization.

Riaz J.K.Khan, Martyn Parker, Daniel Fick, Angus Keogh
Non-operative treatment of Achilles Tendon Ruptures 13 December 2005
Previous Letter to the Editor Next Letter to the Editor Top
Paul E. Levin,
Physician
Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY

Send letter to journal:
Re: Non-operative treatment of Achilles Tendon Ruptures

Plevin{at}montefiore.org Paul E. Levin

To The Editor:

I applaud the attempt by Khan, et al to evaluate various treatments of acute achilles tendon ruptures. Unfortunately, the wide variability in conservative (non- operative) protocols in this meta-analysis substantially compromises the validity and applicability of the conclusions.(1-7).

The non-operative protocols include a number of different approaches: immobilization in short leg casts; long leg casts; and immediate functional bracing. In addition the periods of active treatment vary substantially. As a result, the meta-analysis is not truly comparing operative and non-operative treatments.

I have successfully treated Achilles tendon ruptures non-operatively with a protocol of a non weight bearing long leg cast for four weeks followed by four weeks of a short leg equinus weight bearing cast and an additional four weeks of functional bracing with a dorsiflexion stop.

Ultimately, an analysis of the optimal way to treat Achilles tendon ruptures will have to compare a strict protocol for both operative and non-operative approaches.

Paul E. Levin, M.D. Vice-chairman, Department of Orthopaedic Surgery Montefiore Medical Center, Bronx, NY

References:

1. Bhandari M, Guyatt G, Siddiqui F, Morrow F, Busse, J, Leighton R, Sprague S, Schemitsch E. Treatment of acute Achilles tendon ruptures a systematic overview and metaanalysis. Clin Orthop. 2002;400:190-200.

2. Blake R, Ferguson H. Achilles Tendon Rupture: a protocol for conservative management. JAPMA. 1991;81:486-489.

3. Edna T. Non-operative treatment of Achilles tendon ruptures. Acta orthop scand. 1980;51:991-993

4. Kocher MS, Bishop J, Marshall R, Briggs K, Hawkins R. Operative versus nonoperative management of acute Achilles tendon rupture. Am J Sports Med. 2002;30:783-788.

5. Lea R, Smith, L. Non-surgical treatment of tendo achiilis rupture. J Bone Joint Surg. 1972;54-A:1398-1407.

6. Nistor L. surgical and non-surgical treatment of Achilles tendon rupture. J Bone Joint Surg. 1981;63-A:394-399.

7. Weber M, Niemann M, Laz R, Muller T. Nonoperative treatement and comparison with operative treatment. Am J Sports Med. 2003;31:685-691.