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Basic Sciences? Why do you practice podiatric medicine the way you do? Is there a reason behind your methods? Evidence-based medicine talks a lot about using the literature to determine the best practice methods and treatment guidelines. This is a powerful and effective tool for the best care of our patients. But what about those methods that you use that don’t have a randomized controlled trial to back them up? What about the everyday moment to moment things you do in your practice?
Why Do We Do What We Do?
For example, why do we tell our patients they’ll be weightbearing after a fusion procedure in 6 to 8 weeks? Why do we pull sutures at around 2 weeks on the dorsum of the foot and 3 weeks on the plantar side? Do you weight-bear plantar incisions? Why do some of us mix different types of anesthetics together or use a particular steroid? Is it because this is what we were taught as students and residents? Are we parroting what those who came before us did? I’d argue we should have a better reason than “doctor so-and-so told me.” Regardless of what high powered study exists, we should always have a strong grasp of the basic sciences, the foundation of everything we do. Let’s consider a postoperative treatment regimen for an Achilles tendon rupture repair as an example. You’ve just performed an open primary Achilles tendon repair after an intratendonous rupture 4 cm above its insertion on the calcaneus. Multiple questions now arise. Do you cast the patient? When should the patient start weightbearing? When should mobilization of the area begin? When should physical therapy begin? Back to the Science
A quick “down and dirty” basic sciences tendon healing review will help us answer these questions. Recall tendon healing occurs in 3 overlapping phases: inflammatory (1st 2 to 3 days) with neutrophils being replaced by macrophages after the 1st 24 hours, proliferative (approximately 3-14 days) with increased fibroblasts and neovascularization (at 7 days), and remodeling (2 weeks to up to a year) with type III collagen replaced by type I collagen and a change from a predominantly cellular makeup to a more fibrous one at 3 weeks (Hope and Saxby 2007). It was found in a landmark canine study that early range of motion led to collagen ingrowth from the endotenon at 10 days rather than epitenon, leading to less adhesions and linear collagen fibers, which allowed a smooth range of motion. When the tendon was immobilized, collagen ingrowth from the epitenon was seen leading to greater adhesions and less intratendonous healing(Gelberman, et al. 1983). A recent cadaveric study found the Krakow stitch, with an augmented epitendinous weave-type suture, led to the most stable repair and was strong enough to handle early mobilization and weightbearing forces (Lee, et al. 2009). The Science Leads Us to Clinical Theory From this information, it makes sense to immobilize the tendon for a short 3 days to allow the inflammatory phase to end (and provide pain control), then begin nonweightbearing with a heel lift and passive range of motion, carefully controlled by a physical therapist. Since rerupture is a primary concern and the tendon becomes more fibrous at 3 weeks, the surgeon should consider protected weightbearing as early as 3-4 weeks as long as the repair was strong.We Test the Clinical Theory Before Employing it in Clinical Practice
This basic science evidence provides the foundation for rational decisions. The next step is to look at the clinical research to see if it matches our basic understanding. A Level 1 study, for example, found no reruptures at 6 months in either an early weightbearing (2 weeks) or nonweightbearing group of patients treated surgically for acute Achilles tendon ruptures (Suchak, et al. 2008). Similarly, early functional range of motion with weightbearing at 3 weeks was found to be superior to 6 weeks of below knee casting and weightbearing at 3 weeks in a prospective randomized trial (Kangas, et al. 2003). Good Evidence Based Clinical Decisions Flow from the Science These clinical studies demonstrate the effectiveness of applying the basic science research to this clinical problem. Consider a return to the fundamentals as a foundation for rational health care. Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.
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