Practice Patterns in the Treatment of Acute Achilles Tendon Ruptures in Ontario, Canada

103 Pages·2012·3.02 MB·English

Practice Patterns in the Treatment of Acute Achilles
Tendon Ruptures in Ontario, Canada
by
Ujash Sheth MD
A thesis submitted in conformity with the requirements
for the degree of Master of Science
Institute of Health Policy, Management and Evaluation
University of Toronto
© Copyright by Ujash Sheth 2016
Practice Patterns in the Treatment of Acute Achilles Tendon
Ruptures in Ontario, Canada
Ujash Sheth
Master of Science
Institute of Health Policy, Management and Evaluation
University of Toronto
2016
Abstract
Despite emerging evidence favouring ‘functional’ non-operative treatment (i.e., early
mobilization) over the surgical repair of acute Achilles tendon ruptures, very few studies have
evaluated the impact of this evidence on practice patterns. As such, the overall objective of the
current study was to determine whether the findings of a landmark Canadian trial assessing the
optimal management of acute Achilles tendon ruptures influenced a change in practice among
orthopaedic surgeons in Ontario, Canada. The epidemiology and trends in management of acute
Achilles tendon ruptures were evaluated using population-based health administrative data and
demonstrated an increasing incidence of ruptures and decreasing rate of surgical repair. Using
interrupted time-series analysis, an abrupt and sustained decrease in surgical repair rate was
found to be highly associated with the presentation of landmark trial results at a major
orthopaedic conference. Future work will assess the effect this change in practice has had on
outcomes after Achilles tendon rupture.
ii
Acknowledgments

I would like to extend thanks to the many people who made this thesis possible.
First and foremost, I would like to express my deepest gratitude to my supervisor, Dr. Susan
Jaglal, who I feel very fortunate to have as a mentor. Her enthusiasm, guidance and expertise
have been invaluable to me during this entire process. I thank her for always encouraging me to
explore my own ideas and providing me with an environment to grow as a researcher.
I am also indebted to the members of my thesis committee, Dr. Richard Jenkinson, Dr. Hans
Kreder and Dr. Rahim Moineddin, not only for their time and support, but for their insightful
comments and suggestions.
I am extremely grateful to Dr. David Wasserstein for his mentorship and continued guidance. His
clinical input and constructive criticism throughout the study have helped enrich the overall
quality of this thesis.
I would also like to thank Kristen Pitzul and Andrew Calzavara for their patience and untiring
support in helping me navigate through various statistical and administrative issues along the
way.
Lastly, and most importantly, I would like to thank my family and friends, who have been a
constant source of love and support throughout my studies. To my best friend, Chantel, thank
you for your critical input and continued encouragement. To my sister, Tejas, thank you for your
endless wisdom and advice. Finally, to my parents, Prakash and Sandhya, to whom this thesis is
dedicated, thank you for inspiring me to pursue my dreams and instilling in me the work ethic
and discipline necessary to be successful in life.
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Table of Contents
Acknowledgments .......................................................................................................................... iii
Table of Contents ........................................................................................................................... iv
List of Tables ................................................................................................................................. vi
List of Figures ............................................................................................................................... vii
List of Appendices ....................................................................................................................... viii
Chapter 1 Introduction .....................................................................................................................1
1 Introduction .................................................................................................................................1
Chapter 2 Background .....................................................................................................................3
2 Background .................................................................................................................................3
2.1 Anatomy ...............................................................................................................................3
2.1.1 Muscle Origins .........................................................................................................3
2.1.2 Blood Supply ...........................................................................................................3
2.1.3 Innervation ...............................................................................................................3
2.2 Etiology, Mechanism of Injury and Diagnosis ....................................................................4
2.3 Epidemiology .......................................................................................................................4
2.4 Treatment .............................................................................................................................6
2.4.1 Overview ..................................................................................................................6
2.4.2 Operative vs. Non-Operative Treatment ..................................................................7
2.5 Knowledge Translation ......................................................................................................10
2.5.1 What is Knowledge Translation? ...........................................................................10
2.5.2 Why is Knowledge Translation Important? ...........................................................11
2.5.3 Barriers to Knowledge Translation ........................................................................11
2.5.4 Knowledge Translation Interventions ....................................................................11
2.5.5 Monitoring Use of Knowledge ..............................................................................12
iv
2.5.6 Impact of Level I Evidence on Orthopaedic Practice ............................................13
2.5.7 Treatment of Acute Achilles Tendon Ruptures .....................................................14
2.6 Objectives ..........................................................................................................................15
Chapter 3 Paper #1 .........................................................................................................................16
3 The Epidemiology and Trends in Management of Acute Achilles Tendon Ruptures in
Ontario, Canada: A Population-Based Study of 27,607 Patients. .............................................16
Chapter 4 Paper #2 .........................................................................................................................37
4 Practice Patterns in the Care of Acute Achilles Tendon Ruptures: Is There an Association
with Level I Evidence? .............................................................................................................37
Chapter 5 Discussion .....................................................................................................................54
5 Discussion .................................................................................................................................54
5.1 Summary ............................................................................................................................54
5.2 Implications ........................................................................................................................54
5.3 Strengths & Limitations .....................................................................................................57
5.4 Future Directions ...............................................................................................................58
5.5 Conclusions ........................................................................................................................58
References ......................................................................................................................................60
Appendix A ....................................................................................................................................72
Appendix B ....................................................................................................................................73
Appendix C ....................................................................................................................................87
Appendix D ....................................................................................................................................89
Appendix E ....................................................................................................................................90
Appendix F.....................................................................................................................................91
Appendix G ....................................................................................................................................92
Appendix H ....................................................................................................................................93

v
List of Tables

Table 1 A summary of the literature on the epidemiology of Achilles tendon rupture
Table 2 Key characteristics of randomized controlled trials comparing surgical repair to
early mobilization for the treatment of acute Achilles tendon ruptures
Table 3 A summary of surgical repair techniques and early mobilization protocols used in
high quality randomized controlled trials since 2007
Table 4 Baseline characteristics of study cohort [Paper #1]
Table 5 Incidence density rate and incidence density rate ratio comparisons
Table 6 Mean incidence density rate and incidence density rate difference from 2003-2013
Table 7 Mean surgical repair rate and comparison between 2003 and 2013
Table 8 Baseline characteristics of study cohort [Paper #2]
Table 9 Univariate and multivariate models for predictors of surgical repair utilization
before and after dissemination of landmark trial results

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List of Figures

Figure 1 Flow diagram illustrating the options available for treatment of an acute Achilles
tendon rupture
Figure 2 The knowledge-to-action framework as proposed by Graham et al.
Figure 3 Annual incidence density ratio (IDR) for males by age category
Figure 4 Annual incidence density ratio (IDR) for females by age category
Figure 5 Annual rate of surgical repair in Ontario, Canada from 2003 to 2013 by sex
Figure 6 Annual rate of surgical repair in Ontario, Canada from 2003 to 2013 by hospital
Figure 7 Annual rate of surgical repair in Ontario, Canada from 2003 to 2013 by age
Figure 8 Annual incidence of acute Achilles tendon ruptures in Ontario, Canada
Figure 9 Rate of surgical repair of acute Achilles tendon ruptures per quarter
Figure 10 Rate of surgical repair of acute Achilles tendon ruptures per quarter by hospital

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List of Appendices

Appendix A Diagnostic and procedural codes used to establish the study cohorts
Appendix B Institute of Clinical Evaluative Sciences (ICES) project-specific privacy impact
assessment approval
Appendix C University of Toronto Office of Research Ethics (ORE) administrative approval
Appendix D Study cohort development [Paper #1]
Appendix E Timeline of the dissemination of landmark trial results by Willits and colleagues
Appendix F Study cohort development [Paper #2]
Appendix G Residual diagnostics for time-series ARIMA model [Paper #2]
Appendix H Evaluation of the diagnostic accuracy of ICD-10 coding to identify Achilles
tendon ruptures
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1
Chapter 1
Introduction
1 Introduction
The Achilles tendon is the strongest tendon in the human body.1 It is also the most commonly
ruptured tendon in the adult population.2 Acute Achilles tendon ruptures (AATRs) typically
occur during the most productive years of life, with a peak incidence occurring during the fourth
decade.3 Previous epidemiologic studies have reported an overall increase in the incidence of
AATRs and have attributed this rise to a greater proportion of aging adults participating in high-
level recreational sports.4-6 Naturally, the management of this injury has received considerable
attention over the last decade. In fact, there has been a longstanding debate regarding the optimal
treatment strategy for AATRs. Early randomized controlled trials (RCTs) reported a significantly
higher risk of rerupture with casting and prolonged immobilization when compared to surgical
repair.7, 8 However, these early studies failed to recognize the importance of early mobilization
(i.e., early range of motion and/or early weight-bearing) on tendon healing properties.9 As such,
more recent RCTs have compared surgical repair to non-operative treatment with early
mobilization and found similar rerupture rates between the two groups.10-14 Subsequent meta-
analyses of these studies have also demonstrated an increased risk of complications, such as
infection and wound dehiscence, associated with surgical repair.15, 16
Despite this evolving evidence, it remains unclear what impact it has had on the practice patterns
of orthopaedic surgeons. Unfortunately, the process of implementing best evidence into clinical
practice, known as knowledge translation, has been poorly studied within orthopaedics. Recent
studies evaluating general trends in the management of AATRs have reported conflicting
findings, with some studies demonstrating a decreasing trend in the use of surgical repair, while
others have noted a steady increase over time.17-19 Given the fact that a large, multicenter, RCT
conducted in London, Ontario was one of the most highly publicized studies to demonstrate
similar outcomes between early mobilization and surgical repair, the province of Ontario serves
as an ideal setting to examine knowledge translation among orthopaedic surgeons.10 As a result,
the purpose of this thesis is to (1) describe the epidemiology and secular trends in the
management of AATRs in Ontario, Canada and (2) determine whether the practice patterns of
2
orthopaedic surgeons in Ontario, Canada were influenced by the dissemination of results from a
landmark Canadian trial pertaining to the management of AATRs.
The following chapters provide a detailed description of the background, methods, results and
discussion relevant to this thesis. Chapter 2 begins with an overview of the anatomy, etiology
and epidemiology of AATRs. It continues with a narrative review of key randomized trials
comparing the operative and non-operative treatment of AATRs and closes with a discussion of
knowledge translation as it pertains to orthopaedic practice. After providing a brief synopsis of
each objective of this thesis in section 2.6, Chapters 3 and 4 present the methods, results and
discussions that address each objective in the format of a manuscript. Chapter 5 provides an
overview of conclusions from the two manuscripts that make up the body of this work, discusses
the implications of the findings and identifies areas of future research.