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Anterior Cruciate Ligament Injuries

The New England Journal of Medicine recently published a review on anterior cruciate ligament management, reporting a random controlled trial

http://www.nejm.org/doi/full/10.1056/NEJMoa0907797?query=TOC

It is almost impossible to do a random controlled trial (rct) on anterior cruciate ligament (acl) injuries.

The initial difficulty is that the ultimate measure must be an outcome assessment when the subjects (who are usually in early adulthood when injured) are older than 40, then older than 70 to see if they are more prone to osteoarthritis than average.

A second variable is how much proprioception was lost as a result of the original injury. There is strong evidence that the greater the loss of proprioception, so the worse the long-term outcome, whatever the surgical treatment. But there are no standardised comparative tests of proprioception with the required reproducibility and high sensitivity.

Thirdly the acl injuries are usually related to one or more of a number of other injuries to the radjacent  anatomy, the knee co-laterals, meniscii, posterior cruciate ligament or the patella-femoral joint complex. Unless the rct is standardised for these it will be invalid.

Finally outcomes will depend on a number of life-style variables such as return to sport (and which sports), BMI at various stages of life, other injuries to same and other limb, concomitant illnesses, use of alcohol, smoking and chronic septic foci.

Therefore the variables are huge.

But one additional and not insignificant factor which alters the practice of surgery, and often biases rct selection, is patient demand for the “treatment of their choice” as gleaned from the popular press. This demand is often not resistible by the clinician, and becomes disturbing where the clinical objectivity has been perverted by headline-seeking pronouncements in the popular press.

Anterior cruciate ligament injuries (and their treatment) are frequently exposed in the lay press because of the high cult status of many injured sportspersons.

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Weil, Weil, Weil!

 

In this website enquiries about the Weil Osteotomy  have been frequent. In this web-site (and in conferences around the world) I have asked the surgical community, both orthopaedic and podiatric, to explain how the Weil works. Just what does it do to correct pain? Despite many thousands of hits on my web-site no one has come forward with a valid explanation.

In the literature two pseudo-explanations are offered.

“Restoration of the metatarsal parabola”. Here it is reasoned that an unusually long metatarsal is responsible, particularly the second. It is claimed that the “normal foot” has the metatarsals forming a neat parabolic curve. Is there any evidence for that? Not that I can find. Foot shapes come in great variety. A lifetime of looking at feet has never revealed a “better” or “correct” shape.

Most feet function well for the first three-quarters of life, irrespective of significant variances. There is no hard evidence either that a “long” metatarsal is more prone to pain than a short one. What is true is that the second metatarsal often happens to be the first to become painful, and (by chance association) the second metatarsal also happens to be the longest.

But even if that association (long metatarsal = pain) should be correct, the argument immediately fails when Weil osteotomies are offered on multiple toes, or on a toe which is painful but with a shorter metatarsal.

The ultimate irrationality of this argument is that any given foot anatomy (perhaps with a long metatarsal, or with a “non-parabolic” shape) can function perfectly well for fifty or sixty years. When that foot becomes painful is it because the metatarsal is “long”?

Of course it is not – that metatarsal has had the same length all those years – not only that but it has functioned perfectly when the greatest loads have been on it, with youthful activity, running and jumping, pregnancies, and the rest. So some would try and make be believe that after half a century of service, a bone suddenly becomes “too long”! Really!

The other pseudo-argument promoting the Weil goes like this:

“When conservative modalities have been exhausted, you may consider over 20 surgical techniques, ranging from condylectomies to oblique osteotomies at the proximal, mid-shaft or distal metatarsal levels. Of these procedures, the Weil osteotomy has gained popularity, based upon the simple technique and stable fixation.”

This is another way of saying “If you are going to try something surgically try the easiest “something”.

“Try” is the operative word.