Saxena A, Ewen B, Maffulli N.  Rehabilitation of the operated Achilles tendon: parameters for predicting return to activity.  J Foot Ankle Surg.  2011 Jan-Feb; 50(1): 37-40.   (PubMed ID: 21106412)

WHY did the authors undertake this study?
There is often a great deal of variation with respect to post-operative rehabilitation protocols following lower extremity musculoskeletal surgery, particularly in active patients eager to return to their previous level of activity.  This study aimed to evaluate if the specific post-operative rehabilitation protocols and return to activity criteria utilized by the authors were helpful in predicting return to activity in a cohort of patients.

HOW did they attempt to answer this question?
The primary outcome measure of this study was return to activity (RTA), defined as the time (in weeks) until patients returned to initiation of their sport or main daily activity.  The patient cohort was comprised of 219 patients from a single surgeon’s practice who underwent operative intervention for an acute Achilles rupture or chronic Achilles tendinopathy.

Previous studies by other authors have recommended completion of 3 parameters prior to RTA:

1. Ability to perform 5 sets of 25 single-legged heel raises
2. Operative limb calf circumference within 5mm of the non-operative limb
3. Operative ankle dorsiflexion and plantarflexion within 5 degrees of the non-operative limb

These authors had specific post-operative rehabilitation protocols depending on the specific surgery performed (peritenolysis, debridement, excision of insertional calcification with tenodesis, retrocalcaneal exostectomy with tenodesis, acute rupture repair, or chronic rupture repair).  Time to RTA and time to completion of the above 3 parameters were recorded.

WHAT were the specific results?
Mean (standard deviation) RTA for each of the surgeries was peritenolysis 6.5 (2.8) weeks, debridement 14.0 (4.7) weeks, excision of insertional calcification with tenodesis 17.7 (5.9) weeks, retrocalcaneal exostectomy with tenodesis 20.5 (10.7) weeks, acute rupture repair 21.8 (4.0) weeks, and chronic rupture repair 31.6 (7.8) weeks.  The inability to meet the above 3 parameters resulted in a delay to RTA.

HOW did the authors interpret these results?
 From these results, the authors concluded  that patient RTA following Achilles tendon surgery could be relatively easily predicted with the above 3 parameters.

Mockford KA, Mazari FA, Jordan AR, Vanicek N, Chetter IC, Coughlin PA .  Computerized dynamic posturography in the objective assessment of balance in patients with intermittent claudication.  Ann Vasc Surg.  2011 Feb; 25(2): 182-190. [Pubmed ID#: 20889294]

WHY did the authors undertake this study?
This study begins by reporting some eye-opening data with respect to falls:  1 in 3 adults aged over 65 fall each year, 20% of falls cause serious injury, and the cost for nonfatal falls in the US was $19 billion dollars in the year 2000!  Based on these data, the importance of identifying patients with poor lower limb function is obvious, particularly as exercise and other physical therapy modalities have been shown to reduce the number of falls in this cohort.  The objective of this study was to determine if elderly patients with intermittent claudication were at an increased risk for balance impairment and falls.

HOW did they attempt to answer this question?
A cohort of patients with intermittent claudication (n=58) were compared to historical controls through a variety of assessments:  history of falling (cleverly defined as “the act of unintentionally coming to the ground or to another lower level”), balance assessment (via the Equitest system), the Sensory Organization Test (which assesses the ability of a patient to effectively use different sensory systems), the Motor Control Test (which, in part, reflects the ability of the subject to prevent falling when submitted to certain forces), and fear of falling (assessed with the Activities-specific Balance Confidence scale).

WHAT were the specific results?
Claudicants were found to have impaired balance, particularly secondary to vestibular problems as assessed by the Sensory Organization Test, compared to non-claudicating historical controls.  Interestingly, claudicants were not likely to have an increased fear of falling.

HOW did the authors interpret these results?
From these results, the authors concluded that elderly patients with intermittent claudication are at an increased risk for balance abnormalities and falls.  Identification of these patients may facilitate early intervention of fall-prevention strategies.

Let’s take a closer look at the topic of journal impact factor, particularly as it applies to these two journals.  The 2009 impact factor for our second journal (Annals of Vascular Surgery) was reported as 1.169 What exactly is this number telling me about a given journal, and why should I care about it?

A simple way to conceptualize a journal’s impact factor is as a simple ratio, like the ankle-brachial index (ABI).   As we are all familiar, ABIs are simply a calculation of a patient’s systolic pressure in an ankle artery divided by a patient’s systolic pressure in the brachial artery [ankle systolic pressure ÷ brachial systolic pressure].  If the ABI is low (<1), then there is more pressure in the brachial artery than the ankle artery.  If the ABI is high (>1), then there is more pressure in the ankle artery than the brachial artery. 

In the case of impact factor, the number of times articles from a specific scientific journal are referenced by other scientific journals is divided by the number of articles published by the specific scientific journal.  If the impact factor is high (>1), then the journal is more likely to be referenced than to publish.  If the impact factor is low (<1), then the journal is more likely to publish than to be referenced.

Although this number is far from perfect, we use it as a rough component to calculate how “powerful” a given journal is.  We assume that a journal with a high impact factor is widely read and “used” by other journals to put forth future research.  A journal with a low impact factor may not be as widely read and isn’t as “used” by other journals to put forth future research. 

In 2009, the Annals of Vascular Surgery’s impact factor was 1.169…..pretty close to 1.  So from this simplified approach, we can say that the journal is about as likely to “use” as it is to “be used”.  Some impact factors are very high.  The Journal of the American Medical Association (JAMA) recently recorded an impact factor of 23.5 for example.  This journal is much more likely to “be used” than it is to “use”. 

Interestingly, The Journal of Foot and Ankle Surgery has yet to publish an impact factor, but they are planning to this summer, so that’s something to look out for.  A couple of the other journals that we routinely review in this eZine with their recent impact factors are The Journal of the American Podiatric Medical Association (0.598), Foot and Ankle International (1.101), The Journal of Bone and Joint Surgery-American (3.427), The Journal of Bone and Joint Surgery-British (2.655), and Clinical Orthopedics and Related Research (2.065).  The highest orthopedic journal that I could find (2009 rankings through the Temple Library) was Osteoarthritis and Cartilage at 3.888. 

Again, we know that the impact factor is far from perfect, but it does supply us with an interesting way at looking at journals as a whole, as opposed to reviewing individual articles.