Plaster cast versus functional bracing for Achilles tendon rupture: the UKSTAR RCT

• Published in: Health technology assessment (Winchester, England) England), 2020-02, Vol.24 (8), p.1-86
• Main Authors: Costa, Matthew L, Achten, Juul, Wagland, Susan, Marian, Ioana R, Maredza, Mandy, Schlüssel, Michael Maia, Liew, Anna S, Parsons, Nick R, Dutton, Susan J, Kearney, Rebecca S, Lamb, Sarah E, Ollivere, Benjamin, Petrou, Stavros
• Format: Article
• Language: English
• Subjects: achilles; Achilles Tendon - injuries; ankle; Braces; Casts, Surgical; Female; Humans; Male; Middle Aged; rehabilitation; rupture; Rupture - rehabilitation; tendon; Time Factors; Weight-Bearing - physiology
• ISSN: 1366-5278; 2046-4924
• DOI: 10.3310/hta24080

Achilles tendon rupture affects > 11,000 people each year in the UK, leading to prolonged periods away from work, sports and social activities. Traditionally, the ruptured tendon is held still in a plaster cast for ≥ 8 weeks. Functional bracing is an alternative treatment that allows patients to mobilise earlier, but there is little evidence about how bracing affects patients' recovery. To measure the Achilles Tendon Rupture Score, quality of life, complications and resource use of patients receiving non-operative treatment for an Achilles tendon rupture treated with plaster cast compared with those treated with functional bracing. This was a multicentre, randomised, pragmatic, two-group superiority trial. The setting was 39 NHS hospitals. A total of 540 adult patients treated non-operatively for Achilles tendon rupture were randomised from July 2016 to May 2018. Exclusion criteria included presenting after 14 days, having had previous rupture and being unable to complete questionnaires. A total of 266 participants had a plaster cast applied, with their toes initially pointing to the floor. The cast was changed over 8 weeks to bring the foot into a walking position. A total of 274 patients had a functional brace that facilitated immediate weight-bearing. The foot position was adjusted within the brace over the same 8-week period. Achilles Tendon Rupture Score is patient reported and assesses symptoms and physical activity related to the Achilles tendon (score 0-100, with 100 being the best possible outcome). The secondary outcomes were quality of life, complications and resource use at 8 weeks and at 3, 6 and 9 months. Participants had a mean age of 48.7 years, were predominantly male (79%) and had ruptured their tendon during sports (70%). Over 93% of participants completed follow-up. There was no statistically significant difference in Achilles Tendon Rupture Score at 9 months post injury (-1.38, 95% confidence interval -4.9 to 2.1). There was a statistically significant difference in Achilles Tendon Rupture Score at 8 weeks post injury in favour of the functional brace group (5.53, 95% confidence interval 2.0 to 9.1), but not at 3 or 6 months post injury. Quality of life showed the same pattern, with a statistically significant difference at 8 weeks post injury but not at later time points. Complication profiles were similar in both groups. Re-rupture of the tendon occurred 17 times in the plaster cast group and 13 times in the functional brace group. T