Plaster casts no better than functional braces in patients with nonoperative treatment of Achilles ruptures

Reference

Costa ML, Achten J, Marian IR, et al, for the UKSTAR trial collaborators. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation. Lancet 2020;395(10222):441-448.

Synopsis

This study included patients with acutely ruptured Achilles tendons who, in conversation with their surgeon, decided to forego surgery. All patients were older than 16 years and initially presented to 1 of 39 hospitals in the United Kingdom. The researchers randomized the patients to treatment with a functional brace (n = 274) or with a below-knee plaster cast (n = 266). The plaster casts placed the patient into the gravity equinus position (while seated, raise your leg and let your foot dangle—that is the position). After 6 weeks, the casts were replaced to hold the foot in a neutral position and the patients could begin to bear weight. The casts came off after 8 weeks. Similarly, the functional braces had heel pads that initially placed the patients into the same gravity equinus position, but the bottom of the brace was level, allowing the patients to begin immediate weight-bearing. The brace allowed more frequent, gradual repositioning of the foot into a neutral position over the subsequent 8 weeks before removal of the brace. After 8 weeks, all patients underwent the same rehabilitation program. The main outcome was the Achilles tendon rupture score (ATRS), which includes 10 items that evaluate symptoms and function, each on a scale from 0 to 10. Although the maximum ATRS is 100, the researchers report the minimum clinically important difference is 8, which represents the ability to walk upstairs or run with some difficulty versus with great difficulty. After 9 months, 12 patients either withdrew or had missing data, and 1 patient died. At that time, there was no difference in the mean ATRS between the groups nor in the rate of reruptured tendons (6% and 5%, respectively).