Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation

Costa, Matthew L.; Achten, Juul; Marian, Ioana R; Dutton, Susan; Lamb, Sarah E; Ollivere, B.; Maredza, Mandy; Petrou, Stavros; Kearney, Rebecca S.; Abdallah, Amr; Ballal, Moez S.; Ballester, Jordi; Beastall, James; Bhattacharya, Rajarshi; Burrt, Simon; Deakin, Mark; Deol, Rupe; Dramis, Asterios; El-Kawy, S.; Eyre, Jason; Forder, Justin; Ghosh, Avijeet; Guha, Anhijit; Hancock, Nicholas; Harrold, Fraser; Harwood, Paul; Hull, Peter; Johnstone, Alan J.; Kapoor, Sandeep; Karagkevrekis, Babis; Kelly, Andrew; Kurdy, Nasser; Kurup, Harish; Lyle, Victoria; Madan, Sanjeev; Madeley, Jane; Mahmood, Ansar; Malik, Ahmad Kamran; McAndrew, Andrew; Mishra, Viren; Modi, Nitin; Nanda, Rachita; Reichert, Ines; Reissis, Nikos; Sampalli, Sridhar; Scott, Anne; Walter, Richard; Westwood, Mark

doi:10.1016/s0140-6736(19)32942-3

Cited by 48 publications

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“…The mean direct intervention cost was £35.71 for the plaster cast group compared with £108.64 for the functional brace group; the mean difference of £72.93 was statistically significant at the 5% level. The mean total NHS and PSS costs were significantly lower in the functional brace group between randomisation and 8 weeks post 49 © 2020 The Author(s). Published by Elsevier Ltd.…”

Section: Results Of Economic Analysismentioning

confidence: 98%

Section: Sensitivity Analysesmentioning

confidence: 99%

“…Cost-effectiveness scatterplot at 9 months for base-case analysis (NHS and PSS perspective, imputed, additionally controlled for pre-injury utility, ITT analysis). Reproduced from Costa et al49 © 2020 The Author(s). Published by Elsevier Ltd.…”

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

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Wagland

et al. 2020

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Background 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. Objectives 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. Design This was a multicentre, randomised, pragmatic, two-group superiority trial. Setting The setting was 39 NHS hospitals. Participants 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. Interventions 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. Main outcome measures 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. Results 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. There was no difference in resource use. Conclusions This trial provides strong evidence that early weight-bearing in a functional brace provides similar outcomes to traditional plaster casting and is safe for patients receiving non-operative treatment of Achilles tendon rupture. The probability that functional bracing is cost-effective exceeds 95% for the base-case imputed analysis, assuming a cost-effectiveness threshold of £20,000 per quality-adjusted life-year. On average, functional brace is associated with lower costs (–£103, 95% confidence interval –£290 to £84) and more quality-adjusted life-years (0.015, 95% confidence interval –0.0013 to 0.030) than plaster cast. Limitations Some patients declined to participate in the trial, but only a small proportion of these declined because they had a preference for one treatment or another. Overall, 58% of eligible patients agreed to participate, so the participants are broadly representative of the population under investigation. Future work Although the UK Study of Tendo Achilles Rehabilitation provides guidance with regard to early management, rehabilitation following Achilles tendon rupture is prolonged and further research is required to define the optimal mode of rehabilitation after the initial cast/brace has been removed. Trial registration Current Controlled Trials ISRCTN62639639. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 8. See the NIHR Journals Library website for further project information.

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Section: Results Of Economic Analysismentioning

confidence: 98%

Section: Sensitivity Analysesmentioning

confidence: 99%

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confidence: 99%

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

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Wagland

et al. 2020

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“…There is no official MCID (Minimal Clinically Important Difference) for ATRS. However, earlier studies have defined the MCID as 8–10 points [ 5 , 26 ]. Both the preoperative and the postoperative ATRS were filled out retrospectively.…”

Section: Discussionmentioning

confidence: 99%

The economic cost and patient-reported outcomes of chronic Achilles tendon ruptures

et al. 2020

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Purpose While most Achilles tendon ruptures are dramatic and diagnosed quickly, some are missed, with a risk of becoming chronic. A chronic Achilles tendon rupture is defined as a rupture that has been left untreated for more than 4 weeks. By mapping the health economic cost of chronic Achilles tendon ruptures the health-care system might be able to better distribute resources to detect these ruptures at an earlier time. Method All patients with a chronic Achilles tendon rupture who were treated surgically at Sahlgrenska University Hospital or Kungsbacka Hospital between 2013 and 2018 were invited to participate in the study. The patients were evaluated postoperatively using the validated Achilles tendon Total Rupture Score (ATRS). The health-care costs were assessed using clinical records. The production-loss costs were extracted from the Swedish Social Insurance Agency. The cost of chronic Achilles tendon ruptures was then compared with the cost of acute ruptures in a previous study by Westin et.al. Results Forty patients with a median (range) age of 66 (28–86) were included in the study. The mean total cost (± SD) for the patients with a chronic Achilles tendon rupture was 6494 EUR ± 6508, which is 1276 EUR higher than the mean total cost of acute ruptures. Patients with chronic Achilles tendon ruptures reported a mean (min-max) postoperative ATRS of 73 (14–100). Conclusion Missing an Achilles tendon rupture will entail higher health-care costs compared with acute ruptures. Health-care resources can be saved if Achilles tendon ruptures are detected at an early stage.

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Summary of Data Comparing Nonoperative, Open, and Minimally Invasive Treatment of Achilles Tendon Tears

Hanselman

2023

The Achilles Tendon

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Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation

Cited by 48 publications

References 25 publications

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

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

The economic cost and patient-reported outcomes of chronic Achilles tendon ruptures

Summary of Data Comparing Nonoperative, Open, and Minimally Invasive Treatment of Achilles Tendon Tears

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