SLR - October 2014 - David Auguste
Reference: Young SW, Patel A, Zhu M, Dijck S, McNair P, Bevan WP, Tomlinson M. Weight-Bearing in the Nonoperative Treatment of Acute Achilles Tendon Ruptures. A Randomized Controlled Trial. J Bone Joint Surg Am. 2014;96:1073-9.
Scientific Literature Review
Reviewed By: David Auguste, DPM
Residency Program: New York Hospital Queens
Podiatric Relevance: Achilles tendon ruptures are common in adults and can result in prolonged disability. Treatments for acute ruptures include surgical management and conservative management. In this article the authors attempt to determine, by using a randomized controlled trial (RCT, level 1 evidence), whether traditional non-weight bearing cast or weight bearing cast are superior choices in preventing rerupture after acute Achilles tendon rupture. The authors state there are only few studies that compare weight bearing cast versus non-weight bearing cast for non-operative treatment of acute Achilles tendon rupture, with this study being the largest to date.
Methods: This trial took place at three different centers with a two year follow up period. The 84 patients involved in the study presented either in the emergency department or were referred by their primary doctor for acute Achilles tendon rupture. Patients were included in the RCT if the injury was unilateral, presented within 72 hours after injury, had to be available for follow up evaluations at 6,12, 24 months. Patients were excluded if they had previous Achilles rupture, previous tendon surgery, open injury, or multiple injuries. The participants either received non-weight bearing cast, or weight bearing cast fitted with a Bohler iron (and allowed to weight bear immediately). The authors recorded the patients age, sex, occupation, an ankle activity index score, and time from injury to application of cast. The Achilles ruptures were diagnosed clinically based on history, swelling, and positive Thompson calf-squeeze test. Patients in both groups were placed in cast in max plantarflexed positions initially, then changed to resting equinus position for eight weeks total. Patients were then evaluated 14 weeks after cast removal and two years for re-rupture.
Results: The average time to application of cast was ten hours for weight bearing and ten hours for non-weight bearing group. At the two-year follow up, with 37 patients in each group the weight bearing group had one rerupture and the non-weight bearing group had two re-ruptures. The authors state fewer patients complained of pain, stiffness, or weakness in the weight bearing group, which was significant. There were no other reported complications.
Conclusions: The overall results of this study showed a low complication rate of re-rupture, the acute presentation of the patients within 72 hours of injury was also believed to decrease the rate of re-rupture. Previous studies including this study were unable to show a significant difference between weight bearing and non-weight bearing groups. Overall the authors concluded that a larger study with more participants would be required to determine if there is a difference in treatments.