Early
functional rehabilitation or cast immobilization for the postoperative
management of acute Achilles tendon rupture? A meta-analysis of randomized controlled
trials.
functional rehabilitation or cast immobilization for the postoperative
management of acute Achilles tendon rupture? A meta-analysis of randomized controlled
trials.
McCormack R and Bovard J. Br J Sports Med. 2015. [Epub Ahead of Print].
Take
Home Message: A functional brace following surgery to repair an acute Achilles
tendon rupture is safe and results in higher patient satisfaction than
immobilization after surgery.
Home Message: A functional brace following surgery to repair an acute Achilles
tendon rupture is safe and results in higher patient satisfaction than
immobilization after surgery.
Acute Achilles tendon ruptures are
becoming more common among physically active individuals. While cast
immobilization following Achilles tendon rupture repair has been the standard
of care, there is a growing interest in early post-operative motion with
bracing and functional rehabilitation. If clinicians could gain a better
understanding of the outcomes after both treatments, they may be able to optimize
treatment outcomes and educate patients. Therefore, McCormack and colleagues
completed a meta-analysis of randomized controlled trials to assess which
postoperative treatment strategy is better. The authors completed an exhaustive
literature search and identified 11 articles. Studies were included if they
were randomized controlled trials comparing functional bracing and cast
immobilization for the treatment of acute Achilles tendon rupture repair. The
authors assessed each study for quality and risk of bias with the Downs and Black checklist. Studies were excluded if they did not
meet a minimum score of 19 out of 27 points on the checklist. Overall, the 11 studies
involved 570 patients (281 braced, 289 casted). All of these patients were
treated for an acute Achilles tendon rupture. No re-ruptures were included. The
authors found no difference between treatments with regards to either return to
activity/employment or the rate of return to activity/employment. However, 5 of
the 6 studies that measured rate of return to activity/employment noted that
the bracing group returned to activity/employment faster than patients in the
casting group but this was not statistically significant. Subjectively,
patients in the bracing group were 3 times more likely to be satisfied with
their outcomes following treatment than patients in the casting group. Finally,
the 2 treatment groups did not differ with regards to the number of
complications following treatment.
becoming more common among physically active individuals. While cast
immobilization following Achilles tendon rupture repair has been the standard
of care, there is a growing interest in early post-operative motion with
bracing and functional rehabilitation. If clinicians could gain a better
understanding of the outcomes after both treatments, they may be able to optimize
treatment outcomes and educate patients. Therefore, McCormack and colleagues
completed a meta-analysis of randomized controlled trials to assess which
postoperative treatment strategy is better. The authors completed an exhaustive
literature search and identified 11 articles. Studies were included if they
were randomized controlled trials comparing functional bracing and cast
immobilization for the treatment of acute Achilles tendon rupture repair. The
authors assessed each study for quality and risk of bias with the Downs and Black checklist. Studies were excluded if they did not
meet a minimum score of 19 out of 27 points on the checklist. Overall, the 11 studies
involved 570 patients (281 braced, 289 casted). All of these patients were
treated for an acute Achilles tendon rupture. No re-ruptures were included. The
authors found no difference between treatments with regards to either return to
activity/employment or the rate of return to activity/employment. However, 5 of
the 6 studies that measured rate of return to activity/employment noted that
the bracing group returned to activity/employment faster than patients in the
casting group but this was not statistically significant. Subjectively,
patients in the bracing group were 3 times more likely to be satisfied with
their outcomes following treatment than patients in the casting group. Finally,
the 2 treatment groups did not differ with regards to the number of
complications following treatment.
Overall, functional bracing following
acute Achilles tendon rupture repair is as safe as cast immobilization. Furthermore,
while functional bracing failed to offer faster return to activity/employment,
patients treated with functional bracing reported being more satisfied.
Therefore, functional bracing is safe and subjectively more effective than cast
immobilization. Unfortunately, while all studies scored 19 or more points on
the Down and Black checklist the authors offered little information about the
quality of the individual studies. This information would help clinicians make
a more informed decision and indicate if we need more studies. Until more
information on study quality is reported the current meta-analysis suggests
that clinicians can consider functional bracing as a viable treatment option
for acute Achilles tendon rupture repair.
acute Achilles tendon rupture repair is as safe as cast immobilization. Furthermore,
while functional bracing failed to offer faster return to activity/employment,
patients treated with functional bracing reported being more satisfied.
Therefore, functional bracing is safe and subjectively more effective than cast
immobilization. Unfortunately, while all studies scored 19 or more points on
the Down and Black checklist the authors offered little information about the
quality of the individual studies. This information would help clinicians make
a more informed decision and indicate if we need more studies. Until more
information on study quality is reported the current meta-analysis suggests
that clinicians can consider functional bracing as a viable treatment option
for acute Achilles tendon rupture repair.
Questions for Discussion: Would you advocate for patients to be put in a functional brace after an acute Achilles tendon rupture repair? Considering that there is no difference between
return to activity/employment, why would you advocate one over
the other as a clinician in your current setting?
return to activity/employment, why would you advocate one over
the other as a clinician in your current setting?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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McCormack, R., & Bovard, J. (2015). Early functional rehabilitation or cast immobilisation for the postoperative management of acute Achilles tendon rupture? A systematic review and a meta-analysis of randomised controlled trials British Journal of Sports Medicine DOI: 10.1136/bjsports-2015-094935