BJSM - 2026-06-12 - Journal Article; Randomized Controlled Trial; Multicenter Study
Randomised three-armed trial investigation of the Copenhagen Achilles tendon Rupture Treatment Algorithm (CARTA) for individualised treatment of acute Achilles tendon rupture.
Toft M, Hansen MS, Vestergaard JD, Jenlar J, Pramming AK, Møller S, Nedergaard BSK, Kristensen MT, Simonsen LL, Viberg B, Hölmich P, Barfod KW
Topics
Key Takeaway
CARTA-guided individualized treatment reduced rerupture rates by 73% versus non-operative care (3% vs 11%, p=0.03) while performing 36% fewer surgeries than routine operative treatment, without improving the primary functional outcome (HRWT) at 12 months.
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Summary
This multicenter three-arm RCT tested whether ultrasound-guided individualized treatment (CARTA: surgery if <25% tendon overlap or ≥7% elongation) outperformed default operative or non-operative strategies for acute Achilles tendon rupture. The primary endpoint—Heel-Rise Work Test at 12 months—showed no significant between-group differences. However, CARTA reduced rerupture rates to 3% versus 11% non-operative (p=0.03), improved ATRS by 8 points (p=0.02), and improved Achilles Tendon Resting Angle by 2° (p=0.01) while reducing operative rate by 36% compared to routine surgical care.
Key Limitation
The primary outcome (HRWT) showed no between-group difference, meaning the trial's hypothesis of functional superiority was not proven, and the significant secondary outcomes risk type I error from multiple comparisons without pre-specified adjustment.
Original Abstract
OBJECTIVE
To evaluate whether individualised treatment using the Copenhagen Achilles Rupture Treatment Algorithm (CARTA) is superior to default operative or non-operative strategies.
METHODS
We conducted a multicentre, three-arm, randomised controlled trial. Adults with acute Achilles tendon rupture were randomised (1:1:1) to individualised CARTA, non-operative or operative treatment. In the CARTA arm, surgery was indicated if ultrasound showed<25% tendon overlap or ≥7% elongation. The primary outcome was the Heel-Rise Work Test (HRWT) at 12 months. Secondary outcomes included HRWT at 6 months, and at both 6 and 12 months, the Heel-Rise Height, Achilles tendon Total Rupture Score (ATRS), Tegner activity scale, Copenhagen Achilles tendon Length Measure, Achilles Tendon Resting Angle (ATRA) and complication recordings.
RESULTS
Between May 2018 and June 2023, 970 patients were screened; 300 were randomised (male/female 76%/24%, mean age 41 (SD 1)). At 12 months, data were available for 98 CARTA (64% operated), 100 non-operative and 97 operative patients. There were no significant between-group differences in HRWT at 12 months. However, CARTA significantly reduced rerupture rates by 73% compared with non-operative treatment (3% (95% CI) (1 to 8) vs 11% (6 to 19), p=0.03), improved ATRS by 8 points (1 to 15, p=0.02) and improved ATRA by -2° (-4 to -1), p=0.01). No difference between CARTA and operative treatment was found except 36% less underwent surgery.
CONCLUSION
Individualised CARTA did not improve functional outcomes based on the HRWT at 12 months, but among secondary outcomes, it reduced rerupture rates and improved patient-reported outcomes compared with non-operative treatment and with fewer surgeries than routine operative care.
TRIAL REGISTRATION NUMBER
NCT03525964.