Successful Treatment of Recalcitrant Plantar Fasciitis and Achilles Tendonitis using Platelet-Rich Plasma (PRP) Injection, Short and Intermediate Results

Category:

Basic Sciences/Biologics; Hindfoot

Introduction/Purpose:

PURPOSE: To identify is PRP is an effective alternative to surgery to decrease pain and increase activities for patients with recalitrant plantar faciiitis and Achilles tendonitis/tendonosis after failing greater than 6 months of appropriate conservative treatment. INTRODUCTION: PRP is thought to stimulate the body's natural mechanism of growth factors to promote healing of tissues. This is thought to occur through PRP transforming a chronic inflammatory degenerative process into a 'fresh' inflammatory process. Patients who undergo surgery for recalcitrant plantar fasciitis and Achilles tendonitis/tendonosis often have extended recovery time which can adversely affect employment status and lifestyle activities. The senior author began to use PRP is his orthopedic practice in 2015 as an alternative to surgery for patients with recalcitrant plantar fasciitis and Achilles tendonitis.

Methods:

From 2015 to 2020, patients with recalcitrant plantar fasciitis or Achilles tendonitis (symptoms >6 months and who had failed appropriate conservative measures) were given the choice to proceed with continued non-operative care vs. surgical intervention vs. a one-time PRP injection. All patients reported substantial pain affecting ADLs and recreational activities. All patients underwent preoperative MRI. Only patients with degenerative changes in the painful area on MRI were considered elegible for study inclusion. Informed consent was obtained for all participants prior to PRP injection. Subjects underwent a single PRP injection using a commercially avaialble FDA approved office based PRP centrifuge system. All PRP injections were performed by the senior author without ultrasound guidance using anatomical landmarks and the patient's maximum area of tenderness. Patient subjective assessments of success/failure of the injection and percentage of pain relief using VAS were recorded at 6-8 weeks and > 1 year post injection.

Results:

89 PRP injections were performed on 88 patients (33 male/56 female). The Visual Analog Scale (VAS) was used to evaluate the treatment effectiveness along with the patient's subjective description of their improvement. Initial success was defined as >=50% pain decreased at 6-8 weeks post-injection. 55/89 subjects experienced relief >=50% at 6-8 weeks (overall 62% success rate). The average VAS improvement at 6-8 weeks was 67% for Achilles and 72% for plantar fasciitis (PF). 70 patients were available for intermediate follow-up (either in person or telephone) at an average of 27 months post-injection (range 13 - 41 months). For patients reporting >=50% continued pain relief, average VAS improvement was 83% for Achilles and 89% for PF. No patients with initial relief >=50% at 6-8 weeks had recurrent/worsened symptoms at intermediate follow-up. Patients with >=50% relief at 6-8 weeks trended toward further decreased pain over the next 12-24 months.

Conclusion:

This prospective case series study shows promising support of the short-term and intermediate-term effectiveness of PRP injection as a non-surgical treatment option for patients experiencing chronic recalcitrant plantar fasciitis and Achilles tendonitis. These results not only show a significant percentage of patients were able to avoid surgery with short term improvement in their symptoms, but the study also revealed that patients who experienced greater than 50% pain relief within the first 6 weeks after PRP injection, also showed continued improvement in their symptoms long term.

Arthroscopic Surgical Technique for Lateral Ankle Ligament Instability

In the past several years, arthroscopic repair of the lateral ankle ligaments has grown because it has shown comparable results with the traditional open Brostrom-Gould procedure. In addition, arthroscopic repair allows reduced swelling and cosmesis. This article discusses the authors' technique for lateral ankle instability, with published data supporting biomechanical equivalency to the standard open Brostrom-Gould procedure. An optional internal brace can provide further strength to the repair and lead to a quicker recovery. Arthroscopic repair both with and without the internal brace have shown positive clinical outcomes for patients as well as high satisfaction rates.

Technique for Arthroscopic Deltoid Ligament Repair With Description of Safe Zones

Level V, expert opinion.

Arthroscopic Treatment of Ankle Instability: Brostrom

Over the last 10 years, significant advances have been made and successful techniques have now been developed that effectively treat ankle instability via the arthroscope.Currently arthroscopic lateral ligament repair techniques can be grouped into "arthroscopic-assisted techniques," "all-arthroscopic techniques," and "all-inside techniques." Recent studies have proven these arthroscopic techniques to be a simple, safe, and biomechanically equivalent, stable alternative to open Brostrom Gould lateral ligament reconstruction.

Biomechanical Analysis of an Arthroscopic Broström Ankle Ligament Repair and a Suture Anchor-Augmented Repair

BACKGROUND

Secondary surgical repair of ankle ligaments is often indicated in cases of chronic lateral ankle instability. Recently, arthroscopic Broström techniques have been described, but biomechanical information is limited. The purpose of the present study was to analyze the biomechanical properties of an arthroscopic Broström repair and augmented repair with a proximally placed suture anchor. It was hypothesized that the arthroscopic Broström repairs would compare favorably to open techniques and that augmentation would increase the mean repair strength at time zero.

METHODS

Twenty (10 matched pairs) fresh-frozen foot and ankle cadaveric specimens were obtained. After sectioning of the lateral ankle ligaments, an arthroscopic Broström procedure was performed on each ankle using two 3.0-mm suture anchors with #0 braided polyethylene/polyester multifilament sutures. One specimen from each pair was augmented with a 2.9-mm suture anchor placed 3 cm proximal to the inferior tip of the lateral malleolus. Repairs were isolated and positioned in 20 degrees of inversion and 10 degrees of plantarflexion and loaded to failure using a dynamic tensile testing machine. Maximum load (N), stiffness (N/mm), and displacement at maximum load (mm) were recorded.

RESULTS

There were no significant differences between standard arthroscopic repairs and the augmented repairs for mean maximum load and stiffness (154.4 ± 60.3 N, 9.8 ± 2.6 N/mm vs 194.2 ± 157.7 N, 10.5 ± 4.7 N/mm, P = .222, P = .685).

CONCLUSIONS

Repair augmentation did not confer a significantly higher mean strength or stiffness at time zero.

CLINICAL RELEVANCE

Mean strength and stiffness for the arthroscopic Broström repair compared favorably with previous similarly tested open repair and reconstruction methods, validating the clinical feasibility of an arthroscopic repair. However, augmentation with an additional proximal suture anchor did not significantly strengthen the repair.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Arthroscopic suture anchor repair of the lateral ligament ankle complex: a cadaveric study

BACKGROUND

Operative treatment of mechanical ankle instability is indicated for patients with multiple sprains and continued episodes of instability. Open repair of the lateral ankle ligaments involves exposure of the attenuated ligaments and advancement back to their anatomic insertions on the fibula using bone tunnels or suture implants.

HYPOTHESIS

Open and arthroscopic fixation are equal in strength to failure for anatomic Broström repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seven matched pairs of human cadaveric ankle specimens were randomized into 2 groups of anatomic Broström repair: open or arthroscopic. The calcaneofibular ligament and anterior talofibular ligament were excised from their origin on the fibula. In the open repair group, 2 suture anchors were used to reattach the ligaments to their anatomic origins. In the arthroscopic repair group, identical suture anchors were used for repair via an arthroscopic technique. The ligaments were cyclically loaded 20 times and then tested to failure. Torque to failure, degrees to failure, initial stiffness, and working stiffness were measured. A matched-pair analysis was performed. Power analysis of 0.8 demonstrated that 7 pairs needed to show a difference of 30%, with a 15% standard error at a significance level of α = .05.

RESULTS

There was no difference in the degrees to failure, torque to failure, or stiffness for the repaired ligament complex. Nine of 14 specimens failed at the suture anchor.

CONCLUSION

There is no statistical difference in strength or stiffness of a traditional open repair as compared with an arthroscopic anatomic repair of the lateral ligaments of the ankle.

CLINICAL RELEVANCE

An arthroscopic technique can be considered for lateral ligament stabilization in patients with mild to moderate mechanical instability.

Distal tibial osteotomies for the treatment of foot and ankle disorders

Distal tibial osteotomy is an effective treatment for a variety of pediatric and adult foot and ankle disorders. Exposure osteotomies provide access to the tibiotalar joint for such problems as talar body fractures and osteochondral lesions of the talus. The channel osteotomy provides improved access to posterior talar dome lesions, especially for the use of osteochondral autograft. Although technically demanding, the supramalleolar osteotomy can benefit many patients, including patients with residual clubfoot deformity, primary and secondary osteoarthritis, malunion, and physeal arrest.

Classification and treatment of plantar fibromatosis

A retrospective study of 18 patients (23 feet) with plantar fibromatosis who required surgical excision between January, 1991, and June, 1998, was performed. Subtotal plantar fasciectomy was performed to remove the tumor with a wide disease-free margin. 16 patients (21 feet) were interviewed and 14 patients (19 feet) were examined with an average followup of 36 months. Two patients (2 feet) with less than 12 months followup were excluded. Both subjective and objective evaluations and pre- and postoperative x-rays were reviewed to assess the alignment of the bony arch. There were nine males and nine females, age 49 years, average, at the time of diagnosis. Sixty-seven percent of patients had bilateral disease, and 28% had associated Dupuytren's contracture. There were 18 primary and five recurrent tumors. An operative staging system, I to IV, for plantar fibromatosis is presented which incorporates the extent of plantar fascia involvement, the presence of skin adherence, and the depth of tumor extension. The stage of the tumor correlated well with postoperative wound healing, skin necrosis, and recurrence. In fifteen of 21 feet, the patients were satisfied without reservations, and in three of 21 feet, they were satisfied with reservations. In 18/21 (86%) feet, the patient reported he/she would have surgery done again. There were two recurrent tumors. One was reoperated and the patient was disease free twelve months postoperatively. The other recurrence was asymptomatic 40 months postoperatively and required no treatment. One patient required an excision of a postoperative cutaneous neuroma. Eleven of 21 feet (52%) experienced delayed healing and of which four required a split thickness skin graft. Ten of the eleven feet with delayed wound healing and all four cases requiring a skin graft had a stage ill or IV tumor. Pre- and postoperative weightbearing radiographs revealed a slight decrease in the calcaneal pitch angle, navicular height, and medial cuneiform height indicating a decrease in the height of the medial longitudinal arch.

Treatment of acquired adult planovalgus deformities with subtalar fusion

A retrospective review was conducted of isolated subtalar arthrodeses performed on 32 adults (34 fusions) between August 1990 and September 1993. Each fusion was performed using a single large cannulated lag screw through the talar neck. The American Orthopaedic Foot and Ankle Society standard clinical rating system for the ankle and hindfoot was used to assess outcome. Patients answered subjective questions based on the scale. Followup examination was done to evaluate clinically and radiographically each patient's foot and ankle according to the scale. Average patient age was 53 years (range, 27-80 years). Average followup was 30.8 months (range, 16-55 months). Twenty-four patients answered the subjective questions, and the average subjective score was 47 of a maximum 60 points (range, 9-60 points). Clinical data from 17 patients showed an average objective score of 30 of a maximum 34 points (range, 25-34 points). The average total score was 77 of a maximum 94 possible points (range, 34-94 points). Forty-two percent of the patients indicated a 100% improvement, 42% a 75% improvement, and 16% a 50% improvement. Eighty-three percent stated they definitely would have the procedure again. Results indicate that subtalar arthrodesis is an effective treatment for adult patients with pain and disability secondary to acquired planovalgus, posttraumatic, and inflammatory conditions of the hindfoot. In addition, the American Orthopaedic Foot and Ankle Society standard rating system of the ankle and hindfoot corresponds to clinical outcome.