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A Case Study on the Healing Potential of Platelet-Rich Plasma for Achilles Tendinopathy & Plantar Fasciitis
Stefano Militello DPM, Victor Nwosu DPM, Liane Watanabe DPM
Director: Anthony Benenati DPM
Conclusion:
Intro
Platelet-Rich Plasma is a portion of the plasma fraction of autologous
blood having a platlet concentration above baseline. PRP contains
(and releases through degranulation) several different growth factors
(cytokines) that stimulate healing of bone and soft tissue. PRP serves
as a growth factor agonist and has both mitogenic and chemotactic
properties. These growth factors include: transforming growth factor
(TGF-B), platelet-derived growth factor (PDGF), insulin-like growth
factor (IGF), vascular endothelial growth factor (VEGF), and
fibroblast growth factor-2 (FGF-2). The efficacy of growth factors in
healing various injuries and the physiological concentrations of those
growth factors within PRP are the hypothetical basis for the use of
PRP in tissue repair. The autologous nature of PRP distinguishes it
from recombinant growth factors. As an autologous preparation,
PRP is safer to use than allogenic or homologous preparations and is
free from concerns over transmissible diseases. In addition to its use
in the treatment of chronic skin and soft tissue ulcerations,
publications regarding its use include, peridontal and oral surgery,
maxillofacial surgery, orthopedic and trauma surgery, cosmetic and
plastic surgery, spinal surgery, heart bypass and burns.
Analysis & Discussion
Achilles tendinopathy is a condition encountered by individuals with activity levels
ranging from elite athletes to weekend-warriors and even the sedentary population.
Traditional therapeutic options for chronic Achilles tendinopathy include rest, ice, antiinflammatory medications, immobilization, physical therapy, and surgery. Platelet rich
plasma therapy is a treatment option that was historically first applied to cardiac and
maxillofacial surgeries. It has since been gaining use in many medical specialties such
as orthopedic surgery, plastic surgery, and podiatry.
PRP
b
Although the exact mechanism of action has yet to be understood, Zhang et al
demonstrated that PRP could promote the differentiation of tendon stem cells into
highly proliferative and active tenocytes with an abundant collagen production
capacity. Kajikawa et al pointed out that the blood flow to the tendon is only about
one-third of that to muscles; hence, the importance of circulation-derived cells for
tendon healing. Therefore, similar to the previous study mentioned, Kajikawa et al
focuses on the mesenchymal cells contained in the circulation which have the potential
for differentiation into reparative fibroblasts or tenocytes. Two significant points
reported include: (1) The circulation-derived cells temporarily exist in the wounded
area in the early phase of tendon healing, and (2) the proportion of circulation-derived
cells decreases with time. Therefore, Kajiwara et al hypothesized that the growth
factors in PRP would enhance tendon healing by (1) Activating the circulation-derived
cells, and (2) preventing their time-dependent decrease.
The purpose of this case study is to show the healing potential of the
Arthrex, Autologous Conditioned Plasm (ACP) system and the
injection of PRP on a 48-year-old female. We found extremely
favorable post injection results with the Arthrex ACP system.
Results, although only based on this one case, showed the Arthrex
ACP system is a viable option for patients that are suffering from
achilles tendinopathy, but want an alternative to surgical intervention.
Case Presentation & Method
48 y/o obese female with a history of fibromyalgia, hypoglycemia
and anxiety presents to the Benenati Foot and Ankle Care Center
with c/o left Achilles pain for 6 months duration. She also complains
of pain at the heel upon first waking in the morning. She relays that
her chosen profession of hairdresser has exacerbated her constant
throbbing and aching pain of 9/10 on PAS. Upon physical
examination there was pain upon palpation of the medial tubercle of
the calcaneus, pain upon palpation over the Achilles tendon
approximately 5 cm proximal to the insertion of the tendon, and pain
upon active pantarflexion against dorsiflexory pressure. MRI
revealed an abnormally thickened Achilles tendon distally, which is
compatible with Insertional Achilles Tendonitis. Prior conservative
treatment modalities of casting, custom orthotics and physical
therapy over a 6 month period were able to reduce her pain by 60%.
Generally, at this point in her treatment, surgical intervention would
have been rendered. However, her aforementioned co-morbidities
preclude her from being a surgical candidate.
Being that conservative measures had been exhausted, and surgical
intervention was not warranted, an injection with Arthrex ACP
platelet-rich-plasma was the best option at this juncture.
Upon
presentation to the Benenati Foot an Ankle Care Center having
avoided NSAID’s for the past 7 days. The Arthrex ACP kit was
opened and 3cc of anticoagulant citrate dextrose (ACD) was drawn
into the 20cc sryringe. Approximately 12 cc of blood was withdrawn
from the cubital vein of the pt using aseptic tecnique. The syringe
was then placed into the rotator bucket of the Arthrex centrifuge with
a counterweight in the opposite bucket. The centrifuge was run for 5
minutes, and the syringe was removed. A smaller Syringe was placed
into the larger one and 4ml of PRP was transferred to the smaller
syringe. This PRP is approximately 2 to 3 fold increase baseline.
An 18g needle was then placed on the syringe. The pt was placed
prone in an examination chair and 3 cc of PRP was injected into the
area of the Achilles tendon that corresponded to the tendinopathy and
1cc of PRP was injected into the medial plantar fascia. The pt was
then kept at rest for 10 minutes. The patient was allowed to weight
bear as tolerated with normal shoe gear. Post-injection management
included avoidance of both NSAID’s, and strenuous activity until her
next follow up appointment.
Background:
Platelet rich plasma, obtained by centrifuging and separating out the whole blood and
platelet poor plasma, contains higher concentrations of platelets than whole blood.
Thus, PRP therapy involves introducing high concentrations of the many growth
factors within platelets into the site of tendinopathy to facilitate morphologic healing.
Ultimately, injecting the platelet rich plasma directly into damaged tissue stimulates
new tissue growth and repair.
Results
The patient’s pain went from a
9/10 pre-injection, to a 1/10 two
weeks post-injection in the
Achilles, and a 6/10 to 0 /10 in the
plantar fascia. At 4 months post
injection, the patient has no pain in
the Achilles tendon and the plantar
fascia. The patient is able to
endure the demands of working on
her feet all day without the pain
that she had felt for several months
prior. She relates her decrease in
pain has allowed her to increase
her exercise regimen, thereby
improving her quality of life. The
patient is now completely satisfied
and pleasantly surprised at the
activity level that she has been
able to withstand.
Pros/Cons:
In addition to its convenient use in the outpatient setting, PRP can also be administered
intraoperatively as a more dense preparation referred to as platelet-rich fibrin matrix
(PRFM). Furthermore, the effects of PRFM can be localized to the site of injury by
being sutured (Delos et al). Another advantage of PRP is that it is derived from the
patient’s own blood which thus renders this therapy free of concerns about crossreactions, immunoreactions, and transmissible diseases. While there are theoretical
potential risks to PRP therapy, the most commonly encountered complication, postinjection pain, is one that can be easily managed.
Some theoretical complications to PRP therapy include tendon rupture and vascular
thrombosis/embolism. Also, the enhanced levels of growth factors and its subsequent
effects on progenitor cell proliferation and differentiation creates a theoretical concern
for an increase in risk of neoplasia. However, Delos et al states, “Growth factors are
physiologic proteins that act on the cell membrane rather than the nucleus with no
evidence of mutagenicity.” The more common risks are those found with any
injection such as local pain, bleeding, infection, and nerve injury.
Despite PRP therapy becoming an increasingly popular therapeutic modality, further
research and development are needed. Aside from the limited clinical data on efficacy
and the lack of a concrete molecular understanding, PRP therapy is lacking
standardization in the preparation process, procedure technique, and post-treatment
management.
Consistency between different PRP systems is lacking in regards to the following:
1. Amount of whole blood drawn
2. Length and amount of times of centrifugation
3. Amount of anticoagulant, acid citrate dextrose solution (ACD-A)
4. Amount or lack of activating agents such as calcium chloride or thrombin
5. Use of a sodium bicarbonate buffer
6. Multitude of Platelets above baseline
Differences in the execution of the PRP therapy technique include:
1. Use of ultrasound guidance
2. Single or multiple injection sites with or without redirecting the needle
3. Length of time to remain in prone position after the injection is administered
4. Use and method of local anesthetic
Differences in the post-treatment management and rehabilitation include:
1. Weight-bearing status (full vs protected weight-bearing)
2. Type (stretching vs isometric vs eccentric exercises) and commencement
physiotherapy
Upon a 3cc PRP injection into the Achilles tendon and 1cc into the plantar
fascia with subsequent immediate full weight-bearing status without limitations
on activity, the patient’s pain was significantly reduced in both the Achilles
tendon and plantar fascia. Consequently, the localized positive effects of the
PRP treatments have led to an overall improved quality of life as she was able
to work pain-free and resume an exercise regimen.
Despite this positive outcome, there are limitations to this case study. Most
obviously, only one patient and a single PRP system was included. Also,
ultrasound guidance was not utilized to ensure accuracy of the injection.
Lastly, the results are purely subjective as a post-treatment MRI was not
performed due to the financial burden this would place on the patient.
Ultimately, this case report introduces the emerging use of PRP therapy in the
clinical podiatric setting, however, its level of evidence is V. Thus, considering
the increasing popularity of PRP therapy, a randomized controlled trial is
definitely in need.
Acknowledgments
Special thanks to St. John Macomb/Oakland Hospital, The St. John
Macomb Hospital Staff, Luke Conlon of Arthrex, Dr. Benenati, Dr.
Shaw, and The Benenati foot care staff.
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