Research Article

Effectiveness of Single, Double or Triple Platelets-Rich Plasma Injection in Foot and Ankle Soft Tissue Pathology

Syed Mohsin Ali*, Fatima Hussain Aleid and Alya Abdualrahman Alshammary

Consultant Orthopedic surgeon, Jhon Hopkins Aromco Health Care, Saudi Arbia

Submission: September 05, 2024; Published: September 16, 2024

*Corresponding author: Syed Mohsin Ali, Consultant Orthopedic surgeon, Jhon Hopkins Aromco Health Care, Saudi Arabia

How to cite this article: Syed Mohsin Ali*, Fatima Hussain Aleid and Alya Abdualrahman Alshammary. Effectiveness of Single, Double or Triple Platelets-Rich Plasma Injection in Foot and Ankle Soft Tissue Pathology. Ortho & Rheum Open Access J. 2024; 23(5): 556123. DOI: 10.19080/OROAJ.2024.23.556123

Abstract

Background: Platelets-rich plasma therapies (PRP) has picked up steam in orthopedic surgery. PRP is commonly used to accelerate soft tissue recovery in acute and chronic tendon disorders. When PRP is injected, platelets release numerous growth factors that enhance tissue repair mechanism. There is no strong evidence available regarding the number of injections required for an effective outcome.

Objectives

To evaluate the effectiveness of PRP injection therapy in various foot and ankle soft tissue disorders.

Effectiveness of single, double, or triple injections for higher satisfactory outcomes.

Materials and Methods: We retrospectively reviewed 19 patients, who were diagnosed with ankle and foot soft tissue disorder and treated with PRP injection. We set a protocol of three injections with 2 weeks gap to see the efficiency of each injection. We analyzed patient’s demographics, characteristics of their complaints, plan of management, number of injections and functional outcomes prior and post to injections. An inclusion and exclusion criteria were added.

Results/Expected Results: In this study, a total of 19 patients fulfilling the inclusion criteria completed the study. The participants’ mean age was 54.2 years. 57.9% (11 patients) were females and 42.1% (8 patients) were males. Overall, 58% (11 patients) had an excellent outcome with 2-3 injections and do not require any further management. However, 42% (8 patients) did not benefit from the injections and they require further management including surgery in 10.5% (2 patients). Main reason of intervention was pain.

Conclusion: The study found that 58% of patients had excellent to good outcomes after PRP injections, with no complications. We recommend a trial of more than one PRP injection before any surgical intervention. Due to lack of level, I study we recommend multi-center studies with a larger cohort of patients.

Keywords: PRP; Effectiveness; Accelerate; Repair; PRP injection therapy

Introduction

Platelet-Rich Plasma (PRP) is a product of the autologous blood plasma fraction with a platelet concentration greater than the baseline (before centrifugation). Fundamentally, beside high platelets, PRP consists of supra-physiological concentration of platelet-derived growth factors, chemokines, and cytokines that are needed to stimulate tissues repair and regenerative processes [1]. In the recent past, clinical application of platelet-rich plasma has gained popularity, particularly in orthopedics field, sport, and musculoskeletal medicine [2]. In orthopedic surgery, PRP is utilized to speed up soft tissue recovery in acute and chronic tendon injuries as well as improve bone fusion and fracture healing [3,4]. PRP is used to treat foot and ankle conditions, such as Achilles tendinopathy, ankle sprains, mid-foot arthritis, and plantar fasciitis, that are often managed conservatively [5,6]. Till to date, the literatures lack evidence supporting whether PRP injections brought considerable outcomes in a long-term management of foot and ankle diseases, and the use of it remains controversial among orthopedic surgeons [7]. Our objective of this study was: To evaluate the effectiveness of PRP injection therapy in various foot and ankle soft tissue disorders and effectiveness of single, double, and triple PRP injections.

Methodology

This is a retrospective study conducted to review the effectiveness of PRP injections in different foot and ankle soft tissue pathology. The study reviewed nineteen patients who have been diagnosed with different soft tissue pathologies of foot and ankle and treated with PRP injections starting from April 2022 up till June 2023. The protocol of injections that was followed consists of three injections with two weeks apart. If pain is improved after one or two injections, treatment is stopped. If pain continues after two injections, the third injection was given. Data was taken from patients charts. Those who had any bone pathology were excluded. We analyzed patient’s demographic data age, sex, diagnosis, duration of symptoms, number of injections, management, and the level of activity prior and after the injection. Ethical considerations were obtained from the hospital’s IRB and it was considered throughout the study.

Results

The data were collected and reviewed through the patient chart. A total of nineteen patients fulfilling the inclusion criteria completed the study questionnaire. Participants age range between 17 and 68 years with a mean age of 54.2 years. 57.9% (11 patients) were females and 42.1% (8 patients) were males. Patients’ diagnosis is an independent variable (Table 1). 26.3% (5 patients) were having symptoms for more than three years before starting platelet-rich plasma injection, 36.84% (7 patients) were having symptoms for a one to two year, while 36.84% (7 patients) were having symptoms for less than six months (Figure 1).

Regarding the treatment prior to injections, majority of patients 52.63% (10 patients) had have both multiple physiotherapy session and extracorporeal shockwave therapy, 15.789% (3 patients) had have only physiotherapy session and 10.53% (2 patients) had only have extracorporeal shockwave therapy. 21% (4 patients) had no treatment of any sort prior to injections (Figure 2). For the need of self-administrative drugs prior to the injection, 42.1% (8 patients) depend on medications on a daily basis. Another 42.1% (8 patients) had only used medications depending on their activities, 16% (3 patients) did not use any type of medication. After the PRP injections, a total of 58% (11 patients) stopped using the medication, 21% (4 patients) needed a regular pain medication and 21% (4 patients) only used it with activities (Figure 3 & 4).

Regarding the level of activity, before the injection, a predominant of 63.2% (12 patients) were restricted to household activities. 37% (7 patients) were able to do all kinds of activities but with symptoms. However, after the injection, 9 out of the 12 patients went back to their normal indoors and outdoors activities which make a total of 78.6% (16 patients) (Figure 5 & 6). Regarding the number of injections, only 63% (12 patients) have completed three injections. While 26.3% (5 patients) did not receive a third injection of PRP as they did not feel any improvement. While 10.5% (2 patients) stopped after the first injection due to satisfactory results, the second patient stopped due to aggravation temporary pain (Figure 7). Duration of treatment was fixed to all patients, with a predominant of six weeks for the total injections. Regarding overall satisfaction, 58% (11 patients) had a satisfactory outcome with the injections and do not require any further management. However, 42% (8 patients) did not benefit from the injections and require further management including surgery in 10.5% (2 patients) (Figure 8).

Discussion

Platelet-rich plasma was first described and applied clinically in hematology as a treatment of thrombocytopenia [8]. PRP therapy technique is still relatively new, yet it has already been used widespread in the medical field. Moreover, the preparation technique of PRP is rapid and easy, and the quality of PRP products may be assessed by determining the relative quantity of platelets, leukocytes, and growth factors [9]. When PRP injected, it allows biomolecules to be transported directly to the injured area [10]. PRP promotes wound healing and repair mechanisms through stimulation of vascular proliferation, vascular endothelial cell division, capillary growth, and collagen synthesis in the target site [11]. In orthopedics, literature revealed that PRP can improve the healing of bone and soft tissue, however, its therapeutic usefulness is still controversial.

Rachit Sharma, et al. 2023 compared the effects of PRP vs steroid injection in the treatment of planter fasciitis. Rachit Sharma found that the PRP injection revealed better outcomes than steroid injection in plantar fasciitis treatment over the course of six months [12]. Ravikant U, et al. 2022 conducted a comparative study of PRP, Corticosteroid, and Autologous Whole Blood Injection in Plantar Fasciitis. Author demonstrated that injecting PRP as a therapeutic strategy in planter fasciitis had longer and better benefits. Its action is gradual, but it is more effective over time [13]. Moreover, Bai WB, et al. 2023 concluded that PRP injection therapy has better medium and long-term clinical outcomes on chronic insertional Achilles tendinopathy than that of extracorporeal divergent shock wave [14].

Conversely, Arthur Vithran, et al. 2023 demonstrated no considerable evidence that PRP injections might improve patient functional and clinical outcomes for Achilles tendinopathy [10]. While previous studies showed lack of evidence supporting how many PRP injections yield the most effective functional outcomes in foot and ankle diseases. Parmanantham M, et al., 2023 found that multiple (two) PRP injections resulted in a higher reduction in pain severity compared to a single injection when treating early knee osteoarthritis [15]. In our study most of our patients benefit from the injections and require no further management. The highest success rate was achieved with three doses of PRP injection.

Conclusion

Patients had excellent to good outcomes after PRP injections with no adverse events. We recommend a trial of three injections as compared to a single injection. PRP can be considered as a part of initial management for foot and ankle soft tissue disorder prior to any surgical intervention. Because of the lack of randomized trial for PRP in foot and ankle surgery, we recommend for further level one studies with a larger patient cohort.

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