SLR - October 2023 - Weisel
Title: Platelet-Rich Plasma Injections for the Treatment of Ankle OsteoarthritisReference: Paget LDA, Reurink G, de Vos RJ, Weir A, Moen MH, Bierma-Zeinstra SMA, Stufkens SAS, Goedegebuure S, Krips R, Maas M, Meuffels DE, Nolte PA, Runhaar J, Kerkhoffs GMMJ, Tol JL. Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis. Am J Sports Med. 2023 Aug;51(10):2625-2634.
Level of Evidence: Level of Evidence, 1
Scientific Literature Review
Reviewed By Lauren Weisel, DPM
Residency Program: Inova Fairfax Medical Campus, Falls Church, VA
Podiatric Relevance: Ankle osteoarthritis arises predominantly from previous ankle trauma (70-78% of cases) and often leads to significant debilitation for patients, resulting in arthrodesis for end-stage conditions due to limited treatment options. The increased popularity of regenerative medicine in orthopedics has yielded findings indicating a clinically significant improvement in knee osteoarthritis through platelet-rich plasma (PRP) injections over 6-12 months. Given the absence of prior research on the use of PRP for ankle osteoarthritis, this clinical trial assessed the efficacy of PRP injections in reducing pain and enhancing ankle function. This trial follows up on the authors' previous 26-week randomized control study on patients with ankle osteoarthritis, which revealed no between-group differences between PRP and placebo groups.
Methods: This 1-year follow up was a double-blinded, randomized, and placebo-controlled clinical trial performed across 6 centers in the Netherlands. 100 patients with ankle osteoarthritis (graded 2 on van Dijk classification and VAS >40mm during ADLs) were randomized into 2 treatment groups: intra-articular injections with PRP using Arthrex double-syringe PRP system (n=48) or saline placebo (n=52). At inclusion and 6 weeks, patients received 2 ultrasound-guided intra-articular ankle injections. Patients completed questionnaires at baseline, 6, 12, 26, 39, and 52 weeks generating the primary outcome measure: patient-reported AOFAS scores and secondary outcome measures: patient-reported assessments of pain, function, quality of life, and indirect costs. A sole coordinating research physician conducted all measurements, and the data was interpreted blindly.
Results: 2 patients (2%) were lost to follow-up. The unadjusted between-group differences for patient-reported AOFAS scores over 52 weeks was 4 points in favor of the placebo group. When adjusted for radiologic talar tilt, duration of ankle osteoarthritis symptoms, ankle range of motion, and height/weight, the between-group differences for patient-reported AOFAS scores over 52 weeks was -2 points in favor of the placebo group, with PRP Group having a mean score of 69 +/- 19 points versus 67 +/- 22 points for the Placebo Group. There were no statistically significant differences between the groups for improvement in any of the secondary outcome measures.
Conclusions: The authors concluded that PRP injections for post-traumatic ankle osteoarthritis lacked clinical efficacy in reducing pain and improving function over a year of treatment, contrary to the positive outcomes observed in PRP injections for knee osteoarthritis. The lack of improvement in outcome measures at 52 weeks for PRP injections versus placebo is consistent with the authors’ 26-week findings. Despite the statistically significant 52-week trial data, the conclusion’s validity is obscured by inherent methodological limitations, notably the small sample size (100 patients). While PRP injections did not achieve clinical efficacy in reducing ankle osteoarthritis symptoms, it is premature to dismiss the use of regenerative medicine as an option in a multi-modal approach for ankle arthritis treatment. Further research on combined effects with co-interventions like physical therapy could reveal PRP's value in a broader conservative approach. However, before resorting to regenerative options, other conservative treatments should be considered. PRP injections may prove effective as a supplementary or conservative treatment option, offering pain relief and functional enhancement prior to surgical interventions.