SLR - December 2019 - Zach J. Lubek
Reference: Zhao E, Carney D, Chambers M, Ewalefo S, Hogan M. The Role of Biologic in Foot and Ankle Trauma – A Review of the Literature. Curr Rev Musculoskelet Med. 2018 Sep 11(3); 495-502.Scientific Literature Review
Reviewed By: Zach J. Lubek, DPM
Residency Program: Regions Hospital / Health Partners Institute – St. Paul, MN
Podiatric Relevance: Trauma associated musculoskeletal injuries are a common condition seen and treated by foot and ankle surgeons. Often, such injuries along with medical and social factors can predispose patients to poor healing. The use of biologics as an adjunctive healing measure has been increasingly popular with reports of improved outcomes. Such options provide foot and ankle surgeons with a supplemental tool to aid in healing. This study reviews some of the most recent literature which evaluates the impact and role of various biologics used in foot and ankle trauma.
Methods: A level II systematic review of the literature from the previous five years was analyzed. Orthrobiologic categories that were assessed included bone morphogenic protein and platelet-derived growth factor, hyaluronic acid and scaffolds, bone allografts and bone graft substitutes, platelet-rich plasma, bone marrow aspirate concentrate and demineralized bone matrix. Conclusions for each biologic category were then summarized based on a focused search of the most recent literature.
Results: Bone morphogenic protein and platelet-derived growth factors are used off label for foot and ankle trauma but indicate a positive role in ankle arthrodesis and bony non-unions. Hyaluronic acid/scaffold-based therapy primarily target articular cartilage. Multiple studies have found scaffolds to significantly improve AOFAS hindfoot scores for treating osteochondral lesions (OCLs). Hyaluronic acid has recently been compared with PRP for treating OCLs, both improved AOFAS scores, but PRP was found to be more significant. Bone allografts/bone graft substitutes studies have mainly focused on calcaneal fractures. Findings have shown no significant difference in functional scores between using vs. not using allografts, and therefore conclude their use is based on surgeon preference. Studies evaluating demineralized bone matrix for foot and ankle use have shown inconsistency regarding type, application and evaluation. However, benefit has been shown for its use in OCLs and Jones fractures. Platelet-rich plasma (PRP) studies have focused on soft-tissue injuries – findings suggest benefit in aiding conservative management of Achilles tendon injuries and ankle sprains. Overall the literature findings of PRP are not clear.
Conclusions: The authors concluded that although there is a wealth of biologic materials available for both surgical and nonsurgical management of foot and ankle trauma, more focused studies are needed to document their effects and standardize their use. Overall, this review helps to summarize the various biologic products available to foot and ankle surgeons. Current literature evaluating these products has shown promising early results and suggests their use may be increasingly beneficial to patient outcomes. Foot and ankle surgeons should be aware of biologic options, early results, and further consider using these biologic products to their advantage in the setting of trauma. To improve our understanding of these products, more research will be required to determine optimal dosage, frequency, timing and delivery.