SLR - October 2012 - David Liss
Reference: Wei, LC, et al. 2012. Efficacy of Platelet-Rich Plasma combined with Allograft Bone in the Management of Displaced Intra-Articular Calcaneal Fractures: A Prospective Cohort Study. Journal of Orthopaedic Research. Wiley Online Library: Epub 12 March 2012.
Scientific Literature Review
Reviewed by: David Liss, DPM
Residency Program: Cedars Sinai Medical Center
Podiatric Relevance:
This study aimed to investigate if PRP would augment and improve the management outcomes of displaced intra-articular calcaneal fractures. Autograft use has long been considered to be the gold standard, however, its use has many inherent drawbacks and risks. Allograft with PRP could offer a cheap, convenient, and most importantly, equally efficacious alternative to autograft use.
Methods:
The study consisted of 276 fractures in 254 patients (44 bilateral, 148 male, 106 female). Average age was 46 years with a range of 18-60 years. Inclusion criteria included: closed displaced intra-articular fracture, no nerve or blood vessel injury, Sanders type II, and follow-up of at least three years. Patients were randomly divided into the autograft group, the PRP group and the allograft group by drawing lots, and all patients underwent ORIF with an anatomic standard non-locking plate. PRP preparation commenced intra-op after reduction. Removal of the implant was peformed at 12 months. At each post-op visit, a nurse blinded to the treatment used obtained scores based on the ankle-hind-foot scoring stystem of the American Orthopedic Foot and Ankle Society. Radiological assessments were done using a free application called e-rule system and evaluated Bohler's angle, Gissane's critical angle, and the length, width, and height of the calcaneal body at pre-op, post-op, and during follow-up visits.
Results:
At 12 months postoperatively, clinical and radiographic evaluation revealed that all fractures had healed without collapse of the posterior facet. Gissane's critical angle, as well as Bohler's angle and the height of the calcaneus displayed no statistically significant differences between the three groups. However, at 24 and 72 months post-op, there were statistically significant differences in radiographic anatomy between the allograft alone, and allograft plus PRP groups. No difference existed between the autogenous graft and PRP groups. No difference existed among the three groups with respect to functional scores of AOFAS, residual pain, walking activities, range of motion at the subtalar joint, or alignment of the rearfoot.
Conclusions:
Autograft use has many inherent risks including morbidity of the donor site, post-op pain, donor site infection as well as fracture and sensory disturbances. This study showed that PRP with allograft matched the autograft results radiographically, as well as clinically for displaced intra-articular calcaneal fractures. Radiographically, there was a significant difference in the proper anatomy when evaluated two years post-operatively when compared with the allograft-only group. It is believed that the multitude of growth factors in PRP may aid in recruitment of osteogenic progenitors at the fracture sites, as well as aid in their differentiation into osteoblasts. Addition of PRP may also aid in decreasing the immune response often associated with allograft use. The use of PRP with allograft could be considered a preferred alternative to the harvesting and use of autogenous bone graft in filling calcaneal bone defects after fracture.