Foot, Ankle, Knee & Hip Surgery Update. What s s New. Platelet Rich Plasma (PRP) Platelet Rich Plasma Total Ankle Replacement.

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1 Foot, Ankle, Knee & Hip Surgery Update Geoffrey S. Landis D.O. April 29, 2010 Southwestern Conference on Medicine What s s New Platelet Rich Plasma Total Platelet Rich Plasma (PRP) Why- Need or Desire to heal injuries faster Need to find alternatives to surgical intervention to recalcitrant musculoskeletal problems 1

2 Repair Response Formation of a blood clot Degranulation of platelets Chemotaxis of inflammatory cells Activation of local progenitor cells Platelet Rich Plasma Help stimulate biologic factors Promote Healing Increase concentrations of autologous growth factors Enhance recruitment, proliferation and differentiation of cells in tissue regeneration PRP Basic Science Blood -150, ,000 platlets/ul PRP- 1,000,000/uL 3-55 fold increase in growth factor concentrations 2

3 PRP Basic Science Bioactive Factors Transforming growth factor- beta Platelet derived growth factor Insulin like growth factor Fibroblast growth factor Epidermal growth factor Vascular endothelial growth factor Endothelial cell growth factor PRP Basic Science Cytokines important roles is cell proliferation, chemotaxis, differentiation and angiogenesis Growth Factor Function Platelet-derived growth factor Vascular endothelial growth factor Transforming growth factor-β1 Fibroblast growth factor Epidermal growth factor Hepatocyte growth factor Insulin-like growth factor-1 Stimulates cell replication, angiogenesis, mitogen for fibroblasts Angiogenesis Key regulator in balance between fibrosis and myocyte regeneration Stimulates proliferation of myoblasts, angiogenesis Proliferation of mesenchymal and epithelial cells, potentiation of other growth factors Angiogenesis, mitogen for endothelial cells, antifibrotic Stimulates myoblasts and fibroblasts, mediates growth and repair of skeletal muscle 3

4 PRP Basic Science Dense Granules-Non growth factors that have effects on wound healing Contain Serotonin, Histamine, Calcium, Dopamine, Adenosine PRP Formulation Anticoagulated blood Additon of citrate to bind calcium/inhibit clotting cascade Centrifugation steps Separate RBC/WBC from plasma/platelets 2 nd spin- further concentration of platelets 4

5 PRP Uses Chronic Tendonopathy Bone Healing Acute Ligamentous Injuries Intraoperative Augmentation Lateral Epicondylitis Failure of standard PT, Brace,steroids MRI to confirm diagnosis Edwards&Calandruccio pts 79% success rate with PRP injection Mishra et al pts 15 PRP/5 controls PRP injections- 60% improvement 8 weeks, 81% at 6 months Controls lost in follow up Achilles Tendonopathy Theoretical potential Hypovascualarity and microtrauma Failure of PT/brace/NSAIDS Newest study Vos et al 54 pts Randomized to Saline vs PRP injection No significant difference at 6, 12, 24 wk follow-up 5

6 Plantar Fasciitis Not true tendon/ligament Chronic inflammatory symptoms Failure of standard treatments Barret and Erredge 9 patient case study 6/9 complete symptomatic relief at 2 months 1/3 failures better with 2 nd injection Patellar Tendonopathy Theoretical application Usual approach after failure of standard treatment is surgical debridement PRP offers alternative treatment option Animal studies only Promising results Bone Healing Platlets act as source of growth factors that stimulate bone formation Multiple studies using PRP in treatments of nonunions/ / delayed unions, primary fusions, osteotomies Wide variety of uses makes clear conclusions difficult Continued research promising 6

7 Acute Ligamentous Injuries High Profile athletes Safe/expeditied expeditied return to sport Good potential No clear published data yet Unpublished study reports return to play shorted 27% with single PRP injection for MCL knee injury in 22 pro soccer players Intraoperative augmentation First use of PRP type product Knee replacements Decrease Blood loss and promote wound healing Berghoff et al : 137 pts (61 control) Treatment group higher post op hemoglobin Shorter hospital stays Greater knee range of motion 7

8 Intraoperative Augmentation Achilles Tendon repair Sanchez et al- earlier ROM, return to running vs control group Rotator Cuff Repair Animal studies show increased healing at bone/tendon interface Current studies underway Chondral Lesions/Defects Gobbi et al 20 pts treat chondral defect with PRP collagen membrane 1 yr re-look arthroscopy/biopsy showed good healing with fibro/hyaline cartilage matrix Summary Goal: delivery of safe, autogenous material to enhance healing/recovery Initial small studies and animal studies suggest good potential Need for larger prospective randomized studies to further this treatment Ankle Arthritis OA RA Post traumatic Septic Neuropathic Osteonecrosis Gout 8

9 Ankle Arthritis - Prevalence 2% of population Knee -12% Hip 4% Ankle arthritis Treatments NSAIDS Brace Shoewear modifications Injections Surgery Surgical Management Synovectomy Removal of inflamed tissue in joint Spur Removal Allows for increased motion Osteotomy Deformity correction with joint space preservation 9

10 Arthroscopy Debride joint Evaluate cartilage Remove spurs Remove loose body Treat focal area of cartilage loss(microfracture) GOLD STANDARD Predictable results Stable pain free plantigrade foot Achieved thru Arthroscopy/ mini incision 80% or greater with good results ONLY 40% of normal motion of walking maintained Ankle Fusion Why Arthroplasty? Gait abnormality with arthrodesis Ipsilateral hindfoot DJD % Complications Nonunion up to 12% Pseudoarthrosis Infections Shoe modifications 10

11 History Phase I 1970 s high failure rate of constrained cemented implants Phase II 1980 s Buechal- Pappas/Agility Phase III 2005-present Salto Talaris InBone STAR Newer designs based on previous experience Better Patient selection Goal Treat Ankle DJD with good pain relief, maintanence of function, prevention of ipsilateral hindfoot DJD Patient Selection Contraindications Neuropathy Active infection Peripheral Vascular Disease Relative contraindications Young age Malalignment Osteonecrosis 11

12 Patient Selection Indications Older patients (>55) Ipsilateral DJD RA Minimal deformity Good pre-operative ROM Complications Wound healing 4% Deep infection -.5-3% Fracture - 5% Sensory Defecits 20% Stiffness RSD/CRPS - 3% Experienced Surgeon 50% less complications Complications Revision rate 12% Wound closure Wash out Exostectomy Polyethylene exchange Complete Revision Conversion to arthrodesis 6.3% 12

13 Clinical experience Saltzman et al:prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results Over 500 patients 24 month follow up Pain relief equal Functional ankle scores significantly better in arthroplasy group Clinical experience Saltzman et al: Treatment of isolated ankle osteoarthritis with arthodesis or the total ankle replacement: a comparison of early outcomes. 71 patients Follow up mean 4.2 years Pain scale outcomes significantly better in arthroplasty group Arthroplasty group with more surgical complications Clinical experience Haddad et al- Intermediate and long- term outcomes of total ankle arthroplasty and ankle arthrodesis.. A systematic review of the literature Meta-analysis analysis (88 total studies) Over 2000 patients 10 year survial rate of arthroplasty 77% Equivalent pain scores Revision rates 7% TAR vs 9% fusion 13

14 Clinical experience Bonnin et al Ankle function and sports activity after total ankle arthroplasty. 145 patient questionaires 5 yrs post-op op 75 % reply ankle normal or nearly normal Cycling, swimming, gardening, dancing, hiking, tennis, cross country and downhill skiing Impact activity not possible Clinical experience Wood et al- Total ankle replacement:medioum term results in 200 Scandanavian total ankle replacements. Prospective study 10 yr follow up 12 % revision rate Survivorship 93%@5 yrs; 10 yrs Summary TAR evolving Newer designs and experience leading to better results Best done by experienced surgeon Results equal to arthrodesis with better function in properly selected patients 14