Ankle pain and avascular necrosis of the talus

In this article I will focus on the problem of avascular necrosis in the ankle, mainly the talus bone in the ankle, and to suggest if various injections may be an effective treatment in helping you avoid ankle replacement or ankle fusion surgery.

People usually contact our office to discuss their ankle problems after they have had a long medical history of treatments following an acute ankle injury that turned into a chronic problem. Many people that contact me asking about their ankle pain tell me about a terrible accident or injury that they had in the past. Their ankle was damaged and surgery or long bouts of casting and immobilization was able to put their ankle back together as best as possible. Over the years these people managed along managing various bouts of pain and stiffness. At some point osteoarthritis developed in the ankle and their surgeon recommended an ankle replacement or an ankle fusion once years of splints, tapes, and anti-inflammatory medications, physical therapy and cortisone injections failed to help. Many declined these surgeries as they saw the surgery as the end of their activities and the welcoming point of a sedentary lifestyle.

Surgery is challenging

A late 2020 surgical paper (1) states plainly: “Avascular necrosis (AVN) of the talus remains a clinical challenge with suboptimal outcomes after treatment. In cases of extensive disease, the insufficient blood supply leads to a high rate of complications including non-union after surgical treatment. This, in conjunction with the development of premature adjacent arthritis represents a challenge for the treating surgeon. Nowadays, total ankle arthroplasty is a reasonable option for the treatment of end-stage ankle arthritis with improved short- and long-term outcomes.”

In looking for better options, the surgeons of this paper suggest “a (surgical) technique for patients with end-stage ankle arthritis associated to extensive talar osteonecrosis, and patients with prior total ankle replacement and talar component collapse due to AVN. This technique provides a more anatomic treatment for patients with severely deficient bone stock due to talar necrosis with ankle arthritis or failed ankle replacement. Nonetheless, evaluation of the outcomes at long-term is needed.”

What the surgeons describe is a very advanced from of ankle collapse. This collapse comes from the eventual failure of a previous ankle replacement and a collapse of the talus. The challenge is, is that there is not enough bone for a fusion.

PRP therapy injections for ankle arthritis

There is no narrative in this video

PRP treatments are injection treatments. The treatments are derived from your own healing and growth factors found in your blood. The treatment involves collecting a small amount of your blood and concentrating it in a centrifuge to separate the blood platelets from the red blood cells as opposed to white blood cells. The collected platelets are then injected into areas in and around the ankle to stimulate healing and regeneration to the soft tissue structures that stabilize the ankle.

An August 2021 paper in The Journal of foot and ankle surgery (2) summarizes PRP for ankle osteoarthritis treatments and its effectiveness in patients with ankle osteoarthritis.

“Ankle osteoarthritis can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. The aim (of this study) was to evaluate the efficacy and safety of a single intraarticular injection of platelet-rich plasma (PRP) for patients with ankle osteoarthritis.”

In this paper, the research team recruited patients who suffered with symptomatic ankle osteoarthritis for at least 6 months. These patients received a single injection of PRP into the painful  ankles.

What were the researchers looking for? In the 39 patients who completed the study, outcomes were:

  • The primary outcome was a decrease in pain.
  • Secondary outcomes were increased function, less disability, less medication usage, and the patient’s overall satisfaction with the treatment.

Study findings:

  • Significantly improvement was seen in pain scores at one, three, and six-month follow-ups.
  • Function improved, less disability was felt, medication usage dropped significantly.

The study conclusion: “(This) study showed promise for a single intraarticular injection of PRP in the treatment of ankle osteoarthritis.”

In the patients we see, typically one-treatment one injection of PRP can help many but it is not the complete treatment. In fact one study suggests that good results cannot be attained with two injections. In this study from October 2021 (3) doctors found: “Among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks.” Two injections may also not help a patient. However other doctors questioned this research. One group of doctors writing in response in the Journal of the American Medical Association wrote: (4) : “After review of the recent clinical trial1 examining platelet-rich plasma (PRP) injections for ankle osteoarthritis, we think there are several methodological concerns that make its concluding statement of “not supporting the use of PRP injections for ankle osteoarthritis,” without qualifiers, appear to be an overstatement.”

Others wrote that the patients of this study were not matched correctly. For example compared with patients in the placebo group, those in the PRP group had a higher body mass index, which is significantly associated with ankle osteoarthritis and worsening ankle symptoms. Second, a higher proportion of patients in the PRP group had more advanced stages of ankle osteoarthritis. (5)

PRP injection can be effective for arthritis and degenerative joint disease.

For many people, PRP treatments can help. This was suggested in a 2020 study in the Journal of orthopaedics.(6) Here are the research notes of this study:

“Osteochondral lesion of the talus is common among athletes and is a result of talar cartilage detachment with or without subchondral bone fragmentation after a traumatic event. Treatment strategies for Osteochondral lesion of the talus can be classified as reparative or replacement interventions, with (replacement) taking precedence. Recent studies show that the growth factors and bioactive components in platelet rich plasma (PRP) could improve cartilage regeneration. The prospect of using autologous blood to obtain a product that could enhance regeneration in damaged cartilage has been regarded as innovative, as it could circumvent the need for a replacement, and potentially join the ranks of first line reparative interventions against cartilage diseases. . .

 PRP improves joint function, and reduces pain in patients with Osteochondral lesion of the talus regardless of the method of implementation. In addition, inter-study comparison demonstrated that patients that received surgery along with PRP injections improved more than those that received PRP only. The studies that corroborate this conclusion have high levels of evidence with satisfactory methodological quality.”

Typically we try to repair the ankle without the surgery recommendation as surgery of course comes with its own challenges. Further many people that we see have already had surgery that did not produce the hoped for results.

Dr. Darrow treats the ankle

PRP’s physiological effects include:

  • Increasing tissue regeneration (tendon, ligament, soft tissue).
  • Decreasing inflammation.
  • Decreasing pain.
  • Increasing collagen (base component of connective tissue and cartilage).

Can PRP help you avoid surgery?

This is a question that is obviously often asked as many patients who visit us have a surgical recommendation. PRP treatment can be an effective treatment for ankle osteoarthritis and help people avoid surgery.

A study in The Journal of foot and ankle surgery (7) sought to answer this question:

“Currently, the conservative treatment of osteoarthritis is limited to symptomatic treatment, whose goal is to improve function and pain control. Ankle osteoarthritis is relatively uncommon, in contrast to osteoarthritis of the hip and knee, and the therapeutic options (both pharmacologic and surgical) are limited, with surgery providing poorer and less predictable results. The effectiveness of platelet-rich plasma injections for osteoarthritis is still controversial, especially so for ankle arthritis, owing to the lack of evidence in the present data.”

What the researchers set up was a study to evaluate the mid- to long-term clinical results (average follow-up of 17.7 months) for platelet-rich plasma injections in 20 patients (20 ankles) with ankle osteoarthritis. What they found was: “a strong positive effect for 4 platelet-rich plasma injections (injected once a week) on pain and function, with 80% of patients very satisfied and satisfied, and only 2 patients (10%) required surgery because of early treatment failure. These results suggest that the use of platelet-rich plasma injection is a valid and safe alternative to postpone the need for surgery.”

Realistic expectation of bone marrow derived stem cell therapy injections in helping patients with avascular necrosis in the ankle

There is research to suggest that stem cell therapy may help avascular necrosis. Two studies suggested stem cell therapy could make surgery more successful:

A study published in 2013 (8) reported: “Injection of MSCs (stem cells) with marrow stimulation (core decompression or microfracture into the talus which we do not do) treatment was encouraging in patients older than 50 years compared with patients treated with marrow stimulation treatment alone. Although still in the early stages of application, MSCs may have great potential in the treatment of osteochondral lesions of the talus in patients older than 50 years, and more evaluations of its effect should be performed.”

In a case report published (9) in 2018 indicated that core decompression surgery could be made more successful by treating with stem cell therapy and Platelet Rich Plasma Therapy.

Can we help with your ankle pain?

Generally speaking, if your ankle is not frozen or locked up with bone spurs from osteoarthritis and can rotate, even through the pain, then we can have a realistic expectation that platelet rich plasma injections can provide help. How much help? We can’t be sure until we do the examination. Please us the form to email me about your ankle pain and PRP for ankle osteoarthritis. Best of health to you.

Marc Darrow MD JD


References

1 Bejarano-Pineda L, DeOrio JK, Parekh SG. Combined Total Talus Replacement and Total Ankle Arthroplasty. Journal of Surgical Orthopaedic Advances. 2020 Jan 1;29(4):244-8.
2 Sun SF, Hsu CW, Lin GC, Lin HS, Chou YJ, Wu SY, Huang HY. Efficacy and Safety of a Single Intra-articular Injection of Platelet-rich Plasma on Pain and Physical Function in Patients With Ankle Osteoarthritis—A Prospective Study. The Journal of Foot and Ankle Surgery. 2021 Feb 3.
3 Paget LD, Reurink G, de Vos RJ, Weir A, Moen MH, Bierma-Zeinstra SM, Stufkens SA, Kerkhoffs GM, Tol JL, Goedegebuure S, Krips R. Effect of Platelet-Rich Plasma Injections vs Placebo on Ankle Symptoms and Function in Patients With Ankle Osteoarthritis: A Randomized Clinical Trial. JAMA. 2021 Oct 26;326(16):1595-605.
4 Barber MS, Manning T, Desai R. Platelet-Rich Plasma Injections vs Placebo for Patients With Ankle Osteoarthritis. JAMA. 2022 Feb 22;327(8):778-9.
5 Chu PJ. Platelet-Rich Plasma Injections vs Placebo for Patients With Ankle Osteoarthritis. JAMA. 2022 Feb 22;327(8):779-.
6 Yausep OE, Madhi I, Trigkilidas D. Platelet rich plasma for treatment of osteochondral lesions of the talus: a systematic review of clinical trials. Journal of orthopaedics. 2020 Mar 1;18:218-25.
7 Repetto I, Biti B, Cerruti P, Trentini R, Felli L. Conservative treatment of ankle osteoarthritis: can platelet-rich plasma effectively postpone surgery?. The Journal of Foot and Ankle Surgery. 2017 Mar 1;56(2):362-5.
8 Kim YS, Park EH, Kim YC, Koh YG. Clinical outcomes of mesenchymal stem cell injection with arthroscopic treatment in older patients with osteochondral lesions of the talus. The American journal of sports medicine. 2013 May;41(5):1090-9.
9 Nevalainen MT, Repo JP, Pesola M, Nyrhinen JP. Successful treatment of early talar osteonecrosis by core decompression combined with intraosseous stem cell injection: A case report. Journal of orthopaedic case reports. 2018 Jan;8(1):23.

 

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