SLR - June 2023 - Inez Puente, DPM
Title: Endoscopic debridement for non-insertional Achilles tendinopathy with and without platelet-rich plasmaReference: Thermann H, Fischer R, Gougoulias N, Cipollaro L, Maffulli N. Endoscopic debridement for non-insertional Achilles tendinopathy with and without platelet-rich plasma. J Sport Health Sci. 2023 Mar;12(2):275-280. doi:10.1016/j.jshs.2020.06.012. Epub 2020 Jun 30. PMID: 32619656; PMCID: PMC10105028.
Level of Evidence: Level II
Scientific Literature Review
Reviewed By: Inez Puente, DPM
Residency Program: Baylor Scott & White, Temple, TX
Podiatric Relevance: Non-insertional achilles tendinopathy is an activity altering diagnosis that can persist for some patients despite conservative treatment. When treating a patient population that has attempted conservative therapy with little improvement, treatment adjuncts such as platelet rich plasma (PRP) injection can allow for faster rates of healing and increased functional scores without additional surgical hardware. The aim of this study is to determine if endoscopic debridement of achilles tendinopathy combined with intraoperative application of PRP is more effective than endoscopic debridement alone in improving patient functional outcomes.
Methods: The authors conducted a randomized controlled trial consisting of 36 patients who received a diagnosis of mid-substance achilles tendinopathy and failed conservative management for a minimum of 6 months. Patients were randomized into two groups, one underwent endoscopic debridement of the affected achilles tendon alone, while the other was treated with the same surgical debridement with the addition of intraoperative PRP injection. Patient evaluation was performed pre-operatively and at follow up dates of 6 weeks, 3 months, 6 months, and 12 months. Clinical outcome measures consisted of VAS scores and VISA-A questionnaires to evaluate pain, satisfaction, and functional performance. Objective data was collected via MRI evaluation of achilles tendon cross sectional area pre-operatively, 3 months, and 12 months post-operatively.
Results: Across both groups VAS and VISA-A scores showed improvement at each follow-up visit. VAS metrics for pain and function showed no significant differences between groups. In the PRP group, VAS satisfaction scores were significantly higher at 6 weeks (72.9 vs 44.6) and 3 months (78.0 vs 61.7) when compared to the control group. Though not statistically significant, the PRP group noted a smaller increase in tendon area compared to the control at the 3-month follow-up. Additionally, the PRP group on average had a tendon area that appeared considerably closer to pre-operative levels compared to the control at the 12-month mark.
Conclusions: This study confirms the efficacy of endoscopic debridement of midsubstance achilles tendinopathy in the setting of failed conservative therapy. However, it is inconclusive whether PRP injection has a detectable influence on long-term functional outcomes. Despite the small sample size and, exploratory nature of the study, the findings provide initial evidence for further testing to determine whether PRP injection provides benefit in the early stages of post-operative healing. Decreased tendon area at the 3-month and 12-month follow-up of the PRP group suggests that there are tangible benefits in the remodeling stage of tendon healing when compared to the control. These differences may very well be accounted for by the well-researched healing potential of platelet rich plasma.
When presented with a patient population that has undergone possibly years of failed conservative treatment, increased post-operative VAS satisfaction scores at 6 weeks and 3 months can inspire patient compliance in the post-operative setting. Based on these findings, further research can bring to light the opportunistic uses of platelet rich plasma in the correct patient setting.