SLR - February 2023 - Sanjna Sanghvi, DPM
Title: Platelet-rich plasma injection for Acute Achilles tendon ruptureReference: Keene DJ, Alsousou J, Harrison P, O'Connor HM, Wagland S, Dutton SJ, Hulley P, Lamb SE, Willett K. PATH-2 Trial group. Platelet-rich plasma injection for acute Achilles tendon rupture: two-year follow-up of the PATH-2 randomized, placebo-controlled, superiority trial. Bone Joint J. 2022 Nov;104-B(11):1256-1265.
Level of Evidence: Randomized, Placebo Control Trial, Level 1
Reviewed By: Sanjna Sanghvi, DPM
Residency Program: Hoboken University Medical Center – Hoboken, NJ
Podiatric Relevance: In the podiatric community, there has always been a discussion of surgical versus conservative treatment for acute Achilles tendon rupture. Contributing to that debate is the decision to augment healing with platelet-rich plasma (PRP), which has been known to accelerate healing potential in many musculotendinous disorders. The aim of this two-year randomized control study was to determine whether the administration of PRP influences conservative treatment of acute mid-substance Achilles tendon rupture.
Methods: This study was conducted across 19 hospitals in the United Kingdom on 230 adults (18+ years) that presented with an acute mid-substance tendon rupture within 12 days of injury. Inclusion criteria defined participants who were physically able to walk without assistance prior to injury and were treated solely conservatively. Exclusion criteria included any injury at the insertion of the Achilles tendon, any other major leg deformity, diabetes, autoimmune disease, hematological disorder, and any patient on systemic steroid medication or anticoagulation therapy. Patients were randomized via a centralized system and a cohort of patients were given PRP, with the other cohort receiving the placebo. In the PRP group, 4mL was injected into the tendon gap under ultra sound guidance and remaining 4mL of PRP was processed in the laboratory to assess the level of growth factors of each PRP draw. Using the MAGELLAN system all samples were analyzed for platelets, leucocyte, erythrocyte, and growth factor concentrations to evaluate consistency of injections. The main outcome measure was the Achilles Tendon Rupture Score (ATRS) at two-year mark; the ATRS scale measures pain, recovery goal attainment, and quality of life.
Results: Of the total 230 participants, 114 received PRP treatment and 116 received placebo. 84% of initially recruited patients participated in the two-year questionnaire. Mean age of participants was 46 years, and the mean ATRS score at the two-year interval was 82.2 in the PRP group and 83.8 in the placebo group, indicating no evidence of a significant difference between both groups. The study further evaluated the consistency of the treatment effect using ATRS for sub groups of age, BMI, smoking and athletic lifestyle; no difference was noted when evaluating these additional factors as well. Furthermore, the PRP lab samples evaluated via ELISA assays showcased no difference in platelet and growth factors concentrations; indicating the consistency of PRP samples among the participants.
Conclusions: Based upon this randomized control trial, it appears that PRP injection does not influence or benefit the long-term outcomes of conservatively treated mid-substance Achilles tendon ruptures. No ATRS scores were obtained prior to treatment for comparison, however, this study critically analyzed injected PRP samples to ascertain the cell counts, growth factor content, and platelet quality of each injection.