Ultrasound-guided platelet-rich plasma injections for the treatment of common peroneal nerve palsy associated with multiple ligament injuries of the knee

Abstract

Purpose

Peroneal nerve palsy in traumatic knee dislocations associated with multiple ligament injuries is common. Several surgical approaches are described for this lesion with less-than-optimal outcomes. The present case represents the application of plasma rich in growth factors (PRGF) technology for the treatment of peroneal nerve palsy with drop foot. This technology has already been proven its therapeutic potential for various musculoskeletal disorders. Based on these results, we hypothesized that PRGF could stimulate the healing process of traumatic peroneal nerve palsy with drop foot.

Methods

The patient was a healthy 28-year-old man. He suffered peroneal nerve palsy with drop foot after multiple ligament injuries of the knee. PRGF was prepared according to the manufactured instruction. Eleven months after the trauma with severe axonotmesis, serial intraneural infiltrations of PRGF were started using ultrasound guidance. The therapeutic effect was assessed by electromyography (EMG), echogenicity of the peroneal nerve under ultrasound (US) and manual muscle testing.

Results

Twenty-one months after the first injection, not complete but partial useful recovery is obtained. He is satisfied with walking and running without orthosis. Sensitivity demonstrates almost full recovery in the peroneal nerve distribution area. EMG controls show complete reinnervation for the peroneus longus and a better reinnervation for the tibialis anterior muscle, compared with previous examinations.

Conclusion

Plasma rich in growth factors (PRGF) infiltrations could enhance healing process of peroneal nerve palsy with drop foot. This case report demonstrates the therapeutic potential of this technology for traumatic peripheral nerve palsy and the usefulness of US-guided PRGF.

Level of evidence

V.

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References

  1. 1.

    Andia I, Sánchez M, Maffulli N (2011) Platelet rich plasma therapies for sports muscle injuries: any evidence behind clinical practice? Expert Opin Biol Ther 11:509–518

    PubMed  Article  Google Scholar 

  2. 2.

    Anitua E, Orive G (2012) Endogenous regenerative technology using plasma-and platelet-derived growth factors. J Control Release 57:317–320

    Article  Google Scholar 

  3. 3.

    Anitua E, Sánchez M, Orive G (2010) Potential of endogenous regenerative technology for in situ regenerative medicine. Adv Drug Deliv Rev 62:741–752

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Anitua E, Sánchez M, Zalduendo MM et al (2009) Fibroblastic response to treatment with different preparations rich in growth factors. Cell Prolif 42:162–170

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Berry H, Richardson PM (1976) Common peroneal nerve palsy: a clinical electrophysiological review. J Neurol Neurosurg Psychiatry 39:1162–1171

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  6. 6.

    Dubuisson A, Kline DG (1992) Indications for peripheral nerve and brachial plexus surgery. Neurol Clin 10:935–951

    CAS  PubMed  Google Scholar 

  7. 7.

    Dvali L, Mackinnon S (2003) Nerve repair, grafting, and nerve transfers. Clin Plast Surg 30:203–221

    PubMed  Article  Google Scholar 

  8. 8.

    Elgazzar RF, Mutabagani MA, Abdelaal SE et al (2008) Platelet rich plasma may enhance peripheral nerve regeneration after cyanoacrylate reanastomosis: a controlled blind study on rats. Int J Oral Maxillofac Surg 37:748–755

    CAS  PubMed  Article  Google Scholar 

  9. 9.

    Emel E, Ergün SS, Kotan D et al (2011) Effects of insulin-like growth factor-I and platelet-rich plasma on sciatic nerve crush injury in a rat model. J Neurosurg 114:522–528

    CAS  PubMed  Article  Google Scholar 

  10. 10.

    Farrag TY, Lehar M, Verhaegen P et al (2007) Effect of platelet rich plasma and fibrin sealant on facial nerve regeneration in a rat model. Laryngoscope 117:157–165

    PubMed  Article  Google Scholar 

  11. 11.

    Guadilla J, Fiz N, Andia I et al (2012) Arthroscopic management and platelet-rich plasma therapy for avascular necrosis of the hip. Knee Surg Sports Traumatol Arthrosc 20:393–398

    PubMed  Article  Google Scholar 

  12. 12.

    Highet WB, Holmes W (1943) Traction injuries to the lateral popliteal nerve and traction injuries to peripheral nerves after suture. Br J Surg 30:212–233

    Article  Google Scholar 

  13. 13.

    Hu J, Zou S, Tang Z et al (2003) Response of Schwann cells in the inferior alveolar nerve to distraction osteogenesis: an ultrastructural and immunohistochemical study. Int J Oral Maxillofac Surg 32:318–324

    CAS  PubMed  Article  Google Scholar 

  14. 14.

    Johnson ME, Foster L, DeLee JC (2008) Neurologic and vascular injuries associated with knee ligament injuries. Am J Sports Med 36:2448–2462

    PubMed  Article  Google Scholar 

  15. 15.

    Kanje M, Skottner A, Sjöberg J (1990) Insulin-like growth factor I (IGF-I) and regeneration of the sciatic nerve of the rat. Restor Neurol Neurosci 1:211–215

    CAS  PubMed  Google Scholar 

  16. 16.

    Mei-Dan O, Lippi G, Sánchez M et al (2010) Autologous platelet-rich plasma: a revolution in soft tissue sports injury management? Phys Sportsmed 38:127–135

    PubMed  Article  Google Scholar 

  17. 17.

    Moir MS, Wang MZ, To M et al (2000) Delayed repair of transected nerves: effect of brain-derived neurotrophic factor. Arch Otolaryngol Head Neck Surg 126:501–505

    CAS  PubMed  Article  Google Scholar 

  18. 18.

    Monahan TJ (2003) Treatment of nerve injuries in the multiple-ligament-injured knee. Oper Tech Sports Med 11:208–217

    Article  Google Scholar 

  19. 19.

    Padua L, Martinoli C, Pazzaglia C et al (2012) Intra-and internerve cross-sectional area variability: new ultrasound measures. Muscle Nerve 45:730–733

    PubMed  Article  Google Scholar 

  20. 20.

    Plancher KD, Siliski J (2008) Long-term functional results and complications in patients with knee dislocations. J Knee Surg 21:261–268

    PubMed  Article  Google Scholar 

  21. 21.

    Sánchez M, Anitua E, Orive G et al (2009) Platelet-rich therapies in the treatment of orthopaedic sport injuries. Sports Med 39:345–354

    PubMed  Article  Google Scholar 

  22. 22.

    Sánchez M, Fiz N, Azofra J et al (2012) A randomized clinical trial evaluating plasma rich in growth factors (PRGF-Endoret) versus hyaluronic acid in the short-term treatment of symptomatic knee osteoarthritis. Arthroscopy 28:1070–1080

    PubMed  Article  Google Scholar 

  23. 23.

    Sánchez M, Guadilla J, Fiz N et al (2012) Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip. Rheumatology (Oxford) 51:144–150

    Article  Google Scholar 

  24. 24.

    Sariguney Y, Yavuzer R, Elmas C et al (2008) Effect of platelet-rich plasma on peripheral nerve regeneration. J Reconstr Microsurg 24:159–167

    PubMed  Article  Google Scholar 

  25. 25.

    Sedel L, Nizard RS (1993) Nerve grafting for traction injuries of the common peroneal nerve: a report of 17 cases. J Bone Joint Surg Br 75:772–774

    CAS  PubMed  Google Scholar 

  26. 26.

    Tagliafico A, Bodner G, Rosenberg I et al (2010) Peripheral nerves: ultrasound-guided interventional procedures. Semin Musculoskelet Radiol 14:559–566

    PubMed  Article  Google Scholar 

  27. 27.

    Trumble TE, Vanderhooft E, Khan U (1995) Sural nerve grafting for lower extremity nerve injuries. J Orthop Trauma 9:158–163

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    White J (1986) The results of traction injuries to the common peroneal nerve. J Bone Joint Surg Br 50:346–350

    Google Scholar 

  29. 29.

    Yu W, Wang J, Yin J (2011) Platelet-rich plasma: a promising product for treatment of peripheral nerve regeneration after nerve injury. Int J Neurosci 121:176–180

    PubMed  Article  Google Scholar 

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Acknowledgments

The authors kindly appreciate the technical assistance and advice of Fernando Yanguela, MD, with the ultrasound-guided injections of PRP and Francisco Requena, MD, with the EMG.

Conflict of interest

Eduardo Anitua is currently scientist at BTI Biotechnology Institute, the company that has developed the PRGF-Endoret Technology. BTI has patents related with PRGF-Endoret Technology.

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Correspondence to T. Yoshioka.

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Sánchez, M., Yoshioka, T., Ortega, M. et al. Ultrasound-guided platelet-rich plasma injections for the treatment of common peroneal nerve palsy associated with multiple ligament injuries of the knee. Knee Surg Sports Traumatol Arthrosc 22, 1084–1089 (2014). https://doi.org/10.1007/s00167-013-2479-y

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Keywords

  • Plasma rich in growth factors
  • Platelet-rich plasma
  • Drop foot
  • Common peroneal nerve palsy
  • Knee
  • Ultrasound-guided injection