Medical Miracles - Incomplete Stress Fracture Talar Neck:
Treatment with autologous platelet concentrate injection:
Dr. Harvey Leflcowitz, D.P.M., D.A.B.P.S.
Formatted by Brandi Keyosky
50-year-old female with right ankle pain for approximately two months. Patient may have injured her foot from walking over a long period of time during the month of December, 2007. Patient did not report any overt injury other than the increased walking in the mall during the holiday season of December.
Patient Symptoms & Signs:
- Pain over the anterior lateral ankle mortise and talar neck area
- No instability on range of motion, palpable click on supination and pronation
- Marked pes planus and history of synovitis and difficulty with healing
MM Diagnosis - 2/28/08 (Figure 1):
Incomplete stress fracture of talus specifically at the talar neck. Review of scans reveals obvious lack of blood flow to the head of the talus while the body is well perfused on T2 weighted images. Concern for osteonecrosis of the talar head concerning the fracture line going through the nutrient artery of the talar neck. Posterior tibial tenosynovitis secondary to talar neck injury.
Thought and Rationale:
Due to patient's previous history of difficulty with healing from prior surgical procedures in the foot and anide, as well as the wrist and various other areas of her musculoskeletal system, recoimnendations and decision for use of PRP along with external bone stimulator and immobilization was recommended and followed through.
Description of Procedure - 3/11/08:
Patient presented with chronic delayed union of the right talus, which had been present now for approximately three months. A total ankle block was performed, and under ultrasound guidance 3.3 cc of hemocyte tissue matrix was implanted into the sinus tarsi laterally to the talar neck and dorsally to the talar neck. Patient was instructed to refrain from taking all of her NSAIDS and only to use Tylenol. She was placed into a below-knee AirWalker, and an external bone stimulator from FBI was ordered.
3/18/08 - The patient received her EBI bone stimulator and was trained appropriately.
4/1/08 - The patient continued to have a stabbing type pain and having used the FBI bone stimulator for 11 hours/day x 13 days with 0 unused days.
4/8/08 - We prescribed a Roll-A-Bout for the patient to remain essentially nonweightbearing, as our concern with healing continued. In addition, she was put on had used her external bone stimulator 40 days with 11.4 hours/day and continued to guard the area with the Cam Walker and the EBI unit. Our thought process was that she might require another APC should the talar neck fracture not heal. Our main concern was the fact that the fracture was traversing the nutrient artery in the talar neck. We previously recommended the patient go for bone density testing, which had been performed by her primary care doctor with the results indicating osteopenia with increased risk for fracture.
Repeat Mill - 5/20/08 (Figure 2):
Revealed marked improvement and healing of the edema and stress fracture of the talus since previous examination. 12 weighted images are consistent for the body, neck and head of the talus, being well perfused. Patient continued to use her external bone stimulator with 61 days x 11.22 hours/day used. She remains in an AirWalker for several more weeks, and we anticipate complete recovery (see copies of before and after MRIs).
Patient Follow-up - 6/1 7/08:
She is returned to shoes and has minimal pain. APC enabled neovascularization into the head of the talus.
Incomplete stress fracture of the talus with lack of blood flow to the head of talus
||Fig. 2 (5/20/08)
Well perfused, healing talus
Autologous platelet concentrate injections can be an effective minimally invasive treatment on stress fractures and enables neovascularization into bones. The Harvest SmartPRep® process for concentrating autologous platelet rich plasma is a fairly simple outpatient procedure.