Use of Umbilical Cord Allograft in Achilles Tendon Surgery for Postoperative Pain Reduction in Diabetics: A Case Series

Brandon Brooks, DPM PGY-31; Kevin Pham, DPM PGY-42; Bradley Brooks, DO PGY-23; Brady Brooks, MSII4; James Henry, MSII5; Charles Kean, DPM1; Terria Madison, DPM1

Desert Foot, November 7th to November 10th in Phoenix, AZ

Case 1: Wound and Achilles Tendon DebridementPurpose Results

AffiliationsCharlie Norwood Veterans Affairs Medical Center, Augusta, GA1; The University of California, San Francisco (UCSF) Limb Preservation Fellowship, San Francisco, CA2 ; The University of South Alabama Hospitals, Mobile, AL3; The University of Pikeville -Kentucky College of Osteopathic Medicine, Pikeville, KY4; Barry University School of Podiatric Medicine, Miami Shores, FL5

This case series demonstrates that umbilical cord allograft is an effectivepain-reducing adjunctive treatment in three different Achilles tendon-relatedpathologies that required surgical intervention: a pressure ulceration withexposed Achilles tendon, a complete Achilles tendon rupture, and asymptomatic Haglund’s deformity.

Background

The Achilles TendonIn the U.S. alone, there are 33 million musculoskeletal injuries each year.1.Achilles tendon repairs account for 40% of all tendon repairs.2 The hightension placed on the Achilles tendon can result in posterior calcanealspurring. The small number of blood vessels per cross sectional areaposes a potential problem when it is exposed in a chronic ulceration.3

There are many new products being explored to further enhance tendonhealing and reduce postoperative pain.4

Umbilical Cord AllograftUmbilical Cord Allograft is a minimally manipulated, dehydrated, non-viable cellular allograft derived from the structure that protects the bloodvessels that carry essential nourishment and oxygenated blood to andfrom mother and fetus.5

This allograft is designed to supplement damaged integumental tissueand provide a protective environment for the healing process.5

Umbilical Cord Allograft = EpiCord® EpiCord® is a registered trademark of MiMedx Group, Inc., Marietta, GA

References1. James R, Kesturu G, Balian G, Chhabra AB. Tendon: biology, biomechanics, repair, growth factors, and evolving

treatment options. J Hand Surg Am 2008;33:102-112.2. Jozsa L, Kvist M, Balint B, et al. The role of recreational sport activity in Achilles tendon rupture. A clinical,

pathoanatomical, and sociological study of 292 cases. Am J Sports Med. 1989;17(3):338-43. doi:10.1177/036354658901700305.

3. Ahmed IM, Lagopoulos M, McConnell P, et al. Blood supply of the Achilles tendon. J Orthop Res. 1998; 16: 591–6. doi:10.1002/jor.1100160511

4. Docheva D, Müller SA, Majewski M, Evans CH. Biologics for tendon repair. Adv Drug Deliv Rev2015;84:222-239. 5. EpiCord Product Overview. EpiCord. www.mimedx.com/content/epicord. Published 2017. Accessed December 2017.

Materials and Methods

We identified 3 patients with different Achilles tendon pathologies.Intraoperatively, Umbilical cord allograft 3cm x 5cm was applied directlyto the paratenon.Pain assessment was performed using the Wong-Baker scale (0 to 10).

AcknowledgementsThis material is the result of work supported with resources and the use of facilities at the Charlie Norwood VAMC in Augusta, Georgia. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

74 year old, Type 2 diabetic (A1C 9.4%) White male who was seen as an inpatientat bedside with a pressure ulceration of the posterior leg. His ulceration beganafter he spent weeks in a sub-acute rehab facility s/p bilateral common femoralartery and superficial femoral artery endarterectomies with Vascutek patchangioplasty.The patient admitted to hanging his feet off the end of his bed (in a dependentposition) for pain relief.He complained of 10/10 aching pain on his initial presentation. All pedal pulseswere palpable. His wound measured 12cm x 3.5cm x 0.4cm with tracking along theAchilles tendon. Erythema, increased warmth, edema, and purulence were noted.He was being treated with IV vancomycin/Zosyn.A wound and Achilles tendon debridement was performed. A 3cm x 5cm umbilicalcord allograft was directly applied to the Achilles tendon for augmentation.The patient was seen 1 week (Figure 1), 2 weeks, 4 weeks (Figure 2), and 8 weekspost-op.

67 year old, Type 2 diabetic (A1C 7.0%) White male who presented to the podiatryclinic for left lower leg and heel pain. He heard a loud “pop” sound after hetripped and fell.The patient complains of 10/10 aching pain on his initial presentation. An MRI wasobtained (Figure 3).An Achilles tendon repair on the ruptured tendon (Figure 4) with an end-to-endanastomosis repair and a gastrocnemius recession was performed. A 3cm x 5cmumbilical cord allograft was directly applied to the Achilles tendon foraugmentation (Figure 5).

56 year old, Type 2 diabetic (A1C 7.4%) African-American male who presented tothe podiatry clinic complaining of right posterior heel pain.The patient complained of 10/10 aching pain on his initial presentation. Hepreviously was treated with orthotics, heel lifts, and a steroid injection.X-rays revealed a large posterior calcaneal spur (Figure 6). An Achilles tendondetach-reattach was performed, along with an exostectomy (Figure 7). A 3cm x5cm umbilical cord allograft was directly applied to the Achilles tendon foraugmentation (Figure 8).

All patients were prescribed Percocet 5/325mg to be takenevery 4-6 hours as needed for pain.Pain levels were recorded in the morning for 1, 3, 5, 7, and14 days after treatment with allograft.Case #1 reported 0/10 pain after fourteen days. Case #2and #3 reported 0/10 pain after seven days.Case #2 and #3 discontinued their pain medication afterthree days. Case #1 discontinued his pain medication afterday six.

Conclusions

With the advent of the opioid epidemic, many clinicians are looking for ways to contribute to reducingaddiction and the over-prescribing of narcotics. Non-pharmacological interventions are stronglyrecommended by the “VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic pain.”The favorable results of this case series suggests that umbilical cord allograft can be effective at reducingpostoperative pain by enhancing healing in Achilles tendon related pathologies.

Case 2: End-to-End Anastomosis Repair and a Gastrocnemius Recession

Case 3: Achilles Detach-Reattach with an Exostectomy

Case Photos

Figure 1: Week 1 Post Achilles Debridement and Umbilical Cord

Allograft Augmentation.

Figure 2: Week 4 Post Achilles Debridement and Umbilical Cord

Allograft Augmentation

Figure 3: MRI Revealsa Complete Achilles Tendon Rupture

Figure 4: Achilles Tendon Rupture

Figure 5: End-to-End Anastomosis with Umbilical Cord

Allograft Augmentation

Figure 6: Large Posterior Calcaneal Spur

Figure 7: Excised Posterior Calcaneal Spur

Figure 8: Umbilical Cord Allograft Augmentation Post Reattachment

of the Achilles

Case 1Case 1

Case 3Case 2 Case 3 Case 3

Case 2 Case 2