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Thueakthong W, de Cesar Netto C, Garnjanagoonchorn A, Day J, Friedman G, Auster H, Tan E, Schon LC. Outcomes of iliac crest bone marrow aspirate injection for the treatment of recalcitrant Achilles tendinopathy. INTERNATIONAL ORTHOPAEDICS 2021; 45:2423-2428. [PMID: 34254148 DOI: 10.1007/s00264-021-05112-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Achilles tendinopathy is a common cause of posterior ankle and heel pain in both active and sedentary patients. Though the majority of patients respond to first-line non-operative management including activity modification, immobilization, orthotics, and physical therapy with stretching and eccentric strengthening, there is no consensus for patients who fail these treatments. We evaluate the role of iliac crest bone marrow aspirate (BMA) injections as a treatment option for recalcitrant cases. METHODS A retrospective chart review was conducted of patients with refractory Achilles tendinopathy treated with iliac crest BMA concentrate injection. Symptoms were assessed using the numeric rating system (NRS) pain score at the pre-operative visit and at six, 12, 24, and 48 weeks postoperatively. Post-operative complications were recorded. RESULTS A total of 15 patients (15 feet) with recalcitrant Achilles tendinopathy (5 insertional, 8 non-insertional, 2 combined) treated with iliac crest BMA concentrate injections were included in the study. Average age was 53.2 years (range, 25 to 64), average BMI was 27.1 kg/m2 (range, 18.4 to 34.4), and average duration of symptoms prior to BMA injection was 2.3 years (range, 1 to 7). Pre-operatively, average NRS was 6.26 (95% CI, 5.04 to 7.49), with significant improvement at six weeks (mean, 4.26; 95% CI, 2.94 to 5.59; p = 0.04), ten weeks (mean, 4.13; 95% CI, 2.91 to 5.35; p = 0.012), 24 weeks (mean, 3.40; 95% CI, 2.05 to 4.75; p = 0.03), and 48 weeks (mean, 2.60; 95% CI, 1.14 to 4.06; p = 0.007) post-operatively. Overall, there was trending improvement over the 48-week follow-up period, with a mean improvement in NRS of - 3.22 (95% CI, - 1.06 to - 5.38; p = 0.007) at final follow-up. There was no discernable difference between insertional and non-insertional tendinopathy, and there were no incidences of post-operative complications. CONCLUSION Iliac crest BMA appears to be a safe, effective, and potentially lasting treatment option for patients with intractable, insertional and non-insertional Achilles tendinopathy. Patients demonstrated and maintained statistically significant decrease in NRS pain score post-operatively with no complications at the donor or injection site.
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Affiliation(s)
- Wisutthinee Thueakthong
- Institute of Foot and Ankle Reconstruction, Mercy Medical Center, Baltimore, MD, USA.,Department of Orthopaedics, Georgetown School of Medicine, Washington, DC, USA.,Department of Physical Medicine and Rehabilitation, Bhumibol Adulyadej Hospital, 171 Phahonyothin Road, Khlong Thanon Subdistrict, Sai Mai District, Bangkok, 10220, Thailand
| | - Cesar de Cesar Netto
- Department of Orthopaedics and Rehabilitation, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52240, USA.
| | | | - Jonathan Day
- Department of Orthopaedics, Georgetown School of Medicine, Washington, DC, USA
| | - Guy Friedman
- Institute of Foot and Ankle Reconstruction, Mercy Medical Center, Baltimore, MD, USA
| | - Harry Auster
- Institute of Foot and Ankle Reconstruction, Mercy Medical Center, Baltimore, MD, USA
| | - Eric Tan
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Lew C Schon
- Institute of Foot and Ankle Reconstruction, Mercy Medical Center, Baltimore, MD, USA.,Department of Orthopaedics, Georgetown School of Medicine, Washington, DC, USA.,New York University Langone, New York, NY, USA
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Nauwelaers AK, Van Oost L, Peers K. Evidence for the use of PRP in chronic midsubstance Achilles tendinopathy: A systematic review with meta-analysis. Foot Ankle Surg 2021; 27:486-495. [PMID: 32798020 DOI: 10.1016/j.fas.2020.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/14/2020] [Accepted: 07/25/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) injections have been proposed as an additional therapy in the treatment of chronic midsubstance Achilles tendinopathy (AT). The use of PRP injections as pharmacological treatment added to a conservative approach has gained growing interest, but the efficacy remains highly debated. The varying methodological quality of the available studies may contribute to these contradictory results. The aim of this systematic review with meta-analysis was to establish the existing evidence of PRP injections for chronic midsubstance AT on the functional outcome, with a risk of bias assessment of each included study. METHODS According to the PRISMA guidelines systematic searches were performed in Embase, the Cochrane library and Pubmed on June 12, 2020 for relevant literature. Only clinical trials comparing PRP injections with placebo, additional to an eccentric training program, in midsubstance AT were included. The primary outcome was Victorian Institute of Sport Assessment - Achilles (VISA-A) score at 3, 6 and 12 months post-injection. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (Rob 2). As secondary outcome we assessed reported changes in tendon structure after PRP injections. RESULTS A total of 367 studies were identified with the initial database search. Finally, four randomized controlled trials (RCTs) met inclusion criteria for systematic review and meta-analysis with data of 170 patients available for pooling. Results showed no difference in clinical outcome between the PRP and placebo group at different points in time using the VISA-A score as outcome parameter (3 months 0.23 (CI -0.45, 0.91); 6 months 0.83 (CI -0.26, 1.92); 12 months 0.83 (CI -0.77, 2.44)). The bias analysis showed a low or intermediate risk of bias profile for all studies which supports the good methodological quality of each included article. Finally, it is unclear whether PRP injections cause an improvement in tendon structure. However, no direct relationship between tendon structure and clinical presentation of AT could be found. CONCLUSION PRP has no clear additional value in management of chronic midsubstance Achilles tendinopathy and therefore should not be used as a first-line treatment option.
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Affiliation(s)
- An-Katrien Nauwelaers
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium
| | - Loïc Van Oost
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium.
| | - Koen Peers
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium
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53
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Shala R. Platelet-rich plasma for tendinopathy and osteoarthritis: a narrative review. BULLETIN OF FACULTY OF PHYSICAL THERAPY 2021. [DOI: 10.1186/s43161-021-00028-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Musculoskeletal disorders include a wide range of degenerative and inflammatory problems, which can affect any part of the muscular and skeletal system. Platelet-rich plasma (PRP) has been a breakthrough in musculoskeletal medicine, especially with its effects to speed up soft tissue, cartilage, and bone healing. It is now thought that stem cells are able to reverse the degenerative process and promote rapid healing. Platelet-rich plasma (PRP) has received special attention in treating tendinopathy and osteoarthritis. This review aims to do a comprehensive review of the scientific evidence for the efficiency of PRP application in tendinopathy and osteoarthritis.
Main body of the abstract
In osteoarthritis treatment, platelet-rich plasma is thought to influence the whole joint environment by increasing chondrocyte proliferation. The injection of autologous PRP into the joint space and surrounding soft tissues delivers a concentrated dose of these growth factors, which accelerate the healing process and reduce pain.
Short conclusion
Many studies report some benefits in regard to pain and functionality, especially in tendinopathy, but further investigations are needed to incorporate PRP into clinical practice and be a common form of therapy for tendinopathy and osteoarthritis. Caution should be applied with any treatment we use in clinical practice, especially with PRP and other forms of injections.
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54
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Cole BJ, Gilat R, DiFiori J, Rodeo SA, Bedi A. The 2020 NBA Orthobiologics Consensus Statement. Orthop J Sports Med 2021; 9:23259671211002296. [PMID: 34017878 PMCID: PMC8114275 DOI: 10.1177/23259671211002296] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/14/2020] [Indexed: 12/26/2022] Open
Abstract
This 2020 NBA Orthobiologics Consensus Statement provides a concise summary of available literature and practical clinical guidelines for team physicians and players. We recognize that orthobiologic injections are a generally safe treatment modality with a significant potential to reduce pain and expedite early return to play in specific musculoskeletal injuries. The use of orthobiologics in sports medicine to safely reduce time loss and reinjury is of considerable interest, especially as it relates to the potential effect on a professional athlete. While these novel substances have potential to enhance healing and regeneration of injured tissues, there is a lack of robust data to support their regular use at this time. There are no absolutes when considering the implementation of orthobiologics, and unbiased clinical judgment with an emphasis on player safety should always prevail. Current best evidence supports the following: Key Points There is support for the use of leukocyte-poor platelet-rich plasma in the treatment of knee osteoarthritis. There is support for consideration of using leukocyte-rich platelet-rich plasma for patellar tendinopathy. The efficacy of using mesenchymal stromal cell injections in the management of joint and soft tissue injuries remains unproven at this time. There are very few data to suggest that current cell therapy treatments lead to any true functional tissue regeneration. Meticulous and sterile preparation guidelines must be followed to minimize the risk for infection and adverse events if these treatments are pursued.Given the high variability in orthobiologic formulations, team physicians must stay up-to-date with the most recent peer-reviewed literature and orthobiologic preparation protocols for specific injuries.Evidence-based treatment algorithms are necessary to identify the optimal orthobiologic formulations for specific tissues and injuries in athletes.Changes in the regulatory environment and improved standardization are required given the exponential increase in utilization as novel techniques and substances are introduced into clinical practice.
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Affiliation(s)
- Brian J Cole
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Ron Gilat
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA.,Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - John DiFiori
- Hospital for Special Surgery, New York, New York, USA
| | - Scott A Rodeo
- Hospital for Special Surgery, New York, New York, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Explaining Variability in the Prevalence of Achilles Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals. J Orthop Sports Phys Ther 2021; 51:232-252. [PMID: 33779214 DOI: 10.2519/jospt.2021.9970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To estimate the prevalence of, and factors associated with, Achilles tendon abnormalities observed on imaging in asymptomatic individuals. DESIGN Systematic review with stratified meta-analysis and meta-regression. LITERATURE SEARCH Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science were searched from 1980 to August 2020. STUDY SELECTION CRITERIA We included studies that reported the prevalence of Achilles tendon abnormalities, observed with any imaging modality, in an asymptomatic population. We excluded studies if participant mean age was younger than 12 years or if participants had current/previous lower-limb tendon injuries/symptoms or other systemic conditions. DATA SYNTHESIS Random-effects proportion meta-analysis was used to estimate prevalence. We used meta-regression for continuous variables (mean age and body mass index [BMI], sample size, proportion of female participants) and stratified categorical variables (imaging modality and participation in physical activity) to explain between-study heterogeneity. RESULTS We included 91 studies (10 156 limbs, 5841 participants). The prevalence of Achilles tendon abnormalities on imaging ranged from 0% to 80% per participant. Between-study heterogeneity was high (I2>90%, P<.001), precluding data pooling. Between-study heterogeneity was partly explained by participant mean BMI (slope, 2.8% per 1-unit increase in BMI; 95% confidence interval: 0.57%, 5.03%; P = .015) and participation in physical activity per limb, and mean age of 40 years old or older (P = .022) per participant. CONCLUSION There was substantial variability in the prevalence of Achilles tendon abnormalities on imaging in asymptomatic individuals. Higher prevalence of abnormalities was associated with older age (40 years old or older), higher BMI, and participation in physical activity. A large proportion of heterogeneity remains unaccounted for, likely due to variations in abnormality definitions and study design. J Orthop Sports Phys Ther 2021;51(5):232-252. Epub 28 Mar 2021. doi:10.2519/jospt.2021.9970.
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56
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Liu X, Zhang R, Zhu B, Li Y, Liu X, Guo S, Wang C, Wang D, Li S. Effects of leukocyte- and platelet-rich plasma on tendon disorders based on in vitro and in vivo studies (Review). Exp Ther Med 2021; 21:639. [PMID: 33968170 PMCID: PMC8097231 DOI: 10.3892/etm.2021.10071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/22/2021] [Indexed: 12/21/2022] Open
Abstract
Tendon-related disorders are common musculoskeletal system disorders in clinical practice, accounting for 30-50% of all sports-related injuries, and they are difficult to treat due to the hypovascular structure of the tendons. Platelet-rich plasma (PRP), including pure PRP and leukocyte- and platelet-rich plasma (L-PRP), has been attracting increasing attention, as it may stimulate tissue regeneration through the release of growth factors and cytokines. The aim of the present review was to provide a summary of the effects of L-PRP on tendon disorders and the underlying mechanisms through a comprehensive examination of the published literature, including in vitro, animal and clinical studies. It has been demonstrated that L-PRP results in comparatively greater pain relief and improved function in patients suffering from tendon disorders. Furthermore, L-PRP may exert its effects through a diverse range of mechanisms, such as neovascularization, cell proliferation and differentiation of tendon/progenitor stem cells into tenocytes, as well as extracellular matrix reorganization by transforming type III to type I collagen fibers. It has also been indicated that the effects of leukocytes in L-PRP depend on the biological state of the injured tissue and its surrounding microenvironment. L-PRP is beneficial and promotes tendon healing at the early stage, whereas it is likely detrimental to the repair of tendon at a later stage because of the risk of excessive catabolic and inflammatory responses. Overall, the application of L-PRP in tendon disorders appears to be a promising field that is worthy of further research.
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Affiliation(s)
- Xueli Liu
- Department of Physical Education, Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Department of Rehabilitation, Sichuan Vocational College of Health and Rehabilitation, Zigong, Sichuan 643000, P.R. China
| | - Rong Zhang
- Department of Rehabilitation, Sichuan Vocational College of Health and Rehabilitation, Zigong, Sichuan 643000, P.R. China
| | - Bin Zhu
- Department of Physical Education, Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Yujie Li
- Department of Physical Education, Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Xinyue Liu
- Department of Physical Education, Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Sheng Guo
- Spinal Surgery Department, Hospital (Traditional Chinese Medicine) Affiliated to Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Chenglong Wang
- Spinal Surgery Department, Hospital (Traditional Chinese Medicine) Affiliated to Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Dingxuan Wang
- Department of Physical Education, Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Sen Li
- Department of Physical Education, Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Spinal Surgery Department, Hospital (Traditional Chinese Medicine) Affiliated to Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
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Abstract
CONTEXT Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety. EVIDENCE ACQUISITION An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections, athletes, sports, foot and ankle, corticosteroids, platelet-rich plasma, and placental tissue. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results. CONCLUSIONS Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.
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Affiliation(s)
- Jonathan K Ochoa
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, California
| | - Christopher E Gross
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - Robert B Anderson
- Bellin Health Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin
| | - Andrew R Hsu
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, California
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van der Vlist AC, Winters M, Weir A, Ardern CL, Welton NJ, Caldwell DM, Verhaar JAN, de Vos RJ. Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. Br J Sports Med 2021; 55:249-256. [PMID: 32522732 PMCID: PMC7907558 DOI: 10.1136/bjsports-2019-101872] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy. DESIGN Living systematic review and network meta-analysis. DATA SOURCES Multiple databases including grey literature sources were searched up to February 2019. STUDY ELIGIBILITY CRITERIA Randomised controlled trials examining the effectiveness of any treatment in patients with both insertional and/or midportion Achilles tendinopathy. We excluded trials with 10 or fewer participants per treatment arm or trials investigating tendon ruptures. DATA EXTRACTION AND SYNTHESIS Reviewers independently extracted data and assessed the risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation to appraise the certainty of evidence. PRIMARY OUTCOME MEASURE The validated patient-reported Victorian Institute of Sport Assessment-Achilles questionnaire. RESULTS 29 trials investigating 42 different treatments were included. 22 trials (76%) were at high risk of bias and 7 (24%) had some concerns. Most trials included patients with midportion tendinopathy (86%). Any treatment class seemed superior to wait-and-see for midportion Achilles tendinopathy at 3 months (very low to low certainty of evidence). At 12 months, exercise therapy, exercise+injection therapy and exercise+night splint therapy were all comparable with injection therapy for midportion tendinopathy (very low to low certainty). No network meta-analysis could be performed for insertional Achilles tendinopathy. SUMMARY/CONCLUSION In our living network meta-analysis no trials were at low risk of bias and there was large uncertainty in the comparative estimates. For midportion Achilles tendinopathy, wait-and-see is not recommended as all active treatments seemed superior at 3-month follow-up. There seems to be no clinically relevant difference in effectiveness between different active treatments at either 3-month or 12-month follow-up. As exercise therapy is easy to prescribe, can be of low cost and has few harms, clinicians could consider starting treatment with a calf-muscle exercise programme. PROSPERO REGISTRATION NUMBER CRD42018086467.
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Affiliation(s)
- Arco C van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Marinus Winters
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Adam Weir
- Department of Orthopaedics and Sports Medicine, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
- Aspetar Sports Groin Pain Centre, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar
| | - Clare L Ardern
- Division of Physiotherapy, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Deborah M Caldwell
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Jan A N Verhaar
- Department of Orthopaedics and Sports Medicine, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedics and Sports Medicine, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
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Fares MY, Khachfe HH, Salhab HA, Zbib J, Fares Y, Fares J. Achilles tendinopathy: Exploring injury characteristics and current treatment modalities. Foot (Edinb) 2021; 46:101715. [PMID: 33039245 DOI: 10.1016/j.foot.2020.101715] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/19/2020] [Accepted: 07/03/2020] [Indexed: 02/04/2023]
Abstract
Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.
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Affiliation(s)
- Mohamad Y Fares
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon; College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, Scotland, UK.
| | - Hussein H Khachfe
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Hamza A Salhab
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Jad Zbib
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Youssef Fares
- Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Kirschner JS, Cheng J, Hurwitz N, Santiago K, Lin E, Beatty N, Kingsbury D, Wendel I, Milani C. Ultrasound-guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: A randomized controlled trial. PM R 2021; 13:1340-1349. [PMID: 33644963 DOI: 10.1002/pmrj.12583] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Tendinosis is a chronic degenerative condition. Current research suggests both percutaneous needle tenotomy (PNT) and leukocyte-rich platelet-rich plasma (LR-PRP) may be effective treatments for chronic tendinosis, but no studies have assessed the effectiveness of PNT alone versus PNT with intratendinous LR-PRP for multiple tendon types in a single study. OBJECTIVE To assess the efficacy of PNT versus PNT + LR-PRP to treat chronic tendinosis. STUDY DESIGN Double-blind, randomized, controlled comparative treatment study. SETTING Primary academic institution. PARTICIPANTS A convenience sample of 40 participants who had chronic tendinosis (rotator cuff, wrist extensor, wrist flexor, hip abductor, proximal hamstring, patellar, or Achilles) confirmed via ultrasound, failed conservative treatment, and did not have tendon tears, known coagulopathy, or systemic illnesses. INTERVENTIONS Participants were randomly assigned to PNT (n = 19) or PNT + LR-PRP (n = 21). Participants and outcomes assessors were blinded to treatment assignments. PNT was performed with 20-30 passes of a 22-gauge needle under ultrasound guidance, with 1% lidocaine given outside the tendon. LR-PRP was processed from whole blood (30-60 mL) and injected into the affected tendon using the same PNT technique. MAIN OUTCOME MEASURES Primary outcome was current numerical rating scale pain at 6 weeks. Secondary outcomes were average pain, function, general well-being, and sleep quality at 6, 52, and 104 weeks. RESULTS Baseline characteristics were similar between groups. Overall, there were no significant differences between groups over time for any of the outcomes (P > .05). Between-group analyses showed significantly lower current and average pain after PNT compared to PNT + LR-PRP at 6 weeks (estimated-mean [SE]: 3.1[0.4] vs. 4.6[0.6], P = .04; 3.4[0.4] vs. 4.9[0.5], P = .03) only. Adverse event rates were low (PNT-3.9%; PNT + LR-PRP-5.0%) and related primarily to postprocedural pain and inflammation. CONCLUSIONS Although pain scores were lower after PNT compared to PNT + LR-PRP at 6 weeks, there were no between-group differences in outcomes at 52 or 104 weeks.
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Affiliation(s)
| | - Jennifer Cheng
- Department of Physiatry, Hospital for Special Surgery, New York, New York, USA
| | - Nicole Hurwitz
- Department of Physiatry, Hospital for Special Surgery, New York, New York, USA
| | - Kristen Santiago
- Department of Physiatry, Hospital for Special Surgery, New York, New York, USA
| | - Emerald Lin
- Department of Physiatry, Hospital for Special Surgery, New York, New York, USA
| | - Nicholas Beatty
- Department of Rehabilitation Medicine, Mount Sinai Hospital, New York, New York, USA
- Regenerative SportsCare Institute, New York, New York, USA
| | - Dallas Kingsbury
- Department of Rehabilitation Medicine, NYU Langone Health, New York, New York, USA
| | - Ian Wendel
- Tri-County Orthopedics, Cedar Knolls, New Jersey, USA
| | - Carlo Milani
- Department of Physiatry, Hospital for Special Surgery, New York, New York, USA
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61
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Hogan MV, Scott DM, Canton SP, LaBaze D, Yan AY, Wang JHC. Biologic therapies for foot and ankle injuries. Expert Opin Biol Ther 2020; 21:717-730. [PMID: 33382002 DOI: 10.1080/14712598.2021.1866534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: The use of orthobiologics as supplemental treatment for foot and ankle pathologies have increased in the past decades. They have been used to improve the healing of bone and soft tissue injuries. There have been several studies that examined the use of biologics for knee and hip pathologies but the foot and ankle construct has unique features that must be considered.Areas covered: The biologics for foot and ankle injuries that are covered in this review are platelet-rich plasma (PRP), stem cells, growth factors, hyaluronic acid, bone grafts, bone substitutes, and scaffolds. These modalities are used in the treatment of pathologies related to tendon and soft tissue as well as cartilage.Expert opinion: The utilization of biological adjuncts for improved repair and regeneration of ankle injuries represents a promising future in our efforts to address difficult clinical problems. The application of concentrated bone marrow and PRP each represents the most widely studied and commonly used injection therapies with early clinical studies demonstrating promising results, research is also being done using other potential therapies such as stem cells and growth factors; further investigation and outcome data are still needed.
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Affiliation(s)
- MaCalus V Hogan
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Foot and Ankle Injury Research Center, University of Pittsburgh, Pittsburgh, PA, USA.,Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Devon M Scott
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stephen P Canton
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dukens LaBaze
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan Y Yan
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Foot and Ankle Injury Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - James H-C Wang
- Departments of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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62
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Mansur NSB, Fonseca LF, Matsunaga FT, Baumfeld DS, Nery CADS, Tamaoki MJS. Achilles Tendon Lesions - Part 1: Tendinopathies. Rev Bras Ortop 2020; 55:657-664. [PMID: 33364641 PMCID: PMC7748930 DOI: 10.1055/s-0040-1702953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/29/2019] [Indexed: 11/24/2022] Open
Abstract
Calcaneal tendon injuries are extremely common in the general population and in orthopedics routine care. Its increasing incidence, which is motivated by an aging population, improved access to the health care system, increased prescription of continuous-use medication, erratic participation in sports and other factors, has had a direct impact on society. Consolidated treatment options for tendinopathies lack quality scientific support for many modalities. New therapies have emerged to enhance nonsurgical approach outcomes and to reduce the number of patients requiring surgery. Although these operative procedures provide good pain relief and functional outcomes, they are costly and may lead to complications.
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Affiliation(s)
- Nacime Salomão Barbachan Mansur
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Lucas Furtado Fonseca
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Fábio Teruo Matsunaga
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Daniel Soares Baumfeld
- Departamento de Ortopedia e Traumatologia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Caio Augusto de Souza Nery
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Marcel Jun Sugawara Tamaoki
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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63
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Anz HA, Ahmad HA, Kozemchak AM, Rao M, Warth RJ, Harner CD. Funding sources are under-reported in randomised clinical trials of biological treatments in sports medicine: a systematic review. J ISAKOS 2020. [DOI: 10.1136/jisakos-2020-000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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64
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Tenforde A, Robinson D, Borg‐Stein J, Borgstrom H, Singh JR. Extracorporeal Shockwave Therapy Versus Platelet‐rich Plasma for Achilles Tendinopathy. PM R 2020; 12:1169-1176. [DOI: 10.1002/pmrj.12498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Adam Tenforde
- Department of Physical Medicine and Rehabilitation Harvard Medical School Cambridge MA
- Spaulding National Running Center, Spaulding Hospital Spaulding Rehabilitation Hospital Charlestown MA
| | - David Robinson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School Spaulding Rehabilitation Hospital Charlestown MA
| | - Joanne Borg‐Stein
- Department of Physical Medicine and Rehabilitation, Harvard Medical School Spaulding Rehabilitation Hospital Charlestown MA
| | - Haylee Borgstrom
- Department of Physical Medicine and Rehabilitation, Harvard Medical School Spaulding Rehabilitation Hospital Charlestown MA
| | - Jaspal Ricky Singh
- Weill Cornell Center for Comprehensive Spine Care Weill Cornell Medicine Department of Rehabilitation Medicine New York NY
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65
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Okewunmi J, Guzman J, Vulcano E. Achilles Tendinosis Injuries-Tendinosis to Rupture (Getting the Athlete Back to Play). Clin Sports Med 2020; 39:877-891. [PMID: 32892973 DOI: 10.1016/j.csm.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recreational athletes are susceptible to experiencing pain in the Achilles tendon, affecting their ability to complete daily activities. Achilles tendinosis is a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation, which can be categorized by location into insertional and noninsertional tendinosis. This condition is one that can be treated conservatively with great success or surgically for refractory cases. Currently, there is a lack of consensus regarding the best treatment options. This review aims to explore both conservative and operative treatment options for Achilles tendinopathy and Achilles tendon rupture.
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Affiliation(s)
- Jeffrey Okewunmi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Javier Guzman
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Ettore Vulcano
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
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66
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Chen XT, Fang WH, Vangsness CT. Efficacy of Biologics for Ligamentous and Tendon Healing. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2020.150755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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67
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D'Hooghe P, Vinagre G. In Adults with Acute Achilles Tendon Rupture, a Single Platelet-Rich Plasma Injection Did Not Improve Muscle-Tendon Function at 24 Weeks. J Bone Joint Surg Am 2020; 102:1466. [PMID: 32590399 DOI: 10.2106/jbjs.20.00993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Pieter D'Hooghe
- Department of Orthopaedic Surgery, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
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68
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LaBelle MW, Marcus RE. CORR Synthesis: What Is the Role of Platelet-rich Plasma Injection in the Treatment of Tendon Disorders? Clin Orthop Relat Res 2020; 478:1817-1824. [PMID: 32732562 PMCID: PMC7371072 DOI: 10.1097/corr.0000000000001312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/27/2025] [Indexed: 01/31/2023]
Affiliation(s)
- Mark W LaBelle
- M. W. Labelle, R. E. Marcus, Department of Orthopaedic Surgery, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Randall E Marcus
- M. W. Labelle, R. E. Marcus, Department of Orthopaedic Surgery, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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69
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Masci L, Alfredson H, Neal B, Wynter Bee W. Ultrasound-guided tendon debridement improves pain, function and structure in persistent patellar tendinopathy: short term follow-up of a case series. BMJ Open Sport Exerc Med 2020; 6:e000803. [PMID: 32789022 PMCID: PMC7380954 DOI: 10.1136/bmjsem-2020-000803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 01/17/2023] Open
Abstract
There is a need for effective therapeutic options for resistant patellar tendinopathy. Ultrasound (US)-guided arthroscopic debridement has demonstrated promising clinical results.
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Affiliation(s)
- Lorenzo Masci
- Department of Sports and Execise Medicine, Queen Mary University of London, London, UK.,Department of Sports and Exercise Medicine, ISEH, London, UK
| | - Hakan Alfredson
- Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umea, Sweden.,Clinical Research, Pure Sports Medicine, London, UK
| | - Brad Neal
- Department of Sports and Execise Medicine, Queen Mary University of London, London, UK.,Clinical Research, Pure Sports Medicine, London, UK
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70
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Elksniņš-Finogejevs A, Vidal L, Peredistijs A. Intra-articular platelet-rich plasma vs corticosteroids in the treatment of moderate knee osteoarthritis: a single-center prospective randomized controlled study with a 1-year follow up. J Orthop Surg Res 2020; 15:257. [PMID: 32650801 PMCID: PMC7353717 DOI: 10.1186/s13018-020-01753-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Osteoarthritis is the most prevalent type of arthritis, which significantly impacts the patient's mobility and quality of life. Pharmacological treatments for osteoarthritis, such as corticosteroids, produce an immediate reduction of the patient's pain as well as an improvement in the patient's mobility and quality of life, but with a limited long-term efficacy. In this context, platelet-rich plasma (PRP) infiltrations represent a therapeutic tool due to its trophic properties and its ability to control inflammatory processes, especially in musculoskeletal applications. The aim of this study is to evaluate and compare the clinical benefits of PRP when injected intra-articularly vs a commonly used corticosteroid (CS, triamcinolone acetonide, Kenalog®) in patients affected by mild to moderate symptomatic knee osteoarthritis. METHODS Forty patients affected by symptomatic radiologically confirmed knee osteoarthritis (Kellgren-Lawrence grades II-III) were enrolled in this randomized study. Patients randomized in the PRP group (n = 20) received an intra-articular injection of PRP (8 mL) while patients randomized in the CS group (n = 20) received an intra-articular injection of triamcinolone acetonide (1 mL of 40 mg/mL) plus lidocaine (5 mL of 2%). The pain and function of the target knee were evaluated by the VAS, IKDC, and KSS scales at the baseline (V1), 1 week (V2), 5 weeks (V3), 15 weeks (V4), 30 weeks (V5), and 1 year (V6) after treatment. RESULTS No serious adverse effects were observed during the follow-up period. A mild synovitis was registered in 15 patients (75%) in the PRP group within the first week after treatment which resolved spontaneously. Both treatments were effective in relieving pain and improving the knee function in the very short-term follow-up visit (1 week). A high improvement of the subjective scores was observed for both groups up to 5 weeks, with no significative differences between the groups for the VAS, IKDC, or KSS. After 15 weeks of follow-up, the PRP group showed significative improvements in all scores when compared to the CS group. Overall, the patients who received PRP treatment had better outcomes in a longer follow-up visit (up to 1 year) than those who received CS. CONCLUSIONS A single PRP or CS intra-articular injection is safe and improves the short-term scores of pain and the knee function in patients affected by mild to moderate symptomatic knee OA (with no significant differences between the groups). PRP demonstrated a statistically significant improvement over CS in a 1-year follow-up. This study was registered at ISRCTN with the ID ISRCTN46024618.
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Affiliation(s)
- Andrejs Elksniņš-Finogejevs
- Faculty of Continuing Education, Rīga Stradiņš University, Riga, Latvia. .,"ORTO klinika" Ltd., Riga, Latvia.
| | - Luis Vidal
- Laboratorios Fidia Farmacéutica S.L.U, Madrid, Spain
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71
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Madhi MI, Yausep OE, Khamdan K, Trigkilidas D. The use of PRP in treatment of Achilles Tendinopathy: A systematic review of literature. Study design: Systematic review of literature. Ann Med Surg (Lond) 2020; 55:320-326. [PMID: 32566217 PMCID: PMC7298400 DOI: 10.1016/j.amsu.2020.04.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Chronic Achilles Tendinopathy is a common condition that can be challenging to treat. There are many modalities used as treatment ranging from physiotherapy, injections, shockwave therapy to surgical intervention. Platelet Rich Plasma (PRP) has increased in popularity recently as a treatment option for Achilles Tendinopathy. It contains growth factors that might accelerate healing and speed up the recovery of this condition. Many studies have been conducted in the last few years to assess the effectiveness of this treatment method. However, there was controversy as to whether PRP had a beneficial effect on chronic Achille tendinopathy. AIM This systematic review of the literature was conducted to ascertain the efficacy of Platelet Rich Plasma (PRP) as a treatment option in chronic Achilles tendinopathy. METHODS PRISMA reporting item for systematic review has been used to conduct the selection, Electronic databases included PubMed, EMBASE, Cochrane collaborate, Google scholar, the web of science and Cochrane Library were searched for all RCT, prospective and retrospective studies conducted between January 2010 to February 2019. The quality of each study was evaluated using the Oxford CEBM tool to assess the articles for validity, relevance, and applicability of the results. A total number of 288 were found, and only 11 met the inclusion criteria. RESULTS 5 Randomised control trials, 4 prospective and 2 retrospective cohort study were included in this systematic review. A total number of 406 patients were treated for non-insertional Achilles tendinopathy of which 230 patients had PRP local injection under Ultrasound guide. CONCLUSION Although many of the retrospective studies suggested an advantage of using PRP, the higher level of evidence studies do not support a significant efficacy. This systematic review showed very promising results from the use of Platelet Rich Plasma demonstrated by a significant improvement in the VAST-A score, but we certainly need decent size randomised control trials to show better and more accurate results.
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Affiliation(s)
- Mr Imad Madhi
- Trauma and Orthopaedics Surgery, Wythenshawe Hospital, Manchester, UK
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72
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Aicale R, Bisaccia RD, Oliviero A, Oliva F, Maffulli N. Current pharmacological approaches to the treatment of tendinopathy. Expert Opin Pharmacother 2020; 21:1467-1477. [DOI: 10.1080/14656566.2020.1763306] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Rocco Domenico Bisaccia
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Department of Pharmacology, School of Medicine and Surgery, University of Salerno , Baronissi, Italy
| | - Antonio Oliviero
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London , London, UK
- Keele University, Faculty of Medicine, School of Pharmacology and Bioengineering, Guy Hilton Research Centre , Stoke-on-Trent, UK
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73
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Abstract
BACKGROUND Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional. A variety of treatment methods have been described, although little consensus exists on an optimal method or methods. We sought to investigate the current evidence on different treatment methods for noninsertional Achilles tendinopathy, with a focus on functional outcomes. METHODS We performed a review of the available literature in PubMed and the Cochrane Central Register of Controlled Trials. Data from included studies were categorized according to treatment method and analyzed with respect to functional outcome and complication rate. RESULTS In total, 1420 abstracts were reviewed, of which 72 articles containing 3523 patients met inclusion criteria. Within the 72 studies included, 6 operative techniques and 19 nonoperative treatments were evaluated. CONCLUSION A wide variety of treatments are available for noninsertional Achilles tendinopathy, although newer treatments and most operative methods lack high-level evidence. Eccentric exercise is the most thoroughly studied and supported nonoperative treatment, while tenotomy and debridement is the operative procedure with the most evidence of efficacy. Platelet-rich plasma injections and extracorporeal shockwave therapy have proven to be viable second-line nonoperative treatments. Gastrocnemius recession and flexor hallucis longus transfer have shown benefit in case series. LEVEL OF EVIDENCE Level II, systematic review.
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Affiliation(s)
- Ian Jarin
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Henrik C Bäcker
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - J Turner Vosseller
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
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74
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Melbourne CS, Smith CA, Patel J, Platt B, Cook JL. Indications and associated outcomes for platelet-rich plasma injections performed in an academic orthopaedic-specific hospital: A patient satisfaction survey. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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75
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Townsend C, Von Rickenbach KJ, Bailowitz Z, Gellhorn AC. Post-Procedure Protocols Following Platelet-Rich Plasma Injections for Tendinopathy: A Systematic Review. PM R 2020; 12:904-915. [PMID: 32103599 DOI: 10.1002/pmrj.12347] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Platelet-rich plasma (PRP) has been increasingly studied as a treatment for tendinopathy. Many factors may influence outcomes after PRP, including different protocols following administration. It was hypothesized that there would be heterogeneity in post-PRP protocols. LITERATURE SURVEY A systematized review of the literature on post-PRP protocols for tendinopathy was conducted using an electronic search of MEDLINE and Embase databases through September 2018. METHODOLOGY After duplicates were removed, English language articles involving adult patients who received PRP for tendinopathy were reviewed. Exclusion criteria included studies with fewer than 10 patients, PRP used to treat pathology other than tendinopathy, multiple protocols in one study, and surgical settings. Protocol specifics were extracted including nonsteroidal anti-inflammatory drugs (NSAID) restrictions before and after injection, postinjection restrictions on movement and weight bearing, use of orthoses, activity modifications, and postinjection rehabilitation protocols. Given limitations in the data, a meta-analysis was not performed. SYNTHESIS Eighty-four studies met inclusion criteria. Following PRP injection, weight-bearing restrictions were mentioned rarely (12% of protocols). Orthosis use was uncommon overall (18%) but more common in Achilles tendinopathy protocols (53%). The majority of protocols instituted a period of stretching (51%) and strengthening (54%). Stretching programs generally began 2-7 days following injection, and strengthening programs began within 2-3 weeks. Preinjection NSAID restriction was reported rarely (20%), whereas postinjection NSAID restriction was more common (56%), with a typical restriction of greater than 2 weeks (38%). Return to play or full activity was reported in 42% of protocols, most commonly at 4-6 weeks following injection. CONCLUSION Although the clinical effectiveness of PRP remains controversial, even less is known about the effect of post-PRP protocols, which may affect the outcomes attributed to PRP itself. No studies directly compare post-PRP protocols, and the protocols studied demonstrate substantial heterogeneity. Some consensus regarding post-PRP protocols exists, although the rationale for these recommendations is limited.
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Affiliation(s)
- Christine Townsend
- Department of Rehabilitation Medicine, New York-Presbyterian Rehabilitation Medicine, Weill Cornell Medical College & Columbia University Irving Medical Center, New York, NY, USA
| | - Kristian J Von Rickenbach
- Department of Rehabilitation Medicine, New York-Presbyterian Rehabilitation Medicine, Weill Cornell Medical College & Columbia University Irving Medical Center, New York, NY, USA
| | - Zachary Bailowitz
- Department of Rehabilitation Medicine, New York-Presbyterian Rehabilitation Medicine, Weill Cornell Medical College & Columbia University Irving Medical Center, New York, NY, USA
| | - Alfred C Gellhorn
- Department of Rehabilitation, Weill Cornell Medicine, New York, NY, USA
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76
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Walker-Santiago R, Wojnowski NM, Lall AC, Maldonado DR, Rabe SM, Domb BG. Platelet-Rich Plasma Versus Surgery for the Management of Recalcitrant Greater Trochanteric Pain Syndrome: A Systematic Review. Arthroscopy 2020; 36:875-888. [PMID: 31882270 DOI: 10.1016/j.arthro.2019.09.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/20/2019] [Accepted: 09/25/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a systematic review of the outcomes of platelet-rich plasma (PRP) injections as an in-office procedure versus surgical treatment for recalcitrant greater trochanteric pain syndrome (GTPS). METHODS The MEDLINE and Embase databases were searched in June 2019 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Clinical studies on patients with recalcitrant GTPS treated with PRP or surgery were included. Demographic characteristics, patient-reported outcomes (PROs), and complications were compared. A qualitative analysis using the Methodological Index for Non-randomized Studies and Cochrane Risk of Bias Tool scores was performed. RESULTS A total of 5 PRP and 5 surgery studies met the inclusion criteria, contributing 94 and 185 patients, respectively. The mean follow-up time was shorter for the PRP studies (range, 2-26 months) than with surgery (range, 12-70 months). The mean Methodological Index for Non-randomized Studies scores for the PRP and surgery groups were 11.25 and 11.4, respectively, and the only randomized trial had a low risk of bias. Two studies in the PRP group (n = 56) reported improvements in the modified Harris Hip Score at final follow-up (from 53.8 to 82.6 and from 56.7 to 74.2). The other PRP studies reported improvements using other measures. In the surgery group, 2 studies reported improvements in the Harris Hip Score (from 53.0 to 80 and from 53.3 to 88) whereas 3 used unique PROs (Oxford score, from 20.4 to 37.3; modified Harris Hip Score, from 54.9 to 76.2; and Merle d'Aubigné and Postel score, from 10.9 to 16.7). Although significant improvement was reported in all studies included, PRP showed a large effect size whereas surgery showed a moderate to large effect size. No major complications were associated with PRP treatment; however, the surgery group reported a higher rate of complications including recurrent external snapping hip, retears resulting from falls, trochanteric fracture, venous thrombosis, and wound-related problems. CONCLUSIONS Both PRP and surgical intervention for the treatment of recalcitrant GTPS showed statistically and clinically significant improvements based on PROs. Although not covered by most medical insurance companies, PRP injections for recalcitrant GTPS provides an effective and safe alternative after failed physical therapy. If surgery is indicated, endoscopy is safer than the open technique. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.
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Affiliation(s)
| | | | - Ajay C Lall
- American Hip Institute, Des Plaines, Illinois, U.S.A
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77
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Abate M, Di Carlo L, Belluati A, Salini V. Factors associated with positive outcomes of platelet-rich plasma therapy in Achilles tendinopathy. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:859-867. [PMID: 32112184 DOI: 10.1007/s00590-020-02642-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/22/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The efficacy of platelet-rich plasma in the treatment for Achilles tendinopathy is debated. Therefore, it is important to know which factors, related to the subjects and/or the disease, are associated with positive or negative outcomes. Aim of this study was to evaluate in a large cohort of patients with Achilles mid-portion tendinopathy which variables were independently associated with a positive outcome after platelet-rich plasma treatment. MATERIAL AND METHODS Eighty-four subjects with Achilles tendinopathy were evaluated by means of VISA-A score and ultrasound and treated with a single platelet-rich plasma injection once a week for 3 weeks. Afterward, a rehabilitation program, based on eccentric training, was implemented. At 3 and 6 months, the relationship between the mean VISA-A score and the following putative predictors was evaluated: sex, age, physical activity, sport, smoking, metabolic risk factors, BMI, symptoms duration, tendon damage, neovessels, adherence to eccentric training. Finally, the percentage of clinically evident positive outcomes (defined as an increase in VISA-A score ≥ 20 points) related to each variable was computed. RESULTS At final follow-up, using the General Linear Model for Repeated Measures procedure, male sex (0.02), age ≤ 40 (0.05) and adequate eccentric training (0.02) were found to be independently associated with a significant increase in the mean VISA-A score. Moreover, the clinically evident positive outcomes, as previously defined, were significantly associated with male sex (0.01), age ≤ 40 (0.000), BMI ≤ 25 (0.001), symptoms duration ≤ 12 months (0.02) and good adherence to eccentric training (0.004). CONCLUSION Younger age, male sex and good adherence to eccentric training can be considered predictors of better results after platelet-rich plasma therapy in Achilles tendinopathy.
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Affiliation(s)
- Michele Abate
- Department of Medicine and Science of Aging, University G. D'Annunzio, Chieti-Pescara, Via dei Vestini 31, 66013, Chieti Scalo, CH, Italy.
| | - Luigi Di Carlo
- Department of Medicine and Science of Aging, University G. D'Annunzio, Chieti-Pescara, Via dei Vestini 31, 66013, Chieti Scalo, CH, Italy
| | - Alberto Belluati
- Division of Orthopedics and Traumatology, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Vincenzo Salini
- Division of Orthopedics and Traumatology, San Raffaele Hospital, Milan, Italy
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78
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Mariani E, Pulsatelli L. Platelet Concentrates in Musculoskeletal Medicine. Int J Mol Sci 2020; 21:ijms21041328. [PMID: 32079117 PMCID: PMC7072911 DOI: 10.3390/ijms21041328] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/29/2020] [Accepted: 02/06/2020] [Indexed: 12/02/2022] Open
Abstract
Platelet concentrates (PCs), mostly represented by platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are autologous biological blood-derived products that may combine plasma/platelet-derived bioactive components, together with fibrin-forming protein able to create a natural three-dimensional scaffold. These types of products are safely used in clinical applications due to the autologous-derived source and the minimally invasive application procedure. In this narrative review, we focus on three main topics concerning the use of platelet concentrate for treating musculoskeletal conditions: (a) the different procedures to prepare PCs, (b) the composition of PCs that is related to the type of methodological procedure adopted and (c) the clinical application in musculoskeletal medicine, efficacy and main limits of the different studies.
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Affiliation(s)
- Erminia Mariani
- Laboratorio di Immunoreumatologia e rigenerazione tissutale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy;
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
- Correspondence: ; Tel.: +39-051-6366803
| | - Lia Pulsatelli
- Laboratorio di Immunoreumatologia e rigenerazione tissutale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy;
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Acebes-Huerta A, Arias-Fernández T, Bernardo Á, Muñoz-Turrillas MC, Fernández-Fuertes J, Seghatchian J, Gutiérrez L. Platelet-derived bio-products: Classification update, applications, concerns and new perspectives. Transfus Apher Sci 2019; 59:102716. [PMID: 31928859 DOI: 10.1016/j.transci.2019.102716] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Platelet derived bio-products in the form of platelet rich plasma, plasma rich in growth factors, or plasma-free platelet releasates, are being studied worldwide with the aim of proving their efficacy in tissue regeneration within many different clinical areas, such as traumatology, maxillofacial surgery, ophthalmology, dermatology and otorhinolaryngology, amongst others. The current lack of consensus in the preparation method and application form, or in the quality assessment of each bio-product, precludes adequate interpretation of the relevance of reported clinical outcomes, and, while many in clinicians are very positive about them, many are sceptic. Relevant aspects of these products are considered to propose a classification nomenclature which would aid a comprehensive comparison of clinical outcomes of bio-products of the same characteristics. Finally, the uses of platelet-derived bio-products in in vitro culture (for cell therapy purposes) as a substitute of animal-origin sera, and other future perspectives of applications of platelet-derived bio-products are discussed.
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Affiliation(s)
- Andrea Acebes-Huerta
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Tamara Arias-Fernández
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ángel Bernardo
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Hospital Universitario Central de Asturias (HUCA), Laboratorio de Diagnóstico Clínico Hematología, Oviedo, Spain
| | - María Carmen Muñoz-Turrillas
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Centro Comunitario de Sangre y Tejidos de Asturias, Oviedo, Spain
| | - Judit Fernández-Fuertes
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Cabueñes Hospital Universitario (CAHU), Servicio de Cirugía Ortopédica y Traumatología (COT), Gijón, Spain
| | - Jerard Seghatchian
- International consultancy in blood components quality / safety and DDR strategies, London, UK
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Dept. of Medicine, University of Oviedo, Spain.
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80
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Fallows R, Lumsden G. Pitfalls in the study of neovascularisation in achilles and patellar tendinopathy: a review of important factors for clinicians to consider and the need for greater standardisation. PHYSICAL THERAPY REVIEWS 2019. [DOI: 10.1080/10833196.2019.1690216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Richard Fallows
- Telford Musculoskeletal Services, Shropshire Community Health NHS Trust, Shropshire, UK
| | - Gordon Lumsden
- Physiotherapy Department, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
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81
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Kaplan K, Olivencia O, Dreger M, Hanney WJ, Kolber MJ. Achilles Tendinopathy: An Evidence-Based Overview for the Sports Medicine Professional. Strength Cond J 2019. [DOI: 10.1519/ssc.0000000000000485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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82
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Abstract
Use of orthobiologics in sports medicine and musculoskeletal surgery has gained significant interest. However, many of the commercially available and advertised products are lacking in clinical evidence. Widespread use of products before fully understanding their true indications may result in unknown adverse outcomes and may also lead to increased health care costs. As more products become available, it is important to remain judicial in use and to practice evidence-based medicine. Likewise, it is important to continue advances in research in hopes to improve surgical outcomes. This article reviews clinical evidence behind common orthobiologics in the treatment of foot and ankle pathology.
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83
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Lawson A, Noorkoiv M, Masci L, Mohagheghi AA. Ankle Joint Position and the Reliability of Ultrasound Tissue Characterization of the Achilles Tendon: A Pilot Study. Med Sci Monit 2019; 25:6884-6893. [PMID: 31516131 PMCID: PMC6755937 DOI: 10.12659/msm.915685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Imaging of the Achilles tendon using ultrasound tissue characterization (UTC) involves taking up the slack of the tendon by including dorsiflexion of the ankle. This pilot study aimed to determine whether different longitudinal tension applied to the Achilles tendon during imaging affected the reliability of UTC. Material/Methods Nine asymptomatic active volunteers, aged between 23–49 years underwent imaging of 17 Achilles tendons. Three positions of tension included plantar grade, 50%, and 100% of maximal dorsiflexion, with a range of 18–32°. Ranges were established and standardized using an isokinetic dynamometer. A test and re-test process was conducted at each position to determine the intraclass correlation coefficients (ICCs) and minimum detectable change (MDC) per echotype. Images were analyzed using UTC software. Results Plantar grade positioning images could not be obtained. ICCs for each echotype I–IV between test 1 and test 2 were 0.965, 0.962, 0.858, 0.739 at 100% dorsiflexion (95% CI, 0.86–0.99, 0.84–0.99, 0.51–0.97, and 0.2–0.94), and 0.771, 0.551, 0.569, 0.429 at 50% dorsiflexion (95% CI, 0.29–0.94, −0.09–0.88, −0.01–0.88, and −0.15–0.82). The MDC per echotype I–IV ranged between 4.1–1.0% of echotype data at 100% dorsiflexion, and 17.2–6.3% at 50% dorsiflexion. Conclusions Testing at maximum dorsiflexion provided improved reliability when using UTC in healthy individuals. The ICC at 100% dorsiflexion was increased, and the MDC was reduced for all echotypes. Therefore, standardizing test positions when using UTC is advisable for reliable comparison of results between studies.
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Affiliation(s)
- Arturo Lawson
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University, London, United Kingdom
| | - Marika Noorkoiv
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University, London, United Kingdom
| | | | - Amir A Mohagheghi
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University, London, United Kingdom
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84
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Pavone V, Vescio A, Mobilia G, Dimartino S, Di Stefano G, Culmone A, Testa G. Conservative Treatment of Chronic Achilles Tendinopathy: A Systematic Review. J Funct Morphol Kinesiol 2019; 4:E46. [PMID: 33467361 PMCID: PMC7739415 DOI: 10.3390/jfmk4030046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/19/2019] [Accepted: 07/21/2019] [Indexed: 12/27/2022] Open
Abstract
Achilles tendinopathy is a common musculoskeletal disorder. Athletes, runners and jumpers, and the sedentary are frequently affected. Numerous are the therapeutic choices to manage these kinds of disorders. The aim of this review is to analyze the available literature to document the up-to-date evidence on conservative management of Achilles tendinopathy. A systematic review of two medical electronic databases was performed by three independent authors, using the following inclusion criteria: conservative treatment consisted of pharmacologic, physical therapy without operative treatment, with more of 6 months symptoms and a minimum average of 6-months follow-up. Studies of any level of evidence, reporting clinical results, and dealing with Achilles tendinopathy and conservative treatment were searched for. A total of n = 1228 articles were found. At the end of the first screening, following the previously described selection criteria, we selected n = 94 articles eligible for full-text reading. Ultimately, after full-text reading and a reference list check, we selected n = 29 articles. Achilles tendinopathy is a frequent musculoskeletal disorder and several conservative treatments have been proposed, but no therapy is universally accepted, except for eccentric exercise training, which is the gold standard and a commonly used protocol.
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Affiliation(s)
- Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopedics and Traumatology, A.O.U. Policlinico-Vittorio Emanuele, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
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85
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Hanisch K, Wedderkopp N. Platelet-rich plasma (PRP) treatment of noninsertional Achilles tendinopathy in a two case series: no significant difference in effect between leukocyte-rich and leukocyte-poor PRP. Orthop Res Rev 2019; 11:55-60. [PMID: 31040726 PMCID: PMC6460817 DOI: 10.2147/orr.s187638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background There is a theoretical basis for the treatment of chronic tendinopathies by platelet-rich plasma (PRP), and it can, therefore, be considered a possible treatment of chronic Achilles tendinopathies (CATs), even though the clinical evidence for the use is not clear and, in addition, there is a lack of treatment algorithms and it is unclear which type of PRP is most effective. The objective of this study was through the comparison of two case series to assess: 1) the effect of PRP on CAT and 2) if there is any difference in effect between leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) in the treatment of CAT. Patients and methods Two separate series of achilles tenodinopathies treated with either LR-PRP or LP-PRP were evaluated with a natural experiment/quasi-experimental study design, with a short-term (2 months) and long-term (8–42 months) follow-up to assess the effect and stability of the treatment. In total, 84 patients with failed basic treatment for CAT for at least 6 months were treated with either Biomet’s GPS III recovery kit with LR-PRP (36 patients) or with Arthrex ACP LP-PRP (48 patients). Results The overall probability of reaching a minimal clinically important change (MCIC) of at least 30% reduction in visual analog scale (VAS) was in activity (63%) and during rest (81%), and for Victorian Institute of Sport Assessment Scale (VISA-A), it was 61%. There was no statistical difference in change of VISA-A score or VAS between the patients treated with LP-PRP and LR-PRP. Conclusion PRP seems to be a possible treatment when all other treatment regimens have failed, with a reasonably high probability of reaching MCIC. The choice of either LR-PRP or LP-PRP seems to be up to personal preference as there were no significant differences between patients treated with LR-PRP and LP-PRP.
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Affiliation(s)
- Klaus Hanisch
- Orthopedic Department, Hospital of Southwestern Jutland, Esbjerg, Denmark,
| | - Niels Wedderkopp
- Orthopedic Department, Hospital of Southwestern Jutland, Esbjerg, Denmark, .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark,
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86
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Liu CJ, Yu KL, Bai JB, Tian DH, Liu GL. Platelet-rich plasma injection for the treatment of chronic Achilles tendinopathy: A meta-analysis. Medicine (Baltimore) 2019; 98:e15278. [PMID: 31008973 PMCID: PMC6494278 DOI: 10.1097/md.0000000000015278] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Platelet-rich plasma (PRP) is used as an alternative therapy to reduce pain and improve functional restoration in patients with Achilles tendinopathy (AT). We evaluated the current evidence for the efficacy of PRP as a treatment for chronic AT. METHODS The PubMed, Embase, Web of Science, and The Cochrane Library databases were searched for articles on randomized controlled trials (RCTs) that compared the efficacy of PRP with that of with placebo injections plus eccentric training as treatment for AT. The articles were uploaded over the establishment of the databases to May 01, 2018. The Cochrane risk of bias (ROB) tool was used to assess methodological quality. Outcome measurements included the Victorian Institute of Sports Assessment-Achilles (VISA-A), visual analog scale (VAS) and Achilles tendon thickness. Statistical analysis was performed with RevMan 5.3.5 software. RESULTS Five RCTs (n = 189) were included in this meta-analysis. Significant differences in the VISA-A were not observed between the PRP and placebo groups after 12 weeks [standardized mean difference (SMD) = 0.2, 95% confidence interval (95% CI): 0.36 to 0.76, I = 71%], 24 weeks (SMD = 0.77, 95% CI: -0.10-1.65, I = 85%) and 1 year (SMD = 0.83, 95% CI: -0.76-2.42, I = 72%) of treatment. However, PRP exhibited better efficacy than the placebo treatment after 6 weeks (SMD = 0.46, 95% CI: 0.15-0.77, I = 34%). Two studies included VAS scores and tendon thickness. VAS scores after 6 weeks (SMD = 1.35, 95% CI: -0.1.04-3.74, I = 93%) and 24 weeks (SMD = 1.48, 95% CI: -0.1.59-4.55, I = 95%) were not significantly different. However, VAS scores at the 12th week (SMD = 1.10, 95% CI: 0.53-1.68, I = 83%) and tendon thickness (SMD = 1.51, 95% CI: 0.39-2.63, I = 53%) were significantly different. CONCLUSION PRP injection around the Achilles tendon is an option for the treatment of chronic AT. Limited evidence supports the conclusion that PRP is not superior to placebo treatment. These results still require verification by a large number of well designed, heterogeneous RCT studies.
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Affiliation(s)
- Chun-jie Liu
- Department of Orthopedics, Tangshan Workers Hospital, Tangshan City
| | - Kun-lun Yu
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang
| | - Jiang-bo Bai
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang
| | - De-hu Tian
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang
| | - Guo-li Liu
- Department of Orthopedics, The Second Hospital of Tangshan, Tangshan City Hebei Province, PR China
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87
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Efficacy of platelet-rich plasma injections for treating Achilles tendonitis. DER ORTHOPADE 2019; 48:784-791. [DOI: 10.1007/s00132-019-03711-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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88
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Fitzpatrick J, Bulsara MK, O'Donnell J, Zheng MH. Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up. Am J Sports Med 2019; 47:1130-1137. [PMID: 30840831 DOI: 10.1177/0363546519826969] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A previously published trial showed that patients with chronic gluteal tendinopathy achieved greater clinical improvement at 12 weeks when treated with a single platelet-rich plasma (PRP) injection than those treated with a single corticosteroid injection (CSI). PURPOSE This follow-up study was conducted to determine whether there would be a sustained long-term difference in the modified Harris Hip Score (mHHS) at 2 years for a leucocyte-rich PRP (LR-PRP) injection in the treatment of chronic gluteal tendinopathy. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This trial included 80 patients randomized 1:1 to receive LR-PRP or CSI intratendinously under ultrasound guidance. Patients had a mean age of 60 years, a 9:1 ratio of women to men, a mean body mass index of 27, and a mean length of symptoms >15 months. No patients had full-thickness tears of the gluteal tendons. An open-labeled extension allowed patients to receive crossover treatment after 3 months. The main outcome measure was the mHHS. RESULTS The mean mHHS improved significantly at 12 weeks in the PRP group (74.05; SD, 13.92) as compared with the CSI group (67.13; SD, 16.04) ( P = .048). At 24 weeks, the LR-PRP group (77.60; SD, 11.88) improved further than the CSI group (65.72; SD, 15.28; P = .0003). Twenty-seven patients were deemed to have failed the CSI treatment at 16 to 24 weeks, with an exit score of 59.22 (SD, 11.54), and then had treatment with LR-PRP. The crossover group improved with the LR-PRP: from 59.22 (SD, 11.22) at baseline to 75.55 (SD, 16.05) at 12 weeks, 77.69 (SD, 15.30) at 24 weeks, and 77.53 (SD, 14.54) at 104 weeks. The LR-PRP group retained 38 of 39 patients to 52 weeks and continued to improve. Their baseline scores of 53.77 (SD, 12.08) improved to 82.59 (SD, 9.71) at 104 weeks ( P < .0001). CONCLUSION Among patients with chronic gluteal tendinopathy and a length of symptoms >15 months, a single intratendinous LR-PRP injection performed under ultrasound guidance results in greater improvement in pain and function than a single CSI. The improvement after LR-PRP injection is sustained at 2 years, whereas the improvement from a CSI is maximal at 6 weeks and not maintained beyond 24 weeks. REGISTRATION ACTRN12613000677707 (Australian New Zealand Clinical Trials identifier).
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Affiliation(s)
- Jane Fitzpatrick
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Parkville, Australia.,Joint Health Institute, Melbourne, Australia.,Epworth Hospital, Richmond, Australia
| | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Australia
| | | | - Ming Hao Zheng
- Research Centre for Translational Orthopaedic Research, Sir Charles Gairdner Hospital, Nedlands, Australia.,School of Surgery, University of Western Australia, Crawley, Australia
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89
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The use of PRP injections in the management of knee osteoarthritis. Cell Tissue Res 2019; 376:143-152. [PMID: 30758709 DOI: 10.1007/s00441-019-02996-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 01/11/2019] [Indexed: 01/11/2023]
Abstract
Osteoarthritis (OA) is a degenerative disease involving joint damage, an inadequate healing response and progressive deterioration of the joint architecture that commonly affects the knee and/or hip joints. It is a major world public health problem and is predicted to increase rapidly with an ageing population and escalating rate of obesity. Autologous blood-derived products possess much promise in the repair and regeneration of tissue and have important roles in inflammation, angiogenesis, cell migration and metabolism in pathological conditions, including OA. Utilising platelet-rich plasma (PRP) to treat tendon, ligament and skeletal muscle has shown variable results across many studies with the current evidence base for the efficacy of PRP in treating sports injuries remaining inconclusive. More uniformly positive results have been observed by various studies for PRP in OA knee in comparison to hyaluronic acid, other intra-articular injections and placebo than in other musculoskeletal tissue. However, methodological concerns as well as satisfactory PRP product classification prevent the true characterisation of this treatment. Thus, further research is required to investigate how leukocyte inclusion, activation and platelet concentration affect therapeutic efficacy. Furthermore, the optimisation of timing, dosage, volume, frequency and rehabilitation strategies need to be ascertained. For knee OA management, these concerns must be addressed before this promising treatment can be widely implemented.
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90
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91
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Ooi CC, Schneider M, Malliaras P, Png MA, Chadwick M, Jones D, Venkatanarasimha N, Connell D. Real-time sonoelastography evaluation of the Achilles tendon following ultrasound-guided platelet-rich plasma injection and eccentric exercise for the treatment of refractory Achilles tendinopathy. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2018; 27:138-147. [PMID: 32549893 DOI: 10.1177/1742271x18818608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/08/2018] [Indexed: 11/17/2022]
Abstract
The objective of this study was to investigate the feasibility of using sonoelastography to depict Achilles tendon stiffness after platelet-rich plasma injection and eccentric exercise for chronic Achilles tendinopathy, and to correlate sonoelastography findings with clinical outcome up to 12 months after treatment. Forty-five Achilles tendons from 45 patients (33 males, 12 females; mean age 51 years) were examined using sonoelastography and ultrasound at baseline, 4-6 weeks, 6 months and 12 months post-treatment. The strain ratio (between Achilles tendon and Kager's fat) during sonoelastography was obtained. The proportion of tendons with hypoechogenicity and neovascularity were documented. Clinical outcomes were assessed by the Victorian Institute of Sport Assessment-Achilles questionnaire and correlated with sonographic findings. The Victorian Institute of Sport Assessment-Achilles improved significantly from 38.4 (±14.1) at baseline, 77.2 (±12.5) at 6 months (p < 0.001) to 81.2 (±10.8) at 12 months (p < 0.001). The strain ratio values were 2.16 (±1.02) at baseline, 2.03 (±0.67) at 4-6 weeks, 1.81 (±0.62) at 6 months and 1.19 (±0.34) at 12 months with a significant reduction observed at 6 months (p = 0.006) and 12 months (p < 0.001). At 12-month evaluation, none of the tendons regained a normal echotexture. Strain ratio demonstrated a moderately good inverse correlation with Victorian Institute of Sport Assessment-Achilles (r = -0.610, p<0.001) while B-mode and Doppler ultrasound did not show a significant correlation (r = -0.041, p = 0.817, and r = -0.116, p = 0.514). Achilles tendon stiffness shows moderately good correlation with clinical symptom at 12-month post-treatment. Sonoelastography using strain ratio could be a promising ancillary tool for monitoring Achilles tendon healing after treatment.
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Affiliation(s)
- Chin Chin Ooi
- Division of Radiological Sciences, Singapore General Hospital, Singapore, Singapore.,Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.,Imaging at Olympic Park, AAMI Park, Melbourne, Australia
| | - Michal Schneider
- Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Peter Malliaras
- Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.,Imaging at Olympic Park, AAMI Park, Melbourne, Australia.,Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary, University of London, London, UK
| | - Meng Ai Png
- Division of Radiological Sciences, Singapore General Hospital, Singapore, Singapore
| | | | - Donna Jones
- Imaging at Olympic Park, AAMI Park, Melbourne, Australia
| | | | - David Connell
- Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.,Imaging at Olympic Park, AAMI Park, Melbourne, Australia
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92
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Abstract
Platelet-rich plasma (PRP) is a promising treatment for musculoskeletal maladies and clinical data to date have shown that PRP is safe. However, evidence of its efficacy has been mixed and highly variable depending on the specific indication. Additional future high-quality large clinical trials will be critical in shaping our perspective of this treatment option. The heterogeneity of PRP preparations, both presently and historically, leads sweeping recommendations about its utility impossible to make. This heterogeneity has also made interpreting existing literature more complicated.
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Affiliation(s)
- Adrian D K Le
- Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94063, USA
| | - Lawrence Enweze
- Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94063, USA
| | - Malcolm R DeBaun
- Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94063, USA
| | - Jason L Dragoo
- Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94063, USA.
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93
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Le ADK, Enweze L, DeBaun MR, Dragoo JL. Current Clinical Recommendations for Use of Platelet-Rich Plasma. Curr Rev Musculoskelet Med 2018; 11:624-634. [PMID: 30353479 PMCID: PMC6220007 DOI: 10.1007/s12178-018-9527-7] [Citation(s) in RCA: 193] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW This review evaluates current clinical literature on the use of platelet-rich plasma (PRP), including leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP), in order to develop evidence-based recommendations for various musculoskeletal indications. RECENT FINDINGS Abundant high-quality evidence supports the use of LR-PRP injection for lateral epicondylitis and LP-PRP for osteoarthritis of the knee. Moderate high-quality evidence supports the use of LR-PRP injection for patellar tendinopathy and of PRP injection for plantar fasciitis and donor site pain in patellar tendon graft BTB ACL reconstruction. There is insufficient evidence to routinely recommend PRP for rotator cuff tendinopathy, osteoarthritis of the hip, or high ankle sprains. Current evidence demonstrates a lack of efficacy of PRP for Achilles tendinopathy, muscle injuries, acute fracture or nonunion, surgical augmentation in rotator cuff repair, Achilles tendon repair, and ACL reconstruction. PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.
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Affiliation(s)
- Adrian D. K. Le
- Department of Orthopedic Surgery, Stanford University, 450 Broadway St, Redwood City, CA USA
- Lifemark Health Group, Toronto, ON Canada
| | - Lawrence Enweze
- Department of Orthopedic Surgery, Stanford University, 450 Broadway St, Redwood City, CA USA
| | - Malcolm R. DeBaun
- Department of Orthopedic Surgery, Stanford University, 450 Broadway St, Redwood City, CA USA
| | - Jason L. Dragoo
- Department of Orthopedic Surgery, Stanford University, 450 Broadway St, Redwood City, CA USA
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94
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The Differential Effects of Leukocyte-Containing and Pure Platelet-Rich Plasma on Nucleus Pulposus-Derived Mesenchymal Stem Cells: Implications for the Clinical Treatment of Intervertebral Disc Degeneration. Stem Cells Int 2018; 2018:7162084. [PMID: 30425747 PMCID: PMC6218728 DOI: 10.1155/2018/7162084] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/30/2018] [Accepted: 08/09/2018] [Indexed: 12/18/2022] Open
Abstract
Background Platelet-rich plasma (PRP) is a promising strategy for intervertebral disc degeneration. However, the potential harmful effects of leukocytes in PRP on nucleus pulposus-derived mesenchymal stem cells (NPMSCs) have seldom been studied. This study aimed at comparatively evaluating effects of pure platelet-rich plasma (P-PRP) and leukocyte-containing platelet-rich plasma (L-PRP) on rabbit NPMSCs in vitro. Methods NPMSCs isolated from rabbit NP tissues were treated with L-PRP or P-PRP in vitro, and then cell proliferation and expression of stem cell markers, proinflammatory cytokines (TNF-α, IL-1β), production of ECM (extracellular matrix-related protein), and NF-κB p65 protein were validated by CCK-8 assay, real-time polymerase chain reaction, enzyme-linked immunosorbent assay, immunofluorescence, and western blot respectively. Results NPMSCs differentiate into nucleus pulposus-like cells after treatment of PRPs (P-PRP and L-PRP), and NPMSCs exhibited maximum proliferation at a 10% PRP dose. L-PRP had observably higher concentration of leukocytes, TNF-α, and IL-1β than P-PRP. Furthermore, compared to P-PRP, L-PRP induced the differentiated NPMSCs to upregulate the expression of TNF-α and IL-1β, enhanced activation of the NF-κB pathway, increased the expression of MMP-1 and MMP-13, and produced less ECM in differentiated NPMSCs. Conclusions Both P-PRP and L-PRP can induce the proliferation and NP-differentiation of NPMSCs. Compared to L-PRP, P-PRP can avoid the activation of the NF-κB pathway, thus reducing the inflammatory and catabolic responses.
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Kolber MJ, Purita J, Paulus C, Carreno JA, Hanney WJ. Platelet-Rich Plasma: Basic Science and Biological Effects. Strength Cond J 2018. [DOI: 10.1519/ssc.0000000000000402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Abstract
PURPOSE OF REVIEW Platelet-rich plasma has become an increasingly popular treatment option within the orthopedic community to biologically enhance and stimulate difficult-to-heal musculoskeletal tissues. This review evaluates the recent literature on platelet-rich plasma use in the treatment of foot and ankle pathologies. RECENT FINDINGS Recent literature has demonstrated platelet-rich plasma to have a possible benefit in the treatment of Achilles pathology, chronic plantar fasciitis, osteochondral lesions of the talus, ankle osteoarthritis, and diabetic foot ulcers. However, given the lack of standardization of platelet-rich plasma preparations and protocols and the predominance of low-quality studies, no definitive treatment indications exist. Platelet-rich plasma is a promising treatment option, but at present, there is only limited clinical evidence supporting its use in foot and ankle applications.
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Affiliation(s)
- Peter R Henning
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, 1400 S. Germantown Rd, Germantown, 38138, TN, USA
| | - Benjamin J Grear
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, 1400 S. Germantown Rd, Germantown, 38138, TN, USA.
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97
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Efficacy of platelet-rich plasma as conservative treatment in orthopaedics: a systematic review and meta-analysis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:502-513. [PMID: 30201082 DOI: 10.2450/2018.0111-18] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis was to evaluate the benefit of platelet-rich plasma (PRP) in non-surgical orthopaedic procedures. MATERIAL AND METHODS We searched the Cochrane Wounds Specialized Register, CENTRAL, MEDLINE (through PUBMED), Embase, and SCOPUS. We also searched clinical trials registries for ongoing and unpublished studies and checked reference lists to identify additional studies. RESULTS We found 36 randomised controlled trials (2,073 patients) that met our inclusion criteria. The included studies mostly had small numbers of participants (from 20 to 225). Twenty-eight studies included patients with lateral epicondylitis or plantar fasciitis. PRP was compared to local steroids injection (19 studies), saline injection (6 studies), autologous whole blood (4 studies), local anaesthetic injection (3 studies), dry needling injection (3 studies), and to other comparators (4 studies). Primary outcomes were pain and function scores, and adverse events. On average, it is unclear whether or not use of PRP compared to controls reduces pain scores and functional score at short- (up to 3 months) and medium- (4-6 months) term follow-up. The available evidence for all the comparisons was rated as very low quality due to inconsistency, imprecision, and risk of bias in most of the selected studies. There were no serious adverse events related to PRP injection or control treatments. CONCLUSIONS The results of this meta-analysis, which documents the very marginal effectiveness of PRP compared to controls, does not support the use of PRP as conservative treatment in orthopaedics.
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Lin MT, Wu CH. Author reply to "Regarding 'Meta-analysis Comparing Autologous Blood-Derived Products (Including Platelet-Rich Plasma) Injection Versus Placebo in Patients With Achilles Tendinopathy"'. Arthroscopy 2018; 34:2528-2529. [PMID: 30173792 DOI: 10.1016/j.arthro.2018.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 06/20/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Meng-Ting Lin
- National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chueh-Hung Wu
- National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Shimozono Y, Fortier LA, Kennedy JG. Regarding "Meta-analysis Comparing Autologous Blood-Derived Products (Including Platelet-Rich Plasma) Injection Versus Placebo in Patients With Achilles Tendinopathy". Arthroscopy 2018; 34:2526-2528. [PMID: 30173791 DOI: 10.1016/j.arthro.2018.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/20/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Yoshiharu Shimozono
- Hospital for Special Surgery, New York, New York; Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Lisa A Fortier
- Department of Clinical Sciences, Cornell University, Ithaca, New York
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Zhang YJ, Xu SZ, Gu PC, Du JY, Cai YZ, Zhang C, Lin XJ. Is Platelet-rich Plasma Injection Effective for Chronic Achilles Tendinopathy? A Meta-analysis. Clin Orthop Relat Res 2018; 476:1633-1641. [PMID: 29601383 PMCID: PMC6259774 DOI: 10.1007/s11999.0000000000000258] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Chronic Achilles tendinopathy is common in the general population, and platelet-rich plasma (PRP) is seeing increased use to treat this problem. However, studies disagree as to whether PRP confers a beneficial effect for chronic Achilles tendinopathy, and no one to our knowledge has pooled the available randomized trials in a formal meta-analysis to try to reconcile those differences. QUESTIONS/PURPOSES In the setting of a systematic review and meta-analysis of randomized controlled trials (RCTs), we asked: Does PRP plus eccentric strength training result in (1) greater improvements in Victorian Institute of Sports Assessment-Achilles (VISA-A) scores; (2) differences in tendon thickness; or (3) differences in color Doppler activity compared with placebo (saline) injections plus eccentric strength training in patients with chronic Achilles tendinopathy? METHODS A search of peer-reviewed articles was conducted to identify all RCTs using PRP injection with eccentric training for chronic Achilles tendinopathy in the electronic databases of PubMed, Web of Science (SCI-E/SSCI/A&HCI), and EMBASE from January 1981 to August 2017. Results were limited to human RCTs and published in all languages. Two reviewers assessed study quality using the Cochrane Collaboration risk-of-bias tool. All the included studies had low risk of bias. The primary endpoint was improvement in the VISA-A score, which ranges from 0 to 100 points, with higher scores representing increased activity and less pain; we considered the minimum clinically important difference on the VISA-A to be 12 points. Secondary outcomes were tendon thickness change (with a thicker tendon representing more severe disease), color Doppler activity (with more activity representing a poorer result), and other functional measures (such as pain and return to sports activity). Four RCTs involving 170 participants were eligible and included 85 participants treated with PRP injection and eccentric training and 85 treated with saline injection and eccentric training. The patients in both PRP and placebo (saline) groups seemed comparable at baseline. We assessed for publication bias using a funnel plot and saw no evidence of publication bias. Based on previous studies, we had 80% power to detect a 12-point difference on the VISA-A score with the available sample size in each group. RESULTS With the numbers available, there was no difference between the PRP and saline groups regarding the primary outcome (VISA-A score: mean difference [MD], 5.3; 95% confidence interval [CI], -0.7 to 11.3; p = 0.085). Likewise, we found no difference between the PRP and saline groups in terms of our secondary outcomes of tendon thickness change (MD, 0.2 mm; 95% CI, 0.6-1.0 mm; p = 0.663) and color Doppler activity (MD, 0.1; 95% CI, -0.7 to 0.4; p = 0.695). CONCLUSIONS PRP injection with eccentric training did not improve VISA-A scores, reduce tendon thickness, or reduce color Doppler activity in patients with chronic Achilles tendinopathy compared with saline injection. Larger randomized trials are needed to confirm these results, but until or unless a clear benefit has been demonstrated in favor of the new treatment, we cannot recommend it for general use. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Yi-Jun Zhang
- Yi-Jun Zhang, San-Zhong Xu, Peng-Cheng Gu, Jing-Yu Du, You-Zhi Cai, Chi Zhang, Xiang-Jin Lin, Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
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