Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial

Myths and Facts of In-Office Regenerative Procedures for Tendinopathy

Tendinopathy carries a large burden of musculoskeletal disorders seen in both athletes and aging population. Treatment is often challenging, and progression to chronic tendinopathy is common. Physical therapy, nonsteroidal anti-inflammatory drugs, and corticosteroid injections have been the mainstay of treatment but are not optimal given that most tendon disorders seem to involve degenerative changes in addition to inflammation. The field of regenerative medicine has taken the forefront, and various treatments have been developed and explored including prolotherapy, platelet rich plasma, stem cells, and percutaneous ultrasonic tenotomy. However, high-quality research with standardized protocols and consistent controls for proper evaluation of treatment efficacy is currently needed. This will make it possible to provide recommendations on appropriate treatment options for tendinopathy.

The Effect of Impactful Articles on Clinical Practice in the United States: Corticosteroid Injection for Patients with Lateral Epicondylitis

BACKGROUND

Following publication of high-level evidence demonstrating that it is not an effective treatment for lateral epicondylitis, a reduction in the corticosteroid injection rate would be expected. The authors aimed to clarify current clinical practice pattern for lateral epicondylitis and identify factors that influence the introduction of evidence into clinical practice.

METHODS

In this administrative claims analysis, the authors used 2009 to 2015 Truven MarketScan data to extract claims for corticosteroid injection, physical therapy, platelet-rich plasma injection, and surgery for lateral epicondylitis. The authors performed multivariable analysis using a generalized estimating equation model to identify the variables that potentially affect the odds of receiving a given treatment.

RESULTS

Among 711,726 claims, the authors found that the odds of receiving a corticosteroid injection increased slightly after publication of contradictory evidence (OR, 1.7; 95 percent CI, 1.04 to 1.11 in 2015). Being male (OR, 1.21; 95 percent CI, 1.19 to 1.23), older (OR, 1.16; 95 percent CI, 1.13 to 1.19), and having managed care insurance (OR, 1.15; 95 percent CI, 1.13 to 1.18) significantly contributed to increased odds of receiving corticosteroid injections. Patients seen at facilities in the South (OR, 1.33; 95 percent CI, 1.30 to 1.36 compared with the Northeast) and by plastic/orthopedic surgeons (OR, 2.48; 95 percent CI, 2.43 to 2.52) also had increased odds of receiving corticosteroid injection.

CONCLUSIONS

Corticosteroid injection use did not decrease after publication of impactful articles, regardless of provider specialty or other patient-related factors. This finding emphasizes that there are various barriers for even high-level evidence to overcome the inertia of current practice.

Fifty Most-cited Articles on Lateral Epicondylitis of the Elbow

Introduction:

Citation number can be used as a marker of a scientific article's influence. This study sought to determine and characterize the most-cited investigations on lateral epicondylitis and identify the most influential studies pertaining to this pathology.

Methods:

The Institute for Scientific Information Web of Science database was queried for articles investigating lateral epicondylitis, and the 50 most-cited articles were selected. For each article, number of citations, citation density, journal, publication year, country of origin, language, article type, article subtype, and level of evidence were recorded.

Results:

Citation numbers ranged from 72 to 332 (mean, 127.4), and densities ranged from 1.6 to 34.0 (mean, 9.4). Articles were published across 26 different journals. Most articles (41) were clinical, with randomized controlled trials (29.3%) being the most commonly cited articles.

Discussion:

Compared with previous investigations looking at citation density within orthopaedics, the most commonly cited clinical articles on lateral epicondylitis had a high percentage of level I or II evidence (39.0%). This compilation of the literature can aid in establishing reading curriculums for trainees in both orthopaedic residencies and fellowships. This is a Level V study.

Efficacy of platelet-rich plasma as conservative treatment in orthopaedics: a systematic review and meta-analysis

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.

Regenerative Sports Medicine: Past, Present, and Future (Adapted From the PASSOR Legacy Award Presentation; AAPMR; October 2016)

Regenerative medicine has shown dramatic expanse and evolution in the past decade. Within that milieu, physiatrists are taking an active role in research, clinical care delivery, and education. The purpose of this review is to provide a balance among evidence, theory, experience, clinical trends, and the foreseeable future. We focus on the literature that reports the research with the best methodology in each practice area, recognizing that the level of evidence varies substantially among different treatment modalities and conditions. The following elements are included: an overview of the evolution of currently available regenerative techniques, evidence base for each available modality (prolotherapy, platelet rich plasma, bone marrow aspirate concentrate and stem cells, adipose-derived stem cells, and amniotic tissue products), general principles in the application of these treatments, and discussion and a vision of what lies ahead. We expect that practitioners will use this review to facilitate clinical decision making and to provide a core knowledge base to assist when counseling patients. LEVEL OF EVIDENCE: IV.

Platelet-rich plasma in tendon-related disorders: results and indications

PURPOSE

Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied.

METHODS

A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies.

RESULTS

The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative).

CONCLUSION

Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders.

LEVEL OF EVIDENCE

Systematic review of level I-IV trials, Level IV.

The Efficacy of Platelet-Rich Plasma on Tendon and Ligament Healing: A Systematic Review and Meta-analysis With Bias Assessment

BACKGROUND

There has been a surge in high-level studies investigating platelet-rich plasma (PRP) for tendon and ligament injuries. A number of meta-analyses have been published, but few studies have focused exclusively on tendon and ligament injuries.

PURPOSE

To perform a meta-analysis assessing the ability of PRP to reduce pain in patients with tendon and ligament injuries.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive search of the literature was carried out in April 2017 using electronic databases PubMed, MEDLINE, and the Cochrane Library. Only level 1 studies were included. Platelet and leukocyte count, injection volume, kit used, participant age/sex, comparator, and activating agent used were recorded. The short-term and long-term efficacy of PRP was assessed using the visual analog scale (VAS) to measure pain intensity. Injury subgroups (rotator cuff, tendinopathy, anterior cruciate ligament, and lateral epicondylitis) were evaluated. Funnel plots and the Egger test were used to screen for publication bias, and sensitivity analysis was performed to evaluate the effect of potential outliers by removing studies one at a time.

RESULTS

Thirty-seven articles were included in this review, 21 (1031 participants) of which could be included in the quantitative analysis. The majority of studies published investigated rotator cuff injuries (38.1%) or lateral epicondylitis (38.1%). Seventeen studies (844 participants) reported short-term VAS data, and 14 studies (771 participants) reported long-term VAS data. Overall, long-term follow-up results showed significantly less pain in the PRP group compared with the control group (weighted mean difference [WMD], -0.84; 95% CI, -1.23 to -0.44; P < .01). Patients treated with PRP for rotator cuff injuries (WMD, -0.53; 95% CI, -0.98 to -0.09; P = .02) and lateral epicondylitis (WMD, -1.39; 95% CI, -2.49 to -0.29; P = .01) reported significantly less pain in the long term. Substantial heterogeneity was reported at baseline ( I² = 72.0%; P < .01), short-term follow-up ( I² = 72.5%; P < .01), long-term follow-up ( I² = 76.1%; P < .01), and overall ( I² = 75.8%; P < .01). The funnel plot appeared to be asymmetric, with some missingness at the lower right portion of the plot suggesting possible publication bias.

CONCLUSION

This review shows that PRP may reduce pain associated with lateral epicondylitis and rotator cuff injuries.

Short-Term Effect of Low-Dose, Electromyography-Guided Botulinum Toxin A Injection in the Treatment of Chronic Lateral Epicondylar Tendinopathy: A Randomized, Double-Blinded Study

BACKGROUND

Botulinum toxin A (BoNT-A) is a novel treatment for chronic lateral epicondylar tendinopathy. Preliminary studies have demonstrated promising results; however, confirmation of the effectiveness of BoNT-A treatment and further assessment of its side effects are required. This study investigated the analgesic effects of BoNT-A in the treatment of chronic lateral epicondylar tendinopathy.

METHODS

This was a phase-III, single-center, randomized, double-blinded, placebo-controlled study including 60 patients with chronic lateral epicondylar tendinopathy that had been resistant to treatment for >6 months. Patients received either a 40-IU injection of BoNT-A or saline solution placebo into the extensor carpi radialis brevis (ECRB) muscle, aided by electromyographic (EMG) stimulation. Follow-up was 3 months. The primary assessment criterion was the percentage of patients whose pain was reduced by >50% at 90 days after injection. Secondary outcomes, including pain intensity, pain frequency, interference with quality of life, sick leave taken, maximum grip strength, and side effects, were assessed at days 30 and 90, and the number of participants per group requesting additional therapies at day 90 was recorded.

RESULTS

Twenty-nine patients in the BoNT-A group and 28 patients in the placebo group were included in the day-90 analysis. Fifteen (51.7%) of the patients who were administered BoNT-A and 7 (25%) of the patients who received placebo reported a >50% reduction in initial pain intensity at day 90 (p = 0.005). Pain intensity and the effect on quality of life, measured using visual analog scales, were both significantly lower in the group treated with BoNT-A compared with placebo at day 90 (p < 0.05). The rate of clinically detected transitory paresis of the third finger on extension was 17.2% in the BoNT-A group, with no associated functional impairment.

CONCLUSIONS

BoNT-A at 40 IU injected into the ECRB is an effective treatment for chronic lateral epicondylar tendinopathy that has been otherwise resistant to medical treatment. The rate of paresis of the third finger was low, with no associated functional impairment.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Polydeoxyribonucleotide injection in the patients with partial-thickness tear of supraspinatus tendon: a prospective and pilot study using ultrasound

OBJECTIVE

Polydeoxyribonucleotide as adenosine receptor (A_2A) agonist has been used in plastic surgery and dermatology related to its regenerative property. The aim of this pilot study is to evaluate the safety and efficacy of polydeoxynucleotide injection in patients with rotator cuff tears by a variety of outcomes including pain, disability, physical performance test, and ultrasonography (US).

METHODS

Seventeen patients (9 men, 8 women, age: 57.9 ± 9.1) with partial-thickness tear of supraspinatus tendon were evaluated in a prospective, open-label, and pre-and-post study. Seventeen patients underwent 3 times intra-lesional polydeoxynucleotide injection under ultrasound (US) guidance on weeks 0, 2 and 4. The safety and efficacy were assessed on weeks 0, 6 and 12. Main outcome measures included shoulder pain on Visual Analogue Scale (VAS) and DASH (disabilities of arm, hand, shoulder) score, range of motion in shoulder, shoulder strength and tear volume (cm³) by US. Adverse events were monitored. (CRIS: https://www.cris.nih.go.kr , KCT0000767).

RESULTS

Active shoulder pain on VAS reduced from 5.53 to 3.53 (P = 0.016), and acting pain, one of DASH questionnaires, reduced from 3.35 to 2.00 (P < 0.001). However, resting shoulder pain on VAS and total DASH scores were not significantly different. Forward flexion and internal rotation in range of motion improved significantly (from 169.41 to 178.13 degrees [P = 0.004] and from 83.53 to 88.75 degrees [P = 0.014], respectively). The volume of torn lesion decreased during the study period, however it was not significant. There were no significant adverse events leading to hospitalization.

CONCLUSIONS

Minimally invasive procedure through polydeoxynucleotide injection into torn area of supraspinatus tendon on US could be candidate for the safe and effective treatment on shoulder pain and limited range of motion in patients with rotator cuff tear.

The effect of corticosteroid versus platelet-rich plasma injection therapies for the management of lateral epicondylitis: A systematic review

Introduction: Lateral epicondylitis is a common musculoskeletal disorder of the upper limb. Corticosteroid injection has been widely used as a major mode of treatment. However, better understanding of the pathophysiology of the disease led to a major change in treating the disease, with new options including platelet-rich plasma (PRP) are currently used.

Objectives/research aim: To systematically evaluate the effect of corticosteroid versus PRP injections for the treatment of LE.

Hypothesis: PRP injections provide longer-term therapeutic effect and less rate of complications compared to corticosteroid injection.

Level of evidence: Level 2 evidence (4 included studies are of level 1 evidence, 1 study of level 2 evidence).

Design: Systematic Review (according to PRISMA guidelines).

Methods: Eleven databases used to search for relevant primary studies comparing the effects of corticosteroid and PRP injections for the treatment of LE. Quality appraisal of studies performed using Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0, CASP Randomised Controlled Trial Checklist, and SIGN Methodology Checklist 2.

Results: 732 papers were identified. Five randomised controlled trials (250 Patients) met the inclusion criteria. Clinical findings: Corticosteroid injections provided rapid symptomatic improvement with maximum effect at 6/8/8 weeks before symptoms recurrence, whereas PRP showed slower ongoing improvements up to 24/52/104 weeks(3 studies). Corticosteroid showed more rapid symptomatic improvement of symptoms compared to PRP up to the study end-point of 3 months(1 study). Comparable therapeutic effects of corticosteroid and PRP were observed at 6 weeks(1 study). Ultrasonographic Findings: (1) Doppler activity decreased more significantly in patients who received corticosteroid compared to PRP. (2) Reduced tendon thickness and more patients with cortical erosion noted in corticosteroid group whereas increased tendon thickness and less number of patients with common extensor tendon tears noted in PRP group. (3) Fewer patients reported Probe-induced tenderness and oedema in the common extensor tendon in both corticosteroid and PRP groups (2 studies).

Conclusion: Corticosteroid injections provide rapid therapeutic effect in the short-term with recurrence of symptoms afterwards, compared to the relatively slower but longer-term effect of platelet-rich plasma.

Long-Term Prognosis of Plantar Fasciitis: A 5- to 15-Year Follow-up Study of 174 Patients With Ultrasound Examination

Background:

Plantar fasciitis (PF) affects 7% to 10% of the population. The long-term prognosis is unknown.

Purpose:

Our study had 4 aims: (1) to assess the long-term prognosis of PF, (2) to evaluate whether baseline characteristics (sex, body mass index, age, smoking status, physical work, exercise-induced symptoms, bilateral heel pain, fascia thickness, and presence of a heel spur) could predict long-term outcomes, (3) to assess the long-term ultrasound (US) development in the fascia, and (4) to assess whether US-guided corticosteroid injections induce atrophy of the heel fat pad.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

From 2001 to 2011 (baseline), 269 patients were diagnosed with PF based on symptoms and US. At follow-up (2016), all patients were invited to an interview regarding their medical history and for clinical and US re-examinations. Kaplan-Meier survival estimates were used to estimate the long-term prognosis, and a multiple Cox regression analysis was used for the prediction model.

Results:

In all, 174 patients (91 women, 83 men) participated in the study. All were interviewed, and 137 underwent a US examination. The mean follow-up was 9.7 years from the onset of symptoms and 8.9 years from baseline. At follow-up, 54% of patients were asymptomatic (mean duration of symptoms, 725 days), and 46% still had symptoms. The risk of having PF was 80.5% after 1 year, 50.0% after 5 years, 45.6% after 10 years, and 44.0% after 15 years from the onset of symptoms. The risk was significantly greater for women (P < .01) and patients with bilateral pain (P < .01). Fascia thickness decreased significantly in both the asymptomatic and symptomatic groups (P < .01) from 6.9 mm and 6.7 mm, respectively, to 4.3 mm in both groups. Fascia thickness (P = .49) and presence of a heel spur (P = .88) at baseline had no impact on prognosis. At follow-up, fascia thickness and echogenicity had normalized in only 24% of the asymptomatic group. The mean fat pad thickness was 9.0 mm in patients who had received a US-guided corticosteroid injection and 9.4 mm in those who had not been given an injection (P = .66).

Conclusion:

The risk of having PF in this study was 45.6% at a mean 10 years after the onset of symptoms. The asymptomatic patients had PF for a mean 725 days. The prognosis was significantly worse for women and patients with bilateral pain. Fascia thickness decreased over time regardless of symptoms and had no impact on prognosis, and neither did the presence of a heel spur. Only 24% of asymptomatic patients had a normal fascia on US at long-term follow-up. A US-guided corticosteroid injection did not cause atrophy of the heel fat pad. Our observational study did not allow us to determine the efficacy of different treatment strategies.

The role of rehabilitation after regenerative and orthobiologic procedures for the treatment of tendinopathy: a systematic review

Aim: Significant variability exists in the literature, with no clear consensus to the optimal protocol after a regenerative procedure. Given this uncertainty, the authors systematically reviewed the literature cataloging the different variables that may influence outcomes. Methods: Search was limited to randomized clinical trials and prospective cohort studies of regenerative procedures for the treatment of tendinopathy. Variables were predetermined, and included: cyrotherapy, pre- and post-procedure nonsteroidal anti-inflammatory drugs use, recommendations for alternative pain medications, immobilization and duration of rest. Variables were categorized based on the influence of the intervention on the three phases of healing. Results: 749 studies were assessed for eligibility, and 60 studies were included. Significant variability existed in the literature. Conclusion: Despite the importance of rehabilitation after regenerative procedures, there is a paucity of evidence available to guide clinicians and highlights the need for additional validation.

The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: A Randomized, Double-Blind Controlled Trial Comparing a Single Platelet-Rich Plasma Injection With a Single Corticosteroid Injection

BACKGROUND

Gluteus medius/minimus tendinopathy is a common cause of lateral hip pain or greater trochanteric pain syndrome.

HYPOTHESIS

There would be no difference in the modified Harris Hip Score (mHHS) between a single platelet-rich plasma (PRP) injection compared with a corticosteroid injection in the treatment of gluteal tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

There were 228 consecutive patients referred with gluteal tendinopathy who were screened to enroll 80 participants; 148 were excluded (refusal: n = 42; previous surgery or sciatica: n = 50; osteoarthritis, n = 17; full-thickness tendon tear, n = 17; other: n = 22). Participants were randomized (1:1) to receive either a blinded glucocorticoid or PRP injection intratendinously under ultrasound guidance. A pain and functional assessment was performed using the mHHS questionnaire at 0, 2, 6, and 12 weeks and the patient acceptable symptom state (PASS) and minimal clinically important difference (MCID) at 12 weeks.

RESULTS

Participants had a mean age of 60 years, a ratio of female to male of 9:1, and mean duration of symptoms of >14 months. Pain and function measured by the mean mHHS showed no difference at 2 weeks (corticosteroid: 66.95 ± 15.14 vs PRP: 65.23 ± 11.60) or 6 weeks (corticosteroid: 69.51 ± 14.78 vs PRP: 68.79 ± 13.33). The mean mHHS was significantly improved at 12 weeks in the PRP group (74.05 ± 13.92) compared with the corticosteroid group (67.13 ± 16.04) ( P = .048). The proportion of participants who achieved an outcome score of ≥74 at 12 weeks was 17 of 37 (45.9%) in the corticosteroid group and 25 of 39 (64.1%) in the PRP group. The proportion of participants who achieved the MCID of more than 8 points at 12 weeks was 21 of 37 (56.7%) in the corticosteroid group and 32 of 39 (82%) in the PRP group ( P = .016).

CONCLUSION

Patients with chronic gluteal tendinopathy >4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection. Registration: ACTRN12613000677707 (Australian New Zealand Clinical Trials Registry).

Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention

Objective

We aimed to assess the effectiveness of PRP injections in lateral epicondylitis of the elbow as it was felt after PRP introduction the numbers of patients requiring surgery for had reduced.

Methods

We conducted a retrospective review of cases from the 1^st January 2008 to 31st December 2015. The numbers of patients undergoing surgical release and the numbers of patients requiring PRP injections were recorded each year and the numbers of patients requiring surgery was compared pre and post PRP injection to ascertain if PRP introduction reduced surgical intervention.

Results

Prior to PRP, a yearly mean of 12.75 patients underwent surgery, since PRP this reduced to 4.25 patients, P < 0.001. This leads to an absolute risk reduction of 0.773 and number needed to treat of 1.3. PRP injection successfully reduced symptoms in 56/64 (87.5%) patients in our study.

Conclusion

We consider PRP injection, for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms and have shown it has reduced the need for surgical intervention in this difficult cohort of patients.

Open release versus radiofrequency microtenotomy in the treatment of lateral epicondylitis: a prospective randomized controlled trial

BACKGROUND

Optimal surgical treatment of lateral epicondylitis remains uncertain. Recently, radiofrequency microtenotomy (RFMT) has been proposed as a suitable treatment. We compared RFMT with standard open release (OR) in this prospective randomized controlled trial.

METHODS

In total, 41 patients with symptoms for at least 6 months were randomized into two groups: 23 patients had RFMT and 18 had OR. Two patients from RFMT withdrew. Each patient underwent Numerical Rating Scale (NRS) pain score, grip strength and Disabilities of the Arm, Shoulder and Hand (DASH) scores pre-operatively and at 6 weeks. Pain and DASH scores were repeated at 6 months and 12 months.

RESULTS

NRS pain scores improved by 4.8 points for RFMT and by 3.9 points for OR. There was a significant improvement in both groups from pre-operative scores, although there was no statistically significant difference between the groups at 1 year. Grip strength improved by 31% in the RFMT group compared to 38% in OR. There was no significant difference between the initial and 6 weeks scores or between treatments. At 1 year, DASH was 39.8 points for RFMT and 24.4 points for OR. There was a significant improvement in both groups from pre-operative scores, although there was no statistically significant difference between the groups at 1 year.

CONCLUSIONS

Both groups showed significant improvements and similar benefit to the patient. The results of the present study do not show any benefit of RFMT over the standard OR. As a result of the extra expense of RFMT, we therefore recommend that OR is offered as the standard surgical management.

Platelet-Rich Plasma Injection With Percutaneous Needling for Recalcitrant Lateral Epicondylitis: Comparison of Tenotomy and Fenestration Techniques

Background

Recalcitrant lateral epicondylitis (LE) is a common debilitating condition, with numerous treatment options of varying success. An injection of platelet-rich plasma (PRP) has been shown to improve LE, although it is unclear whether the method of needling used in conjunction with a PRP injection is of clinical importance.

Purpose

To determine whether percutaneous needle tenotomy is superior to percutaneous needle fenestration when each is combined with a PRP injection for the treatment of recalcitrant LE.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 93 patients with recalcitrant LE were treated with a PRP injection and percutaneous needle fenestration (n = 45) or percutaneous needle tenotomy (n = 48) over a 5-year study interval. Preoperative patient data, including visual analog scale for pain (VAS-P), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores and grip strength, were obtained from a chart review and compared with postoperative values obtained prospectively. Secondary outcomes included the incidence of complications, need for additional interventions, return to work, and patient satisfaction.

Results

At a mean follow-up of 40 months, significant improvements in VAS-P (mean, -6.1; 95% CI, -6.8 to -5.5; P < .0001), QuickDASH (mean, -46; 95% CI, -52 to -40; P < .0001), and PRTEE (mean, -57; 95% CI, -64 to -50; P < .0001) scores and grip strength (mean, +6.1 kg; 95% CI, 4.9 to 7.3; P < .0001) were observed across the entire study cohort, with no significant differences noted between the fenestration and tenotomy groups. Nine of 45 patients (22%) underwent additional procedures to treat recurrent symptoms in the fenestration group compared with 5 of 48 patients (10%) in the tenotomy group (P = .05). No complications occurred in any patients, and no patients expressed dissatisfaction with their treatment course.

Conclusion

A PRP injection with concomitant percutaneous needling is an effective treatment for recalcitrant LE, with sustained improvements in pain, strength, and function demonstrated at a mean follow-up of longer than 3 years. Although the method of concomitant needling does not appear to have a significant effect on treatment outcomes, more aggressive needle tenotomy is less likely to require conversion to open tenotomy than needle fenestration in the short term to midterm.

Peritendinous injection of platelet-rich plasma to treat tendinopathy: A retrospective review

Objective

The aim of this study was to determine factors associated with the likelihood of a better clinical outcome after the peritendinous injection of PRP for the treatment of chronic tendinopathy and identify whether PRP represents an effective treatment option for chronic tendinopathies.

Methods

The study included 214 patients (86 males and 128 females; mean age: 39.3 (18–75) years) who received PRP injections for tendinopathy refractory to conventional treatments. The mean duration of symptoms at the moment of the PRP treatment was 8.3 months. Primary outcome measurement was perceived improvement in symptoms for each anatomic compartment for upper and lower limbs at 6 months after treatment. Also, a visual analog scale (VAS) score (pain intensity on a 0–10 scale) was used for pain scoring questionnaire before treatment, 6 weeks and 6 months following the PRP injection(s). To identify factors associated with the likelihood of a better clinical outcome, patients were categorized on the basis of their perceived improvement in symptoms 6 months after the PRP injection(s)—that is, as lower (less than 50% global improvement) or higher (more than 50% global improvement).

Results

A visual analogue scale score and perceived improvement in symptoms were significantly lower after peritendinous injection in 6-week and 6-month follow-ups compared with the baseline (P < 0.001) except for peroneal and Achilles tendons. Overall, 83% of patients indicated moderate to complete improvement in symptoms. The most common injection sites were the lateral epicondyle, Achilles, and patellar tendons. Furthermore, 30% of patients received only 1 injection, 30% received 2 injections, and 40% received 3 or more injections. A total of 85% of patients were satisfied (more than 50% global improvement) with the procedure. In addition, upper limb tendons, increase in the age, and female gender were associated with a higher likelihood of perceived improvement in symptoms.

Conclusions

In the present retrospective study assessing PRP injections in the treatment of chronic tendinopathy, a moderate improvement (>50%) in pain symptoms was observed in most of the patients. Our research found that results were most promising with patellar and lateral epicondylar tendinopathy in the short to medium term. Female patients, patients with upper extremity tendinopathy and older patients appeared to benefit more from PRP injection.

Level of evidence

Level IV, Therapeutic study.

Efficacy of platelet-rich plasma injections for symptomatic tendinopathy: systematic review and meta-analysis of randomised injection-controlled trials

Aim

To determine the efficacy of platelet-rich plasma (PRP) injections for symptomatic tendinopathy.

Design

Systematic review of randomised, injection-controlled trials with meta-analysis.

Data sources

Systematic searches of MEDLINE and EMBASE, supplemented by manual searches.

Eligibility criteria for selecting studies

Randomised controlled trials with 3 months minimum follow-up that evaluated pain reduction with PRP versus control (saline, local anaesthetic, corticosteroid) injections in patients with symptomatic tendinopathy.

Results

A total of 16 randomised controlled trials (18 groups) of PRP versus control were included. Median sample size was 35 patients, a study size that would require an effect size ≥1.0 to achieve statistical significance. PRP was more efficacious than control in reducing tendinopathy pain, with an effect size of 0.47 (95% CI 0.22 to 0.72, p<0.001), signifying a moderate treatment effect. Heterogeneity among studies was moderate (I²=67%, p<0.001). In subgroup analysis and meta-regression, studies with a higher proportion of female patients were associated with greater treatment benefits with PRP.

Conclusions

Injection of PRP is more efficacious than control injections in patients with symptomatic tendinopathy.

A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature

BACKGROUND

Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized nomenclature, and ambiguous classifications make comparison among studies challenging. A comprehensive assessment of orthopaedic clinical PRP trials is key to unraveling the biological complexity of PRP, while improving standardized communication. Toward this goal, we performed a systematic review of the PRP preparation protocols and PRP composition utilized in clinical trials for the treatment of musculoskeletal diseases.

METHODS

A systematic review of the literature was performed from 2006 to 2016. Inclusion criteria were human clinical trials, English-language literature, and manuscripts that reported on the use of PRP in musculoskeletal/orthopaedic conditions. Basic-science articles, editorials, surveys, special topics, letters to the editor, personal correspondence, and nonorthopaedic applications (including cosmetic use or dental application studies) were excluded.

RESULTS

A total of 105 studies (in 104 articles) met the inclusion criteria for analysis. Of these studies, only 11 (10%) provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 17 studies (16%) provided quantitative metrics on the composition of the final PRP product.

CONCLUSIONS

Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced. Furthermore, the current reporting of PRP preparation and composition does not enable comparison of the PRP products being delivered to patients. A detailed, precise, and stepwise description of the PRP preparation protocol is required to allow comparison among studies and provide reproducibility.

Comparison of Effects of Leukocyte-Rich and Leukocyte-Poor Platelet-Rich Plasma on Pain and Functionality in Patients With Lateral Epicondylitis

Objectives

This study aims to compare the effect of leukocyte concentration in platelet-rich plasma (PRP) on pain, functionality and post-injection local inflammatory reactions in patients with lateral epicondylitis.

Patients and methods

The study included 90 patients (26 males, 64 females; mean age 38.6 years; range 18 to 75 years) with lateral epicondylitis- related pain visual analog scale (VAS) score of ≥5 for more than three months. Patients were randomly assigned into three groups. Normal saline (1.5 mL) was injected in group 1 (control group) while a single dose of leukocyte-poor-PRP (1.5 mL) and leukocyte-rich-PRP (1.5 mL) were injected in groups 2 and 3, respectively. An exercise program was recommended to patients in all three groups. Patients were assessed according to VAS, Patient-Rated Tennis Elbow Evaluation, grip dynamometer and pinchmeter, extensor tendon thickness and cortical derangement at baseline and at fourth and eighth weeks after therapy. All patients were questioned regarding paracetamol use and adverse effects after therapy.

Results

No significant differences were detected between groups regarding VAS, Patient-Rated Tennis Elbow Evaluation, grip and pinch measurements, extensor tendon thickness and cortical derangement (p>0.05). In intra-group comparisons, VAS and Patient-Rated Tennis Elbow Evaluation scores obtained at fourth and eighth weeks were significantly decreased in all groups when compared to baseline values (p>0.05). Again, there was no significant difference in the control visit at eighth week when compared to baseline. Assessment of grip and pinch measurements revealed that values obtained at fourth and eighth weeks were significantly increased compared to baseline in all three groups (p<0.05). In leukocyte-rich-PRP group, a significant increase was detected in the values obtained at eighth week compared to those obtained at fourth week, but no significant change was detected in other groups. No significant difference was detected in extensor tendon thickness in any group. No significant difference was detected between groups in terms of paracetamol use and post-injection reactions.

Conclusion

According to our study findings, lateral epicondylitis does not seem to affected either leukocyte-rich-PRP or leukocyte-poor-PRP on pain and function in the short term. Leukocyte concentration had no association with post-injection local inflammatory reactions.

Effect of Metabolic Syndrome on the Functional Outcome of Corticosteroid Injection for Lateral Epicondylitis: Retrospective Matched Case-Control Study

Both obesity and diabetes mellitus are well-known risk factors for tendinopathies. We retrospectively compared the efficacy of single corticosteroid injections in treating lateral epicondylitis in patients with and without metabolic syndrome (MetS). Fifty-one patients with lateral epicondylitis and MetS were age- and sex-matched with 51 controls without MetS. Pain severity, Disability of the Arm, Shoulder, and Hand score, and grip strength were assessed at base line and at 6, 12 and 24 weeks post-injection. The pain scores in the MetS group were greater than those in the control group at 6 and 12 weeks. The disability scores and grip strength in the MetS group were significantly worse than those of the control group at 6 weeks. However, there were no significant differences at 24 weeks between the groups in terms of pain, disability scores and grip strengths. After 24 weeks, three patients (6%) in the control group and five patients (10%) in the MetS group had surgical decompression (p = 0.46). Patients with MetS are at risk for poor functional outcome after corticosteroid injection for lateral epicondylitis in the short term, but in the long term there was no difference in outcomes of steroid injection in patients with and without MetS.

The use of platelet-rich plasma to treat chronic tendinopathies: A technical analysis

Platelet-rich plasma (PRP) is blood plasma with a high concentration of autologous platelets which constitute an immense reservoir of growth factors. The clinical use of PRP is widespread in various medical applications. Although highly popular with athletes, the use of PRP for the treatment of tendinopathies remains scientifically controversial, particularly due to the diversity of products that go by the name of "PRP." To optimize its use, it is important to look at the various stages of obtaining PRP. In this literature review, we take a closer look at eight parameters which may influence the quality of PRP: 1) anticoagulants used to preserve the best platelet function, 2) the speed of centrifugation used to extract the platelets, 3) the platelet concentrations obtained, 4) the impact of the concentration of red and while blood cells on PRP actions, 5) platelet activators encouraging platelet degranulation and, hence, the release of growth factors, and 6) the use or nonuse of local anesthetics when carrying out infiltration. In addition to these parameters, it may be interesting to analyze other variables such as 7) the use of ultrasound guidance during the injection with a view to determining the influence they have on potential recovery.

Intratendon Delivery of Leukocyte-Poor Platelet-Rich Plasma Improves Healing Compared With Leukocyte-Rich Platelet-Rich Plasma in a Rabbit Achilles Tendinopathy Model

BACKGROUND

Chronic tendinopathy is a commonly occurring clinical problem that affects both athletes and inactive middle-aged patients. Although some studies have shown that different platelet-rich plasma (PRP) preparations could exert various therapeutic effects in vitro, the role of leukocytes in PRP has not yet been defined under tendinopathy conditions in vivo.

PURPOSE

This study compared the effects of the intratendon delivery of leukocyte-poor PRP (Lp-PRP) versus leukocyte-rich PRP (Lr-PRP) in a rabbit chronic tendinopathy model in vivo.

STUDY DESIGN

Controlled laboratory study.

METHODS

Four weeks after a local injection of collagenase in the Achilles tendon, the following treatments were randomly administered on the lesions: injections of (1) 200 μL of Lp-PRP (n = 8), (2) 200 μL of Lr-PRP (n = 8), or (3) 200 μL of saline (n = 8). Healing outcomes were assessed at 4 weeks after therapy with magnetic resonance imaging (MRI), cytokine quantification, real-time polymerase chain reaction analysis of gene expression, histology, and transmission electron microscopy (TEM).

RESULTS

MRI revealed that the Lr-PRP and saline groups displayed higher signal intensities compared with the Lp-PRP group with T2 mapping. Histologically, the Lp-PRP group displayed significantly better general scores compared with the Lr-PRP ( P = .001) and saline ( P < .001) groups. Additionally, TEM showed that the Lp-PRP group had larger collagen fibril diameters than the Lr-PRP group ( P < .001). Enzyme-linked immunosorbent assay showed a significantly lower level of catabolic cytokine IL-6 in the Lp-PRP group compared with the Lr-PRP ( P = .001) and saline ( P = .021) groups. The Lp-PRP group displayed significantly increased expression of collagen I compared with the saline group ( P = .004) but not the Lr-PRP group. Both the Lp-PRP and Lr-PRP groups exhibited significantly lower matrix metalloproteinase (MMP)-1 and MMP-3 expression levels compared with the saline group. However, only the Lp-PRP group displayed significantly higher expression of TIMP-1 than the saline group ( P = .024).

CONCLUSION

Compared with Lr-PRP, Lp-PRP improves tendon healing and is a preferable option for the clinical treatment of tendinopathy.

CLINICAL RELEVANCE

PRP is widely used in the clinical management of chronic tendinopathy. However, the clinical results are ambiguous. It is imperative to understand the influence of leukocytes on PRP-mediated tissue healing in vivo, which could facilitate the better clinical management of chronic tendinopathy. Further studies are needed to translate our findings to the clinical setting.

Autologous Blood and Platelet-Rich Plasma Injections for Treatment of Lateral Epicondylitis

Lateral epicondylitis (tennis elbow) is a frequent cause of elbow pain; most patients (80%-90%) are successfully treated with standard nonoperative methods (rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy). Autologous blood injections and platelet-rich plasma injections are the two most frequently used orthobiologic techniques in the treatment of lateral epicondylitis. Studies of the effectiveness of autologous blood injections and platelet-rich plasma report varying outcomes, some citing significant clinical relief and others reporting no beneficial effect. More research is needed to determine how to best use orthobiologics in the treatment of lateral epicondylitis.

Injection of tennis elbow: Hit and miss? A cadaveric study of injection accuracy

PURPOSE

Different injection therapies are used in the treatment of lateral epicondylitis (LE). Usually, the extensor carpi radialis brevis (ECRB) tendon is affected. Therefore, an injection should be aimed at the origin of this tendon. This study demonstrates the accuracy of manual injections in the treatment of LE.

METHODS

Ten surgeons have injected a cadaver elbow with acrylic paint, using the same injection technique (i.e. number of perforations, amount of injected fluid) that they in daily practice would use in the treatment of LE. After the injection, an arthroscopy and dissection of the elbow were performed. The injection technique and localization of acrylic paint were reported.

RESULTS

Only a third of the injections were (partially) localized in the ECRB tendon; 60 % were localized intra-articular.

CONCLUSION

Injections carried out manually for the treatment of LE are not accurate, resulting in the majority being localized intra-articular. For future research to the effect of injection therapy in the treatment of LE, it is important that injections should be performed in a reproducible and standardized way.

Editorial Commentary: The Needle or the Knife? Platelet-Rich Plasma Versus Surgery for Lateral Epicondylitis

The most efficacious treatment for patients with lateral epicondylitis who have not adequately improved despite being treated for extended periods with commonly used nonoperative measures is controversial. Are locally applied platelet-rich plasma (PRP) injections more effective than a surgical procedure, such as arthroscopic lateral epicondylitis debridement, in reducing symptoms for such patients? Level II evidence shows that long-term clinical benefits are much less likely to occur in patients receiving PRP injections. Moreover, in patients treated with PRP injection, progressively worsening pain is more likely to develop during activity at 1 and 2 years of follow-up in contradistinction to arthroscopically managed patients.

A Systematic Review of Tennis Elbow Surgery: Open Versus Arthroscopic Versus Percutaneous Release of the Common Extensor Origin

PURPOSE

To compare complications, function, pain, and patient satisfaction after conventional open, percutaneous, or arthroscopic release of the extensor origin for the treatment of lateral epicondylitis.

METHODS

A thorough review of 4 databases-PubMed, EBSCOhost, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus, and Scopus-was performed to identify all studies that addressed surgical management of lateral epicondylitis. We included (1) studies published between 2000 and 2015 and (2) studies with clearly defined surgical techniques. We excluded (1) non-English-language manuscripts, (2) isolated case reports, (3) studies with fewer than 10 subjects, (4) animal studies, (5) studies with additional adjunctive procedures aside from release of the extensor origin, (6) clinical or systematic review manuscripts, (7) studies with a follow-up period of 6 months or less, and (8) studies in which less than 80% of patients completed follow-up. Each study was analyzed for complication rates, functional outcomes, pain, and patient satisfaction.

RESULTS

Thirty reports were identified that included 848 open, 578 arthroscopic, and 178 percutaneous releases. Patients within each release group had a similar age (46 years vs 46 years vs 48 years; P = .9 and P = .4, respectively), whereas there was a longer follow-up time in patients who underwent surgery by an open technique (49.4 months vs 42.6 months vs 23 months, P < .001). There were no differences in complication rates among these techniques (3.8% vs 2.9% vs 3.9%; P = .5 and P = .9, respectively). However, open techniques were correlated with higher surgical-site infection rates than arthroscopic techniques (0.7% vs 0%, P = .04). Mean Disabilities of the Arm, Shoulder and Hand scores were substantially better with both open and arthroscopic techniques than with percutaneous release (19.9 points vs 21.3 points vs 29 points, P < .001). In addition, there was less pain reported in the arthroscopic and percutaneous release groups as opposed to their open counterparts (1.9 points vs 1.4 points vs 1.3 points, P < .0001). There were no differences among the techniques in patient satisfaction rate (93.7% vs 89% vs 88%; P = .08 and P = .07, respectively).

CONCLUSIONS

Functional outcomes of open and arthroscopic releases may be superior to those of percutaneous release. In addition, patients may report less pain with arthroscopic and percutaneous techniques. Although the risk of complications is similar regardless of technique, patients may be counseled that their risk of infectious complications may be slightly higher with open releases. However, it is important to note that this statistical difference may not necessarily portend noticeable clinical differences.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV evidence.

Ultrasonographic Characteristics of the Common Extensor Tendon of the Elbow in Asymptomatic Individuals: Thickness, Color Doppler Activity, and Bony Spurs

Background:

Ultrasonography (US) of the common extensor tendon (CET) of the elbow is often part of the assessment of patients with lateral epicondylitis. This US assessment is currently based on general tendinopathy references and not well-defined US entities.

Purpose:

To describe CET thickness, color Doppler activity, and bony spurs on US in asymptomatic volunteers and to investigate the influence of sex, age, height, body mass index (BMI), weight, and elbow dominance on the measurements.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Tendon thickness, color Doppler activity, and bony spurs of the CET were measured sonographically in 264 adults (50% women) aged 20 to 96 years. Two different tendon-thickness measuring techniques were applied, labeled the “plateau measure” and the “1-cm measure.” Color Doppler activity was based on a 0 to 4 rating scale (negative, grades 0 and 1; positive, grades 2-4). A bony spur was defined as a bony outgrowth (≥0.3 mm) arising at the insertional site of the CET.

Results:

With both tendon-thickness measuring techniques, the CET in the dominant elbow was thicker than that in the nondominant elbow, and male tendons were thicker than female tendons (all P ≤ .03). In regression analysis, tendon thickness correlated with weight, color Doppler activity, and arm dominance for both measuring techniques in multiple regression analysis. In addition, the plateau measure correlated with height and the presence of bony spurs. No correlations were observed regarding BMI, sex, or age. Positive color Doppler activity was found in 9% of examined elbows, with no difference between the sexes regarding dominant versus nondominant elbows (all P ≥.20). Bony spurs were found to increase with age, from 23% for people in their 20s to 74% in people older than 70 years. Bony spurs were more common in the dominant elbow (P ≤ .01). Women had a higher prevalence of bony spurs than men, but only in the dominant elbow (P = .03).

Conclusion:

This study presents the US characteristics and normal values of the CET. In 264 asymptomatic participants, the CET was found to be thicker in men and in the dominant elbow. No difference in tendon thickness could be demonstrated with regard to different age groups. Color Doppler activity was found to be positive in nearly 1 of 10 asymptomatic subjects. Bony spurs were a common finding; they increased in prevalence with every decade in age and were considered part of the aging process. Normal variations in CET morphologic characteristics should therefore be considered when implementing US in trials and clinical practice.

Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis: an analysis of 3863 patients

BACKGROUND

This study was conducted to identify the rate of failure of operative treatment of lateral epicondylitis, defined as progression to ipsilateral revision surgery, and associated patient-specific risk factors for failure.

METHODS

A national database was used to identify patients undergoing surgical treatment of lateral epicondylitis from 2005 to 2012. Patients undergoing concomitant procedures were excluded. Patients who then required subsequent ipsilateral extensor carpi radialis brevis débridement or release within 2 years were identified using similar methods. A multivariate binomial logistic regression analysis was used to evaluate patient-related risk factors for revision surgery. In addition, the number of preoperative injections (1, 2, or ≥3) in the ipsilateral elbow was identified and included in the regression analysis. Adjusted odds ratios (OR) and 95% confidence intervals were calculated for each risk factor.

RESULTS

Of 3863 patients who underwent operative treatment of lateral epicondylitis, 58 (1.5%) required ipsilateral revision surgery. Risk factors for revision surgery included age <65 years (OR, 2.95; P = .003), male gender (OR, 1.53; P = .017), morbid obesity (OR, 2.13; P = .002), tobacco use (OR, 1.87; P < .001), and inflammatory arthritis (OR, 1.79; P = .009). Having ≥3 ipsilateral preoperative injections was the most significant risk factor (OR, 3.55; P < .001), whereas having 2 (OR, 1.44; P = .135) or 1 (OR, 1.15; P = .495) was not significant.

CONCLUSIONS

The incidence of failure requiring revision surgery for lateral epicondylitis in the studied population is low (1.5%). Risk factors for revision surgery include younger age, male gender, morbid obesity, tobacco use, and inflammatory arthritis. The most significant risk factor for revision surgery is having ≥3 ipsilateral preoperative injections.

Tendinopathies around the Elbow Part 1: Lateral Elbow Tendinopathy

Tendinopathies of the elbow and in particular of the common extensor origin are a common cause of elbow pain. Part one of this two part review of tendinopathies of the elbow will focus on the pathophysiology and management of lateral elbow tendinopathy, frequently referred to as tennis elbow. Lateral elbow tendinopathy is a common condition with an incidence of 1 – 2%. The pathology arises from the origin of extensor carpi radialis brevis where changes, consistent with all tendinopathies, of angiofibroblastic hyperplasia occur secondary to repetitive micro trauma. It is not an inflammatory condition. Clinical history and examination is usually sufficient for diagnosis although MRI and ultrasound can be used. The many treatment options that have been proposed have a mixed quality of supporting evidence. Thus management protocols are difficult to define. Treatment depends on the length of symptoms. Acute presentation is managed through conservative measures including activity modification, topical NSAIDs and physiotherapy. For patients with recalcitrant symptoms, injection therapy with, for example, platelet rich plasma can be used. Alternatively surgical excision of the diseased tissue can be performed. This review article will consider the available evidence in order to identify both treatments that are effective and those that are not.

Upper Extremity Injuries in Tennis Players: Diagnosis, Treatment, and Management

Upper extremity tennis injuries are most commonly characterized as overuse injuries to the wrist, elbow, and shoulder. The complex anatomy of these structures and their interaction with biomechanical properties of tennis strokes contributes to the diagnostic challenges. A thorough understanding of tennis kinetics, in combination with the current literature surrounding diagnostic and treatment methods, will improve clinical decision-making.

Analysis of Platelet-Rich Plasma Extraction: Variations in Platelet and Blood Components Between 4 Common Commercial Kits

Background:

Platelet-rich plasma (PRP) has been extensively used as a treatment in tissue healing in tendinopathy, muscle injury, and osteoarthritis. However, there is variation in methods of extraction, and this produces different types of PRP.

Purpose:

To determine the composition of PRP obtained from 4 commercial separation kits, which would allow assessment of current classification systems used in cross-study comparisons.

Study Design:

Controlled laboratory study.

Methods:

Three normal adults each donated 181 mL of whole blood, some of which served as a control and the remainder of which was processed through 4 PRP separation kits: GPS III (Biomet Biologics), Smart-Prep2 (Harvest Terumo), Magellan (Arteriocyte Medical Systems), and ACP (Device Technologies). The resultant PRP was tested for platelet count, red blood cell count, and white blood cell count, including differential in a commercial pathology laboratory. Glucose and pH measurements were obtained from a blood gas autoanalyzer machine.

Results:

Three kits taking samples from the “buffy coat layer” were found to have greater concentrations of platelets (3-6 times baseline), while 1 kit taking samples from plasma was found to have platelet concentrations of only 1.5 times baseline. The same 3 kits produced an increased concentration of white blood cells (3-6 times baseline); these consisted of neutrophils, leukocytes, and monocytes. This represents high concentrations of platelets and white blood cells. A small drop in pH was thought to relate to the citrate used in the sample preparation. Interestingly, an unexpected increase in glucose concentrations, with 3 to 6 times greater than baseline levels, was found in all samples.

Conclusion:

This study reveals the variation of blood components, including platelets, red blood cells, leukocytes, pH, and glucose in PRP extractions. The high concentrations of cells are important, as the white blood cell count in PRP samples has frequently been ignored, being considered insignificant. The lack of standardization of PRP preparation for clinical use has contributed at least in part to the varying clinical efficacy in PRP use.

Clinical Relevance:

The variation of platelet and other blood component concentrations between commercial PRP kits may affect clinical treatment outcomes. There is a need for standardization of PRP for clinical use.

Optimisation of platelet concentrates therapy: Composition, localisation, and duration of action

Platelet concentrates (PC) generally refers to a group of products that are prepared from autologous blood intended to enhance healing activities. PC therapy is now very popular in treating musculoskeletal injuries; however, inconsistent clinical results urge the need to understand the working mechanism of PC. It is generally believed that the platelet-derived bioactive factors are the active constituents, and their bioavailability in the vicinity of the lesion sites determines the treatment efficacies. Therefore, the composition, localisation, and duration of the action of PC would be key determinants. In this review, we discuss how different preparations and delivery methods of PC would affect the treatment outcomes with respect to clinical evidence about PC therapy for osteoarthritis, tendinopathies, rotator cuff tears, anterior cruciate ligament injuries, and bone fractures. This review can be used as a quick guide for the use of PC therapy and provide insights for the further optimisation of the therapy in the near future.

The Effectiveness of Platelet-Rich Plasma in the Treatment of Tendinopathy: A Meta-analysis of Randomized Controlled Clinical Trials

BACKGROUND

Tendinopathy is very common in the general population. There are increasing numbers of clinical studies referring to platelet-rich plasma (PRP) and platelet-poor plasma (PPP) as treatments for tendinopathy.

PURPOSE

To perform a meta-analysis of the outcomes of the PRP groups by preparation method and injection technique in tendinopathy. To determine the clinical effectiveness of the preparations and to evaluate the effect of controls used in the studies reviewed.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed, EMBASE, CINAHL, and Medline databases were searched in March 2012, April 2014, and August 2015, and randomized controlled trials using autologous blood, PRP, PPP, or autologous conditioned plasma in tendinopathy with outcome measures of pain and follow-up time of 3 months were included in this review. Trials including surgery, tendon tears, and muscle or ligament injuries were excluded. Study quality was assessed using the Cochrane Collaboration risk-of-bias tool by 2 reviewers. Data were pooled using random-effects meta-analysis. The primary outcome measure was a change in pain intensity. Where more than 1 pain scale was included, a functional score was selected ahead of a visual analog scale score.

RESULTS

A total of 18 studies (1066 participants) were included. Eight studies were deemed to be at low risk of bias. The most significant outcomes in the PRP groups were seen in those treated with highly cellular leukocyte-rich PRP (LR-PRP) preparations: GPS kit (standardized mean difference [SMD], 35.75; 95% CI, 28.40-43.10), MyCells kit (SMD, 31.84; 95% CI, 17.56-46.13), Prosys kit (SMD, 42.99; 95% CI, 37.73-48.25), and unspecified LR-PRP (SMD, 34.62; 95% CI, 31.69-37.55). When the LR-PRP system types were grouped, there was a strongly positive effect (SMD, 36.38; 95% CI, 34.00-38.77) when compared with leukocyte-poor PRP (SMD, 26.77; 95% CI, 18.31-35.22). In assessing the control groups, there was no clear difference between different types of control injections: saline (SMD, 14.62; 95% CI, 10.74-18.50), local anesthetic (SMD, 15.00; 95% CI, 7.66-22.34), corticosteroid (SMD, 23.82; 95% CI, 10.74-18.50), or dry needling (SMD, 25.22; 95% CI, 21.27-29.16).

CONCLUSION

There is good evidence to support the use of a single injection of LR-PRP under ultrasound guidance in tendinopathy. Both the preparation and intratendinous injection technique of PRP appear to be of great clinical significance.

A comparative study to evaluate the efficacy of platelet-rich plasma and triamcinolone to treat tennis elbow

BACKGROUND

Lateral elbow pain is common with a population prevalence of 1%-3%. The study was a comparative trial to validate the efficacy of single injection of platelet-rich plasma (PRP) for tennis elbow as compared with single injections of triamcinolone and placebo (normal saline) over a short term period.

MATERIALS AND METHODS

Comparative trial with 3- and 6-month followup evaluated with visual analog scale (VAS) and facial pain scale (FPS). Our study included a total of eighty patients with unilateral or bilateral tennis elbows. The study population included patients between 20 and 40 years age group belonging to either sex with seventy unilateral and ten bilateral affections for more than 3-month duration. Patients suffering from elbow pain due to other problems or those who have received any form of injection were excluded from the study. One milliliter of 2% Xylocaine injection was given before injecting the proposed formulation under trial. VAS and FPS were used for scoring pain. Kruskal-Wallis test and Mann-Whitney U-tests were used for statistical analyses at 12 and 24 weeks.

RESULTS

Overall, 49 females and 31 males were included with thirty elbows in each group. Both the PRP and triamcinolone groups had better pain relief at 3 and 6 months as compared to normal saline group (P < 0.05), but at 6 months followup, the PRP group had statistically significant better pain relief than triamcinolone group. In the triamcinolone group, 13 patients had injection site hypopigmentation and 3 patients had subdermal atrophy.

CONCLUSION

Over a short term period, PRP gives better pain relief than triamcinolone or normal saline in tennis elbow which needs to be validated over long term period by further studies.

Lateral Elbow Tendinopathy: Development of a Pathophysiology-Based Treatment Algorithm

Lateral elbow tendinopathy, commonly known as tennis elbow, is a condition that can cause significant functional impairment in working-age patients. The term tendinopathy is used to describe chronic overuse tendon disorders encompassing a group of pathologies, a spectrum of disease. This review details the pathophysiology of tendinopathy and tendon healing as an introduction for a system grading the severity of tendinopathy, with each of the 4 grades displaying distinct histopathological features. Currently, there are a large number of nonoperative treatments available for lateral elbow tendinopathy, with little guidance as to when and how to use them. In fact, an appraisal of the clinical trials, systematic reviews, and meta-analyses studying these treatment modalities reveals that no single treatment reliably achieves outstanding results. This may be due in part to the majority of clinical studies to date including all patients with chronic tendinopathy rather than attempting to categorize patients according to the severity of disease. We relate the pathophysiology of the different grades of tendinopathy to the basic science principles that underpin the mechanisms of action of the nonoperative treatments available to propose a treatment algorithm guiding the management of lateral elbow tendinopathy depending on severity. We believe that this system will be useful both in clinical practice and for the future investigation of the efficacy of treatments.

A Meta-Analysis of the Effect of Corticosteroid Injection for Enthesopathy of the Extensor Carpi Radialis Brevis Origin

PURPOSE

The null hypothesis that there is no effect of corticosteroid injection on visual analog scale for pain in patients with enthesopathy of the extensor carpi radialis brevis (eECRB) origin 6 months after treatment was tested. Our secondary hypotheses were that there is no effect of corticosteroid injection on pain intensity at 1 and 3 months after treatment; that there is no effect of corticosteroid injection on grip strength at 1, 3, and 6 months after treatment; and that there is no effect of corticosteroid injection on Disabilities of the Arm, Shoulder, and Hand scores at 1, 3 and 6 months after treatment.

METHODS

EMBASE, PubMed Publisher, MEDLINE, OvidSP, Web of Science, Google Scholar, and the Cochrane Central were searched for relevant studies. Studies were eligible if there was (1) a description of corticosteroid injection treatment for eECRB; (2) randomized placebo injection-controlled trials with at least 10 adults included with eECRB; (3) a full-text article available with data describing the mean differences between the corticosteroid and the control groups and the outcome measures used; and (4) follow-up of at least 1 month. In total, 7 randomized controlled trials comparing the effect of corticosteroid injection with a placebo injection on symptoms of eECRB were included in our meta-analysis.

RESULTS

We found no difference in pain intensity 6 months after injection of corticosteroids or placebo. Pain intensity was slightly, but significantly, lower 1 month, but not 3 months, after steroid injection. There were no significant differences in grip strength or Disabilities of the Arm, Shoulder, and Hand score at any time point.

CONCLUSIONS

This meta-analysis showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection. We interpret the weight of evidence to date as suggesting that corticosteroid injections are neither meaningfully palliative nor disease modifying when used to treat eECRB.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.