One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial

[Surgical treatment of chronic non-insertional Achilles tendinopathy in runners using bipolar radiofrequency]

OBJECTIVE

To present the surgical technique with release of peritendon and radiofrequency as an effective treatment for athletes with chronic tendinopathy of the Achilles tendon body.

MATERIALS AND METHODS

This is a retrospective case series descriptive type study. The series consists of 17 Achilles tendon surgeries in 13 patients, who habitually run. The study included patients with non-insertional Achilles tendinopathy refractory to conservative treatments. After a minimum follow-up of 12 months, clinical improvement of the athletes was assessed using the Nirschl pain scale, as well as athletic performance.

RESULTS

An improvement was obtained in 94% of symptoms and a return to the previous performance in of 70% of cases in the 12 months follow-up.

DISCUSSION

Peritendon release combined with bipolar radiofrequency is presented as an effective solution in this condition, for which there is currently no consensus on the best treatment. In patients in whom, after an appropriate conservative treatment for a sufficient period (at least 6 months) the non-insertional Achilles tendinopathy persists, open adhesiolysis combined with bipolar radiofrequency is a safe and with a high success rate clinical and functional intervention. In high performance athletes this technique allows a return to previous activity in a high percentage of cases.

Retrospective Analysis of the Effectiveness of Platelet-Rich Plasma in the Treatment of Achilles Tendinopathy: Pretreatment and Posttreatment Correlation of Magnetic Resonance Imaging and Clinical Assessment

Platelet-rich plasma (PRP) has been presented as a means of treating Achilles tendinopathy. Over the past dozen years, a plethora of medical articles have advocated this treatment, yet little evidentiary-based research exists in support of this approach. Treatment protocols with PRP have been performed in 2 ways during this time: administered adjunctively during tendon surgery and as a stand-alone injection. The senior author has utilized PRP by both methods to treat Achilles tendinopathy over the past 7 years; 26 patients so treated were able to be recalled, half having undergone Achilles tendon surgery in combination with PRP administration and the other half PRP alone. In this retrospective study, qualified patients had pretreatment and posttreatment magnetic imaging studies and completed a Victorian Institute of Sports Assessment-Achilles questionnaire. In this limited study, PRP showed promise in the treatment of Achilles tendinopathy. Both the stand-alone injection group and surgical/injection groups had statistically significant degrees of improvement in pre-MRI and post-MRI imaging studies. There was no statistically significant difference between the 2 treatment groups. Of interest, it appears that the difference between the MRI scoring correlates with the survey score.

LEVEL OF EVIDENCE

Therapeutic, Level, IV: Case series.

Platelet-Rich Plasma Injection With Arthroscopic Acromioplasty for Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial

BACKGROUND

Platelet-rich plasma (PRP) has been proposed to augment tendon healing through improving tissue structure during the initial repair phase.

PURPOSE

To investigate both the clinical and tissue effects of the coapplication of PRP injection with arthroscopic acromioplasty (AA) in patients with chronic rotator cuff tendinopathy.

DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

The study comprised 60 randomized patients diagnosed with rotator cuff tendinopathy (55% women) aged between 35 and 75 years. Patients were randomized to AA alone or in combination with an injection of autologous PRP into the subacromial bursa (AA + PRP). Efficacy of treatment was assessed by analysis of patient-reported outcomes up to 2 years after treatment (Oxford Shoulder Score [OSS]) and by analysis of tendon biopsy specimens taken 12 weeks after treatment.

RESULTS

There was no significant difference in the OSS between AA alone and AA + PRP at any time point in the study. From 12 weeks onward, there was a significant increase in the OSS for both groups compared with their baseline scores (P < .001). Bonar scoring determined no significant change in tissue structure with the coapplication of PRP compared with surgery alone. The number of blood vessels and tendon cellularity were significantly decreased in tissue biopsy specimens taken from PRP-treated patients. The expression of p53-positive apoptotic cells increased after AA + PRP but decreased after AA alone.

CONCLUSION

Arthroscopic acromioplasty significantly improves long-term clinical outcomes up to 2 years. The coapplication of PRP did not affect clinical outcomes. PRP significantly alters the tissue characteristics in tendons after surgery with reduced cellularity and vascularity and increased levels of apoptosis.

CLINICAL RELEVANCE

The coapplication of PRP did not improve clinical outcomes and may have potential deleterious effects on healing tendons.

REGISTRY NUMBER

ISRCTN 10464365.

The Tendon Structure Returns to Asymptomatic Values in Nonoperatively Treated Achilles Tendinopathy but Is Not Associated With Symptoms: A Prospective Study

BACKGROUND

Tendinopathy is characterized by alterations in the tendon structure, but there are conflicting results on the potential of tendon structure normalization and no large studies on the quantified, ultrasonographic tendon structure and its association with symptoms.

PURPOSE

To determine whether the tendon structure returns to values of asymptomatic individuals after treatment with 2 substances injected within the tendon, to assess the association between the tendon structure and symptoms, and to assess the prognostic value of the baseline tendon structure on treatment response.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

This study was part of a randomized trial on chronic midportion Achilles tendinopathy using eccentric exercises with either a platelet-rich plasma or saline injection. Symptoms were recorded using the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. The tendon structure was quantified with ultrasound tissue characterization (UTC); echo types I + II (as a percentage of total tendon types I-IV) are structure related. Follow-up was at 6, 12, 24, and 52 weeks. A control group of asymptomatic subjects (similar age) was selected to compare the tendon structure. Patient symptoms were correlated with the tendon structure using a linear model.

RESULTS

Fifty-four patients were included in the symptomatic group. The mean (± SD) echo types I + II in the symptomatic group increased significantly from 74.6% ± 10.8% at baseline to 85.6% ± 6.0% at 24-week follow-up. The result for echo types I + II at 24 weeks was not significantly different (P = .198) from that of the asymptomatic control group (87.5% ± 6.0%). In 54 repeated measurements at 5 time points, the adjusted percentage of echo types I + II was not associated with the VISA-A score (main effect: β = .12; 95% CI, -0.12 to 0.35; P = .338). The adjusted baseline echo types I + II were not associated with a change in the VISA-A score from baseline to 52 weeks (β = -.15; 95% CI, -0.67 to 0.36; P = .555).

CONCLUSION

In symptomatic, tendinopathic Achilles tendons, the ultrasonographic tendon structure improved during nonoperative treatment and normalized after 24 weeks to values of matched asymptomatic controls. There was no association between the tendon structure and symptoms. The percentage of echo types I + II before treatment was not associated with change in symptoms over time. This study demonstrates that restoration of the tendon structure is not required for an improvement of symptoms.

Ultrasound-guided procedures to treat sport-related muscle injuries

Ultrasound is well known as a low-cost, radiation-free and effective imaging technique to guide percutaneous procedures. The lower limb muscles represent a good target to perform such procedures under ultrasound guidance, thus allowing for clear and precise visualization of the needle during the whole procedure. The knowledge of guidelines and technical aspects is mandatory to act in the most safe and accurate way on target tissues that can be as small as a few millimetres. This review will focus above the local treatments of traumatic lower limb muscle injuries described in literature, focusing on new and promising approaches, such as platelet-rich plasma treatment of muscle tears in athletes. For each procedure, a brief how-to-do practical guide will be provided, emphasizing precautions and tricks based on day-by-day experience that may help to improve the outcome of percutaneous ultrasound-guided procedures around the lower limb muscles.

Ultrasound-Guided Fenestration of Tendons About the Hip and Pelvis: Clinical Outcomes

OBJECTIVES

Percutaneous ultrasound-guided needle fenestration has been used to treat tendinopathy of the elbow, knee, and ankle with promising results. The purpose of this study was to evaluate the clinical outcome of ultrasound-guided fenestration of tendons about the hip and pelvis.

METHODS

After Institutional Review Board approval, a retrospective search of imaging reports from January 1, 2005, to June 30, 2011, was completed to identify patients treated with ultrasound-guided tendon fenestration about the hip or pelvis. Subsequent clinic notes were retrospectively reviewed to determine whether the patient showed marked improvement, some improvement, no change, or worsening symptoms.

RESULTS

The study group consisted of 22 tendons in 21 patients with an average age of 55.8 years (range, 26.7-77.0 years). The treated tendons included 11 gluteus medius (9 tendinosis and 2 partial tears), 2 gluteus minimus (both tendinosis), 8 hamstring (6 tendinosis and 2 partial tears), and 1 tensor fascia latae (tendinosis). The average interval to clinical follow-up was 70 days (range, 7-813 days). There was marked improvement in 45.5% (10 of 22), some improvement in 36.4% (8 of 22), no change in symptoms in 9.1% (2 of 22), and worsening symptoms in 9.1% (2 of 22). There were no patient variables (age, chronicity of symptoms, sex, tendon, tendinosis versus tear, prior physical therapy, and prior corticosteroid injection) that were significantly different between patients who improved and those who did not. There were no cases of a subsequent tendon tear or infection.

CONCLUSIONS

Clinical follow-up after ultrasound-guided fenestration of the gluteus medius, gluteus minimus, proximal hamstring, and tensor fascia latae tendons showed that 82% of patients had improvement in their symptoms.

Tendinopathy: Is Imaging Telling Us the Entire Story?

Synopsis Tendinopathy is frequently associated with structural disorganization within the tendon. As such, the clinical use of ultrasound and magnetic resonance imaging for tendinopathy has been the focus of numerous academic studies and clinical discussions. However, similar to other musculoskeletal conditions (osteoarthritis and intervertebral disc degeneration), there is no direct link between tendon structural disorganization and clinical symptoms, with findings on imaging potentially creating a confusing clinical picture. While imaging shows the presence and extent of structural changes within the tendon, the clinical interpretation of the images requires context in regard to the features of pain and the aggravating loads. This review will critically evaluate studies that have investigated the accuracy and sensitivity of imaging in the detection of clinical tendinopathy and the methodological issues associated with these studies (subject selection, lack of a robust gold standard, reliance on subjective measures). The advent of new imaging modalities allowing for the quantification of tendon structure or mechanical properties has allowed new critical insight into tendon pathology. A strength of these novel modalities is the ability to quantify properties of the tendon. Research utilizing ultrasound tissue characterization and sonoelastography will be discussed. This narrative review will also attempt to synthesize current research on whether imaging can predict the onset of pain or clinical outcome, the role of monitoring tendon structure during rehabilitation (ie, does tendon structure need to improve to get a positive clinical outcome?), and future directions for research, and to propose the clinical role of imaging in tendinopathy. J Orthop Sports Phys Ther 2015;45(11):842-852. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5880.

The differential effects of leukocyte-containing and pure platelet-rich plasma (PRP) on tendon stem/progenitor cells - implications of PRP application for the clinical treatment of tendon injuries

Introduction

Platelet-rich plasma (PRP) is widely used to treat tendon injuries in clinics. These PRP preparations often contain white blood cells or leukocytes, and the precise cellular effects of leukocyte-rich PRP (L-PRP) on tendons are not well defined. Therefore, in this study, we determined the effects of L-PRP on tendon stem/progenitor cells (TSCs), which play a key role in tendon homeostasis and repair.

Methods

TSCs isolated from the patellar tendons of rabbits were treated with L-PRP or P-PRP (pure PRP without leukocytes) in vitro, followed by measuring cell proliferation, stem cell marker expression, inflammatory gene expression, and anabolic and catabolic protein expression by using immunostaining, quantitative real-time polymerase chain reaction, Western blot, and enzyme-linked immunosorbent assay, respectively.

Results

Cell proliferation was induced by both L-PRP and P-PRP in a dose-dependent manner with maximum proliferation at a 10 % PRP dose. Both PRP treatments also induced differentiation of TSCs into active tenocytes. Nevertheless, the two types of PRP largely differed in several effects exerted on TSCs. L-PRP induced predominantly catabolic and inflammatory changes in differentiated tenocytes; its treatment increased the expression of catabolic marker genes, matrix metalloproteinase-1 (MMP-1), MMP-13, interleukin-1beta (IL-1β), IL-6 and tumor necrosis factor-alpha (TNF-α), and their respective protein expression and prostaglandin E₂ (PGE₂) production. In contrast, P-PRP mainly induced anabolic changes; that is, P-PRP increased the gene expression of anabolic genes, alpha-smooth muscle actin (α-SMA), collagen types I and III.

Conclusions

These findings indicate that, while both L-PRP and P-PRP appear to be “safe” in inducing TSC differentiation into active tenocytes, L-PRP may be detrimental to the healing of injured tendons because it induces catabolic and inflammatory effects on tendon cells and may prolong the effects in healing tendons. On the other hand, when P-PRP is used to treat acutely injured tendons, it may result in the formation of excessive scar tissue due to the strong potential of P-PRP to induce inordinate cellular anabolic effects.

Efficacy of platelet-rich plasma injections in pain associated with chronic tendinopathy: A systematic review

BACKGROUND

Chronic tendinopathy has often been a management dilemma for general practitioners. With our understanding of the pathophysiology of tendinopathy evolving, so has our management, with the advent of newer strategies such as topical glycerol trinitrate, extracorporeal shock-wave therapy, as well as platelet-rich plasma (PRP).

AIM

To systematically review the literature regarding PRP therapy in chronic tendinopathy.

DESIGN AND SETTING

The databases used in our search include the Elton B. Stephens Co. (EBSCO) database, Medline, the Cochrane library, Ovid, and Embase (the Excerpta Medica database). A total of 389 articles were reviewed from Feb 2010 to April 2014, for possible inclusion. Of these articles, a total of 9 randomized controlled trials (RCTs) met our inclusion criteria. Only 1 RCT was excluded due to previous surgery in both the trial and control groups.

METHODS

Each article was reviewed independently by 2 authors. Each article was analyzed using the Cochrane Criteria checklist. Where any discrepancy occurred in results, a third independent reviewer was consulted.

RESULTS

Our review found that PRP was most effective in patellar and lateral epicondylar tendinopathy, with both RCTs in the patellar section of our study supporting the use of PRP in pain reduction at 3 and 12 months, whereas 2 of 4 studies in the lateral epicondylar section showed improvements in pain and disability at 6 and 12 months. There was a lack of evidence to support the use of PRP in Achilles and rotator cuff tendinopathy.

CONCLUSIONS

Although the results of this review show promise for the use of PRP in chronic tendinopathy, the analysis highlighted the need for more controlled clinical trials comparing PRP with placebo.

Hamstring injuries: prevention and treatment-an update

Despite increased knowledge of hamstring muscle injuries, the incidence has not diminished. We now know that not all hamstring injuries are the same and that certain types of injuries require prolonged rehabilitation and return to play. The slow stretch type of injury and injuries involving the central tendon both require longer times to return to play. A number of factors have been proposed as being indicators of time taken to return to play, but the evidence for these is conflicting. Recurrence rates remain high and it is now thought that strength deficits may be an important factor. Strengthening exercise should be performed with the hamstrings in a lengthened position. There is conflicting evidence regarding the efficacy of platelet-rich plasma injection in the treatment of hamstring injuries so at this stage we cannot advise their use. Various tests have been proposed as predictors of hamstring injury and the use of the Nordboard is an interesting addition to the testing process. Prevention of these injuries is the ultimate aim and there is increasing evidence that Nordic hamstring exercises are effective in reducing the incidence.

Injection therapies for Achilles tendinopathy

BACKGROUND

Achilles tendinopathy is a common condition, often with significant functional consequences. As a wide range of injection treatments are available, a review of randomised trials evaluating injection therapies to help inform treatment decisions is warranted.

OBJECTIVES

To assess the effects (benefits and harms) of injection therapies for people with Achilles tendinopathy.

SEARCH METHODS

We searched the following databases up to 20 April 2015: the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and SPORTDiscus. We also searched trial registers (29 May 2014) and reference lists of articles to identify additional studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials evaluating injection therapies in adults with an investigator-reported diagnosis of Achilles tendinopathy. We accepted comparison arms of placebo (sham) or no injection control, or other active treatment (such as physiotherapy, pharmaceuticals or surgery). Our primary outcomes were function, using measures such as the VISA-A (Victorian Institute of Sport Assessment-Achilles questionnaire), and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies. We assessed treatment effects using mean differences (MDs) and 95% confidence intervals (CIs) for continuous variables and risk ratios (RRs) and 95% CIs for dichotomous variables. For follow-up data, we defined short-term as up to six weeks, medium-term as up to three months and longer-term as data beyond three months. We performed meta-analysis where appropriate.

MAIN RESULTS

We included 18 studies (732 participants). Seven trials exclusively studied athletic populations. The mean ages of the participants in the individual trials ranged from 20 years to 50 years. Fifteen trials compared an injection therapy with a placebo injection or no injection control, four trials compared an injection therapy with active treatment, and one compared two different concentrations of the same injection. Thus no trials compared different injection therapies. Two studies had three trial arms and we included them twice in two different categories. Within these categories, we further subdivided injection therapies by mode of action (injury-causing versus direct repair agents).The risk of bias was unclear (due to poor reporting) or high in six trials published between 1987 and 1994. Improved methodology and reporting for the subsequent trials published between 2004 and 2013 meant that these were at less risk of bias.Given the very low quality evidence available from each of four small trials comparing different combinations of injection therapy versus active treatment and the single trial comparing two doses of one injection therapy, only the results of the first comparison (injection therapy versus control) are presented.There is low quality evidence of a lack of significant or clinically important differences in VISA-A scores (0 to 100: best function) between injection therapy and control groups at six weeks (MD 0.79, 95% CI -4.56 to 6.14; 200 participants, five trials), three months (MD -0.94, 95% CI -6.34 to 4.46; 189 participants, five trials) or between six and 12 months (MD 0.14, 95% CI -6.54 to 6.82; 132 participants, three trials). Very low quality evidence from 13 trials showed little difference between the two groups in adverse events (14/243 versus 12/206; RR 0.97, 95% CI 0.50 to 1.89), most of which were minor and short-lasting. The only major adverse event in the injection therapy group was an Achilles tendon rupture, which happened in a trial testing corticosteroid injections. There was very low quality evidence in favour of the injection therapy group in short-term (under three months) pain (219 participants, seven trials) and in the return to sports (335 participants, seven trials). There was very low quality evidence indicating little difference between groups in patient satisfaction with treatment (152 participants, four trials). There was insufficient evidence to conclude on subgroup differences based on mode of action given that only two trials tested injury-causing agents and the clear heterogeneity of the other 13 trials, which tested seven different therapies that act directly on the repair pathway.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials to draw conclusions on the use, or to support the routine use, of injection therapies for treating Achilles tendinopathy. This review has highlighted a need for definitive research in the area of injection therapies for Achilles tendinopathy, including in older non-athletic populations. This review has shown that there is a consensus in the literature that placebo-controlled trials are considered the most appropriate trial design.

Achilles tendon structure improves on UTC imaging over a 5-month pre-season in elite Australian football players

Pre-season injuries are common and may be due to a reintroduction of training loads. Tendons are sensitive to changes in load, making them vulnerable to injury in the pre-season. This study investigated changes in Achilles tendon structure on ultrasound tissue characterization (UTC) over the course of a 5-month pre-season in elite male Australian football players. Eighteen elite male Australian football players with no history of Achilles tendinopathy and normal Achilles tendons were recruited. The left Achilles tendon was scanned with UTC to quantify the stability of the echopattern. Participants were scanned at the start and completion of a 5-month pre-season. Fifteen players remained asymptomatic over the course of the pre-season. All four echo-types were significantly different at the end of the pre-season, with the overall echopattern suggesting an improvement in Achilles tendon structure. Three of the 18 participants developed Achilles tendon pain that coincided with a change in the UTC echopattern. This study demonstrates that the UTC echopattern of the Achilles tendon improves over a 5-month pre-season training period, representing increased fibrillar alignment. However, further investigation is needed to elucidate with this alteration in the UTC echopattern results in improved tendon resilience and load capacity.

Muscle and tendon injuries: the role of biological interventions to promote and assist healing and recovery

PURPOSE

To summarize clinical studies after platelet-rich plasma (PRP) therapy for tendinopathy, plantar fasciopathy, and muscle injuries; to review PRP formulations used across studies; and to identify knowledge deficits that require further investigation.

METHODS

After a systematic review in PubMed, we identified clinical studies assessing PRP efficacy in tendon and muscle during the past decade. We standardized data extraction by grouping studies based on anatomic location; summarized patient populations, PRP formulations, and clinical outcomes; and identified knowledge deficits that require further investigation.

RESULTS

Overall, 1,541 patients had been treated with PRP in 58 clinical studies; of these, 26 addressed upper limb tendinopathies and 32 addressed the lower limb (810 patients and 731 patients treated with PRP, respectively). The quality of research is higher for the upper limb than for the lower limb (23 controlled studies, of which 17 are Level I, v 19 controlled studies, of which 6 are Level I, respectively). Patients have been treated mostly with leukocyte-platelet-rich plasma, except in the arthroscopic management of the rotator cuff. The safety and efficacy of PRP for muscle injuries has been addressed in 7 studies including 182 patients. Differences across results are mainly attributed to dissimilarities between tissues and different stages of degeneration, numbers of PRP applications, and protocols.

CONCLUSIONS

Given the heterogeneity in tendons and tendinopathies, currently, we are not able to decide whether PRP therapies are useful. Despite advances in PRP science, data are insufficient and there is a clear need to optimize protocols and obtain more high-quality clinical data in both tendinopathies and muscle injuries before making treatment recommendations.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Platelet-rich plasma in orthopedic therapy: a comparative systematic review of clinical and experimental data in equine and human musculoskeletal lesions

BACKGROUND

This systematic review aimed to present and critically appraise the available information on the efficacy of platelet rich plasma (PRP) in equine and human orthopedic therapeutics and to verify the influence of study design and methodology on the assumption of PRP's efficacy. We searched Medline, PubMed, Embase, Bireme and Google Scholar without restrictions until July 2013. Randomized trials, human cohort clinical studies or case series with a control group on the use of PRP in tendons, ligaments or articular lesions were included. Equine clinical studies on the same topics were included independently of their design. Experimental studies relevant to the clarification of PRP's effects and mechanisms of action in tissues of interest, conducted in any animal species, were selected.

RESULTS

This review included 123 studies. PRP's beneficial effects were observed in 46.7% of the clinical studies, while the absence of positive effects was observed in 43.3%. Among experimental studies, 73% yielded positive results, and 7.9% yielded negative results. The most frequent flaws in the clinical trials' designs were the lack of a true placebo group, poor product characterization, insufficient blinding, small sampling, short follow-up periods, and adoption of poor outcome measures. The methods employed for PRP preparation and administration and the selected outcome measures varied greatly. Poor study design was a common feature of equine clinical trials. From studies in which PRP had beneficial effects, 67.8% had an overall high risk of bias. From the studies in which PRP failed to exhibit beneficial effects, 67.8% had an overall low risk of bias.

CONCLUSIONS

Most experimental studies revealed positive effects of PRP. Although the majority of equine clinical studies yielded positive results, the human clinical trials' results failed to corroborate these findings. In both species, beneficial results were more frequently observed in studies with a high risk of bias. The use of PRP in musculoskeletal lesions, although safe and promising, has still not shown strong evidence in clinical scenarios.

Platelet-rich plasma and other cellular strategies in orthopedic surgery

The use of biologics in the treatment of musculoskeletal disease has become increasingly more common as research studies continue to provide further elucidation of their mechanisms in healing. Platelet-rich plasma, patches, growth factors, and stem cells are among the many biologics under active investigation and have varying levels of success in augmenting surgical or nonoperative interventions. However, the limitations of these treatments exist, and clear guidelines for their indications and application have yet to be established. Well-designed clinical trials will help determine the appropriate future use of biologics to ensure consistent outcomes.

Biologics in Achilles tendon healing and repair: a review

Injuries of the Achilles tendon are relatively common with potentially devastating outcomes. Healing Achilles tendons form a fibrovascular scar resulting in a tendon which may be mechanically weaker than the native tendon. The resulting strength deficit causes a high risk for reinjury and other complications. Treatments using biologics aim to restore the normal properties of the native tendon and reduce the risk of rerupture and maximize tendon function. The purpose of this review was to summarize the current findings of various therapies using biologics in an attempt to improve the prognosis of Achilles tendon ruptures and tendinopathies. A PubMed search was performed using specific search terms. The search was open for original manuscripts and review papers limited to publication within the last 10 years. From these searches, papers were included in the review if they investigated the effects of biological augmentation on Achilles tendon repair or healing. Platelet-rich plasma may assist in the healing process of Achilles tendon ruptures, while the evidence to support its use in the treatment of chronic Achilles tendinopathies remains insufficient. The use of growth factors such as hepatocyte growth factor, recombinant human platelet-derived growth factor-BB, interleukin-6, and transforming growth factor beta as well as several bone morphogenetic proteins have shown promising results for Achilles tendon repair. In vitro and preclinical studies have indicated the potential effectiveness of bone marrow aspirate as well. Stem cells also have positive effects on Achilles tendon healing, particularly during the early phases. Polyhydroxyalkanoates (PHA), decellularized tendon tissue, and porcine small intestinal submucosa (SIS) are biomaterials which have shown promising results as scaffolds used in Achilles tendon repair. The application of biological augmentation techniques in Achilles tendon repair appears promising; however, several techniques require further investigation to evaluate their clinical application.

Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials

INTRODUCTION

Several pharmacological interventions have been proposed for the management of Achilles tendinopathy, with no agreement on which is the overall best option available. This systematic review investigates the efficacy and safety of different local pharmacological treatments for Achilles tendinopathy.

SOURCES OF DATA

We included only randomized controlled studies (RCTs) focusing on clinical and functional outcomes of therapies consisting in injection of a substance or local application. Assessment of the methodological quality was performed using a modified version of the Coleman methodology score (CMS) to determine possible risks of bias.

AREAS OF AGREEMENT

Thirteen RCTs were included with a total of 528 studied patients. Eleven studies reported the outcomes of injection therapies. Two studies examined the outcomes of patients who applied glyceryl trinitrate patch. The mean modified CMS was 70.6 out of 90.

AREAS OF CONTROVERSY

There was no significant evidence of remarkable benefits provided by any of the therapies studied.

GROWING POINTS

There is not univocal evidence to advise any particular pharmacological treatment as the best advisable non-operative option for Achilles tendinopathy as equivalent alternative to the most commonly used eccentric loading rehabilitation program. However, potential was shown by the combination of different substances administered with physical therapy.

RESEARCH

There is a need for more long-term investigations, studying large enough cohort with standardized scores and evaluations shared by all the investigations to confirm the healing potential, and provide a stronger statistical comparison of the available treatments.

Achilles tendinosis: treatment options

Athletes usually complain of an ongoing or chronic pain over the Achilles tendon, but recently even non-athletes are experiencing the same kind of pain which affects their daily activities. Achilles tendinosis refers to a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation. Treatment is based on whether to stimulate or prevent neovascularization. Thus, until now, there is no consensus as to the best treatment for this condition. This paper aims to review the common ways of treating this condition from the conservative to the surgical options.

The use of autologous platelet-rich plasma in the orthopedic setting

BACKGROUND

Autologous platelet-rich plasma (aPRP) is widely used with orthopedic patients to help treat injuries to tendons, cartilage, ligaments, and muscle. A comprehensive review of the literature was conducted to evaluate aPRP's efficacy and compare available methods. In addition, the production and administration of aPRP were explored.

STUDY DESIGN AND METHODS

A literature search was performed. Randomized controlled clinical trials (RCTs) in orthopedic procedures on adult patients were included and assessed for methodologic quality. The main outcomes were pain relief, increase in function, structural integrity, and "healing" based on various validated scales.

RESULTS

Twelve RCTs and one controlled cohort were included (four lateral epicondylitis, two chronic Achilles tendinopathy, two anterior cruciate ligament injury, and five rotator cuff injuries). Four trials reported some benefit from aPRP versus controls while eight trials found no benefit from aPRP applications versus control. One study had too many patients withdraw from the control arm for acceptable data interpretation. All protocols used a different aPRP formulation or method of delivery or application.

CONCLUSIONS

Despite its popularity, there are no standardized criteria that define aPRP. Different techniques yield wide variability in terms of platelet count and concentration. These variations make it difficult to compare clinical trials that use aPRP or draw conclusions concerning its clinical efficacy in orthopedic procedures. Blood bankers have experience in the production of standardized blood components. This expertise may be used to develop and implement protocols for the production and administration of aPRP, as well as quality control measures.

Achilles tendons in people with type 2 diabetes show mildly compromised structure: an ultrasound tissue characterisation study

BACKGROUND

Musculotendinous overuse injuries are prevalent in people with type 2 diabetes. Non-enzymatic glycosylation of collagen resulting in tendon stiffening may play a role. In this case-control study we determined whether patients with diabetes had poorer ultrasonographic structure in their Achilles tendons compared to age-matched controls.

METHODS

People with type 1 diabetes or type 2 diabetes, and age-matched controls, had computerised ultrasound tissue characterisation of both Achilles tendons. In contiguous ultrasonographic images of the tendon, echopatterns were quantified and categorised into four echo-types. Tendon abnormality was quantified as sum of echo-types III+IV. Furthermore, skin autofluorescence (AF) of the forearm (AF-value) was gathered.

RESULTS

Twenty four type 2 diabetes patients, 24 controls, 24 type 1 diabetes patients and 20 controls were included. AF-value was higher in type 1 diabetes (1.55±0.17) than in their controls (1.39±0.18, p<0.001) and in type 2 diabetes (2.28±0.38) compared to their controls (1.84±0.32, p<0.001) Achilles tendons of type 2 diabetes patients contained more echo-types III+IV (14.1±7.9%) than matched controls (8.0±5.4%, p<0.001). There was a trend towards a difference in echo-types III+IV between type 1 diabetes patients (9.5±5.3%) and their controls (6.5±3.7%, p=0.055). In a stepwise linear regression analysis, body mass index (BMI) was moderately associated with tendon abnormality in patients with diabetes and controls (β=0.393, p<0.001).

CONCLUSIONS

Type 2, and possibly type 1, diabetes patients showed poorer ultrasonographic Achilles tendon structure that may be a risk factor for tendinopathy. Although markers for accumulation of advanced glycation end products were elevated in both diabetes populations, only BMI was associated with these abnormalities.

TRIAL REGISTRATION NUMBER

NTR2209.

Sports medicine and platelet-rich plasma: nonsurgical therapy

A Cochrane Review was performed to assess the effects of platelet-rich therapies for treating musculoskeletal soft tissue injuries. Selection criteria were randomized and quasirandomized controlled trials (RCTs) that compared platelet-rich therapy with either placebo, autologous whole blood, dry needling, or no platelet-rich therapy for people with acute or chronic musculoskeletal soft tissue injuries. Primary outcomes were functional status, pain, and adverse effects. The investigators found 19 studies that compared platelet-rich therapy with placebo, autologous whole blood, dry needling, or no platelet-rich therapy. Disorders included rotator cuff tears (arthroscopic repair; 6 trials); shoulder impingement syndrome surgery (1 trial); elbow epicondylitis (3 trials); anterior cruciate ligament (ACL) reconstruction (4 trials), ACL reconstruction (donor graft site application; 2 trials), patellar tendinopathy (1 trial), Achilles tendinopathy (1 trial), and acute Achilles rupture surgical repair (1 trial). They further subdivided the studies based on type of treatment, including tendinopathies in which platelet-rich therapy injections were the main treatment (5 trials), and surgical augmentation procedures in which platelet-rich therapy was applied during surgery (14 trials). The conclusion was that there is currently insufficient evidence to support the use of platelet-rich therapy for treating musculoskeletal soft tissue injuries. Researchers contemplating RCTs should consider the coverage of currently ongoing trials when assessing the need for future RCTs on specific conditions. There is a need for standardization of PRP preparation methods. At this time, the use of PRP in foot and ankle surgery as an orthobiologic does not have an absolute indication. Many of the studies are lower evidence-based from surgical techniques. Several in vitro studies have shown that growth factors promote the regeneration of bone, cartilage, and tendons. More clinical studies are needed to evaluate the use of PRP as an orthobiologic. In the author’s opinion, PRP does have a role when conservative treatment has failed and the next treatment option is an invasive surgical procedure

Platelet-rich plasma: evidence for the treatment of patellar and Achilles tendinopathy--a systematic review

Platelet-rich plasma (PRP) has been introduced in the clinical practice to treat a growing number of different musculoskeletal pathologies. It is currently applied in the treatment of Achilles and patellar tendinopathies, which are common sport-related injuries very challenging to manage. Aim of the present paper was to review systematically the available clinical evidence concerning the application of PRP in the treatment of patellar and Achilles tendinopathy. A systematic review of the literature was performed according to the following inclusion criteria for relevant articles: (1) clinical reports of any level of evidence, (2) written in the English language, (3) with no time limitation and (4) on the use of PRP to treat conservatively Achilles and patellar tendinopathy. Twenty-two studies were included and analyzed. Two studies on patellar tendinopathy were randomized controlled trials (RCTs), whereas just one RCT was published on Achilles tendon. All the papers concerning patellar tendon reported positive outcome for PRP, which proved to be superior to other traditional approaches such as shock-wave therapy and dry needling. In the case of Achilles tendon, despite the encouraging findings reported by case series, the only RCT available showed no significant clinical difference between PRP and saline solution. The main finding of this study was the paucity of high-level literature regarding the application of PRP in the management of patellar and Achilles tendinopathy. However, the clinical data currently available, although not univocal, suggest considering PRP as a therapeutic option for recalcitrant patellar and Achilles tendinopathies.

Treatment of tendinopathies with platelet-rich plasma

Pain and dysfunction related to tendinopathy are often refractory to traditional treatments and offer a unique challenge to physicians, because no gold standard treatment exists. Injectable biologics may represent a new modality in conjunction with a multifaceted treatment approach. Platelet-rich plasma (PRP) injections are not associated with the systemic or tendon degradation risks of corticosteroids or the inherent risks of surgery. Studies are promising but have not been replicated with high-powered evidence at the clinical level. Further evidence to expand understanding of the role of PRP in the treatment of tendinopathy is needed.

Comparison of postinjection protocols after intratendinous Achilles platelet-rich plasma injections: a cadaveric study

The purpose of the present investigation was to evaluate the distribution of intratendinous injected platelet-rich plasma (PRP) after 15 minutes of prone resting versus immediate manipulation simulating weightbearing. Ten cadaveric lower limbs were injected under ultrasound guidance with PRP dyed with India blue ink. The dyed PRP was injected into the mid-portion of the Achilles tendon, after which 5 specimens were placed in the prone position for 15 minutes (simulating rest) and the remaining 5 specimens were manipulated through 100 cycles of ankle dorsiflexion and plantarflexion (simulating walking). Thereafter, the specimens were dissected, and the distribution of the India blue dye was ascertained. In the simulated rest group, every specimen showed dyed PRP in the Achilles tendon and in the space between the paratenon and tendon. The median craniocaudal spread of the PRP was 140 (range 125 to 190) mm. In 4 of the simulated rest tendons (80%), the distribution of PRP extended across the entire transverse plane width of the tendon. In the simulated motion group, every specimen showed dyed PRP extending across the entire transverse plane width of the tendon and in the space between the paratenon and tendon. The median craniocaudal spread was 135 (range 115 to 117) mm. No statistically significant difference was found in the amount of craniocaudal spread between the simulated motion and rest groups. In conclusion, it does not appear to matter whether the ankle has been moved through its range of motion or maintained stationary during the first 15 minutes after PRP injection into the mid-portion of the Achilles tendon. The precise meaning of this information in the clinical realm remains to be discerned.

Platelet concentration in platelet-rich plasma affects tenocyte behavior in vitro

Since tendon injuries and tendinopathy are a growing problem, sometimes requiring surgery, new strategies that improve conservative therapies are needed. Platelet-rich plasma (PRP) seems to be a good candidate by virtue of its high content of growth factors, most of which are involved in tendon healing. This study aimed to evaluate if different concentrations of platelets in PRP have different effects on the biological features of normal human tenocytes that are usually required during tendon healing. The different platelet concentrations tested (up to 5 × 10(6) plt/µL) stimulated differently tenocytes behavior; intermediate concentrations (0.5 × 10(6), 1 × 10(6) plt/µL) strongly induced all tested processes (proliferation, migration, collagen, and MMPs production) if compared to untreated cells; on the contrary, the highest concentration had inhibitory effects on proliferation and strongly reduced migration abilities and overall collagen production but, at the same time, induced increasing MMP production, which could be counterproductive because excessive proteolysis could impair tendon mechanical stability. Thus, these in vitro data strongly suggest the need for a compromise between extremely high and low platelet concentrations to obtain an optimal global effect when inducing in vivo tendon healing.

Platelet-rich plasma: underlying biology and clinical correlates

Platelet-rich plasma (PRP) has recently become the focus of intensive interest and discussion, in part because of the expanding understanding of platelet function. Anucleate platelets within PRP release a myriad of growth factors and cytokines while contributing to plasma coagulation and fibrin development; the latter acts as vehicle for the local delivery. The biological effects of PRP are largely attributed to the platelet secretome and plasma signaling proteins. Clinical data suggest that PRPs may exploit different regenerative mechanisms under diverse disease conditions, including hemostasis, inflammation, angiogenesis and the synthesis of extracellular matrix. The success of PRP therapies depends on current tissue healing research and the translation of this knowledge into clinical developments.

Platelet-rich plasma injections for the treatment of refractory Achilles tendinopathy: results at 4 years

BACKGROUND

Chronic Achilles tendinopathy is responsible for a severe reduction in physical performance and persistent pain. There is currently a number of therapeutic options and the local administration of growth factors is an emerging treatment strategy. In particular, platelet-rich plasma (PRP) is a widely used way to provide a local regenerative stimulus for tendon healing. The aim of this study was to document the mid-term results obtained after treating recalcitrant Achilles tendinopathy with injections of high concentrate, leucocyte-rich PRP.

MATERIALS AND METHODS

Twenty-seven patients (mean age: 44.6 years; 22 men and 5 women) affected by chronic mid-portion Achilles tendinopathy (7 bilateral, for a total of 34 tendons), refractory to previous treatments, were enrolled. Patients were treated with three ultrasound-guided intra-tendinous injections of PRP at 2-week intervals. Patients were prospectively evaluated at baseline, and then at 2, 6, and up to a mean of 54.1 months of follow-up (minimum 30 months), using the following tools: Blanzina, VISA-A, EQ-VAS for general health, and Tegner scores.

RESULTS

The VISA-A score showed a significant improvement: the baseline score of 49.9±18.1 increased to 62.9±19.8 at 2 months (p=0.002), with a further improvement at 6 months (84.3±17.1, p<0.0005), and stable results at 4.5 years (90.0±13.9). The EQ-VAS score also showed a similar positive trend. An evaluation of the activity level confirmed these findings, showing a significant improvement in the Tegner score over time (p=0.017 for the final evaluation). The longer duration of symptoms before treatment was associated with a slower return to sport (p=0.041).

DISCUSSION

PRP injections produced good overall results for the treatment of chronic recalcitrant Achilles tendinopathy with a stable outcome up to a medium-term follow-up. Longer symptom duration was related with a more difficult return to sporting activity.

Morphogen and proinflammatory cytokine release kinetics from PRGF-Endoret fibrin scaffolds: evaluation of the effect of leukocyte inclusion

The potential influence of leukocyte incorporation in the kinetic release of growth factors from platelet-rich plasma (PRP) may explain the conflicting efficiency of leukocyte platelet-rich plasma (L-PRP) scaffolds in tissue regeneration. To assess this hypothesis, leukocyte-free (PRGF-Endoret) and L-PRP fibrin scaffolds were prepared, and both morphogen and proinflammatory cytokine release kinetics were analyzed. Clots were incubated with culture medium to monitor protein release over 8 days. Furthermore, the different fibrin scaffolds were morphologically characterized. Results show that leukocyte-free fibrin matrices were homogenous while leukocyte-containing ones were heterogeneous, loose and cellular. Leukocyte incorporation produced a significant increase in the contents of proinflammatory cytokines interleukin (IL)-1β and IL-16 but not in the platelet-derived growth factors release (<1.5-fold). Surprisingly, the availability of vascular endothelial growth factor suffered an important decrease after 3 days of incubation in the case of L-PRP matrices. While the release of proinflammatory cytokines was almost absent or very low from PRGF-Endoret, the inclusion of leukocytes induced a major increase in these cytokines, which was characterized by the presence of a latent period. The PRGF-Endoret matrices were stable during the 8 days of incubation. The inclusion of leukocytes alters the growth factors release profile and also increased the dose of proinflammatory cytokines.

The role of eccentric exercise in sport injuries rehabilitation

INTRODUCTION

Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field.

SOURCES OF DATA

A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as 'eccentric exercise', 'sports injuries rehabilitation', 'tendinopathy', 'hamstrings strain' 'adductor injuries' and 'ACL reconstruction rehabilitation'.

AREAS OF AGREEMENT

EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation.

AREA OF CONTROVERSY

The lack of standardization of protocols, the variable amount, quality and follow-up of studies, the different anatomy and pathophysiology of the therapeutic targets limit the evidence of applicability of EE to sports injuries.

GROWING POINTS

The role of pathology and biomechanics in the response to EE should be further investigated.

AREAS TIMELY FOR DEVELOPING RESEARCH

New randomized controlled trials should test the effectiveness of standardized EE regimens to various sites of sports injuries.

Platelet-rich plasma in the conservative treatment of painful tendinopathy: a systematic review and meta-analysis of controlled studies

BACKGROUND

Platelet-rich plasma (PRP) seeks to meet the multifaceted demand of degenerated tendons providing several molecules capable of boosting healing.

AREAS TIMELY FOR DEVELOPING RESEARCH

PRP is used for managing tendinopathy, but its efficacy is controversial.

SOURCES OF DATA

Electronic databases were searched for clinical studies assessing PRP efficacy. Methodological quality was evaluated using the methods described in the Cochrane Handbook for systematic reviews.

AREAS OF AGREEMENT

Thirteen prospective controlled studies, comprising 886 patients and diverse tendons were included; 53.8% of studies used identical PRP protocol.

AREAS OF CONTROVERSY

Sources of heterogeneity included different comparators, outcome scores, follow-up periods and diverse injection protocols, but not PRP formulation per se.

GROWING POINTS

Pooling pain outcomes over time and across different tendons showed that L-PRP injections ameliorated pain in the intermediate-long term compared with control interventions, weighted mean difference (95% CI): 3 months, -0.61 (-0.97, -0.25); 1 year, -1.56 (-2.27, -0.83). However, these findings cannot be applied to the management of individual patients given low power and precision.

RESEARCH

Further studies circumventing heterogeneity are needed to reach firm conclusions. Available evidence can help to overcome hurdles to future clinical research and bring forward PRP therapies.

Platelet-rich therapies for musculoskeletal soft tissue injuries

BACKGROUND

Platelet-rich therapies are being used increasingly in the treatment of musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies. These therapies can be used as the principal treatment or as an augmentation procedure (application after surgical repair or reconstruction). Platelet-rich therapies are produced by centrifuging a quantity of the patient's own blood and extracting the active, platelet-rich, fraction. The platelet-rich fraction is applied to the injured tissue; for example, by injection. Platelets have the ability to produce several growth factors, so these therapies should enhance tissue healing. There is a need to assess whether this translates into clinical benefit.

OBJECTIVES

To assess the effects (benefits and harms) of platelet-rich therapies for treating musculoskeletal soft tissue injuries.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (25 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL 2013 Issue 2), MEDLINE (1946 to March 2013), EMBASE (1980 to 2013 Week 12) and LILACS (1982 to March 2012). We also searched trial registers (to Week 2 2013) and conference abstracts (2005 to March 2012). No language or publication restrictions were applied.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared platelet-rich therapy with either placebo, autologous whole blood, dry needling or no platelet-rich therapy for people with acute or chronic musculoskeletal soft tissue injuries. Primary outcomes were functional status, pain and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed each study's risk of bias. Disagreement was resolved by discussion or by arbitration by a third author. We contacted trial authors for clarification of methods or missing data. Treatment effects were assessed using risk ratios for dichotomous data and mean differences (MD) or standardised mean differences (SMD) for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using the fixed-effect model for RR and MD, and the random-effects model for SMD. The quality of the evidence for each outcome was assessed using GRADE criteria.

MAIN RESULTS

We included data from 19 small single centre trials (17 randomised and two quasi-randomised; 1088 participants) that compared platelet-rich therapy with placebo, autologous whole blood, dry needling or no platelet-rich therapy. These trials covered eight clinical conditions: rotator cuff tears (arthroscopic repair) (six trials); shoulder impingement syndrome surgery (one trial); elbow epicondylitis (three trials); anterior cruciate ligament (ACL) reconstruction (four trials), ACL reconstruction (donor graft site application) (two trials), patellar tendinopathy (one trial), Achilles tendinopathy (one trial) and acute Achilles rupture surgical repair (one trial). We also grouped trials into 'tendinopathies' where platelet-rich therapy (PRT) injections were the main treatment (five trials), and surgical augmentation procedures where PRT was applied during surgery (14 trials). Trial participants were mainly male, except in trials including rotator cuff tears, and elbow and Achilles tendinopathies.Three trials were judged as being at low risk of bias; the other 16 were at high or unclear risk of bias relating to selection, detection, attrition or selective reporting, or combinations of these. The methods of preparing platelet-rich plasma (PRP) varied and lacked standardisation and quantification of the PRP applied to the patient.We were able to pool data for our primary outcomes (function, pain, adverse events) for a maximum of 11 trials and 45% of participants. The evidence for all primary outcomes was judged as being of very low quality.Data assessing function in the short term (up to three months) were pooled from four trials that assessed PRT in three clinical conditions and used four different measures. These showed no significant difference between PRT and control (SMD 0.26; 95% confidence interval (CI) -0.19 to 0.71; P value 0.26; I² = 51%; 162 participants; positive values favour PRT). Medium-term function data (at six months) were pooled from five trials that assessed PRT in five clinical conditions and used five different measures. These also showed no difference between groups (SMD -0.09, 95% CI -0.56 to 0.39; P value 0.72; I² = 50%; 151 participants). Long-term function data (at one year) were pooled from 10 trials that assessed PRT in five clinical conditions and used six different measures. These also showed no difference between groups (SMD 0.25, 95% CI -0.07 to 0.57; P value 0.12; I² = 66%; 484 participants). Although the 95% confidence intervals indicate the possibility of a poorer outcome in the PRT group up to a moderate difference in favour of PRT at short- and long-term follow-up, these do not translate into clinically relevant differences.Data pooled from four trials that assessed PRT in three clinical conditions showed a small reduction in short-term pain in favour of PRT on a 10-point scale (MD -0.95, 95% CI -1.41 to -0.48; I² = 0%; 175 participants). The clinical significance of this result is marginal.Four trials reported adverse events; another seven trials reported an absence of adverse events. There was no difference between treatment groups in the numbers of participants with adverse effects (7/241 versus 5/245; RR 1.31, 95% CI 0.48 to 3.59; I² = 0%; 486 participants).In terms of individual conditions, we pooled heterogeneous data for long-term function from six trials of PRT application during rotator cuff tear surgery. This showed no statistically or clinically significant differences between the two groups (324 participants).The available evidence is insufficient to indicate whether the effects of PRT will differ importantly in individual clinical conditions.

AUTHORS' CONCLUSIONS

Overall, and for the individual clinical conditions, there is currently insufficient evidence to support the use of PRT for treating musculoskeletal soft tissue injuries. Researchers contemplating RCTs should consider the coverage of currently ongoing trials when assessing the need for future RCTs on specific conditions. There is need for standardisation of PRP preparation methods.

Platelet-rich plasma for foot and ankle pathologies: a systematic review

BACKGROUND

The aim of this article is to review systematically all the literature available on the clinical application of PRP for the treatment of foot and ankle pathologies, to understand its potential and best indications for clinical use.

METHODS

A systematic search of the PubMed database was performed. Research criteria were the following: (1) papers in the English language, (2) dealing with the clinical application of PRP for the treatment of orthopedic-related conditions affecting the foot and ankle district, (3) with I to IV level of evidence, and (4) reporting clinical results.

RESULTS

A total of 17 studies fulfilled the inclusion criteria. Nine papers dealt with Achilles tendon management, 2 articles with plantar fasciitis, 3 papers with talar osteochondral lesions, 2 with PRP application in total ankle replacement, and 1 article with PRP in foot and ankle fusions. The overall evaluation of the results reported does not clearly demonstrate the potential of PRP treatment in any of the specific fields of application.

CONCLUSIONS

Considering the literature currently available, no clear indications for using PRP in the foot and ankle district emerged.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I, II, III and IV studies.

Video Q&A: state-of-the-art therapy for the elite and non-elite athlete: an interview with Mike Carmont

In this video Q&A, Mr Mike Carmont answers questions about state-of-the-art treatments for elite athletes, and the progress and challenges behind translating these into successful therapies for the non-elite athlete.

Orthobiologics and platelet rich plasma

Orthobiologics have evolved to the extent that they significantly influence modern orthopedic surgical practice. A better understanding of the role of various growth factors and cells in the process of tendon healing, ligament repair, cartilage regeneration and bone formation has stimulated focused research in many chronic musculoskeletal ailments. Investigators have published results of laboratory as well as clinical studies, using orthobiologics like platelet rich plasma, stem cells, autologous conditioned serum etc., with variable results. However, a clear consensus over the best orthobiologic substance and the method of preparation and usage of these substances is lacking. Much of the confusion is due to the fact that studies ranging from RCTs to case reports present variable results, and the interpretations are wide-ranging. We have reviewed the available orthobiologics related data with a focus on platelet rich plasma in orthopedic conditions.

Platelet-rich therapies for musculoskeletal soft tissue injuries

BACKGROUND

Platelet-rich therapies are being used increasingly in the treatment of musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies. These therapies can be used as the principal treatment or as an augmentation procedure (application after surgical repair or reconstruction). Platelet-rich therapies are produced by centrifuging a quantity of the patient's own blood and extracting the active, platelet-rich, fraction. The platelet-rich fraction is applied to the injured tissue; for example, by injection. Platelets have the ability to produce several growth factors, so these therapies should enhance tissue healing. There is a need to assess whether this translates into clinical benefit.

OBJECTIVES

To assess the effects (benefits and harms) of platelet-rich therapies for treating musculoskeletal soft tissue injuries.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (25 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL 2013 Issue 2), MEDLINE (1946 to March 2013), EMBASE (1980 to 2013 Week 12) and LILACS (1982 to March 2012). We also searched trial registers (to Week 2 2013) and conference abstracts (2005 to March 2012). No language or publication restrictions were applied.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared platelet-rich therapy with either placebo, autologous whole blood, dry needling or no platelet-rich therapy for people with acute or chronic musculoskeletal soft tissue injuries. Primary outcomes were functional status, pain and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed each study's risk of bias. Disagreement was resolved by discussion or by arbitration by a third author. We contacted trial authors for clarification of methods or missing data. Treatment effects were assessed using risk ratios for dichotomous data and mean differences (MD) or standardised mean differences (SMD) for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using the fixed-effect model for RR and MD, and the random-effects model for SMD. The quality of the evidence for each outcome was assessed using GRADE criteria.

MAIN RESULTS

We included data from 19 small single centre trials (17 randomised and two quasi-randomised; 1088 participants) that compared platelet-rich therapy with placebo, autologous whole blood, dry needling or no platelet-rich therapy. These trials covered eight clinical conditions: rotator cuff tears (arthroscopic repair) (six trials); shoulder impingement syndrome surgery (one trial); elbow epicondylitis (three trials); anterior cruciate ligament (ACL) reconstruction (four trials), ACL reconstruction (donor graft site application) (two trials), patellar tendinopathy (one trial), Achilles tendinopathy (one trial) and acute Achilles rupture surgical repair (one trial). We also grouped trials into 'tendinopathies' where platelet-rich therapy (PRT) injections were the main treatment (five trials), and surgical augmentation procedures where PRT was applied during surgery (14 trials). Trial participants were mainly male, except in trials including rotator cuff tears, and elbow and Achilles tendinopathies.Three trials were judged as being at low risk of bias; the other 16 were at high or unclear risk of bias relating to selection, detection, attrition or selective reporting, or combinations of these. The methods of preparing platelet-rich plasma (PRP) varied and lacked standardisation and quantification of the PRP applied to the patient.We were able to pool data for our primary outcomes (function, pain, adverse events) for a maximum of 11 trials and 45% of participants. The evidence for all primary outcomes was judged as being of very low quality.Data assessing function in the short term (up to three months) were pooled from five trials that assessed PRT in three clinical conditions and used four different measures. These showed no significant difference between PRT and control (SMD 0.24; 95% confidence interval (CI) -0.07 to 0.56; P value 0.13; I² = 35%; 273 participants; positive values favour PRT). Medium-term function data (at six months) were pooled from six trials that assessed PRT in five clinical conditions and used six different measures. These also showed no difference between groups (SMD 0.06; 95% CI -0.39 to 0.51; P value 0.79; I² = 64%; 262 participants). Long-term function data (at one year) were pooled from 10 trials that assessed PRT in five clinical conditions and used six different measures. These also showed no difference between groups (SMD 0.25, 95% CI -0.07 to 0.57; P value 0.12; I² = 66%; 484 participants). Although the 95% confidence intervals indicate the possibility of a slightly poorer outcome in the PRT group up to a moderate difference in favour of PRT at short- and long-term follow-up, these do not translate into clinically relevant differences.Data pooled from four trials that assessed PRT in three clinical conditions showed a small reduction in short-term pain in favour of PRT on a 10-point scale (MD -0.95, 95% CI -1.41 to -0.48; I² = 0%; 175 participants). The clinical significance of this result is marginal.Four trials reported adverse events; another seven trials reported an absence of adverse events. There was no difference between treatment groups in the numbers of participants with adverse effects (7/241 versus 5/245; RR 1.31, 95% CI 0.48 to 3.59; I² = 0%; 486 participants).In terms of individual conditions, we pooled heterogeneous data for long-term function from six trials of PRT application during rotator cuff tear surgery. This showed no statistically or clinically significant differences between the two groups (324 participants). Pooled data for short-term function for three elbow epicondylitis trials (179 participants) showed a statistically significant difference in favour of PRT, but the clinical significance of this finding is uncertain.The available evidence is insufficient to indicate whether the effects of PRT will differ importantly in individual clinical conditions.

AUTHORS' CONCLUSIONS

Overall, and for the individual clinical conditions, there is currently insufficient evidence to support the use of PRT for treating musculoskeletal soft tissue injuries. Researchers contemplating RCTs should consider the coverage of currently ongoing trials when assessing the need for future RCTs on specific conditions. There is need for standardisation of PRP preparation methods.

Current concepts: tissue engineering and regenerative medicine applications in the ankle joint

Tissue engineering and regenerative medicine (TERM) has caused a revolution in present and future trends of medicine and surgery. In different tissues, advanced TERM approaches bring new therapeutic possibilities in general population as well as in young patients and high-level athletes, improving restoration of biological functions and rehabilitation. The mainstream components required to obtain a functional regeneration of tissues may include biodegradable scaffolds, drugs or growth factors and different cell types (either autologous or heterologous) that can be cultured in bioreactor systems (in vitro) prior to implantation into the patient. Particularly in the ankle, which is subject to many different injuries (e.g. acute, chronic, traumatic and degenerative), there is still no definitive and feasible answer to ‘conventional’ methods. This review aims to provide current concepts of TERM applications to ankle injuries under preclinical and/or clinical research applied to skin, tendon, bone and cartilage problems. A particular attention has been given to biomaterial design and scaffold processing with potential use in osteochondral ankle lesions.