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Abstract
Any new method of treatment is associated with high expectations for its success, particularly if the therapy is based not only on the premise of achieving a symptomatic effect, but also improving functional quality and repairing structurally damaged tissues. Platelet Rich Plasma (PRP) application was shown to be a successful catalyst in the healing process for a wide variety of conditions in animal and human models. However, its use has been controversial due to many types of the PRP definition, optimal concentration, and modalities of implementation. In the qualification of patients for PRP treatment, not only should medical indications be considered, but also the role of participation in therapy with a physiotherapist supervising physical parameters and techniques used during recovery time. Further study is required in order to define optimal handling procedures of PRP injection. Long-term follow up will reveal if the promise of this substance can be realized and implemented to maximize its potential as a therapeutic remedy.
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Abstract
The shoulder is a common source of disability resulting from traumatic and degenerate tears of the rotator cuff, subacromial impingement, and osteoarthritis. Nonoperative management has focused on treatment of the predisposing factors, the use of analgesics and anti-inflammatory medication usually in association with local anesthetic and steroid injections. Surgical intervention allows debridement of the degenerate cuff and partial thickness cuff tears, subacromial bursitis, impinging bone spurs and osteophytes together with rotator cuff repairs. Repairs of degenerate and torn tissue are often prone to failure due to many intrinsic and extrinsic factors. It is assumed that some biological therapies might improve clinical, mechanical, and histologic outcomes. Injections of platelet-rich plasma (PRP) have led to reduced pain and improved recovery in other degenerate pathologies areas together with the restoration of function. This study reviews the current literature on PRP and in particular discusses its relevance in the treatment of rotator cuff tears.
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Griffin XL, Wallace D, Parsons N, Costa ML. Platelet rich therapies for long bone healing in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
Platelet-rich plasma (PRP), a portion of autologous blood containing concentrated platelets above baseline values, has gained recent popularity in the field of orthopaedics. Many orthopaedic surgeons feel that PRP plays an influential role in enhancing the healing process following soft-issue injuries in patients who have failed conservative management or in patients requiring surgical intervention. Platelet-rich plasma is currently being used to treat acute and chronic tendinopathies in the clinical and surgical settings. For clinicians to fully understand the role of PRP, it is imperative that they have a general understanding of the body's healing process. Clinicians should also be aware of the various commercial systems available that may be utilized to produce PRP and the basis behind the performance of these systems. The presence of PRP provides additional treatment options when managing and treating soft-tissue injuries. However, clinicians must realize that little clinical evidence exists supporting the efficacy of PRP and more well-designed, controlled, clinical trials are needed.
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Vieira DFF, Guarniero R, Vaz CES, de Santana PJ. EFFECT OF USE OF BONE-MARROW CENTRIFUGATE ON MUSCLE INJURY TREATMENT: EXPERIMENTAL STUDY ON RABBITS. Rev Bras Ortop 2011; 46:718-25. [PMID: 27047832 PMCID: PMC4799337 DOI: 10.1016/s2255-4971(15)30331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 05/26/2011] [Indexed: 12/02/2022] Open
Abstract
Objective: The objective of this study was to evaluate the effect of bone-marrow centrifugate on the healing of muscle injuries in rabbits. Methods: This experimental study involved use of fifteen adult male New Zealand White rabbits. Each animal received a transverse lesion in the middle of the right tibialis anterior muscle, to which an absorbable collagen sponge, soaked in a centrifugate of bone marrow aspirate from the ipsilateral iliac bone, was added. The left hind limb was used as a control and underwent the same injury, but in this case only the absorbable collagen sponge. Thirty days later, the animals were sacrificed to study the muscle healing. These muscle areas were subjected to histological analysis with histomorphometry, with the aim of measuring the number of muscle cells per square micrometer undergoing regeneration and the proportion of resultant fibrosis. Results: The centrifugation method used in this study resulted in an average concentration of nucleated cells greater than the number of these cells in original aspirates, without causing significant cell destruction. Addition of the bone marrow centrifugate did not result in any significant increase in the number of muscle cells undergoing regeneration, in relation to the control group. There was also no significant difference in the proportion of resultant fibrosis, compared with the control group. Conclusion: Administration of the bone marrow centrifugate used in this study did not favor healing of muscle injuries in rabbits.
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Affiliation(s)
- Daniel Ferreira Fernandes Vieira
- Orthopedics and Traumatology, Master's degree in Medicine and Health Sciences at the Universidade Estadual de Londrina - Londrina, PR, Brazil
| | - Roberto Guarniero
- Associate Professor of the School of Medicine of Universidade de São Paulo - São Paulo, SP, Brazil
| | - Carlos Eduardo Sanches Vaz
- Doctor and Adjunct Professor of the Orthopedics and Traumatology Discipline of Universidade Estadual de Londrina - Londrina, PR, Brazil
| | - Paulo José de Santana
- Doctor and Adjunct Professor of the Orthopedics and Traumatology Discipline of Universidade Estadual de Londrina - Londrina, PR, Brazil
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Vavken P, Sadoghi P, Murray MM. The effect of platelet concentrates on graft maturation and graft-bone interface healing in anterior cruciate ligament reconstruction in human patients: a systematic review of controlled trials. Arthroscopy 2011; 27:1573-83. [PMID: 21862277 PMCID: PMC3206130 DOI: 10.1016/j.arthro.2011.06.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 06/02/2011] [Accepted: 06/02/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the current evidence for the effects of platelet concentrates on (1) graft maturation and (2) graft-bone interface healing in anterior cruciate ligament (ACL) reconstruction in human, controlled trials and for ensuing differences in clinical outcomes. METHODS A systematic search of PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews was performed for controlled trials of human ACL reconstruction with and without platelet concentrates. Data validity was assessed, and data were collected on graft maturation, graft-bone interface healing, and clinical outcome. RESULTS Eight studies met the inclusion criteria. Seven studies reported on graft maturation with significantly better outcomes in the platelet groups in 4, and there were large differences in means in an additional 2 studies. Five studies reported on tunnel healing, and 4 found no difference between groups. Three studies assessed clinical outcome but found no differences, regardless of whether they had shown a beneficial effect (1 of 3) or no effect (2 of 3) of platelets on graft and tunnel healing. CONCLUSIONS The current best evidence suggests that the addition of platelet concentrates to ACL reconstruction may have a beneficial effect on graft maturation and could improve it by 20% to 30% on average, but with substantial variability. The most likely mode of action is that treatment with platelets accelerates graft repopulation and remodeling, and this interpretation is supported by the existing data and is biologically plausible. However, the current evidence also shows only a very limited influence of platelet concentrates on graft-bone interface healing and no significant difference in clinical outcomes. LEVEL OF EVIDENCE Level III, systematic review of Level I, II, and III studies.
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Affiliation(s)
- Patrick Vavken
- Sports Medicine Research Laboratory, Department of Orthopedic Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA, Harvard Center for Population and Development Studies, Harvard School of Public Health, Cambridge, MA, USA
| | - Patrick Sadoghi
- Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria
| | - Martha M Murray
- Sports Medicine Research Laboratory, Department of Orthopedic Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA
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Owens RF, Ginnetti J, Conti SF, Latona C. Clinical and magnetic resonance imaging outcomes following platelet rich plasma injection for chronic midsubstance Achilles tendinopathy. Foot Ankle Int 2011; 32:1032-9. [PMID: 22338951 DOI: 10.3113/fai.2011.1032] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The successful treatment of chronic mid-substance Achilles tendinopathy remains elusive. Approximately 25% to 50% of patients fail conservative treatment modalities. Scientific evidence has supported the use of platelet rich plasma (PRP) in the tendon healing process, however despite initial promise there is a paucity of clinical data to validate a role for PRP in the treatment of tendon disorders including chronic midsubstance Achilles tendinopathy. METHODS As an alternative to operative treatment, our practice offers patients with chronic midsubstance Achilles tendinopathy intratendinous injection of PRP. We retrospectively reviewed all patients treated for Achilles tendinopathy with PRP injection over a 2-year period. Baseline and post injection functional scores including the Foot and Ankle Ability Measure (FAAM), Foot and Ankle Ability Measure - Sports (FAAMS), and the Short Form health survey (SF-8) were examined. Patients also underwent post-injection magnetic resonance imaging (MRI), which were compared to available pre-injection MRI data. RESULTS Ten patients were identified for this study. Pre- and postinjection functional outcome scores were available for eight of ten patients. The average SF-8 score improved from 24.9 to 30.0, the average FAAM score improved from 55.4 to 65.8, and the average FAAMS score improved from 14.8 to 17.4. Complete MRI data was available for six patients. Only one in six Achilles tendons demonstrated qualitative MRI improvement post-injection. CONCLUSION Patients who received PRP injection demonstrated modest improvement in functional outcome measures, however MRI appearance of diseased Achilles tendons remained largely unchanged following PRP injection.
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Affiliation(s)
- Richard F Owens
- Southern Oregon Orthopedics, Orthopaedic Surgery, 2780 E. Barnett Road, Suite 200, Medford, OR 97504, USA.
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Mautner K, Malanga G, Colberg R. Optimization of ingredients, procedures and rehabilitation for platelet-rich plasma injections for chronic tendinopathy. Pain Manag 2011; 1:523-32. [DOI: 10.2217/pmt.11.56] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
SUMMARY There is considerable interest amongst clinicians and researchers to create the optimal platelet product to maximize outcomes with platelet-rich plasma (PRP) injections. PRP has been widely introduced as a safe alternative for treating tendinopathies. However, there is still limited clinical evidence describing the components of the platelet product and supporting its use in clinical trials. This article reviews the current literature regarding the role of PRP injections in the treatment of recalcitrant tendinopathies and the different factors in the platelet product that could affect the outcome, including the platelet count, presence of leukocytes, activators used, pH of solution and delivery method, among others. In addition, we address important concepts regarding rehabilitation after PRP procedures, which has little consensus to date and is the subject of much debate. Based on the phases of soft tissue healing, basic science research on platelets, as well as our clinical experience in treating over 500 patients with PRP, we will suggest guidelines regarding the optimal progression of rehabilitation and timing for return to previous activity following the procedure.
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Affiliation(s)
| | - Gerard Malanga
- Department of Physical Medicine & Rehabilitation, University of Medicine & Dentistry, 30 Bergen Street, Newark, NJ, USA
| | - Ricardo Colberg
- Department of Physical Medicine & Rehabilitation & Department of Orthopedics, Emory University, Atlanta, GA, USA
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Fortier LA, Barker JU, Strauss EJ, McCarrel TM, Cole BJ. The role of growth factors in cartilage repair. Clin Orthop Relat Res 2011; 469:2706-15. [PMID: 21403984 PMCID: PMC3171543 DOI: 10.1007/s11999-011-1857-3] [Citation(s) in RCA: 400] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Full-thickness chondral defects and early osteoarthritis continue to present major challenges for the patient and the orthopaedic surgeon as a result of the limited healing potential of articular cartilage. The use of bioactive growth factors is under consideration as a potential therapy to enhance healing of chondral injuries and modify the arthritic disease process. QUESTIONS/PURPOSES We reviewed the role of growth factors in articular cartilage repair and identified specific growth factors and combinations of growth factors that have the capacity to improve cartilage regeneration. Additionally, we discuss the potential use of platelet-rich plasma, autologous-conditioned serum, and bone marrow concentrate preparations as methods of combined growth factor delivery. METHODS A PubMed search was performed using key words cartilage or chondrocyte alone and in combination with growth factor. The search was open for original manuscripts and review papers and open for all dates. From these searches we selected manuscripts investigating the effects of growth factors on extracellular matrix synthesis and excluded those investigating molecular mechanisms of action. RESULTS By modulating the local microenvironment, the anabolic and anticatabolic effects of a variety of growth factors have demonstrated potential in both in vitro and animal studies of cartilage injury and repair. Members of the transforming growth factor-β superfamily, fibroblast growth factor family, insulin-like growth factor-I, and platelet-derived growth factor have all been investigated as possible treatment augments in the management of chondral injuries and early arthritis. CONCLUSIONS The application of growth factors in the treatment of local cartilage defects as well as osteoarthritis appears promising; however, further research is needed at both the basic science and clinical levels before routine application.
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Affiliation(s)
- Lisa A. Fortier
- Department of Clinical Sciences, VMC C3-181, Cornell University, Ithaca, NY 14853 USA
| | - Joseph U. Barker
- Midwest Orthopedics at Rush, 1611 Harrison, Suite 300, Chicago, IL USA
| | - Eric J. Strauss
- Midwest Orthopedics at Rush, 1611 Harrison, Suite 300, Chicago, IL USA
| | - Taralyn M. McCarrel
- Department of Clinical Sciences, VMC C3-181, Cornell University, Ithaca, NY 14853 USA
| | - Brian J. Cole
- Midwest Orthopedics at Rush, 1611 Harrison, Suite 300, Chicago, IL USA
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Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A. Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: a randomized controlled clinical trial. Am J Sports Med 2011; 39:2130-4. [PMID: 21813443 DOI: 10.1177/0363546511417113] [Citation(s) in RCA: 266] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Chronic lateral elbow epicondylitis is a tendinosis with angiofibrolastic degeneration of the wrist extensors' origin. Healing of this lesion is reported with the use of autologous blood as well as with platelet-rich plasma (PRP). PURPOSE A comparative study of these 2 treatments was conducted in an effort to investigate the possible advantages of PRP. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Twenty-eight patients were divided equally into 2 groups, after blocked randomization. Group A was treated with a single injection of 3 mL of autologous blood and group B with 3 mL of PRP under ultrasound guidance. A standardized program of eccentric muscle strengthening was followed by all patients in both groups. Evaluation using a pain visual analog scale (VAS) and Liverpool elbow score was performed at 6 weeks, 3 months, and 6 months. RESULTS The VAS score improvement was larger in group B at every follow-up interval but the difference was statistically significant only at 6 weeks, when mean improvement was 3.8 points (95% confidence interval [CI], 3.1-4.5) in group B (61.47% improvement) and 2.5 points (95% CI, 1.9-3.1) in group A (41.6% improvement) (P < .05). No statistically significant difference was noted between groups regarding Liverpool elbow score. CONCLUSION Regarding pain reduction, PRP treatment seems to be an effective treatment for chronic lateral elbow epicondylitis and superior to autologous blood in the short term. Defining details of indications, best PRP concentration, number and time of injections, as well as rehabilitation protocol might increase the method's effectiveness. Additionally, the possibility of cost reduction of the method might justify the use of PRP over autologous whole blood for chronic or refractory tennis elbow.
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Abstract
Platelet-rich plasma (PRP) therapy is a recently developed technique that uses a concentrated portion of autologous blood to try to improve and accelerate the healing of various tissues. There is considerable interest in using these PRP products for the treatment of musculoskeletal disorders, particularly athletic injuries. Because PRP products are safe and easy to prepare and administer, there has been increased attention toward using PRP in numerous clinical settings. Platelet-rich plasma has been used to treat conditions such as lateral epicondylitis, ligament and muscle strains, and tears of the rotator cuff, anterior cruciate ligament, and Achilles tendon. Platelet-rich plasma can be applied at the site of injury either during surgery or through an injection performed in the physician's office. The benefits of PRP therapy appear to be promising, and many investigators are exploring the ways in which this therapy can be used in the clinical setting. However, there is little published clinical evidence that proves its efficacy in treating the multitude of injuries/disorders that are thought to benefit from PRP. The purpose of this article is to review the current evidence on PRP therapy.
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Affiliation(s)
- Eric D Bava
- Plano Orthopedic Sports Medicine and Spine Center, Plano, TX, USA.
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213
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Garbis N, Romeo AA, Van Thiel G, Ghodadra N, Provencher MT, Cole BJ, Verma N. Clinical Indications and Techniques for the Use of Platelet-Rich Plasma in the Shoulder. OPER TECHN SPORT MED 2011. [DOI: 10.1053/j.otsm.2011.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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214
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Jia X, Peters PG, Schon L. The Use of Platelet-Rich Plasma in the Management of Foot and Ankle Conditions. OPER TECHN SPORT MED 2011. [DOI: 10.1053/j.otsm.2011.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Evaluation of autologous platelet concentrate for intertransverse lumbar fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20 Suppl 3:361-6. [PMID: 21786039 DOI: 10.1007/s00586-011-1904-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 03/16/2011] [Accepted: 06/29/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The aim of the study was to analyze if the adding of autologous platelet concentrate (APC) to a mixture of local autograft plus tricalcium phosphate and hidroxiapatite (TCP/HA) would improve the fusion rate in posterolateral lumbar fusion. MATERIALS AND METHODS A prospective, controlled, blinded, non-randomized clinical trial was carried out in 107 patients affected by degenerative lumbar pathology. The study group consisted of 67 patients, in which autologous platelet concentration was added to a mixture of autologous local bone graft and TCP/HA. A control group of 40 patients with same pathology and surgical technique but without APC addition was used to compare the fusion mass obtained. By means of plain X-rays, a blinded evaluation of the intertransverse fusion mass quality at twelve and twenty-four months was made according to type A (bilateral uniform mass), type B (unilateral uniform mass) and type C (irregular or lack bilateral mass). Patients with type C were regarded as pseudoarthrosis. RESULTS In the study group 17 patients had lack or irregular fusion mass (25.4%) versus three patients in the control group (7.5%), which was statistically significant. CONCLUSIONS This study shows that the adding of autologous platelet concentration to a mixture of autologous bone graft plus TCP/HA has decreased our rates of posterolateral lumbar fusion.
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Resultados funcionales tras la reparación artroscópica de roturas masivas del manguito rotador: influencia de la aplicación de plasma rico en plaquetas asociado a fibrina. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recot.2011.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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217
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Autologous fat grafting as a mesenchymal stem cell source and living bioscaffold in a patellar tendon tear. Clin J Sport Med 2011; 21:359-61. [PMID: 21562415 DOI: 10.1097/jsm.0b013e31821d0864] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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218
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Multi-composite bioactive osteogenic sponges featuring mesenchymal stem cells, platelet-rich plasma, nanoporous silicon enclosures, and Peptide amphiphiles for rapid bone regeneration. J Funct Biomater 2011; 2:39-66. [PMID: 24956163 PMCID: PMC4030897 DOI: 10.3390/jfb2020039] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 05/25/2011] [Accepted: 06/17/2011] [Indexed: 12/20/2022] Open
Abstract
A novel bioactive sponge was created with a composite of type I collagen sponges or porous poly(ε-caprolactone) (PCL) scaffolds, platelet-rich plasma (PRP), BMP2-loaded nanoporous silicon enclosure (NSE) microparticles, mineralizing peptide amphiphiles (PA), and mesenchymal stem cells (MSC). Primary MSC from cortical bone (CB) tissue proved to form more and larger colony units, as well as produce more mineral matrix under osteogenic differentiation, than MSC from bone marrow (BM). Coating pre-treatments were optimized for maximum cell adhesion and mineralization, while a PRP-based gel carrier was created to efficiently deliver and retain MSC and microparticles within a porous scaffold while simultaneously promoting cell recruitment, proliferation, and angiogenesis. Components and composite sponges were evaluated for osteogenic differentiation in vitro. Osteogenic sponges were loaded with MSC, PRP, PA, and NSE and implanted subcutaneously in rats to evaluate the formation of bone tissue and angiogenesis in vivo. It was found that the combination of a collagen sponge with CB MSC, PRP, PA, and the BMP2-releasing NSE formed the most bone and was most vascularized by four weeks compared to analogous composites featuring BM MSC or PCL or lacking PRP, PA, and NSE. This study indicates that CB MSC should be considered as an alternative to marrow as a source of stem cells, while the PRP-PA cell and microparticle delivery system may be utilized for diverse tissue engineering applications.
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219
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Platelet rich plasma in arthroscopic rotator cuff repair: a prospective RCT study, 2-year follow-up. J Shoulder Elbow Surg 2011; 20:518-28. [PMID: 21570659 DOI: 10.1016/j.jse.2011.02.008] [Citation(s) in RCA: 327] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 02/15/2011] [Indexed: 02/06/2023]
Abstract
HYPOTHESIS Local application of autologous platelet rich plasma (PRP) improves tendon healing in patients undergoing arthroscopic rotator cuff repair. STUDY DESIGN Prospective, randomized, controlled, double blind study; considering an alpha level of 5%, a power of 80%, 22 patients for group are needed. MATERIALS AND METHODS Fifty-three patients who underwent shoulder arthroscopy for the repair of a complete rotator cuff tear were randomly divided into 2 groups, using a block randomization procedure. A treatment group (N = 26) consisted of those who received an intraoperative application of PRP in combination with an autologous thrombin component. A control group (N = 27) consisted of those who did not receive that treatment. Patients were evaluated with validated outcome scores. A magnetic resonance image (MRI) was performed in all cases at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol. RESULTS The 2 groups were homogeneous. The pain score in the treatment group was lower than the control group at 3, 7, 14, and 30 days after surgery (P < .05). On the Simple Shoulder Test (SST), University of California (UCLA), and Constant scores, strength in external rotation, as measured by a dynamometer, were significantly higher in the treatment group than the control group at 3 months after surgery (strength in external rotation [SER]: 3 ± 1.6 vs 2.1 ± 1.3 kg; SST: 8.9 ± 2.2 vs 7.1 ± 2.7; UCLA: 26.9 ± 3 vs 24.2 ± 4.9; Constant: 65 ± 9 vs 57.8 ± 11; P < .05). There was no difference between the 2 groups after 6, 12, and 24 months. The follow-up MRI showed no significant difference in the healing rate of the rotator cuff tear. In the subgroup of grade 1 and 2 tears, with less retraction, SER in the PRP group was significant higher at 3, 6, 12, and 24 months postoperative (P < .05). CONCLUSION The results of our study showed autologous PRP reduced pain in the first postoperative months. The long-term results of subgroups of grade 1 and 2 tears suggest that PRP positively affected cuff rotator healing.
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Jakubova R, Mickova A, Buzgo M, Rampichova M, Prosecka E, Tvrdik D, Amler E. Immobilization of thrombocytes on PCL nanofibres enhances chondrocyte proliferation in vitro. Cell Prolif 2011; 44:183-91. [PMID: 21401760 DOI: 10.1111/j.1365-2184.2011.00737.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The aim of this study was to develop functionalized nanofibres as a simple delivery system for growth factors (GFs) and make nanofibre cell-seeded scaffold implants a one-step intervention. MATERIALS AND METHODS We have functionalized polycaprolactone (PCL) nanofibres with thrombocytes adherent on them. Immobilized, these thrombocytes attached to nanofibre scaffolds were used as a nanoscale delivery system for native (autologous) proliferation and differentiation factors, in vitro. Pig chondrocytes were seeded on the thrombocyte-coated scaffolds and levels of proliferation and differentiation of these cells were compared with those seeded on non-coated scaffolds. RESULTS Immobilized thrombocytes on PCL nanofibres effectively enhanced chondrocyte proliferation due to time-dependent degradation of thrombocytes and release of their GFs. CONCLUSIONS These simply functionalized scaffolds present new possibilities for nanofibre applications, as smart cell scaffolds equipped with a GF delivery tool.
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Affiliation(s)
- R Jakubova
- Institute of Biophysics, 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
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221
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Platelet-rich plasma intra-articular knee injections for the treatment of degenerative cartilage lesions and osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2011; 19:863-4; author reply 865-6. [PMID: 21161706 DOI: 10.1007/s00167-010-1339-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 11/11/2010] [Indexed: 10/18/2022]
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222
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Gastrocnemius injury complicated by an arteriovenous malformation in a professional American football player. Clin J Sport Med 2011; 21:266-8. [PMID: 21427568 DOI: 10.1097/jsm.0b013e31820b9129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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223
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DeChellis DM, Cortazzo MH. Regenerative medicine in the field of pain medicine: Prolotherapy, platelet-rich plasma therapy, and stem cell therapy—Theory and evidence. ACTA ACUST UNITED AC 2011. [DOI: 10.1053/j.trap.2011.05.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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224
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Harrison S, Vavken P, Kevy S, Jacobson M, Zurakowski D, Murray MM. Platelet activation by collagen provides sustained release of anabolic cytokines. Am J Sports Med 2011; 39:729-34. [PMID: 21398575 PMCID: PMC3176726 DOI: 10.1177/0363546511401576] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) has been increasingly used in sports medicine applications. Platelets are thought to release growth factors important in wound healing, including transforming growth factor (TGF-β1), platelet-derived growth factor (PDGF-AB), and vascular endothelial growth factor (VEGF). However, little is known about the effect of platelet activator choice on growth factor release kinetics. HYPOTHESIS The choice of platelet activator would affect the timing and level of growth factor release from PRP. STUDY DESIGN Controlled laboratory study. METHODS Platelet-rich plasma aliquots were activated with either thrombin or collagen. A control group of whole blood aliquots was clotted with thrombin. Supernatant containing the released growth factors was collected daily for 1 week. Levels of TGF-β1, PDGF-AB, and VEGF were measured using enzyme-linked immunosorbent assay (ELISA). RESULTS The use of thrombin as an activator resulted in immediate release of TGF-β1 and PDGF-AB, while the collagen-activated PRP clots released similar amounts each day for 5 days. The use of collagen as an activator resulted in an 80% greater cumulative release of TGF-β1 from the PRP aliquots over 7 days (P < .001). Concentrating platelets to 3 times the systemic blood level resulted in a 3-fold higher release of TGF-β1, 2.5-fold greater release of PDGF, and 5-fold greater release of VEGF (all P < .0001) when compared with whole blood control clots, but no significant differences in the timing of release were noted. CONCLUSION These experiments demonstrated that the choice of platelet activator can significantly influence the release kinetics of cytokines from PRP, with thrombin resulting in an immediate release and collagen having a more sustained release pattern. CLINICAL RELEVANCE The level and rate of growth factor release depends on the selected platelet activator, a factor that should be considered when selecting a PRP system for a given application.
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Affiliation(s)
| | | | | | | | | | - Martha M. Murray
- Address correspondence to Martha M. Murray, MD, Children’s Hospital of Boston, Department of Orthopaedic Surgery, 300 Longwood Avenue, Boston, MA 02115 ()
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225
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Nguyen RT, Borg-Stein J, McInnis K. Applications of Platelet-Rich Plasma in Musculoskeletal and Sports Medicine: An Evidence-Based Approach. PM R 2011; 3:226-50. [DOI: 10.1016/j.pmrj.2010.11.007] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Revised: 10/17/2010] [Accepted: 11/09/2010] [Indexed: 01/15/2023]
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226
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Gehrig SM, Lynch GS. Emerging drugs for treating skeletal muscle injury and promoting muscle repair. Expert Opin Emerg Drugs 2011; 16:163-82. [DOI: 10.1517/14728214.2010.524743] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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227
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Castillo TN, Pouliot MA, Kim HJ, Dragoo JL. Comparison of growth factor and platelet concentration from commercial platelet-rich plasma separation systems. Am J Sports Med 2011; 39:266-71. [PMID: 21051428 DOI: 10.1177/0363546510387517] [Citation(s) in RCA: 309] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Clinical studies claim that platelet-rich plasma (PRP) shortens recovery times because of its high concentration of growth factors that may enhance the tissue repair process. Most of these studies obtained PRP using different separation systems, and few analyzed the content of the PRP used as treatment. PURPOSE This study characterized the composition of single-donor PRP produced by 3 commercially available PRP separation systems. STUDY DESIGN Controlled laboratory study. METHODS Five healthy humans donated 100 mL of blood, which was processed to produce PRP using 3 PRP concentration systems (MTF Cascade, Arteriocyte Magellan, Biomet GPS III). Platelet, white blood cell (WBC), red blood cell, and fibrinogen concentrations were analyzed by automated systems in a clinical laboratory, whereas ELISA determined the concentrations of platelet-derived growth factor αβ and ββ (PDGF-αβ, PDGF-ββ), transforming growth factor β1 (TGF-β1), and vascular endothelial growth factor (VEGF). RESULTS There was no significant difference in mean PRP platelet, red blood cell, active TGF-β1, or fibrinogen concentrations among PRP separation systems. There was a significant difference in platelet capture efficiency. The highest platelet capture efficiency was obtained with Cascade, which was comparable with Magellan but significantly higher than GPS III. There was a significant difference among all systems in the concentrations of WBC, PDGF-αβ, PDGF-ββ, and VEGF. The Cascade system concentrated leukocyte-poor PRP, compared with leukocyte-rich PRP from the GPS III and Magellan systems. CONCLUSION The GPS III and Magellan concentrate leukocyte-rich PRP, which results in increased concentrations of WBCs, PDGF-αβ, PDGF-ββ, and VEGF as compared with the leukocyte-poor PRP from Cascade. Overall, there was no significant difference among systems in the platelet concentration, red blood cell, active TGF-β1, or fibrinogen levels. CLINICAL RELEVANCE Products from commercially available PRP separation systems produce differing concentrations of growth factors and WBCs. Further research is necessary to determine the clinical relevance of these findings.
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Affiliation(s)
- Tiffany N Castillo
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA 94063, USA
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228
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Andia I, Sánchez M, Maffulli N. Platelet rich plasma therapies for sports muscle injuries: any evidence behind clinical practice? Expert Opin Biol Ther 2011; 11:509-18. [DOI: 10.1517/14712598.2011.554813] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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229
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Castricini R, Longo UG, De Benedetto M, Panfoli N, Pirani P, Zini R, Maffulli N, Denaro V. Platelet-rich plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial. Am J Sports Med 2011; 39:258-65. [PMID: 21160018 DOI: 10.1177/0363546510390780] [Citation(s) in RCA: 318] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND After reinsertion on the humerus, the rotator cuff has limited ability to heal. Growth factor augmentation has been proposed to enhance healing in such procedure. PURPOSE This study was conducted to assess the efficacy and safety of growth factor augmentation during rotator cuff repair. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Eighty-eight patients with a rotator cuff tear were randomly assigned by a computer-generated sequence to receive arthroscopic rotator cuff repair without (n = 45) or with (n = 43) augmentation with autologous platelet-rich fibrin matrix (PRFM). The primary end point was the postoperative difference in the Constant score between the 2 groups. The secondary end point was the integrity of the repaired rotator cuff, as evaluated by magnetic resonance imaging. Analysis was on an intention-to-treat basis. RESULTS All the patients completed follow-up at 16 months. There was no statistically significant difference in total Constant score when comparing the results of arthroscopic repair of the 2 groups (95% confidence interval, -3.43 to 3.9) (P = .44). There was no statistically significant difference in magnetic resonance imaging tendon score when comparing arthroscopic repair with or without PRFM (P = .07). CONCLUSION Our study does not support the use of autologous PRFM for augmentation of a double-row repair of a small or medium rotator cuff tear to improve the healing of the rotator cuff. Our results are applicable to small and medium rotator cuff tears; it is possible that PRFM may be beneficial for large and massive rotator cuff tears. Also, given the heterogeneity of PRFM preparation products available on the market, it is possible that other preparations may be more effective.
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Affiliation(s)
- Roberto Castricini
- Department of Orthopaedic and Trauma Surgery, Ospedale Civile, Jesi, Italy
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230
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Redler LH, Thompson SA, Hsu SH, Ahmad CS, Levine WN. Platelet-rich plasma therapy: a systematic literature review and evidence for clinical use. PHYSICIAN SPORTSMED 2011; 39:42-51. [PMID: 21378486 DOI: 10.3810/psm.2011.02.1861] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Platelet-rich plasma (PRP) is an autologous blood-derived product with an increased concentration of platelets in plasma, which are used to deliver supraphysiological levels of growth factors. Platelet-rich plasma has been used in many fields, including oral, maxillofacial, and plastic surgery. Its use in sports medicine has been increasing after recent evidence and media publicity suggest that it may augment the treatment of muscle strains, as well as tendon and ligament healing. Basic science and animal studies show promising results, but high-level clinical trials have yet to prove its efficacy. With increasing media coverage on the use of PRP in athletes, it is paramount that orthopedic surgeons and sports medicine physicians understand the various methods of preparation and administration, potential clinical applications, and available clinical results to best counsel patients on its advantages and disadvantages.
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Affiliation(s)
- Lauren H Redler
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
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231
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Maffulli N, Longo UG, Loppini M, Denaro V. Current treatment options for tendinopathy. Expert Opin Pharmacother 2011; 11:2177-86. [PMID: 20569088 DOI: 10.1517/14656566.2010.495715] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management. AREAS COVERED IN THIS REVIEW We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy. WHAT THE READER WILL GAIN The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined. TAKE-HOME MESSAGE Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.
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Affiliation(s)
- Nicola Maffulli
- Queen Mary University of London, Mile End Hospital, Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, 275 Bancroft Road, London E1 4 DG, UK.
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Sánchez Márquez J, Martínez Díez J, Barco R, Antuña S. Functional results after arthroscopic repair of massive rotator cuff tears; influence of the application platelet-rich plasma combined with fibrin. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/s1988-8856(11)70320-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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233
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Kampa RJ, Connell DA. Treatment of tendinopathy: is there a role for autologous whole blood and platelet rich plasma injection? Int J Clin Pract 2010; 64:1813-23. [PMID: 21070532 DOI: 10.1111/j.1742-1241.2010.02432.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Chronic tendinopathies are a common source of disability and can be recalcitrant to conservative measures, which once exhausted may necessitate operative intervention. Blood and platelets, in particular, are a rich source of factors necessary for tissue healing. Autologous blood injections (ABI) are thought to promote tendon healing, but have been explored clinically in only a few limited studies. However, recently they have attracted media attention in relation to the world of professional athletes and sports-related injuries. METHOD We review the evidence base for this technique using the available literature on PubMed. CONCLUSION Refractory chronic tendinopathy may be responsive to ABIs, but the data available to date are limited by quality and size of study, as well as length of follow up, and are currently insufficient to recommend this modality for routine clinical use.
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Affiliation(s)
- R J Kampa
- Department of Orthopaedics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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234
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Nikolopoulos DD, Spiliopoulou C, Theocharis SE. Doping and musculoskeletal system: short-term and long-lasting effects of doping agents. Fundam Clin Pharmacol 2010; 25:535-63. [PMID: 21039821 DOI: 10.1111/j.1472-8206.2010.00881.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Doping is a problem that has plagued the world of competition and sports for ages. Even before the dawn of Olympic history in ancient Greece, competitors have looked for artificial means to improve athletic performance. Since ancient times, athletes have attempted to gain an unfair competitive advantage through the use of doping substances. A Prohibited List of doping substances and methods banned in sports is published yearly by the World Anti-Doping Agency. Among the substances included are steroidal and peptide hormones and their modulators, stimulants, glucocorticosteroids, β₂-agonists, diuretics and masking agents, narcotics, and cannabinoids. Blood doping, tampering, infusions, and gene doping are examples of prohibited methods indicated on the List. Apart from the unethical aspect of doping, as it abrogates fair-play's principle, it is extremely important to consider the hazards it presents to the health and well-being of athletes. The referred negative effects for the athlete's health have to do, on the one hand, by the high doses of the performance-enhancing agents and on the other hand, by the relentless, superhuman strict training that the elite or amateur athletes put their muscles, bones, and joints. The purpose of this article is to highlight the early and the long-lasting consequences of the doping abuse on bone and muscle metabolism.
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Affiliation(s)
- Dimitrios D Nikolopoulos
- Department of Forensic Medicine and Toxicology University of Athens, Medical School, Athens, Greece
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235
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Exuberant synovitis after subacromial decompression and platelet rich growth factor (PRGF) injection. J Shoulder Elbow Surg 2010; 19:e6-9. [PMID: 20452249 DOI: 10.1016/j.jse.2010.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 01/15/2010] [Accepted: 01/17/2010] [Indexed: 02/01/2023]
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236
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Weber SC, Kauffman JI. But he isn't wearing anything at all! "The Emperor's New Clothes" (Kejserens Nye Klaeder by Hans Christian Andersen). Arthroscopy 2010; 26:723-4; author reply 724-5. [PMID: 20511023 DOI: 10.1016/j.arthro.2010.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 04/08/2010] [Indexed: 02/02/2023]
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237
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Sánchez M, Anitua E, Andia I. Poor standardization in platelet-rich therapies hampers advancement. Arthroscopy 2010; 26:725-6; author reply 726. [PMID: 20511025 DOI: 10.1016/j.arthro.2010.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Accepted: 03/01/2010] [Indexed: 02/02/2023]
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238
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Maffulli N, Longo UG, Loppini M, Spiezia F, Denaro V. New options in the management of tendinopathy. Open Access J Sports Med 2010; 1:29-37. [PMID: 24198540 PMCID: PMC3781852 DOI: 10.2147/oajsm.s7751] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Tendon injuries can be acute or chronic, and caused by intrinsic or extrinsic factors, either alone or in combination. Tendinopathies are a common cause of disability in occupational medicine and account for a substantial proportion of overuse injuries in sports. Tendinopathy is essentially a failed healing response, with haphazard proliferation of tenocytes, abnormalities in tenocytes, with disruption of collagen fibres and subsequent increase in noncollagenous matrix. The scientific evidence base for managing tendinopathies is limited. What may appear clinically as an "acute tendinopathy" is actually a well advanced failure of a chronic healing response in which there is neither histologic nor biochemical evidence of inflammation. In this review we report the new options for the management of tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, injections (intratendinous injections of corticosteroids, aprotinin, polidocanol platelet-rich plasma, autologous blood injection, high-volume injections) and surgery. Open surgery aims to excise fibrotic adhesions, remove areas of failed healing and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New surgical techniques aim to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. These procedures are intrinsically different from the classical ones in present use, because they do not attempt to address directly the pathologic lesion, but act only to denervate them. They include endoscopy, electrocoagulation, and minimally invasive stripping. Further randomized controlled trials are necessary to clarify better the best therapeutic options for the management of tendinopathy.
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Mile end Hospital, London, England
| | - Umile Giuseppe Longo
- Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
| | - Mattia Loppini
- Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
| | - Filippo Spiezia
- Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
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239
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Editorial. Orthopaedic advances. J Am Acad Orthop Surg 2009; 17:601. [PMID: 19794216 DOI: 10.5435/00124635-200910000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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