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

Retrospective Evaluation of Ultrasound Guided Percutaneous Plantar Fasciotomy With and Without Platelet Rich Plasma

Plantar fasciitis is one of the most common foot conditions presenting to a foot and ankle specialist. Surgical treatment outcomes following plantar fasciotomy vary but short-term studies have reported excellent early pain relief and significant improvements in symptoms. This study evaluates patient reported pain scores collected pre- and post-op for patients who underwent percutaneous ultrasonic microtenotomy (PUT) plantar fasciotomy with PRP injection vs without the use of PRP. We compared pain visual analog scale (VAS) scores, for patients treated surgically by Orthopedic Surgery department of foot and ankle faculty members between December 2007 and December 2022. A total of 30 patients were identified that met inclusion and exclusion criteria. Our results showed that there was a significant decrease in pain VAS scores from pre-op visit (at least 1 month prior to operation) to post-op visit (at least 1 month following operation) for both groups, with a paired t test (p value <.0001). However, patients who received PRP had a statistically significant decrease in pain level compared to the group who did not receive PRP. Statistical analysis completed with a 2-sample t test (p-value <.0325). Our results found the mean time between the initial pre-op visit and last post-op follow-up visit was 19 months. The mean for time following surgical intervention was 10 months. The findings of our study suggest that the dual use of PUT and PRP to treat plantar fasciitis, could potentially lead to an improvement in pain reduction and longevity of pain relief.

Current concept review of Achilles tendinopathy

Achilles tendinopathy is a common overuse injury affecting the ankle and foot. It manifests as a clinical condition that includes pain, edema, and decreased functionality. This condition can be broadly categorized into two main types based on anatomical location: insertional and noninsertional tendinopathy. The development of Achilles tendinopathy involves various factors, both internal and external. Patients with Achilles tendinopathy often experience stiffness worsened by prolonged rest, and pain exacerbated by physical activity. These symptoms can limit work activity and sports participation, with many patients facing discomfort while wearing shoes due to heel sensitivity. Diagnosis is primarily clinical, although MRI and ultrasound imaging can aid in differential diagnosis. Identifying risk factors and understanding the patient's biomechanics assist in accurate diagnosis and subsequent management. Management of Achilles tendinopathy involves a range of conservative and surgical options. However, due to varying results in clinical studies, a definitive gold standard treatment has not emerged. Eccentric exercises are a valuable tool in managing the condition. The recommend treatments such as shock wave therapy or nitric oxide patches are sought if symptoms do not improve. Peritendinous injections could be options if physical therapy proves ineffective. Surgical intervention is required after six months of conservative treatment. Recent research on Achilles tendinopathy emphasizes the need for individualized treatment plans that address its multifaceted nature. Combining biomechanical analysis, advanced imaging, and patient-specific factors is key to achieving optimal outcomes. Additionally, preventive strategies focusing on proper training techniques, load management, and addressing modifiable risk factors play a critical role in reducing the incidence of this condition. In conclusion, this article provides a current overview of Achilles tendinopathy. It highlights the importance of a comprehensive approach to understanding its causes, pathophysiology, diagnosis, and management strategies.

The Best Current Research on Patellar Tendinopathy: A Review of Published Meta-Analyses

Patellar tendinopathy is a frequent overuse injury in sports that can cause significant pain and disability. It requires evidence-based guidelines on effective prevention and management. However, optimal treatments remain uncertain. We aimed to analyze available meta-analyses to summarize treatment recommendations, compare therapeutic modalities, examine included trials, and offer methodological suggestions to improve future systematic reviews. Meta-analyses were systematically searched for in PubMed (PROSPERO: CRD42023457963). A total of 21 meta-analyses were included. The AMSTAR-2 scale assessed study quality, which was low, with only 23.8% of the meta-analyses being of moderate quality, and none were considered to be of high quality. Heterogeneous outcomes are reported. Multiple platelet-rich plasma (PRP) injections appear superior to eccentric exercises and provide lasting improvements compared to eccentric exercises when conservative treatments fail. Extracorporeal shockwave therapy (ESWT) also seems superior to non-operative options and similar to surgery for patellar tendinopathy in the long term. However, evidence for eccentric exercise efficacy remains unclear due to inconclusive findings. Preliminary findings also emerged for genetic risk factors and diagnostic methods but require further confirmation. This review reveals a lack of high-quality evidence on optimal patellar tendinopathy treatments. While PRP and ESWT show promise, limitations persist. Further rigorous meta-analyses and trials are needed to strengthen the evidence base and guide clinical practice. Methodological enhancements are proposed to improve future meta-analyses.

Platelet-Rich Plasma - a remedy present in every human being. History, functioning, and the benefits of therapy using it

Platelet-rich plasma is an autologous product used in restorative medicine. It contains a high concentration of platelets, which are rich in growth factors and other biologically active substances known for their ability to stimulate regenerative processes in the body. Currently, research is being conducted into the use of platelet-rich plasma in many areas of medicine. This publication provides information on the nature, mechanism of action, therapeutic properties and application of autologous platelet-rich plasma in medicine. Furthermore, ongoing investigations explore its potential in wound healing, orthopedics, dermatology, and even in dentistry, showcasing its versatility and promising outcomes across various medical disciplines. Additionally, the safety and efficacy of platelet-rich plasma therapies are subjects of continual scrutiny, aiming to refine protocols and expand its clinical utility with robust scientific evidence. The growing interest in this regenerative approach underscores its potential as a valuable tool in modern medical practice. Platelet-rich plasma therapy represents a promising avenue for personalized medicine, offering tailored treatment approaches that capitalize on the body's own healing mechanisms to promote tissue repair and regeneration.

Autologous Platelet-Rich Plasma Administration on the Intervertebral Disc in Low Back Pain Patients with Modic Type 1 Change: Report of Two Cases

Background and Objectives: Modic type 1 is known to be associated with lower back pain (LBP), but at present, a treatment has not been fully established. Meanwhile, platelet-rich plasma (PRP) has been used for tissue regeneration and repair in the clinical setting. There is no clinical PRP injection trial for the intervertebral disc of LBP patients with Modic type 1. Thus, this study aimed to verify PRP injection safety and efficacy in LBP patients with Modic type 1. As a preliminary experiment, two LBP cases with Modic type 1 are presented. Materials and Methods: PRP was administered intradiscally to two LBP patients with Modic type 1. PRP was obtained from the patients' anticoagulated blood. Primary endpoints were physical condition, laboratory data, and X-ray for safety evaluation. Secondary endpoints were pain scores using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and the Roland-Morris Disability Questionnaire (RDQ) to evaluate PRP efficacy. The observation period was 24 weeks after the PRP injection. In addition, changes in Modic type 1 using MRI were evaluated. Results: This study assessed two LBP patients with Modic type 1. There were no adverse events in physical condition, laboratory data, or lumbar X-rays after injection. Follow-up MRI showed a decrease of high signal intensity on T2WI compared to before PRP administration. The pain scores tended to improve after the injection. Conclusions: PRP injection into the intervertebral disc of LBP patients with Modic type 1 might be safe and effective. This analysis will be continued as a prospective study to establish the efficacy.

Ilizaliturri Jr. V, Kohlrieser D, Laskovski J, Lifshitz L, P. McGovern R, Monnington K, O’Donnell J, Takla A, Tyler T, Voight M, Wuerz T, Martin RL. The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

The Mechanism of Action between Pulsed Radiofrequency and Orthobiologics: Is There a Synergistic Effect?

Radiofrequency energy is a common treatment modality for chronic pain. While there are different forms of radiofrequency-based therapeutics, the common concept is the generation of an electromagnetic field in the applied area, that can result in neuromodulation (pulsed radiofrequency—PRF) or ablation. Our specific focus relates to PRF due to the possibility of modulation that is in accordance with the mechanisms of action of orthobiologics. The proposed mechanism of action of PRF pertaining to pain relief relies on a decrease in pro-inflammatory cytokines, an increase in cytosolic calcium concentration, a general effect on the immune system, and a reduction in the formation of free radical molecules. The primary known properties of orthobiologics constitute the release of growth factors, a stimulus for endogenous repair, analgesia, and improvement of the function of the injured area. In this review, we described the mechanism of action of both treatments and pertinent scientific references to the use of the combination of PRF and orthobiologics. Our hypothesis is a synergic effect with the combination of both techniques which could benefit patients and improve the life quality.

Farrerol alleviates collagenase-induced tendinopathy by inhibiting ferroptosis in rats

Tendinopathy is mainly characterized by local pain, functional limitation and decreased athletic ability, which seriously affects the quality of life of patients and the career of athletes. Farrerol (FA), one of the main active compounds extracted from Rhododendron and plants in the Rhododendron family, has a wide range of pharmacological activities, such as immunomodulatory, anti-inflammatory and antiviral effects. However, the effect of FA on tendinopathy is unclear. Here, we investigated the pharmacological effect and mechanism of FA in tendon injury through collagenase-induced tendinopathy in vivo and RSL3-induced tenocytes injury in vitro. The results showed that FA alleviated the infiltration of inflammatory cells, promoted tenogenesis and improved mechanical properties of the Achilles tendon in rats. In addition, ferroptosis inducer RSL3 inhibits the tenogenesis in vitro and in vivo, which accelerates the progression of tendinopathy. Moreover, FA effectively inhibited iron accumulation and alleviated ferroptosis in the Achilles tendon. Using in vitro experiments, we found that FA antagonized ferroptosis by reducing lipid peroxidation and iron accumulation in tenocytes. Finally, we found that glutathione peroxidase 4 silencing could block the protective effect of FA on ferroptosis of tenocytes. Therefore, the results of this study suggest that FA can relieve collagenase-induced tendinopathy by inhibiting ferroptosis, and reveal that FA may be a potentially effective drug for the treatment of tendinopathy in the future.

Platelet-rich plasma injection in the treatment of patellar tendinopathy: a systematic review and meta-analysis

PURPOSE

The objective of the study was to assess the efficacy of autologous platelet-rich plasma (PRP) injections in the treatment of patellar tendinopathy.

METHODS

The PubMed, MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases were searched for clinical trials which compared PRP injection with other 'active treatment' interventions ('Non-PRP' injection and 'No-injection' treatments) or 'No-active treatment' interventions. Randomized and non-randomized clinical trials that had been published up to 15 November 2021, were included in the meta-analysis. The primary outcome, pain relief, was measured on a 'visual analog scale.' Secondary outcomes were knee functional activities and quality of life (QoL). The PRISMA guidelines were followed throughout the study.

RESULTS

Eight comparative studies were identified for inclusion in the meta-analysis. Assessment of these studies revealed that there were no significant differences in pain relief, functional outcomes, and QoL in the short, medium, and long term between PRP injection and Non-PRP injection interventions. Similarly, comparison of PRP injection to the No-active treatment intervention showed no differences in short- and medium-term pain relief. However, when PRP injection was compared to the No-injection treatment intervention extracorporeal shock wave therapy (ECWT), the former was found to be more effective in terms of pain relief in the medium term (mean difference [MD] - 1.50; 95% confidence interval [CI] - 2.72 to - 0.28) and long term (MD - 1.70; 95% CI, - 2.90 to - 0.50) and functional outcomes in the medium term (MD 13.0; 95% CI 3.01-22.99) and long term (MD 13.70; 95% CI 4.62-22.78).

CONCLUSIONS

In terms of pain relief and functional outcomes, the PRP injection did not provide significantly greater clinical benefit than Non-PRP injections in the treatment of patellar tendinopathy. However, in comparison with ESWT, there was a significant benefit in favor of PRP injection.

Conservative Treatment of the Fifth Metatarsal Bone Fractures in Professional Football Players Using Platelet-Rich Plasma

Injuries of the metatarsal bones in football are relatively rare and in most cases are localized in the fifth metatarsal. The gold standard of the diagnosis of fractures in this area can be X-rays, which in most cases allows verifying the diagnosis. The treatment tactics depend on the localization of the fracture according to Lawrence and Botte's classification: 3 zones of localization are distinguished. Fractures located in zones 2 and 3 belong to a high-risk group due to delayed consolidation and nonunion and therefore athletes are most often treated with osteosynthesis using intramedullary screws. The minimal recovery time for this type of treatment is at least 8 weeks. This report describes 7 cases of the fifth metatarsal bone fractures, located in zones 2 and 3 in professional football players who were treated with an immobilization boot, cryotherapy, nutritional supplements of calcium and vitamin D, and local injections of platelet-rich plasma, which contains numerous growth factors. The deadline for returning to regular training activities was 43 to 50 days, and there was no relapse of damage within 6 months of follow-up.Levels of Evidence: Level of evidence 4: case report study.

Radiofrequency Microtenotomy or Physical Therapy for Achilles Tendinopathy: Results of a Randomized Clinical Trial

Background:

Achilles tendinopathy is a painful disorder, and various treatment options are available. Bipolar radiofrequency microtenotomy (RFM) has shown promising results in treating tendinosis.

Purpose/Hypothesis:

The purpose was to compare the results between treatment with bipolar RFM and physical therapy (PT) for patients with midportion Achilles tendinopathy. It was hypothesized that RFM would be equivalent or superior to PT.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 38 patients with midportion Achilles tendinopathy were evaluated for 2 years. The patients were randomized to receive either RFM or PT. There were 20 patients in the RFM group and 18 patients in the PT group. Clinical outcomes were assessed using the visual analog scale (VAS) for pain and the Foot and Ankle Outcome Score (FAOS). The degree of tendinosis was evaluated with magnetic resonance imaging (MRI) of the affected ankle performed before intervention and 2 years after intervention.

Results:

In both groups, the VAS scores at the 2-year follow-up were significantly improved compared with preintervention: from 7.2 ± 1.5 to 1.0 ± 1.4 for the RFM group and from 5.9 ± 1.3 to 3.1 ± 1.8 for the PT group (P < .01 for both). Compared with the PT group, the RFM group had significantly better VAS scores at both the 1- and 2-year follow-ups (P < .01 for both) and better scores on 4 of the 5 FAOS subscales at the 2-year follow-up (P < .01 for all). MRI revealed an improvement in the tendinosis score in both groups, without any significant difference between the groups.

Conclusion:

In this randomized study, the clinical assessments revealed significant improvements in the VAS, FAOS, and tendinosis score as seen on MRI 2 years after intervention with either RFM or PT in patients with midportion Achilles tendinopathy. The improvement was significantly better in the RFM group with regard to VAS and FAOS, but not in the MRI appearance.

Registration:

NCT03274557 (ClinicalTrials.gov identifier).

Intra-individual Right-Left Comparative Study of Combined Therapy of Intramatricial Triamcinolone and Platelet-Rich Plasma vs. Intramatricial Triamcinolone Only in Lichen Planus-Associated Nail Dystrophy

Background

While intramatricial triamcinolone is the most commonly used treatment option for onychodystrophy due to lichen planus, the role of platelet-rich plasma (PRP) in the treatment of onychodystrophy is not established. So we combined the two treatment modalities to assess the synergistic action on nail dystrophy.

Aims and Objectives

The aim of this article is to compare the effect of combination of intramatricial triamcinolone and PRP vs. intramatricial triamcinolone alone in the treatment of onychodystrophy.

Materials and Methods

This study was done in 26 and 25 pairs of symmetrical dystrophic nails in hands and feet, respectively. The patients received intramatricial injection of triamcinolone and PRP on one side of finger and toe nails and triamcinolone on the contralateral side.

Results

Statistically significant improvements in grades of dystrophy according to the Nail Dystrophy Grading System (NDGS) in the finger and toe nails treated with combined therapy were obtained (P < 0.001 and = 0.002, respectively). According to the physician global assessment, response to combination therapy was statistically significant between the two comparison groups of finger and toe nails (P = 0.001 and = 0.004, respectively). Similarly, according to the patient satisfaction score, statistically significant difference was found between the comparison groups of combination therapy and single therapy (P < 0.001).

Conclusion

Addition of PRP significantly improved the nail quality. Intramatricial PRP is a safe and effective therapeutic modality in refractory nail dystrophies.

Micronized Dehydrated Human Amnion/Chorion Membrane Injection in the Treatment of Chronic Achilles Tendinitis

BACKGROUND

Human amniotic membrane contains growth factors and cytokines that promote epithelial cell migration and proliferation, stimulate metabolic processes that lead to collagen synthesis, and attract fibroblasts, while also reducing pain and inflammation. Randomized studies have shown effectiveness of micronized dehydrated human amnion/chorion membrane (mdHACM) allograft injection in treatment of plantar fasciitis. We present our experience and short-term outcomes with using mdHACM injection as a treatment for Achilles tendinopathy.

METHODS

Retrospective case series of patients with Achilles tendinopathy treated with mdHACM by a single physician. Participants had at least two follow-up visits within 45 days of mdHACM injection. Outcomes examined included change in reported level of pain during the 45-day observation period and treatment-associated adverse events.

RESULTS

Follow-up data were available for 32 mdHACM-treated patients. At treatment initiation, 97% of patients reported severe (66%) or moderate (31%) pain. At the first follow-up visit (mean ± SD of 8.1 ± 2.7 days postinjection), 27 patients (84%) reported improvement in pain levels, although 37% of patients continued to report severe (6%) or moderate (31%) pain. At the second follow-up visit (mean ± SD of 23.1 ± 6.2 days postinjection), no patients reported severe pain and one reported moderate pain. Within 45 days of mdHACM injection, complete symptom resolution was reported by 66% of treated patients (n = 21), with the remaining 34% (n = 11) reporting symptom improvement but not complete resolution. Two patients reported calf or quadricep pain or tightness after injection.

CONCLUSIONS

In our experience, mdHACM injection reduced or eliminated pain in all 32 patients with follow-up data.

Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies

Objectives

We performed a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) to provide insights into the effectiveness of available treatment modalities in patellar tendinopathy(PT).

Methods

Several databases were searched in May 2021 for RCTs assessing the effectiveness of any intervention compared with any other intervention, placebo or no treatment for pain and/or function in PT. The risk of bias and strength of evidence were assessed with the Cochrane Collaboration and GRADE (Grading of Recommendations, Assessment, Development and Evaluations)/GRADE-NMA tools.

Results

A total of 37 RCTs were eligible that assessed 33 different interventions and their combinations, most represented by single studies. Based on pairwise meta-analyses of two RCTs, extracorporeal shockwave therapy (ESWT) does not appear to be superior to sham ESWT (eccentric exercise in both groups) for short-term pain (mean differences (MD) +0.1, 95% CI (−0.8 to 1), p=0.84) or function (MD −1.8, 95% CI (–8 to 4.4), p=0.57). Based on a pairwise meta-analysis of three RCTs, isometric exercise appears as effective as isotonic exercise for immediate postintervention pain relief (MD −1.03, 95% CI (−2.6 to 0.5), p=0.19). Our NMA showed that topical glyceryl trinitrate (GTN) and hyaluronic acid injection, both combined with eccentric exercise and moderate, slow resistance exercise had the highest probability of being the most effective interventions (low/very low strength of evidence).

Conclusions

Promising interventions with inadequate evidence, such as topical GTN, hyaluronic acid injections and isometric and slow resistance exercise, should be further investigated through high-quality RCTs. Meanwhile, eccentric loading with or without adjuncts should remain the first-line treatment for all individuals with patellar tendinopathy.

Enhanced Platelet-Rich Plasma (ePRP) Stimulates Wound Healing through Effects on Metabolic Reprogramming in Fibroblasts

As a source of growth factors for expediting wound healing and tissue regeneration, plasma-rich plasma (PRP) has been extensively applied in diverse fields including orthopaedics, ophthalmology, oral and maxillofacial surgery, dentistry, and gynaecology. However, the function of PRP in metabolic regulations remains enigmatic. A standardized method was devised herein to enrich growth factors and to lyophilize it as enhanced PRP (ePRP) powder, which could become ubiquitously available without mechanical centrifugation in clinical practice. To identify metabolic reprogramming in human dermal fibroblasts under ePRP treatment, putative metabolic targets were identified by transcriptome profiling and validated for their metabolic effects and mechanism. ePRP does not only promote wound healing but re-aligns energy metabolism by shifting to glycolysis through stimulation of glycolytic enzyme activity in fibroblasts. On the contrary, oxygen consumption rates and several mitochondrial respiration activities were attenuated in ePRP-treated fibroblasts. Furthermore, ePRP treatment drives the mitochondrial resetting by hindering the mitochondrial biogenesis-related genes and results in a dampened mitochondrial mass. Antioxidant production was further increased by ePRP treatment to prevent reactive oxygen species formation. Besides, ePRP also halts the senescence progression of fibroblasts by activating SIRT1 expression. Importantly, the glycolytic inhibitor 2-DG can completely reverse the ePRP-enhanced wound healing capacity, whereas the mitochondrial inhibitor oligomycin cannot. This is the first study to utilize PRP for comprehensively investigating its effects on the metabolic reprogramming of fibroblasts. These findings indicate that PRP’s primary metabolic regulation is to promote metabolic reprogramming toward glycolytic energy metabolism in fibroblasts, preserving redox equilibrium and allowing anabolic pathways necessary for the healing and anti-ageing process.

A single step, centrifuge-free method to harvest bone marrow highly concentrated in mesenchymal stem cells: results of a pilot trial

PURPOSE

The aims of the present study were: (1) to characterize the bone-marrow aspirate (BMA) obtained with a centrifuge-free process, employing a dedicated aspiration device; (2) to test the in vitro efficacy of BMA in a model of cartilage inflammation; and (3) to report the preliminary clinical results in a small cohort of patients affected by knee OA.

METHODS

Ten patients (4 M, 6 W; mean age: 51.9 ± 9.2 yy) affected by mild to moderate unicompartmental knee OA (KL grade 2-3) were treated by intra-articular and subchondral injections of BMA obtained by a centrifuge-free process. To evaluate the effectiveness of the device in harvesting mesenchymal stem cells (MSCs), samples of the obtained BMA were tested by flow cytometry before and after subculture; BMA ability to counteract inflammation was also tested in an in vitro model of cartilage cell inflammation, evaluating the expression of MMP1, MMP3, TGFβ and TIMP-1 by real-time PCR. Patients were also evaluated up to two years' follow-up by using: VAS for pain, IKDC-subjective and KOOS scores.

RESULTS

The laboratory analysis showed that BMSCs accounted for 0.011% of BMA cells, similar to what had been expected in native bone marrow. The paracrine activity of BMA was able to reduce in vitro the catabolic response of human chondrocyte, as shown by the decrease in metalloproteases concentration and increase in anti-inflammatory mediators. Moreover, the clinical evaluation showed significant improvements in all scores adopted, with stable results up to two years.

CONCLUSION

The present data showed the effectiveness of the study device to harvest pure bone marrow with minimal peripheral blood contamination. The relevant content of MSCs resulted in the ability to counteract the catabolic cascade through a paracrine action. The clinical outcomes in patients affected by unicompartmental knee OA were encouraging in terms of pain reduction and functional improvement up to mid-term evaluation.

Possible clinical efficacy and tolerability of platelet-rich plasma with atopic dermatitis

BACKGROUND

Narrowband-ultraviolet B (NB-UVB) is a promising, effective, and safe therapeutic option for atopic dermatitis (AD), but the treating courses frequently need an extended period since they might have a possible hazard for several side effects and cases of non-compliance.

OBJECTIVE

To discover the influence of platelet-rich plasma (PRP) injecting on the outcomes of short-term NB-UVB treatment for AD cases.

PATIENTS AND METHODS

The present study includes 44 atopic dermatitis cases with general symmetric lesions. For every case, the left side of the body was treated with NB-UVB (control side) whereas the right side was treated with NB-UVB plus PRP intradermal injection, at 3-week interval for 3-months.

RESULTS

A statistically high significant reduction was found in the EASI score, IGA score in the combined side (PRP plus NB-UVB) in comparison with NB-UVB side.

CONCLUSION

Intradermal PRP injecting in addition to NB-UVB can be considered as a simple, acceptable, and economical method for treating atopic dermatitis. It decreases the NB-UVB therapeutic period and is predictable to raise case compliance. Assessments through follow-up were proposed and undertaken to rate the efficacy of treatment.

Hamid MS. Efficacy of prolotherapy in comparison to other therapies for chronic soft tissue injuries: A systematic review and network meta-analysis

Introduction

Prolotherapy and other injections, primarily acting on pathways associated with maladaptive tissue repair, are recommended for recalcitrant chronic soft tissue injuries (CSTI). However, selection of injection is challenging due to mixed results. This network meta-analysis (NMA) aimed to compare prolotherapy with other therapies, particularly injections, for CSTI and establish robustness of the results.

Methodology

Pubmed, Medline, SPORTDiscus and Google scholar were searched from inception to 4^th January 2021 for randomised controlled trials (RCTs) involving injection therapies (e.g. blood derivatives, corticosteroid, hyaluronic acid, botulinum toxin) for CSTI. The primary and secondary outcomes were pain and function, respectively, at (or nearest to) 6 months. Effect size (ES) was presented as standardised mean difference with 95% confidence interval (CI). Frequentist random effect NMA was used to generate the overall estimates, subgroup estimates (by region and measurement time point) and sensitivity analyses.

Results

A total of 91 articles (87 RCTs; 5859 participants) involving upper limb (74%), lower limb (23%) and truncal/hip (3%) injuries were included. At all time points, prolotherapy had no statistically significant pain benefits over other therapies. This observation remained unchanged when tested under various assumptions and with exclusion of studies with high risk of bias. Although prolotherapy did not offer statistically significant functional improvement compared to most therapies, its ES was consistently better than non-injections and corticosteroid injection for both outcomes. At selected time points and for selected injuries, prolotherapy demonstrated potentially better pain improvement over placebo (<4 months: shoulder [ES 0.65; 95% CI 0.00 to 1.30]; 4–8 months: elbow [ES 0.91; 95% CI 0.12 to 1.70]; >8 months: shoulder [ES 2.08; 95% CI 1.49, to 2.68]). Injections generally produced greater ES when combined with non-injection therapy.

Conclusion

While clinical outcomes were generally comparable across types of injection therapy, prolotherapy may be used preferentially for selected conditions at selected times.

Effect of Autologous Expanded Bone Marrow Mesenchymal Stem Cells or Leukocyte-Poor Platelet-Rich Plasma in Chronic Patellar Tendinopathy (With Gap >3 mm): Preliminary Outcomes After 6 Months of a Double-Blind, Randomized, Prospective Study

BACKGROUND

Patellar tendinopathy is common. The success of traditional management, including isometric or eccentric exercises combined with shockwave therapy and even surgery, is limited. Therefore, it is important to determine whether biological treatments such as ultrasound-guided intratendinous and peritendinous injections of autologous expanded bone marrow mesenchymal stem cells (BM-MSCs) or leukocyte-poor platelet-rich plasma (Lp-PRP) improve clinical outcomes in athletic patients with patellar tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A prospective, double-blinded, randomized, 2-arm parallel group, active controlled, phase 1/2 single-center clinical study was performed in patients who had proximal patellar tendinopathy with a lesion >3 mm. A total of 20 participants (age 18-48 years) with pain for >4 months (mean, 23.6 months) and unresponsive to nonoperative treatments were randomized into 2 groups. Of these, 10 participants were treated with BM-MSC (20 × 10⁶ cells) and 10 with Lp-PRP. Both groups performed the same postintervention rehabilitation protocol. Outcomes included the Victorian Institute of Sport Assessment for pain (VISA-P), self-reported tendon pain during activity (visual analog scale [VAS]), muscle function by dynamometry, tendon thickness and intratendinous vascularity by ultrasonographic imaging and Doppler signal, ultrasound tissue characterization (UTC) echo type changes, and magnetic resonance imaging (MRI) T2-weighted mapping changes. Participants were followed longitudinally for 6 months.

RESULTS

The average VAS scores improved in both groups at all time points, and there was a significant reduction in pain during sporting activities (P < .05). In both groups, the average mean VISA-P scores at 6 months were significantly increased compared with baseline (66 BM-MSC group and 72.90 Lp-PRP group), with no significant differences in VAS or VISA-P scores between the groups. There were statistically significant greater improvements in tendon structure on 2-dimensional ultrasound and UTC in the BM-MSC group compared with the Lp-PRP group at 6 months. Similarly, the BM-MSC group demonstrated significant evidence of restoration of tendon structure on MRI compared with the Lp-PRP group at 6 months. Only the participants in the BM-MSC group showed evidence of normalization of tendon structure, with statistically significant differences between the groups on T2-weighted, fat-saturated sagittal and coronal scans and hypersignal in T2-weighted on spin-echo T2-weighted coronal MRI scan. Both treatments were safe, and no significant adverse events were reported in either group.

CONCLUSION

Treatment with BM-MSC or Lp-PRP in combination with rehabilitation in chronic patellar tendinopathy is effective in reducing pain and improving activity levels in active participants. Participants who received BM-MSC treatment demonstrated greater improvement in tendon structure compared with those who received Lp-PRP.

REGISTRATION

2016-001262-28 (EudraCT identifier); NCT03454737 (ClinicalTrials.gov identifier).

Ultrasound-guided versus blind interventions in patellar tendon lesions: a cadaveric study

PURPOSE

The present study aims to analyze the accuracy of injections aimed to hit the proximal and depth part of the patellar tendon "target point" in patellar tendinopathy, comparing ultrasound-guided or non-ultrasound-guided (blind) injections.

METHODS

A cadaver randomized study was carried out. Injections were performed under ultrasound control, as well as blinded. There were 26 knees from fresh cadavers and injections were placed by 26 practitioners with experience in the use of musculoskeletal ultrasound and injection treatment. Each participant performed 6 ultrasound-guided and 6 blind punctures in different cadaveric specimens. This provided 312 injections that were analyzed in 2 different anatomical cuts, thus providing a database of 624 measurements for statistical analysis.

RESULTS

Statistically significant differences were observed (p < 0.0001) in the distance from the target point between the ultrasound-guided and the non-guided infiltrations. The "unguided" injections were considered to have been performed on average 10 mm away from the target point compared to the "ultrasound-guided" injections. The ultrasound-guided injections obtained an accuracy of 74.36% while the "non-ultrasound-guided" injections obtained an accuracy of 11.54% (p < 0.0001).

CONCLUSION

The use of ultrasound to guide the positioning of injections on the dorsal side of the proximal patellar tendon had a significantly higher accuracy compared to blind injections. The finding provides knowledge of importance for injection treatment.

[Evidence in Infiltrative Pain Therapy of the Musculoskeletal System]

Musculoskeletal pain symptoms frequently generate limitations in daily work and life in many patients. Usually, symptomatic treatment is possible before clarifying the in depth diagnosis. A symptom-based infiltration therapy will never replace a thoroughly done physical examination and thoughtful collection of patient history, however, it can be of great benefit for the patient when done focused on the point of pain and executed with profound anatomical knowledge. Furthermore, the knowledge of the level of evidence of therapeutic infiltrations improves their outcomes and shapes realistic patients' expectations. Ultrasound-guided therapeutic infiltrations improve the outcome despite the use of lower amounts of active agents by pinpointed applications. This article provides an overview of the scientific evidence of effectiveness of (ultrasound-guided) infiltration techniques in diverse musculoskeletal regions.

Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review

CONTEXT

Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results.

OBJECTIVE

To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure.

DATA SOURCES

PubMed, MEDLINE, EMBASE, and Google Scholar.

STUDY SELECTION

The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected.

RESULTS

There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking.

CONCLUSION

PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.

Injectable platelet-rich fibrin for facial rejuvenation: A prospective, single-center study

BACKGROUND

Autologous platelet-derived preparations have been used in many surgical fields to improve healing outcomes, with benefits reported in several aesthetic indications.

AIMS

This single-center, prospective, uncontrolled study evaluated the efficacy of injectable platelet-rich fibrin (i-PRF) for facial skin rejuvenation using an objective skin analysis system and validated patient-reported outcome measures.

PATIENTS/METHODS

PRF^® PROCESS system technology was used to prepare i-PRP. Eleven healthy female individuals were included in the study and over 3-months received monthly intradermal injections of i-PRF in 3 facial regions: malar areas (1 mL each side), nasolabial fold (0.5 mL each side), and upper lip skin above the vermilion border (1 mL). The efficacy of the procedures was assessed by objective skin analysis (VISIA^® ) and a subjective patient-reported outcome (FACE-Q) assessment at baseline and after 3 months.

RESULTS

A significant improvement in skin surface spots (P = .01) and pores (P = .03) was seen at 3-months follow-up. Other variables, such as skin texture, wrinkles, ultraviolet spots, and porphyrins, showed a numerical improvement. FACE-Q scales that measure satisfaction with appearance all showed a significant improvement from baseline, including satisfaction with skin (P = .002), satisfaction with facial appearance (P = .025), satisfaction with cheeks (P = .001), satisfaction with lower face and jawline (P = .002), and satisfaction with lips (P = .04). No major adverse effects were reported.

CONCLUSIONS

A series of three i-PRF injections resulted in significant rejuvenation of the face skin at 3-month follow-up, as shown by improved skin analysis parameters and patient self-assessment scores.

Platelet-Rich Plasma Versus Corticosteroid Injections in the Management of Elbow Epicondylitis and Plantar Fasciitis: An Updated Systematic Review and Meta-analysis

BACKGROUND

Platelet-rich plasma (PRP), as a promising alternative to traditional corticosteroid (CS), is now increasingly used in the treatment of elbow epicondylitis (EE) and plantar fasciitis (PF). To date, however, the synthesis of information on the clinical efficacy of PRP versus CS is limited with divergent conclusions.

PURPOSE

To compare the clinical efficacy of PRP and CS injections in reducing pain and improving function in EE and PF.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Online databases were searched from inception to October 2018 for prospective studies evaluating PRP versus CS injections for EE or PF. Independent reviewers undertook searches, screening, and risk-of-bias appraisals. The primary outcomes of interest were pain and function in both the short term (1-3 months) and the long term (≥6 months).

RESULTS

Twenty trials with 1268 participants were included. For EE, PRP provides a statistically and clinically meaningful long-term improvement in pain, with a very large effect size of -1.3 (95% CI, -1.9 to -0.7) when compared with CS, but the evidence level was low. For EE, there was moderate evidence that CS provides a statistically meaningful improvement in pain in the short term, with a medium effect size of 0.56 (95% CI, 0.08-1.03) as compared with PRP; this improvement might not be clinically significant. For PF, there was low evidence that PRP provides a statistically and clinically meaningful long-term improvement in function (American Orthopedic Foot & Ankle Society score), with a very large effect size of 1.94 (95% CI, 0.61-3.28). There were no significant differences between the groups in improvement in function in EE and pain and short-term function in PF, but the quality of the evidence was low.

CONCLUSION

The use of PRP yields statistically and clinically better improvement in long-term pain than does CS in the treatment of EE. The use of PRP yields statistically and clinically better long-term functional improvement than that of CS in the treatment of PF.

Effectiveness of platelet-rich plasma in the management of hip osteoarthritis: a systematic review and meta-analysis

The effectiveness of platelet-rich plasma (PRP) injections for osteoarthritis (OA) is still controversial. Previous research supports the use of intra-articular PRP injections to promote a favorable environment for joint tissue healing and to delay the progression of OA. The purpose of this review is to investigate the effectiveness of PRP in the management of hip osteoarthritis (HOA). Five electronic databases were searched from inception to May 2019: Medline (via PubMed), SportDiscus via EBSCO, ProQuest Health & Medical Complete, CINAHL, and Cochrane. Risk of bias was assessed with the Cochrane risk of bias tool. The GRADE method was used to assess the level of evidence for the studies included in this review. Clinical trials evaluate PRP injections among adult patients diagnosed with HOA according to the American College of Rheumatology criteria. At least one outcome measure for pain or function must have been reported. A total of 4 trials (334 participants, 340 hips) were included, all marked as "moderate risk of bias". Pain and function were assessed throughout the studies with visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Harris Hip Score (HHS) tools. Intra-articular PRP injections were more effective at stages earlier than 3 months for both treatment groups with the exception of WOMAC score in one study. The superiority of PRP against comparative treatments was only reported in one study; longer-term evaluations from 4 to 12 months showed diverse results, with only one study reporting significantly better results for PRP. PRP may be beneficial and safe for patients with HOA at mid-term follow-up. However, its superiority over other procedures such as hyaluronic acid remains unclear. Further researches with high-quality designs and larger samples become imperative.

Bioaugmentation in the surgical treatment of anterior cruciate ligament injuries: A review of current concepts and emerging techniques

Injuries involving the anterior cruciate ligament are among the most common athletic injuries, and are the most common involving the knee. The anterior cruciate ligament is a key translational and rotational stabilizer of the knee joint during pivoting and cutting activities. Traditionally, surgical intervention in the form of anterior cruciate ligament reconstruction has been recommended for those who sustain an anterior cruciate ligament rupture and wish to remain active and return to sport. The intra-articular environment of the anterior cruciate ligament makes achieving successful healing following repair challenging. Historically, results following repair were poor, and anterior cruciate ligament reconstruction emerged as the gold-standard for treatment. While earlier literature reported high rates of return to play, the results of more recent studies with longer follow-up have suggested that anterior cruciate ligament reconstruction may not be as successful as once thought: fewer athletes are able to return to sport at their preinjury level, and many still go on to develop osteoarthritis of the knee at a relatively younger age. The four principles of tissue engineering (cells, growth factors, scaffolds, and mechanical stimuli) combined in various methods of bioaugmentation have been increasingly explored in an effort to improve outcomes following surgical treatment of anterior cruciate ligament injuries. Newer technologies have also led to the re-emergence of anterior cruciate ligament repair as an option for select patients. The different biological challenges associated with anterior cruciate ligament repair and reconstruction each present unique opportunities for targeted bioaugmentation strategies that may eventually lead to better outcomes with better return-to-play rates and fewer revisions.

Effect of Storage Conditions and Activation on Growth Factor Concentration in Platelet-Rich Plasma

This study aimed to evaluate growth factor concentration in platelet-rich plasma (PRP) (leukocyte-rich PRP) based on storage temperature, duration of storage, and method of activation. PRP samples were stored at 24℃ (room temperature group), 4℃ (refrigerator group), and -70℃ (deep-freezer group). In each temperature, four aliquots were prepared based on the time of analysis (immediately, 1, 3, and 7 days after preparation). After storage, concentrations of platelet-derived growth factor-AA (PDGF-AA), transforming growth factor-β (TGF-β), vascular endothelial growth factor (VEGF), insulin-like growth factor-1 (IGF-1), and fibroblast growth factor-basic (FGF-B) were assessed with/without activation using Quantikine colorimetric sandwich immunoassay kits. PRP was activated with 10% Triton-X for PDGF-AA, VEGF, FGF-B, IGF-1 measurement and sonication for TGF-β1 measurement. Without activation, PDGF-AA concentration was highest on day 7 in the room temperature group. With activation, the concentration of PDGF-AA was constant over the observation period at all temperatures. Without activation, the TGF-β1 concentration remained negligible over the observation period at all temperatures. However, with activation, TGF-β1 gradually increased to its highest concentration on day 7 at all temperatures. Over the observation period, VEGF and IGF-1 concentrations were constant with and without activation at all temperatures. Without activation, FGF-B concentration increased, with the highest concentration observed on day 7 in the deep-freezer group. With activation, FGF-B concentration decreased after day 1 in the room temperature group. Growth factor concentration in PRP differed significantly based on storage temperature, duration of storage, and method of activation. Appropriate storage conditions and activation are important to optimize its effects on desired clinical outcomes. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:777-784, 2020.

Platelet-Rich Plasma for Sport-Active Patients with Knee Osteoarthritis: Limited Return to Sport

Objective

To evaluate a cohort of sport-active patients suffering from cartilage degeneration and OA, in terms of clinical outcome and return to sport (RTS) after platelet-rich plasma (PRP) injective treatment.

Design

This study included forty-seven sport-active patients ≤50 years old with unilateral symptomatic knee cartilage degeneration or OA. Patients received 3 PRP injections and were prospectively evaluated at baseline and then at 2, 6, 12, and 24 months follow-up by IKDC subjective EQ-VAS, and Tegner scores. Furthermore, patients were asked about their RTS, in terms of return to any sport level or to their activity level before symptoms onset.

Results

IKDC subjective score improved significantly at all follow-ups, changing from 59.2 ± 13.6 to 70.6 ± 13 at 12 months and to 76.7 ± 12.5 at 24 months (p < 0.0005). A similar outcome was observed with the EQ-VAS score. Tegner score improved from 3.6 ± 1.4 to 4.8 ± 0.9 at 24 months (p < 0.0005). A similar outcome was observed with the EQ-VAS score. Tegner score improved from 3.6 ± 1.4 to 4.8 ± 0.9 at 24 months (p < 0.0005). A similar outcome was observed with the EQ-VAS score. Tegner score improved from 3.6 ± 1.4 to 4.8 ± 0.9 at 24 months (p < 0.0005). A similar outcome was observed with the EQ-VAS score. Tegner score improved from 3.6 ± 1.4 to 4.8 ± 0.9 at 24 months (

Conclusions

Sport-active patients affected by knee OA can benefit from PRP injections, with pain and function improvement over time. However, results are less satisfactory in terms of RTS since only half can achieve the same sport level as before the onset of symptoms. Patients undergoing PRP treatment should be made aware of their low chances to go back to high-impact sport activities.

Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study

Purpose

The purpose of this clinical study was to evaluate and compare the effectiveness of ultrasound (US)-guided platelet-rich plasma (PRP) injections versus US-guided corticosteroid injections (CSI) in the treatment of greater trochanteric pain syndrome (GTPS).

Methods

Between January 2015 and December 2016, 24 patients with GTPS were enrolled and randomized in two groups (A and B). Group A (study group) patients received US-guided PRP injection treatment, while group B (control group) patients received US-guided CSI treatment. Clinical outcomes in both groups were evaluated and compared using the Visual Analogue Scale (VAS) of pain, the Harris Hip Score (HHS) and the presence or absence of complications at 4, 12, and 24 weeks post-injection. The level of significance was set at p<0.05.

Results

Both groups showed improved scores (VAS and HHS) compared to the pre-injection period, but patients in group A had a statistically significant (p <0.05) decrease in VAS score and a significantly increased HHS at the last follow-up (24 weeks post-injection). No complications were reported.

Conclusions

In conclusion, patients with GTPS present better and longer-lasting clinical results when treated with US-guided PRP injections compared to those with CSI. Further studies are needed to optimize the technical preparation of PRP, the sample concentration, the number of injections and the time intervals between them, in order to achieve the maximum desired results.

Is Platelet-rich Plasma Injection more Effective than Steroid Injection in the Treatment of Chronic Plantar Fasciitis in Achieving Long-term Relief?

Introduction: Plantar fasciitis is characterised by pain in the heel, which is aggravated on weight bearing after prolonged rest. Many modalities of treatment are commonly used in the management of plantar fasciitis including steroid injection. Many studies show that steroid injection provides pain relief in the short term but not long lasting. Recent reports show autologous platelet-rich plasma (PRP) injection promotes healing, resulting in better pain relief in the short as well as long term. The present study was undertaken to compare the effects of local injection of platelet-rich plasma and Corticosteroid in the treatment of chronic plantar fasciitis. Materials and methods: Patients with the clinical diagnosis of chronic plantar fasciitis (heel pain of more than six weeks) after failed conservative treatment and plantar fascia thickness more than 4mm were included in the study. Patients with previous surgery for plantar fasciitis, active bilateral plantar fasciitis, vascular insufficiency or neuropathy related to heel pain, hypothyroidism and diabetes mellitus were excluded from the study. In this prospective double-blind study, 60 patients who fulfilled the criteria were divided randomly into two groups. Patients in Group A received PRP injection and those in Group B received steroid injection. Patients were assessed with visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score. Assessment was done before injection, at six weeks, three months and six months follow-up after injection. Plantar fascia thickness was assessed before the intervention and six months after treatment using sonography. Results: Mean VAS in Group A decreased from 7.14 before injection to 1.41 after injection and in Group B decreased from 7.21 before injection to 1.93 after injection, at final follow-up. Mean AOFAS score in Group A improved from 54 to 90.03 and in Group B from 55.63 to 74.67 at six months' follow-up. The improvements observed in VAS and AOFAS were statistically significant. At the end of six months' follow-up, plantar fascia thickness had reduced in both groups (5.78mm to 3.35mm in Group A and 5.6 to 3.75 in Group B) and the difference was statistically significant. Conclusion: Local injection of platelet-rich plasma is an effective treatment option for chronic plantar fasciitis when compared with steroid injection with long lasting beneficial effect.

Platelet-rich plasma for sports-related muscle, tendon and ligament injuries: an umbrella review

BACKGROUND

Platelet-rich plasma (PRP) has been used in different non-transfusion indications due to its role in tissue regeneration and healing. The aim of this overview of systematic reviews (umbrella review) is to provide a summary of the existing research syntheses related to PRP use for sports-related muscle, tendon and ligament injuries.

MATERIALS AND METHODS

Literature searches were performed in MEDLINE, Embase, and Cochrane Library to identify systematic reviews focusing on PRP use for sports-related muscle, tendon and ligament injuries. The methodological quality of included studies was assessed using the checklist for systematic reviews and research syntheses developed by the Joanna Briggs Institute and the GRADE assessment.

RESULTS

Twenty-two studies met the inclusion criteria. Five studies evaluated PRP use for acute muscle injury, and 17 evaluated PRP use for tendon and ligament injury. Studies were heterogeneous in terms of the dose and number of PRP injections, and the control groups. Three of the 5 reviews evaluating acute muscle injury concluded that PRP had no effect on the outcomes considered. One review shows superior efficacy of rehabilitation exercise compared to PRP. One review shows that PRP may result in an earlier return to sport for acute grade I-II injury. Eight out of the 17 reviews evaluating PRP for tendon and ligament injuries show a statistically significant (p<0.05) difference in pain and/or function outcome measures favouring PRP compared to controls, although most of the observed differences were small. Adverse events data and quality of life outcomes were rarely analysed or reported in the included studies and were considered clinically insignificant.

DISCUSSION

In most of the included reviews, the available evidence was judged to be of low/very low quality due to risk of bias, inconsistency and imprecision, thus making the level of certainty of these findings low and not adequate to support the general use of PRP in this setting.

Orthobiologics

Use of orthobiologics in sports medicine and musculoskeletal surgery has gained significant interest. However, many of the commercially available and advertised products are lacking in clinical evidence. Widespread use of products before fully understanding their true indications may result in unknown adverse outcomes and may also lead to increased health care costs. As more products become available, it is important to remain judicial in use and to practice evidence-based medicine. Likewise, it is important to continue advances in research in hopes to improve surgical outcomes. This article reviews clinical evidence behind common orthobiologics in the treatment of foot and ankle pathology.

Biologics in the Treatment of Achilles Tendon Pathologies

Regenerative medicine is gaining more and more space for the treatment of Achilles pathologic conditions. Biologics could play a role in the management of midportion Achilles tendinopathy as a step between conservative and surgical treatment or as an augmentation. Higher-level studies are needed before determining a level of treatment recommendation for biologic strategies for insertional Achilles tendinopathy. Combining imaging with patient's functional requests could be the way to reach a protocol for the use of biologics for the treatment of midportion Achilles tendinopathy and, for this perspective, the authors describe the Foot and Ankle Reconstruction Group algorithm of treatment.

Comparison of Platelet Rich Plasma and Prolotherapy in the Management of Osteochondral Lesions of the Talus: A Retrospective Cohort Study

BACKGROUND Osteochondral lesions of talus (OLT) are among the most common ankle problems. Platelet-rich plasma (PRP) and prolotherapy (PrT) are 2 successful injection-based techniques for treatment of chronic musculoskeletal problems. The aim of the present study was to compare PRP and PrT injections for the management of OLT. MATERIAL AND METHODS This was a retrospective cohort study of 49 patients with OLT symptoms of more than 6 months who had been refractory to 3 months of treatment using conservative methods. The patients were divided into 2 groups: PrT injections (PrT group, n=27) or PRP injections (PRP group, n=22). The patients were given 3 injections of 4 mL solution into periarticular and intra-articular ankle joint spaces. After treatment, patients were evaluated via Visual Analogue Scale (VAS), American Orthopedic Foot and Ankle Society Score (AOFAS), and Ankle Osteoarthritis Scale (AOS) at baseline and 21-, 90-, 180-, and 360-day follow-up periods. RESULTS Both PRP and PrT treatments resulted in greater improvement in pain and ankle functions at follow-up periods extending to 1 year (P<0.001) and there was no difference between the groups for the outcomes at follow-up periods (P>0.05). Excellent or good outcomes were reported by 88.8% of the patients in PrT group and 90.9% of the patients in PRP group. CONCLUSIONS Both PRP and PrT are efficient and safe methods in treatment of OLT. PrT offers advantages of less cost and minimal invasiveness.

How strong is the evidence that conservative treatment reduces pain and improves function in individuals with patellar tendinopathy? A systematic review of randomised controlled trials including GRADE recommendations

OBJECTIVE

To determine the effectiveness of conservative treatment (CT) on pain and function in patients with patellar tendinopathy (PT) compared with minimal intervention (MI) or other invasive intervention, or in addition to decline eccentric squat.

METHODS

Searches were performed in MEDLINE, Embase, Cochrane, PEDro, SPORTDiscus, CINAHL and AMED databases. All randomised trials that evaluated CT (any intervention not involving invasive procedures or medication) in individuals with PT were included. Two reviewers screened studies, extracted data and assessed risk of bias of all included studies. Where suitable, meta-analyses were conducted; we assessed certainty of the evidence using GRADE methodology.

RESULTS

When compared with MI, CT did not improve pain (weighted mean difference (WMD) -2.6, 95% CI -6.5 to 1.2) or function (WMD 1.8, 95% CI -2.4 to 6.1) in the short-term (up to 3 months) follow-up. When compared with invasive intervention, CT did not improve pain (WMD 0.7, 95% CI -0.1 to 1.4) or function (WMD -6.6, 95% CI -13.3 to 0.2) in the short-term follow-up. No overall effects were found for combined CT (when a conservative intervention was added to decline eccentric squat) on pain (WMD -0.5, 95% CI -1.4 to 0.4) or function (WMD -2.3, 95 % -9.1 to 4.6) at short-term follow-up. Single studies showed an effect on pain with iontophoresis at short-term follow-up (d = 2.42) or dry needling at medium/long-term follow-up (d = 1.17) and function with exercise intervention at medium/long-term follow-up (over 3 months) (d = 0.83).

SUMMARY/CONCLUSION

Our estimates of treatment effect have only low to very low certainty evidence to support them. This field of sports medicine/sports physiotherapy urgently needs larger, high-quality studies with pain and function among the potential primary outcomes.

Impact of Platelet-Rich Plasma Use on Pain in Orthopaedic Surgery: A Systematic Review and Meta-analysis

CONTEXT

Amid extensive debate, evidence surrounding the use of platelet-rich plasma (PRP) for musculoskeletal injuries has rapidly proliferated, and an overall assessment of efficacy of PRP across orthopaedic indications is required.

OBJECTIVES

(1) Does PRP improve patient-reported pain in musculoskeletal conditions? and (2) Do PRP characteristics influence its treatment effect?

DATA SOURCES

MEDLINE, EMBASE, Cochrane, CINAHL, SPORTDiscus, and Web of Science libraries were searched through February 8, 2017. Additional studies were identified from reviews, trial registries, and recent conferences.

STUDY SELECTION

All English-language randomized trials comparing platelet-rich therapy with a control in patients 18 years or older with musculoskeletal bone, cartilage, or soft tissue injuries treated either conservatively or surgically were included. Substudies of previously reported trials or abstracts and conference proceedings that lacked sufficient information to generate estimates of effect for the primary outcome were excluded.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

All data were reviewed and extracted independently by 3 reviewers. Agreement was high between reviewers with regard to included studies.

RESULTS

A total of 78 randomized controlled trials (5308 patients) were included. A standardized mean difference (SMD) of 0.5 was established as the minimum for a clinically significant reduction in pain. A reduction in pain was associated with PRP at 3 months (SMD, -0.34; 95% CI, -0.48 to -0.20) and sustained until 1 year (SMD, -0.60; 95% CI, -0.81 to -0.39). Low- to moderate-quality evidence supports a reduction in pain for lateral epicondylitis (SMD, -0.69; 95% CI, -1.15 to -0.23) and knee osteoarthritis (SMD, -0.91; 95% CI, -1.41 to -0.41) at 1 year. PRP characteristics did not influence results.

CONCLUSION

PRP leads to a reduction in pain; however, evidence for clinically significant efficacy is limited. Available evidence supports the use of PRP in the management of lateral epicondylitis as well as knee osteoarthritis.

Can platelet-rich plasma therapy save patients with ulnar collateral ligament tears from surgery?

Introduction

Platelet-rich plasma (PRP) has been shown to be effective in treating partial tears of the ulnar collateral ligament (UCL) of the elbow in overhead throwing athletes, but it is still unknown whether it has a role in complete tears. The aim of this study was to assess the effectiveness of PRP in treating complete as well as partial UCL tears. We hypothesized that trephination of the injured UCL followed by injection with PRP can promote healing of both partial and complete tears.

Methods

Thirty-four baseball players with partial or complete UCL tears confirmed by magnetic resonance imaging (MRI) were included in the study. They were all recalcitrant to more than two months of rest and physical therapy. Under ultrasound guidance, trephination of the UCL was performed using an 18-gauge needle, followed by PRP injection. Visual analog scale (VAS) scores, Disabilities of the Arm, Shoulder, and Hand (DASH) sports module scores, and sonographic ulnohumeral joint space measurements with valgus stress were all obtained prior to the procedure and six months after.

Results

Twenty-six of 30 athletes were able to return to sport with pre-injury level of play within six months after the procedure, at an average time of 12.4 weeks (range: 10-18). Four subjects needed surgical treatment for persistent UCL insufficiency. The average follow-up was 54.2 weeks (range: 26-148). The average VAS and DASH scores improved from 53.5 to 17.2 (p < 0.0001) and from 81.7 to 24.2 (p < 0.0001), respectively. The average ulnohumeral joint space opening with valgus stress decreased from 3.81 mm to 3.45 mm (p = 0.018). Subgroup analysis by injury location revealed that the average VAS score improved from 48.2 to 8.6 (p < 0.0001) and from 64.0 to 34.5 (p = 0.0023) in proximal and distal tears, respectively. The average DASH score improved from 83.8 to 17.8 (p = 0.0001) and from 77.5 to 36.7 (p < 0.0001) in proximal and distal tears, respectively. The average ulnohumeral joint space opening with valgus stress decreased from 3.64 to 3.21 mm (p = 0.003) and from 4.14 to 3.92 mm (p = 0.0023) in proximal and distal tears, respectively. There was one case with a proximal tear that needed surgical management for failure of treatment, while there were three cases needing surgery in those with distal tears.

Conclusion

Ultrasound-guided PRP injection following trephination can be an effective treatment option for both partial and complete UCL tears of the elbow, especially proximal tears. The use of this technique for complete UCL tears may allow more athletes to avoid surgery and enable them to return to play faster.

Platelet-rich plasma in the management of chronic low back pain: a critical review

Low back pain (LBP) is now regarded as the first cause of disability worldwide and should be a priority for future research on prevention and therapy. Intervertebral disc (IVD) degeneration is an important pathogenesis of LBP. Platelet-rich plasma (PRP) is an autologous blood concentrate that contains a natural concentration of autologous growth factors and cytokines and is currently widely used in the clinical setting for tissue regeneration and repair. PRP has great potential to stimulate cell proliferation and metabolic activity of IVD cells in vitro. Several animal studies have shown that the injection of PRP into degenerated IVDs is effective in restoring structural changes (IVD height) and improving the matrix integrity of degenerated IVDs as evaluated by magnetic resonance imaging (MRI) and histology. The results of this basic research have shown the great possibility that PRP has significant biological effects for tissue repair to counteract IVD degeneration. Clinical studies for evaluating the effects of the injection of PRP into degenerated IVDs for patients with discogenic LBP have been reviewed. Although there was only one double-blind randomized controlled trial, all the studies reported that PRP was safe and effective in reducing back pain. While the clinical evidence of tissue repair of IVDs by PRP treatment is currently lacking, there is a great possibility that the application of PRP has the potential to lead to a feasible intradiscal therapy for the treatment of degenerative disc diseases. Further large-scale studies may be required to confirm the clinical evidence of PRP for the treatment of discogenic LBP.

[Insertional Achilles tendinopathy : Differentiated diagnostics and therapy]

Achilles tendinopathy at the calcaneal insertion is classified into insertional tendinopathy, retrocalcaneal and superficial bursitis. The aim of this study was to present the current evidence on conservative and surgical treatment of insertional tendinopathy of the Achilles tendon. Conservative first-line therapy includes reduction of activity levels, administration of non-steroidal anti-inflammatory drugs (NSAID), adaptation of footwear, heel wedges and orthoses or immobilization. In addition, further conservative therapy options are also available. Eccentric stretching exercises should be integral components of physiotherapy and can achieve a 40% reduction in pain. Extracorporeal shock wave therapy has been shown to reduce pain by 60% with a patient satisfaction of 80%. Due to the limited evidence, injections with platelet-rich plasma (PRP), dextrose (prolotherapy) or polidocanol (sclerotherapy) cannot currently be recommended. Operative therapy is indicated after 6 months of unsuccessful conservative therapy. Open debridement allows all pathologies to be addressed, including osseous abnormalities and intratendinous necrosis. The success rate of over 70% is contrasted by complication rates of up to 40%. The Achilles tendon should be reattached, if detached by >50%. No valid data are available for the transfer of the tendon of the flexor hallucis longus (FHL) muscle but it is frequently applied in cases of more than 50% debridement of the diameter of the Achilles tendon. Lengthening of the gastrocnemius muscle cannot be recommended because insufficient data are available. Tendoscopy is a promising treatment option for isolated retrocalcaneal bursitis and has shown similar success rates to open debridement with significantly lower complication rates.

Synergistic activity of platelet rich plasma and high volume image guided injection for patellar tendinopathy

PURPOSE

Platelet rich plasma and high volume image guided injections of saline have been used in the treatment of patellar tendinopathy with positive results. As the different mechanisms of action do not interfere each other, it can be hypothesized that they can be used in combination. Aim of this study was twofold: first, to evaluate the efficacy of these two treatments in the management of patellar tendinopathy; second, to verify whether the combination of these therapies could provide further advantages.

METHODS

Fifty-four patients suffering from patellar tendinopathy were enrolled. After clinical (VAS and VISA-P) and sonographic evaluation, two ultrasound guided injections (2 weeks apart) of platelet rich plasma, high-volume image-guided injections of saline, or both in association were performed. The VAS and VISA-P scores obtained from the three treatments groups (18 patients in each group) were compared across the different follow-up times (3 and 6 months).

RESULTS

In the short term both treatments showed comparable efficacy, whereas in the medium term the positive effects of high-volume image-guided injections gradually diminished and platelet rich plasma showed greater efficacy. Better results (reduced pain, improved function and increased number of subjects who exhibited optimal recovery [> 20 points in VISA-P score]) were observed when both procedures were associated.

CONCLUSIONS

The contemporaneous administration of platelet rich plasma and high volume image guided injections of saline treatments, which influence tendon repair by means of different mechanisms, grants a greater improvement for patellar tendinopathy. This finding has clinical relevance, given that this condition has a substantial impact on sports and work performance.

LEVEL OF EVIDENCE

III.

Platelet-Rich Plasma: Review of Current Literature on its Use for Tendon and Ligament Pathology

PURPOSE OF REVIEW

Platelet-rich plasma (PRP) contains numerous growth factors and cytokines that potentially offer an alternative treatment modality to assist in the healing of multiple musculoskeletal issues. The purpose of this review was to examine the latest literature on the use of PRP for various ligament and tendon pathologies.

RECENT FINDINGS

Recent literature has shown moderate- to high-quality evidence that PRP can have positive clinical effects in certain conditions such as lateral epicondylitis and rotator cuff tendinopathy. Prospective studies have shown that it can also be useful in the treatment of patella tendinopathy. In summary, we found PRP to have variable success in ligament and tendon pathology; however, it should be considered a viable option in chronic musculoskeletal disease that has failed other treatments. Patient selection, duration of symptoms, and combining with other modalities such as physical therapy should all be taken into consideration in treatment with PRP.

Myths and Facts of In-Office Regenerative Procedures for Tendinopathy

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

Should orthopedic surgeons consider reducing the negative effects of Outerbridge grade 2 patellofemoral chondral lesion on early postoperative recovery during anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to comparatively evaluate the effectiveness of intra-articular PRP and HA injections applied as the treatment of Outerbridge grade 2 chondral lesions in patellofemoral joint during arthroscopic ACL reconstruction.

METHODS

The clinical and radiographic data of 61 patients between 18 and 45 years of age were evaluated. The patients were separated into three groups. Hyaluronic acid injection was applied in 22 knees (Group 1), PRP injection was applied in 18 knees (Group 2), and 21 knees did not have any specific treatment except ACL reconstruction (Group 3). All patients were followed clinically at least for 12 months. Clinical examination of the operated knee, visual analogue scale (VAS) score, Lysholm knee score, and Tegner activity scale were the outcome measures. Routine X-ray and MRI were also performed for all patients at 12-month postoperative follow-up visit.

RESULTS

Although the mean VAS and Lysholm scores at 3-month follow-up were better in Group 1 and 2 than Group 3, the efficacy of intra-articular PRP on healing process regarding progression of the mean VAS and Lysholm scores through 6- and 12-month follow-ups was significantly better and longer than HA. No statistically significant differences were detected according to Tegner activity scale between the groups at 3 and 6 months; however, Group 2 had better activity level than both Group 1 (p < 0.001) and 3 (p < 0.001) at the end of 12 months after surgery.

CONCLUSION

Intra-articular PRP injection applied as the treatment of concomitant Outerbridge grade 2 chondral lesion in patellofemoral joint during ACL reconstruction revealed better and durable clinical outcomes via decreasing the potentially negative effects of chondral pathology on postoperative healing with respect to HA injection.

LEVEL OF EVIDENCE

III-retrospective comparative study.

The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review

This review aims to determine whether platelet-rich plasma (PRP) has any role in improving clinical outcomes in patients with symptomatic greater trochanteric pain syndrome (GTPS). A search of NICE healthcare database advanced search (HDAS) via Athens (PubMed, MEDLINE, CINAHL, EMBASE and AMED databases) was conducted from their year of inception to April 2018 with the keywords: ‘greater trochanteric pain syndrome’ or ‘GTPS’ or ‘gluteus medius’ or ‘trochanteric bursitis’ and ‘platelet rich plasma’ (PRP). A quality assessment was performed using the JADAD score for RCTs and MINORS for non-RCT studies. Five full-text articles were included for analysis consisting of three RCTs and two case series. We also identified four additional studies from published conference abstracts (one RCT and three case series). The mean age in 209 patients was 58.4 years (range 48–76.2 years). The majority of patients were females and the minimum duration of symptoms was three months. Diagnosis was made using ultrasound or MRI. Included studies used a variety of outcome measures. Improvement was observed during the first 3 months after injection. Significant improvement was also noted when patients were followed up till 12 months post treatment. PRP seems a viable alternative injectable option for GTPS refractory to conservative measures. The current literature has revealed that PRP is relatively safe and can be effective. Considering the limitations in these studies, more large-sample and high-quality randomized clinical trials are required in the future to provide further evidence of the efficacy for PRP as a treatment in GTPS.