Corticosteroids and local anesthetics decrease positive effects of platelet-rich plasma: an in vitro study on human tendon cells

Efficacy of Autologous Platelet-Rich Plasma Injections for Treating Plantar Fasciitis

Introduction Plantar fasciitis, a common cause of heel pain, is often treated conservatively. Platelet-rich plasma (PRP) injections have emerged as a promising treatment option. This study aimed to evaluate the efficacy of autologous PRP injections for plantar fasciitis. The objective of this study was to assess the effectiveness of autologous PRP injections delivered at the plantar fascia origin in reducing pain (measured by the Visual Analog Scale (VAS) pain intensity score) in patients with plantar fasciitis. Materials and methods A prospective cohort study was conducted at the Department of Orthopedics, Hayatabad Medical Complex, Peshawar. Patients with plantar fasciitis, a VAS pain score ≥ 7, and failure of conservative treatment were included. A single injection of autologous PRP was administered to the plantar fascia. Pain reduction was assessed using the VAS score at a 12-week follow-up. Result The study included 163 patients. Success was achieved in 80.3% of cases, showing that autologous PRP injection resulted in significant pain improvement in patients with plantar fasciitis (p≤0.05). An increased likelihood of successful treatment was observed in individuals with symptoms lasting less than 12 months. No other variables (gender, age group, residence, literacy) significantly impacted treatment efficacy. Conclusion Autologous PRP injections may be a promising treatment option for plantar fasciitis, particularly when administered early. Further research is needed to validate these findings and explore optimal patient selection criteria.

Interventional Radiology for Rheumatic Diseases

Imaging plays a key role in the management of rheumatological pathologies, also as guidance for diagnostic and therapeutic interventional procedures, as it can provide better accuracy and safety compared to palpation-guided interventions. Inflammatory and degenerative conditions nonresponsive to systemic treatment may benefit from intra-articular and periarticular administration of drugs, with therapeutic and symptomatic actions or providing a bridge for surgery. Desired effects include reduction of inflammation and pain and improvement of physical function of patients. Training and knowledge of indications, appropriate procedures, contraindications, and side effects are necessary to obtain maximum accuracy and safety in performing interventional procedures.

Platelet-Rich Plasma Has Better Results for Long-term Functional Improvement and Pain Relief for Lateral Epicondylitis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Corticosteroids (CS) have shown good short-term performance in terms of pain relief and functional improvement. However, the safety and long-term efficacy of this treatment remains controversial. Several studies have reported good results of platelet-rich plasma (PRP) in the treatment of tendinopathies. However, whether its use in the treatment of lateral epicondylitis (LE) is superior to that of CS remains controversial.

PURPOSE

To perform a systematic review and meta-analysis of original studies to determine whether the prognosis of LE patients treated with PRP is better than that of CS.

STUDY DESIGN

Meta-analysis; Level of evidence, 2.

METHODS

Two independent reviewers searched online databases from January 2000 to July 2022 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to evaluate prospective studies of PRP versus CS injection for LE. A third author addressed any discrepancies. Evidence quality was assessed using the Cochrane risk of bias tool. Risk ratios for dichotomous variables and mean differences (MDs) for continuous variables were used to compare clinical outcomes. P values <.05 were considered statistically significant.

RESULTS

Eleven randomized controlled trials with 730 patients were included in this review. PRP provided a significantly worse short-term (<2 months) improvement in the visual analog scale (VAS) pain score (MD, 0.93 [95% CI, 0.42 to 1.44]; I2 = 85%; P = .0003) and Disabilities of the Arm, Shoulder and Hand (DASH) score (MD, 10.23 [95% CI, 9.08 to 11.39]; I2 = 67%; P < .0001) but better long-term (≥6 months) improvement in the VAS score (MD, -2.18 [95% CI, -3.13 to -1.22]; I2 = 89%; P < .0001), DASH score (MD, -8.13 [95% CI, -9.87 to -6.39]; I2 = 25%; P < .0001), and Mayo Elbow Performance Score (MD, 16.53 [95% CI, 1.52 to 31.53]; I2 = 98%; P = .03) than CS. The medium-term (2-6 months) reduction in the VAS score was not significantly different between the 2 groups. After sensitivity analysis, none of the results changed except for the short-term VAS scores (MD, 0.53 [95% CI, -0.13 to 1.19]; I2 = 78%; P = .12).

CONCLUSION

Both PRP and CS injections are effective treatments for patients with LE. CS provides better short-term (<2 months) functional improvement and may be more advantageous in terms of short-term pain relief, while PRP provides better long-term (≥6 months) functional improvement and better performance regarding long-term pain relief.

Cytotoxicity of local anaesthetics and protective effects of platelet rich plasma on equine tenocytes: An in vitro study

Local anaesthetics (LAs) can have detrimental effects on rat, bovine, canine, and human tendon tissues and cells. Currently, there has been no available data on the impact of these drugs on equine tenocytes. Even if LA injection for managing painful tendon conditions in horses is limited, it is usually used via intra-articular, intrasynovial, perineural, and intrathecal as well as for lameness examinations. In this in vitro study, the cytotoxic effects of LAs, including lidocaine, mepivacaine, and bupivacaine on equine tenocytes, in the presence and absence of platelet rich plasma (PRP), were investigated. PRP accelerates tissue healing and can exert cytoprotective effects on different cell types exposed to different stressful conditions, including drugs. Results indicated that the exposure to LAs significantly reduced tenocytes viability in dose- and time-dependent manners while PRP was able to counteract their cytotoxic effects. Furthermore, microscopy and flow cytometry analyses revealed apoptosis and necrosis in equine tenocytes exposed to these drugs, that were both reduced when PRP was in the medium. These findings highlight the importance of considering the tenocyte toxicity associated with intrathecal and intraneural LA injections, as they might affect tenocytes or reduce the efficacy of associated therapies. Moreover, this study also highlights the protective effects of PRP, which could make LA injections safer.

Lidocaine inhibits migration of tenocytes by downregulating focal adhesion kinase and paxillin phosphorylation

Lidocaine is the most frequently applied local infiltration anesthetic agent for treating tendinopathies. However, studies have discovered lidocaine to negatively affect tendon healing. In the current study, the molecular mechanisms and effects of lidocaine on tenocyte migration were evaluated. We treated tenocytes intrinsic to the Achilles tendons of Sprague-Dawley rats with lidocaine. The migration ability of cells was analyzed using electric cell-substrate impedance sensing (ECIS) and scratch wound assay. We then used a microscope to evaluate the cell spread. We assessed filamentous actin (F-actin) cytoskeleton formation through immunofluorescence staining. In addition, we used Western blot analysis to analyze the expression of phospho-focal adhesion kinase (FAK), FAK, phospho-paxillin, paxillin, and F-actin. We discovered that lidocaine had an inhibitory effect on the migration of tenocytes in the scratch wound assay and on the ECIS chip. Lidocaine treatment suppressed cell spreading and changed the cell morphology and F-actin distribution. Lidocaine reduced F-actin formation in the tenocyte during cell spreading; furthermore, it inhibited phospho-FAK, F-actin, and phospho-paxillin expression in the tenocytes. Our study revealed that lidocaine inhibits the spread and migration of tenocytes. The molecular mechanism potentially underlying this effect is downregulation of F-actin, phospho-FAK, and phospho-paxillin expression when cells are treated with lidocaine.

Plasma rich in growth factors versus corticosteroid injections for management of chronic rotator cuff tendinopathy: a prospective double-blind randomized controlled trial with 1 year of follow-up

BACKGROUND

Rotator cuff tendinopathy (RCT) is a painful and dysfunctional shoulder condition traditionally considered as a degenerative pathology. However, evidence is pointing to immunocompetent cells and activated stromal fibroblasts as the drivers of a nonresolved inflammatory condition in RCT. As potent anti-inflammatory agents, corticosteroid injections have been among the first-line and the most common therapeutic strategies. Recently, another adjuvant therapy to treat musculoskeletal inflammation-driven painful conditions, namely, platelet-rich plasma (PRP), has emerged as safe and effective. The aim of this study was to compare the clinical efficacy of intratendinous injections of plasma rich in growth factors (PRGF) with conventional intratendinous corticosteroid injections on patients with chronic RCT using patient-reported outcome measures.

METHODS

A total of 39 patients received PRGF treatment (3 infiltrations, 1 every other week), whereas 40 patients, as a control group, received corticosteroid (3 infiltrations, 1 every other week). Patients were evaluated before treatment and at 3, 6, and 12 months of follow-up using the University of California Los Angeles (UCLA) scale, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Constant test. The primary outcome of the study was a 15% superior improvement of the PRGF group compared with the corticosteroid group in the UCLA scale and QuickDASH test at 6 months of follow-up, considering this difference to be clinically relevant.

RESULTS

Both PRGF and corticosteroid groups showed significant clinical improvement in the 3 scores at all time points of the study compared with baseline. However, at 6 and 12 months of follow-up, the PRGF group had 22.1% and 21.2% superior improvement of the UCLA test, 14.3% and 13.5% for QuickDASH, and 16.4% and 20.2% for the Constant-Murley test, respectively, compared to the corticosteroid group.

CONCLUSIONS

Three PRGF intratendinous injections every other week in patients with chronic rotator cuff tendinopathy show significantly superior and sustained pain-relieving and functional improvements compared with corticosteroid intratendinous injections assessed by 3 patient-reported outcome scales at 6 and 12 months of follow-up.

Advances in the Clinical Application of Platelet-Rich Plasma in the Foot and Ankle: A Review

Autologous and recombinant biologic substances have been generated as a result of the research into the cellular features of the healing process. Orthobiologics are increasingly being used in sports medicine and musculoskeletal surgery. Nevertheless, clinical data are limited; consequently, further studies are required, particularly in foot and ankle pathologies. This review aims to provide evidence of the most recent literature results and ignite the interest of orthopedic specialists eager for an update about the most current discussion on platelet-rich plasma (PRP) clinical applications in the foot and ankle fields. Previous studies have shown that platelet-rich plasma can be beneficial in treating various conditions, such as chronic foot ulcers, osteoarthritis, Achilles tendinopathy, etc. Despite the positive effects of PRP on various musculoskeletal conditions, more prospective studies are needed to confirm its effectiveness at treating ankle and foot pathologies. In addition to clinical trials, other factors, such as the quality of the research and the procedures involved, must be considered before they can be used in patients. More long-term evaluations are needed to support or oppose its application in treating foot and ankle disorders. We present the most extensive review of PRP's clinical applications in the foot and ankle field.

Comparison of Platelet-Rich Plasma Treatment and Partial Plantar Fasciotomy Surgery in Patients with Chronic Plantar Fasciitis: A Randomized, Prospective Study

Platelet-Rich Plasma (PRP) injection has become a desirable alternative to Partial Plantar Fasciotomy (PPF) surgery and steroid injection for patients with chronic plantar fasciitis (CPF) due to its potential for shorter recovery times, reduced complications, and similar activity scores. As such, we compared PRP treatment to PPF surgery in patients with CPF. Between January 2015 and January 2017, patients were randomly divided into two groups, a PRP treatment group, and a PPF group. All procedures were performed by a single foot and ankle fellowship-trained specialist surgeon. Visual Analog Score (VAS) and Roles-Maudsley Scale (RM) were collected during the preoperative visit and 3, 6, and 12 months postoperatively. The patients were also closely followed by a physiotherapist. There were 16 patients in each group after four patients refused to participate. Patients in the PPF had low Roles-Maudsley Scale (RM) scores compared to the PRP group one-year after treatment (3.77 vs. 2.72, p < 0.0001). Both procedures showed a reduction in RM scores during the follow-up year (9 to 1.62 for PPF and 8.7 to 2.4 for PRP). There was no significant change in VAS pain between the two groups (p = 0.366). Patients treated with PRP injection reported a significant increase in their activity scores, shorter recovery time, and lower complication rates compared to PPF treatment. Moreover, with respect to existing literature, PRP may be as efficient as steroid injection with lower complication rates, including response to physical therapy. Therefore, PRP treatment may be a viable option before surgery as an earlier line treatment for CPF. Level of Clinical Evidence: II.

Effects of local anesthetics and contrast agents on musculoskeletal regenerative medicine procedures

In regenerative medicine, cells, tissues and organs are often replaced, engineered or regrown in order to restore their function after they have been damaged or lost. Local anesthetics, corticosteroids and contrast agents are commonly employed for both diagnostic and therapeutic objectives in interventional pain and musculoskeletal treatments for regenerative medicine. There is growing evidence that routine injectables promote catabolism and disease processes. Thus, understanding the effects of these compounds on regenerative medicine injectates and target tissues such as tenocytes, chondrocytes, nucleus pulposus and ligamentous tissue is critical. This review includes the current research on the effects of local anesthetics and contrast agents, as well as their use and recommendations in regenerative medicine operations.

Efficacy of Single Injection of Platelet-Rich Plasma in Shoulder Impingement Syndrome

Introduction

To analyze the change in Visual Analog Scale (VAS), QuickDASH score, and the range of motion at the shoulder joint following a single injection of platelet-rich plasma (PRP) in shoulder impingement syndrome.

Methods

Twenty patients (21 shoulders) of either sex above the age of 18 years with a clinical diagnosis of shoulder impingement having a positive shoulder impingement test (positive Hawkins-Kennedy impingement test and/or positive Neer's impingement sign), ultrasonographic confirmation of shoulder impingement, and a failure to respond to standard non-operative methods for a minimum period of four weeks were included in this prospective interventional study. PRP was injected at the proposed site. At three months after the injection, the changes in the VAS, QuickDASH score, and the range of motion at the shoulder joint were analyzed.

Results

There were significant changes in the VAS, QuickDASH score, and range of motion at the shoulder joint following a single injection of PRP.

Conclusions

Platelet-rich plasma (PRP) injection results in a significant decrease in pain and improvement in the range of motion and an overall excellent functional outcome in shoulder impingement syndrome. However, future studies with a bigger sample size and longer follow-up are needed.

Anti-inflammatory and Tendon-Protective Effects of Adipose Stem Cell-Derived Exosomes with Concomitant Use of Glucocorticoids

Glucocorticoid (GC) injections are commonly used in clinical practice to relieve pain and improve function in patients with multiple shoulder disabilities but cause detrimental effects on rotator cuff tendons. Adipose stem cell-derived exosomes (ASC-Exos) reportedly recover impaired tendon matrix metabolism by maintaining tissue homeostasis. However, it is unclear whether additional treatment with ASC-Exos overrides the detrimental effects of GCs without interfering with their anti-inflammatory effects. Thus, we aimed to investigate the anti-inflammatory effect of ASC-Exos with GCs and protective effect of ASC-Exos against GC-induced detriments. The present study comprised in vitro and in vivo studies. In vitro inflammatory analysis revealed that ASC-Exos exerted a synergic anti-inflammatory effect with GCs by significantly decreasing secretion of proinflammatory cytokines by RAW cells and increasing secretion of anti-inflammatory cytokines. In vitro cytoprotective analysis showed that ASC-Exos overrode GC-induced detrimental effects on tenocytes by significantly improving GC-suppressed cellular proliferation, migration, and transcription of tenocytic matrix molecules and degradative enzyme inhibitors and significantly decreasing GC-induced cell senescence, apoptosis, and transcription of ROS and tenocytic degradative enzymes. In vivo studies revealed that additional ASC-Exo injection restored impairments in histological and biomechanical properties owing to GC administration. Collectively, these results suggest that ASC-Exos exert a stronger anti-inflammatory effect in combination with GCs, overriding their detrimental effects on rotator cuff tendons.

Autologes plättchenreiches Plasma in der Behandlung der Alopezie

Autologes plättchenreiches Plasma wird aufgrund seiner wundheilenden Eigenschaften vielfach angewandt u. a. in Orthopädie, Chirurgie und Dermatologie. Zunehmend stellt plättchenreiches Plasma außerdem bei bestimmten Formen der Alopezie eine interessante neue Behandlungsoption dar, sei es als alleinige Therapie oder auch als Adjuvans im Rahmen einer Haartransplantation. Kontrollierte klinische Studien an kleineren Patientengruppen zeigten vielfach positive Ergebnisse, größere Studien stehen bislang noch aus. Die Wirkung auf das Haarwachstum wird sehr wahrscheinlich über die in plättchenreichem Plasma enthaltenen Wachstumsfaktoren und Zytokine vermittelt.

Effect of local anesthetics on platelet physiology and function

Local anesthetics are often used at the site of injury or mixed with platelet-rich plasma to reduce pain when treating orthopedic and sports-related injuries. Local anesthetics have been shown to have deleterious effects on stromal cells, but their impact on platelets has not been investigated. In this study, we aimed to assess the effects of lidocaine, bupivacaine, and ropivacaine on platelet health. Based on the deleterious effects of local anesthetics on nucleated cells, we hypothesized that these compounds would affect platelet viability, intracellular physiology, and function. Platelet preparations were derived from randomly selected donors and exposed to lidocaine 1%, bupivacaine 0.75%, ropivacaine 0.5%, and saline at 1:1 and 1:3 ratios. Platelet morphology, viability, intracellular calcium, production of radical oxygen species (ROS), apoptosis, and adhesion were assessed via fluorescent microscopy and flow cytometry. Bupivacaine resulted in increased ROS production, calcium dysregulation, apoptosis, and reduced platelet adhesion. By contrast, ropivacaine and lidocaine were similar to saline in most assays, except for a low degree of mitochondrial stress as evidenced by increased ROS production. Ultimately, bupivacaine 0.75% was harmful to platelets as evidenced by reduced platelet viability, adhesion, and increased apoptosis, whereas lidocaine 1% and ropivacaine 0.5% were relatively safe at the 1:1 and 1:3 dilutions. Clinical significance: Lidocaine 1% and ropivacaine 0.5% can be used at up to a 1:1 ratio with platelet preparations to reduce the pain and discomfort of PRP procedures while maintaining platelet therapeutic potential.

Effects of corticosteroids and platelet-rich plasma on synoviocytes in IL-1ß-induced inflammatory condition

AIMS

Corticosteroid injections are used to treat shoulder pain. Platelet-rich plasma (PRP) is known to have anti-inflammatory and anabolic effects, as well as cytoprotective effects against corticosteroids. Thus, this study was to investigate the effects of co-treatment of corticosteroid and PRP on anti-inflammatory and matrix homeostasis of synoviocytes in IL-1ß-induced inflammatory conditions.

MATERIALS AND METHODS

Synoviocytes were cultured with 1 ng/mL IL-1β, 1 μM dexamethasone, and 10% (vol/vol) Platelet-poor plasma (PPP), PRP200, PRP1000, and PRP4000 X 10³/μL. Gene expressions of pro-inflammatory and anti-inflammatory cytokines, degradative enzymes, and their inhibitors were evaluated and protein synthesis of degradative enzymes and their inhibitors were also examined.

RESULTS

Corticosteroid modulated anti-inflammatory and pro-inflammatory cytokines, and subsequent PRP treatment did not interfere with the effect of a corticosteroid and modulated the gene expressions of cytokines such as TNF-α and IL-4, which were not regulated by the corticosteroid alone. Gene expressions and protein expressions of degradative enzymes and their inhibitors were suppressed by corticosteroid. Additional PRPs did not alter the gene expression and protein regulated by the corticosteroid and inhibited the gene expression of ADAMTS-5 and protein synthesis of MMP-9 and ADAMTS-5, which were not modulated by the corticosteroid alone.

CONCLUSION

Corticosteroid regulated the inflammation and synovial homeostasis. When PRP and the corticosteroid were used together, it exhibited synergistic effects on synoviocytes by regulating the parts that were not controlled by corticosteroid alone while not interfering with the effects of the corticosteroid in an inflammatory condition.

Current Biological Strategies to Enhance Surgical Treatment for Rotator Cuff Repair

Rotator cuff tear is one of the most common shoulder problems encountered by orthopedic surgeons. Due to the slow healing process and high retear rate, rotator cuff tear has distressed millions of people all around the world every year, especially for the elderly and active athletes. This disease significantly impairs patients' motor ability and reduces their quality of life. Besides conservative treatment, open and arthroscopic surgery contributes a lot to accelerate the healing process of rotator cuff tear. Currently, there are many emerging novel treatment methods to promote rotator cuff repair. A variety of biological stimulus has been utilized in clinical practice. Among them, platelet-rich plasma, growth factors, stem cells, and exosomes are the most popular biologics in laboratory research and clinical trials. This review will focus on the biologics of bioaugmentation methods for rotator cuff repair and tendon healing, including platelet-rich plasma, growth factors, exosomes and stem cells, etc. Relevant studies are summarized in this review and future research perspectives are introduced.

Magnetic resonance imaging and clinically controlled improvement of a combined autologous conditioned plasma combined with rh collagen type I injections in lateral epicondylitis

The purpose of the study was to investigate the effect of combined autologous conditioned plasma and recombinant human collagen type I injections on lateral epicondylitis. Outcome was measured in 5 patients before the single application of ACP+rhCollagen type I (Arthrex ACP® Tendo) and after 10.60±3.58wks by means of (i) the Visual Analogue Scale for pain, (ii) range of motion for wrist extension/flexion as well as supination/pronation, and (iii) MRI-scans. VAS-scores significantly decreased from 6.40±1.14 at baseline to 1.80±2.49 at follow- up, and the effect was very large (p=0.04, d^z=2.22). In addition, range of motion either improved or remained unrestricted, and MRI-scans showed healing of the extensor carpi radialis brevis tendon in most cases. A combined ACP+rhCollageninjection successfully reduces pain in lateral epicondylitis. Due to the small sample size, however, these promising preliminary results need further investigation in future research.

Return to Play After Platelet-Rich Plasma Injection for Elbow UCL Injury: Outcomes Based on Injury Severity

Background:

Ulnar collateral ligament (UCL) injuries of the elbow are uncommon in the general population but prevalent in the athletic community, particularly among baseball players. Platelet-rich plasma (PRP) injection therapy has become a popular nonoperative adjuvant treatment for such injuries to help reduce recovery time and avoid surgery.

Purpose/Hypothesis:

To analyze patient outcomes by injury severity and identify injury types that responded most favorably and unfavorably to PRP treatment. It was hypothesized that PRP therapy would prove to be most beneficial in the treatment of lower-grade, partial UCL tears and less effective in the treatment of more severe, complete UCL tears.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A cohort of 50 patients with UCL injuries in their dominant elbow, diagnosed by MRI (magnetic resonance imaging) arthrogram, underwent PRP therapy in conjunction with an established rehabilitation program. UCL injuries were classified by MRI as low-grade partial tear (Type I), high-grade partial tear (Type II), complete tear (Type III), or tear in more than 1 location (Type IV).

Results:

In total, 24 of 39 (61.5%) Type I and II tears, 3 of 3 (100%) Type III tears, and 1 of 8 (12.5%) patients with Type IV tears responded to UCL PRP injection therapy and were able to return to play without surgery. Ten patients required subsequent UCL PRP injections, of which 3 (30%) were able to return to sport without surgery.

Conclusion:

PRP treatment for Types I and II UCL tears shows great promise when combined with physical therapy and a rehabilitation program. Type III UCL tears demonstrated a high rate of success, although with low cohort numbers. Type IV UCL tears did not appear to respond well to PRP injection therapy and often required surgical intervention or cessation of sport. Therefore, PRP treatment does not appear to be appropriate for patients with complete Type IV UCL tears but may enhance recovery and improve outcomes in throwing athletes with Types I, II, and III UCL injuries.

Platelet-Rich Plasma Applications for Achilles Tendon Repair: A Bridge between Biology and Surgery

Achilles tendon ruptures are very common tendon ruptures and their incidence is increasing in modern society, resulting in work incapacity and months off sport, which generate a need for accelerated and successful therapeutic repair strategy. Platelet-rich plasma (PRP) is emerging as adjuvant human blood-derived constructs to assist Achilles tendon rupture treatment. However, myriad PRP preparation methods in conjunction with poor standardization in the modalities of their applications impinge on the consistent effectiveness of clinical and structural outcomes regarding their therapeutic efficacy. The purpose of this review is to provide some light on the application of PRP for Achilles tendon ruptures. PRP has many characteristics that make it an attractive treatment. Elements such as the inclusion of leukocytes and erythrocytes within PRP, the absence of activation and activation ex vivo or in vivo, the modality of application, and the adjustment of PRP pH can influence the biology of the applied product and result in misleading therapeutic conclusions. The weakest points in demonstrating their consistent effectiveness are primarily the result of myriad PRP preparation methods and the poor standardization of modalities for their application. Selecting the right biological scaffold and applying it correctly to restitutio ad integrum of ruptured Achilles tendons remains a daunting and complex task.

Intra-articular injections of platelet-rich plasma in symptomatic knee osteoarthritis: a consensus statement from French-speaking experts

PURPOSE

There has been much debate regarding the use of intra-articular injections of platelet-rich plasma (PRP) as symptomatic treatment for knee osteoarthritis. The objective of this consensus was to develop guidelines for PRP injections in knee osteoarthritis according to the French National Authority for Health recommendations.

METHODS

Fifteen physicians from different French-speaking countries (10 rheumatologists, 4 specialists in rehabilitation and sports medicine and 1 radiologist) were selected for their expertise in the areas of PRP and osteoarthritis. A comprehensive literature review was conducted on Medline including all published therapeutic trials, open studies, meta-analysis and systematic reviews focusing on the effects of PRP in knee OA, as well as fundamental studies concerning the characteristics of the various types of PRP and their mechanisms, indexed before April 2019. Using the method recommended by the French National Authority for Health inspired by the Delphi consensus process, 25 recommendations were finally retained and evaluated. The recommendations were classified as appropriate or not appropriate, with strong or relative agreement, or uncertain if a consensus was not achieved.

RESULTS

Among the 25 recommendations selected, the main ones are the following: (1) Intra-articular injections of PRP are an effective symptomatic treatment for early to moderate knee osteoarthritis. This recommendation was considered appropriate with a relative agreement (Median = 8; rank = 6-9). Level of evidence 1A. (2) A PRP treatment sequence in knee osteoarthritis may include 1-3 injections. This recommendation was considered appropriate with a strong agreement (Median = 9; rank = 7-9). Level of evidence 1A. (3) Leucocytes-poor PRP should be preferred in knee osteoarthritis. This recommendation was considered appropriate with a relative agreement (Median = 8; rank = 5-9). Level of evidence 5. (4) Intra-articular PRP knee injections should be performed under ultrasound or fluoroscopic guidance. This recommendation was considered uncertain with no consensus (Median = 8; rank = 3-9). Level of evidence 5. (5) PRP should not be mixed with an anesthetic or intra-articular corticosteroid. This recommendation was considered appropriate with a relative agreement (Median = 9; rank = 6-9). Level of evidence 5 CONCLUSION: Those 25 recommendations should standardize and facilitate the use of IA PRP injections, which are considered by experts as an effective treatment especially in early or moderate knee OA. Although a strong or relative agreement from the experts was obtained for most of the recommendations, many of them had a very low level of evidence (Level 5) and were principally based on the clinical experience of the experts.

Technical Procedures for Preparation and Administration of Platelet-Rich Plasma and Related Products: A Scoping Review

INTRODUCTION

Platelet-rich plasma is widely used for different types of clinical situations, but universal standardization of procedures for its preparation is still lacking.

METHODS

Scoping review of comparative studies that have assessed at least two alternatives in one or more stages of preparation, storage and/or administration of PRP or its related products. A systematic search was conducted in MEDLINE, Embase, and LILACS. Two authors screened references independently. Data extraction was performed iteratively, and results were presented for each included comparison.

RESULTS

Thirty-nine studies were included after assessing full texts, focusing on the comparison of PRP to a related product, types of anticoagulants, centrifugation protocols, commercial kits, processing time, methods for activation, and application concomitantly to other substances. Only laboratory outcomes were assessed, as platelet, leukocyte and growth factor concentrations.

CONCLUSION

Results showed great variability related to methods employed in different stages of PRP processing, which may explain the variability observed in clinical trials assessing the efficacy of PRP for different clinical situations.

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.

Rotator Cuff-Related Shoulder Pain: To Inject or Not to Inject?

The most common source of shoulder pain is thought to involve the tendons of the rotator cuff and associated structures around the subacromial space. A generic diagnostic term has been suggested, rotator cuff-related shoulder pain (RCRSP), which is an overarching clinical term that includes a number of conditions, such as subacromial impingement syndrome, subacromial pain syndrome, and rotator cuff tendinopathy. The management of RCRSP may include exercise, surgery, or injection therapy. Those who perform or recommend injection therapy for RCRSP have a duty of care to provide advice on the expected benefits and outcomes, as well as the potential risks and associated harms. Clinicians also need to consider what medication to inject, where to inject it, and how to inject it. The aim of this Viewpoint is to discuss these issues. J Orthop Sports Phys Ther 2019;49(5):289-293. doi:10.2519/jospt.2019.0607.

Real-Time Monitoring of Ascorbic Acid-Mediated Reduction of Cytotoxic Effects of Analgesics and NSAIDs on Tenocytes Proliferation

Tendinopathy is a common painful musculoskeletal disorder treated by injection of analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs), which are believed to have cytotoxicity toward tenocytes. Ascorbic acid is an antioxidant that promotes collagen biosynthesis and prevents free radical formation. It is believed to protect tenocytes from oxidative stress. The optimal concentration of ascorbic acid, especially when used in conjunction with anesthetics and NSAIDs injection, to treat different stages of tendinopathies is unknown. Human tenocytes were isolated from a torn edge of the supraspinatus tendon of a 51-year-old male patient during arthroscopic repair. We monitored real-time changes in human tenocyte proliferation upon exposure to different concentrations of ascorbic acid, bupivacaine, and ketorolac tromethamine using the xCELLigence system. No significant changes in cell index were observed between the control group and tenocytes treated with the 3 concentrations of ascorbic acid. Tenocytes exposed to 0.5% bupivacaine and 30 or 15 mg/mL ketorolac tromethamine revealed significant reduction in tenocytes proliferation. Bupivacaine 0.5% with 250 μg/mL ascorbic acid and 15 mg/mL ketorolac tromethamine with 250 μg/mL ascorbic acid showed the least cytotoxicity against tenocytes. The optimal ascorbic acid concentration required to reduce the cytotoxic effects of bupivacaine and ketorolac tromethamine was demonstrated using this platform.

Single-dose intra-articular corticosteroid injection prior to platelet-rich plasma injection resulted in better clinical outcomes in patients with knee osteoarthritis: A pilot study

BACKGROUND

The synergistic and protective effect of platelet-rich plasma (PRP) added to methlyprednisolone (MP) has been demonstrated via in-vitro studies. However, there is no report in the literature about this issue.

OBJECTIVE

The aim of this study was to evaluate clinical outcomes of intra-articular (IA) MP injection prior to PRP injection in comparison with single-dose MP and PRP injections alone in patients with knee osteoarthritis (OA).

METHODS

The treatment groups were "PRP group" (n= 37) who underwent single-dose IA PRP injection, "PRP + MP group" (n= 40) who underwent MP injection one week prior to single-dose PRP injection, and "MP group" (n= 38) who underwent single-dose MP injection. Visual Analog Scale (VAS) and The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were applied at first admission and at 1st, 3rd, 6th, and 12th month follow-ups.

RESULTS

At the end of the 1st month, WOMAC score in PRP + MP group was significantly lower than PRP group. At the 3rd month, WOMAC score in PRP + MP group was significantly lower than PRP and MP groups. At the 6th month, VAS and WOMAC score in PRP + MP group was significantly lower than MP group. At the end of the 12th month, no significant difference was observed among three groups in VAS and WOMAC scores.

CONCLUSION

According to our results, IA MP injection prior to PRP injection resulted in significantly better clinical outcomes compared to PRP and MP injections alone in patients who had mild to moderate knee OA.

Autologous fibrin scaffolds: When platelet- and plasma-derived biomolecules meet fibrin

The healing of vascularized mammalian tissue injuries initiate with hemostasis and clotting as part of biological defense system leading to the formation of a fibrin clot in which activated platelets are trapped to quickly stop bleeding and destroy microbials. In order to harness the therapeutic potential of biomolecules secreted by platelets and stemmed from plasma, blood deconstruction has allowed to yield autologous platelet-and plasma-derived protein fibrin scaffold. The autologous growth factors and microparticles stemmed from platelets and plasma, interact with fibrin, extracellular matrix, and tissue cells in a combinatorial, synergistic, and multidirectional way on mechanisms governing tissue repair. This interplay will induce a wide range of cell specifications during inflammation and repair process including but not limited to fibrogenesis, angiogenesis, and immunomodulation. As biology-as-a-drug approach, autologous platelet-and plasma-derived protein fibrin scaffold is emerging as a safe and efficacious natural human-engineered growth factor delivery system to repair musculoskeletal tissues, and skin and corneal ulcers and burns. In doing so, it acts as therapeutic agent not perfect but close to biological precision. However, this autologous, biocompatible, biodegradable, and long in vivo lasting strategy faces several challenges, including its non-conventional single dose-response effect, the lack of standardization in its preparation and application, and the patient's biological features. In this review, we give an account of the main events of tissue repair. Then, we describe the procedure to prepare autologous platelet-and plasma-derived protein fibrin scaffolds, and the rationale behind these biomaterials, and finally, we highlight the significance of strategic accuracy in their application.

Iodine contrast agents do not influence Platelet-Rich Plasma function at an early time point in vitro

BACKGROUND

Iodine contrast agents (ICAs) are routinely used by radiologists to help guide intra-articular infiltrations. The aim of this study was to assess the in vitro effects of ICA on platelet function of human autologous Platelet-Rich Plasma (PRP).

METHODS

One hundred thirty-seven consecutive patients with symptomatic femoral-patellar osteoarthritis were included. All were addressed to our institution for a fluoroscopy-guided intra-articular PRP infiltration of the pathological femoral-patellar joint. For each patient, 500 μl of PRP were sampled before intra-articular injection. First, PRP samples were mixed with 50 μl of 2 widely used ICA: Visipaque270® (Iodixanol, n = 58) and Iopamiron200® (Iopamidol, n = 69). PRP concentration ([PRP]) was measured at different delays of incubation (t = 0, 5, 10, 15, 20 and 30 min) enabling to calculate PRP ratio (defined as [PRP](t)/[PRP](0mn)) at each delay, for each mixture, in order to quantitatively assess the influence of ICA on PRP ratio. Second, the PRP samples of 10 additional patients were mixed with Visipaque270®, Visipaque270®, Iopamiron200® and phosphate buffer saline (PBS: control solution) in order to qualitatively assess the influence of ICA on platelet aggregation, using ADP, Collagen, Arachidonic acid and TRAP tests. The surface expression of human P-selectin, a marker of α-granule release, in the PRP + Visipaque270® and PRP + Iopamiron200® mixtures was finally compared. Repeated-measures ANOVA, classical 2-way ANOVA and Wilcoxon matched-pairs test were used to study the influence of ICA on PRP quality.

RESULTS

There was no significant change in PRP ratio during the first 30mn of incubation (p = 0.991) whatever the ICA (p = 0.926). Whatever the aggregation test, there was no significant difference in the percentage of platelet aggregation between PRP + PBS, PRP + Visipaque270® and PRP + Iopamiron200® (p = 0.998), nor between PRP + PBS and PRP + Visipaque320® (p = 0.470). Finally, there was no significant difference in P-selectin expression between the PRP + Visipaque270® and PRP + Iopamiron200® mixtures (p = 0.500).

CONCLUSION

At early delays of incubation, Visipaque® and Iopamiron®, which are two widely used ICA for intra-articular infiltrations, did not influence the in vitro platelet function nor the quality of PRP.

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

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

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

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

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

Design: Systematic Review (according to PRISMA guidelines).

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

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

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

Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review

Objective

To compare the effectiveness of corticosteroid injections to local anaesthetic injections in the management of rotator cuff-related shoulder pain (RCRSP).

Design

Systematic review with best evidence synthesis.

Data sources

The Cochrane, PubMed, CINAHL Plus, PEDro and EMBASE electronic databases were searched (inception until 8 June 2017). Reference lists of included articles were also hand searched.

Eligibility criteria

Two reviewers independently evaluated eligibility. Randomised controlled trials (RCTs) were included if they compared subacromial injections of corticosteroid with anaesthetic injections. Two reviewers independently extracted data regarding short-term, midterm and long-term outcomes for pain, self-reported function, range of motion and patient-perceived improvement.

Results

Thirteen RCTs (n=1013) were included. Four trials (n=475) were judged as being at low risk of bias. Three studies of low risk of bias favoured the use of corticosteroid over anaesthetic-only injections in the short term (up to 8 weeks). There was strong evidence of no significant difference between injection types in midterm outcomes (12–26 weeks). There was limited evidence of no significant difference between injection types in long-term outcomes.

Conclusion

Corticosteroid injections may have a short-term benefit (up to 8 weeks) over local anaesthetic injections alone in the management of RCRSP. Beyond 8 weeks, there was no evidence to suggest a benefit of corticosteroid over local anaesthetic injections.

Trial registration number

PROSPERO CRD42016033161.

Comparison between xCELLigence biosensor technology and conventional cell culture system for real-time monitoring human tenocytes proliferation and drugs cytotoxicity screening

Background

Local injections of anesthetics, NSAIDs, and corticosteroids for tendinopathies are empirically used. They are believed to have some cytotoxicity toward tenocytes. The maximal efficacy dosages of local injections should be determined. A commercial 2D microfluidic xCELLigence system had been developed to detect real-time cellular proliferation and their responses to different stimuli and had been used in several biomedical applications. The purpose of this study is to determine if human tenocytes can successfully proliferate inside xCELLigence system and the result has high correlation with conventional cell culture methods in the same condition.

Methods

First passage of human tenocytes was seeded in xCELLigence and conventional 24-well plates. Ketorolac tromethamine, bupivacaine, methylprednisolone, and betamethasone with different concentrations (100, 50, and 10% diluted of clinical usage) were exposed in both systems. Gene expression of type I collagen, type III collagen, tenascin-C, decorin, and scleraxis were compared between two systems.

Results

Human tenocytes could proliferate both in xCELLigence and conventional cell culture systems. Cytotoxicity of each drug revealed dose-dependency when exposed to tenocytes in both systems. Significance was found between groups. All the four drugs had comparable cytotoxicity in their 100% concentration. When 50% concentration was used, betamethasone had a relatively decreased cytotoxicity among them in xCELLigence but not in conventional culture. When 10% concentration was used, betamethasone had the least cytotoxicity. Strong and positive correlation was found between cell index of xCELLigence and result of WST-1 assay (Pearson’s correlation [r] = 0.914). Positive correlation of gene expression between tenocytes in xCELLigence and conventional culture was also observed. Type I collagen: [r] = 0.823; type III collagen: [r] = 0.899; tenascin-C: [r] = 0.917; decorin: [r] = 0.874; and scleraxis: [r] = 0.965.

Conclusions

Human tenocytes could proliferate inside xCELLigence system. These responses varied when tenocytes were exposed to different concentrations of ketorolac tromethamine, bupivacaine, methylprednisolone, and betamethasone. The result of cell proliferation and gene expression of tenocytes in both xCELLigence and conventional culture system is strongly correlated.

Clinical relevance

xCELLigence culture system may replace conventional cell culture, which made real-time tenocyte proliferation monitoring possible.

Leukocyte-reduced platelet-rich plasma increases proliferation of tenocytes treated with prednisolone: a cell cycle analysis

INTRODUCTION

The purpose of this study was to evaluate the effect of allogenic leukocyte-reduced platelet-rich plasma on human tenocytes after treatment with prednisolone and to develop a standardization of its application for clinical practice.

METHODS

A leukocyte-reduced PRP was produced using the Arthrex Double Syringe (Arthrex, Inc., Naples, FL, USA), in a modified single-spin separation method. Human tenocytes were isolated from discarded rotator cuff segments. Tenocytes were cultured in the presence of PRP and prednisolone, both alone and in combination. Control samples were treated in media containing 2% FCS for 72 h. After 72 h of incubation, cell cycle kinetics of tenocytes were analyzed to assess proliferation.

RESULTS

Incubation of the tenocytes with PRP alone for 48 h led to high proliferation rate (10% PRP, 28.0 ± 10.5%; 20% PRP, 40.9 ± 3.3%). Incubation in the presence of prednisolone led to a significant decrease of the proliferation rate (5.2 ± 3.1%; p < 0.05). Treatment with PRP for 48 h significantly increased the proliferation of tenocytes in a dose-dependent manner (10% PRP, 28.0 ± 10.5%; 20% PRP, 40.9 ± 3.3%; p < 0.05). The presence of prednisolone resulted in a decreased tenocyte proliferation (5.2 ± 3.1%; p < 0.05), whereas addition of PRP for 24 and 48 h after prednisolone exposure did not show any compensating effect independent of PRPs concentration (10% PRP, 3.7 ± 3.0%; 20% PRP, 2.5 ± 2.5%). However, a significantly increased cell proliferation of tenocytes was evident when PRP was applied 24 h after prednisolone incubation for 48 h (31.0 ± 3.4 and 34.3 ± 4.7%).

CONCLUSION

The use of leukocyte-reduced PRP stimulates the proliferation of tenocytes and antagonizes the negative effect of prednisolone 24 h after treatment. Addition of PRP 48 h after treatment with prednisolone has no positive effect on the proliferation rate of tenocytes.

Successful Treatment of Osgood-Schlatter Disease with Autologous-Conditioned Plasma in Two Patients

Osgood–Schlatter Disease (OSD) is a painful, growth-related overuse condition of the tibial tuberosity, leading to inflammation of the patellar ligament at the tibial tuberosity. It primarily affects young adolescents, athletic population, and usually, resolves with age or skeletal maturity. Therapy is usually conservative, with surgery indicated in a minority of cases. For patients with treatment-resistant or refractory OSD, an alternative is the application of autologous platelet concentrate. Here, we describe two cases in which autologous-conditioned plasma therapy was used to treat OSD, and present the treatment protocol developed in our clinic.

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

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

Treatment of Subacromial Impingement Syndrome: Platelet-Rich Plasma or Exercise Therapy? A Randomized Controlled Trial

BACKGROUND

Subacromial impingement syndrome (SAIS) is the most common disorder of the shoulder. The evidence for the effectiveness of treatment options is inconclusive and limited. Therefore, there is a need for more evidence in this regard, particularly for long-term outcomes.

HYPOTHESIS

Platelet-rich plasma (PRP) would be an effective method in treating subacromial impingement.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This was a single-blinded randomized clinical trial with 1-, 3-, and 6-month follow-up. Sixty-two patients were randomly placed into 2 groups, receiving either PRP or exercise therapy. The outcome parameters were pain, shoulder range of motion (ROM), muscle force, functionality, and magnetic resonance imaging findings.

RESULTS

Both treatment options significantly reduced pain and increased shoulder ROM compared with baseline measurements. Both treatments also significantly improved functionality. However, the treatment choices were not significantly effective in improving muscle force. Trend analysis revealed that in the first and third months, exercise therapy was superior to PRP in pain, shoulder flexion and abduction, and functionality. However, in the sixth month, only shoulder abduction and total Western Ontario Rotator Cuff score were significantly different between the 2 groups.

CONCLUSION

Both PRP injection and exercise therapy were effective in reducing pain and disability in patients with SAIS, with exercise therapy proving more effective.

Effect of platelet concentration on clinical improvement in treatment of early stage-knee osteoarthritis with platelet-rich plasma concentrations

[Purpose] To compare two platelet-rich plasma kits with different platelet concentrations for treatment of knee osteoarthritis. [Subjects and Methods] Male and female patients with knee osteoarthritis who had confirmed diagnosis with X-ray and magnetic resonance imaging were included in this retrospective study. Eligible patients were divided into two groups: Group I, which received platelet-rich plasma kit I, and Group II, which received platelet-rich plasma kit II. Platelet concentrations of both kits were measured by manual counting. For each group, platelet-rich plasma kit was injected twice with a one-month interval between injections. The Western Ontario and McMaster Universities Osteoarthritis Index and the Visual Analog Scale were applied for clinical evaluation before the first injection and one, three and six months after the second injection. [Results] Kits I and II contained 1,000,000 and 3,000,000 platelets/µl respectively. In both groups, initial Western Ontario and McMaster Universities Osteoarthritis Index and Visual Analog Scale scores were significantly higher compared to the latter evaluations. However, no significant difference was observed between groups in terms of clinical evaluations. [Conclusion] Similar clinical results were found in groups receiving different platelet concentrations, therefore, a concentration of 1,000,000 platelet/µl is considered sufficient for pain relief and functional recovery.

Meloxicam and diclofenac do not change VEGF and PDGF-ABserum levels of platelet-rich plasma

BACKGROUND/AIM

Platelet-rich plasma (PRP) application has gained widespread interest for musculoskeletal injuries. Nonsteroidal antiinflammatory drugs are frequently used in sports medicine before and/or after PRP application. Our study seeks to determine whether serum levels of platelet-derived growth factor-AB (PDGF-AB) and vascular endothelial growth factor (VEGF) levels of PRP would be affected by nonsteroidal antiinflammatory drugs.

MATERIALS AND METHODS

Two different final concentrations of diclofenac (0.5 μg mL^-1 and 2.5 μg mL^-1), meloxicam (0.8 μg mL^-1 and 2.0 μg mL^-1), and acetylsalicylic acid (final concentration 450 μm) were obtained in separate tubes with PRPs prepared from 20 healthy male volunteers. Medicine-free PRP was the control group. Growth factors were measured using ELISA.

RESULTS

PDGF-AB and VEGF serum levels did not change with diclofenac, meloxicam, or acetylsalicylic acid addition. PDGF-AB and VEGF serum levels correlated with each other.

CONCLUSION

Diclofenac, meloxicam, and acetylsalicylic acid did not affect PDGF-AB and VEGF serum levels.

Effects of Platelet-Rich Plasma With Concomitant Use of a Corticosteroid on Tenocytes From Degenerative Rotator Cuff Tears in Interleukin 1β-Induced Tendinopathic Conditions

BACKGROUND

A corticosteroid injection is commonly used to treat tendinopathy, but it has been associated with negative effects on tendon homeostasis. Platelet-rich plasma (PRP) is known to have proliferative and anabolic effects as well as cytoprotective effects against corticosteroids on tenocytes. However, the combined effects of a corticosteroid and PRP on the anti-inflammatory, matrix synthesis, and cytoprotective potential of tenocytes in conditions simulating tendinopathy have not been investigated.

PURPOSE

To assess the effects of PRP on tenocytes from degenerative rotator cuff tears with the concomitant use of a corticosteroid in interleukin 1β (IL-1β)-induced tendinopathic conditions.

STUDY DESIGN

Controlled laboratory study.

METHODS

Tenocytes were enzymatically isolated and cultured from patients with degenerative rotator cuff tears. PRP was prepared using a plateletpheresis system, and growth factor concentrations were measured. To evaluate the gene expression of proinflammatory and anti-inflammatory cytokines, enzymes and their inhibitors, and matrix molecules, cells were cultured with 1 ng/mL IL-1β, 1 μM dexamethasone, and 10% (vol/vol) platelet-poor plasma (PPP) and PRP of 200, 1000, and 4000 × 10³/μL; quantitative real-time reverse transcriptase polymerase chain reaction was also performed. Western blotting was performed to investigate the protein synthesis of degradative enzymes and their inhibitors. Cell viability, apoptosis, and senescence assays were also conducted.

RESULTS

PRP did not interfere with the anti-inflammatory effects of dexamethasone on tenocytes pretreated with IL-1β, but it increased the synthesis of tissue inhibitor of metalloproteinase (TIMP)-1 and -3. Meanwhile, PRP did not induce anti-inflammatory cytokines that had been suppressed with a corticosteroid. It did increase the type I/III collagen ratio mainly through the suppression of type III collagen expression. PRP reversed the decreased viability, increased apoptosis, and induced senescence with IL-1β and a corticosteroid.

CONCLUSION

This study shows that the addition of PRP does not interfere with the anti-inflammatory effects of a corticosteroid on IL-1β-treated tenocytes from degenerative rotator cuff tears but that it does avoid the deleterious side effects of a corticosteroid.

CLINICAL RELEVANCE

PRP can be clinically useful with a corticosteroid as a treatment for tendinopathy.