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Boksh K, Elbashir M, Thomas O, Divall P, Mangwani J. Platelet-Rich Plasma in acute Achilles tendon ruptures: A systematic review and meta-analysis. Foot (Edinb) 2022; 53:101923. [PMID: 36037774 DOI: 10.1016/j.foot.2022.101923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Platelet Rich Plasma (PRP) is known to exert multi-directional biological effects favouring tendon healing. However, conclusions drawn by numerous studies on its clinical efficacy for acute Achilles tendon rupture are limited. We performed a systematic review and meta-analysis to investigate this and to compare to those without PRP treatment. METHODS The Cochrane Controlled Register of Trials, Pubmed, Medline and Embase were used and assessed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ('plasma' OR 'platelet-rich' OR 'platelet-rich plasma' or 'PRP') AND ('Achilles tendon rupture/tear' OR 'calcaneal tendon rupture/tear' OR 'tendo calcaneus rupture/tear'). Data pertaining to biomechanical outcomes (heel endurance test, isokinetic strength, calf-circumference and range of motion), patient-reported outcome measures (PROMs) and incidence of re-ruptures were extracted. Meta-analysis was performed for same outcomes measured in at least three studies. Pooled outcome data were analysed by random- and fixed-effects models. RESULTS After abstract and full-text screening, 6 studies were included. In total there were 510 patients of which 256 had local PRP injection and 254 without. The average age was 41.6 years, mean time from injury to treatment 5.9 days and mean follow-up at 61 weeks. Biomechanically, there was similar heel endurance, isokinetic strength, calf circumference and range of motion between both groups. In general, there were no differences in patient reported outcomes from all scoring systems used in the studies. Both groups returned to their pre-injured level at a similar time and there were no differences on the incidence of re-rupture (OR 1.13, 95% CI, 0.46-2.80, p = 0.79). CONCLUSION PRP injections for acute Achilles tendon ruptures do not improve medium to long-term biomechanical and clinical outcomes. However, future studies incorporating the ideal application and biological composition of PRP are required to investigate its true clinical efficacy.
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Affiliation(s)
- Khalis Boksh
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Mohamed Elbashir
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Owain Thomas
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Pip Divall
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jitendra Mangwani
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
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Daley P, Menu P, Louguet B, Crenn V, Dauty M, Fouasson-Chailloux A. Interest of platelet rich plasma in Achilles tendon rupture management: a systematic review. PHYSICIAN SPORTSMED 2022; 50:463-470. [PMID: 34392780 DOI: 10.1080/00913847.2021.1969216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Acute Achilles tendon rupture (ATR) is a disabling sport-related injury. Its management involves conservative treatment with early weight-bearing or surgical treatment. Platelet-rich plasma (PRP) has raised interest as an adjuvant for treatment, given its properties on tendon repair and its anti-inflammatory effect. We aimed to assess clinical impact of PRP use in surgical or non-surgical treatment of acute ATR: range of motion, muscle strength, function, return to sport and adverse events. METHOD A systematic literature research was performed using PubMed, ScienceDirect, and Google Scholar databases to collect studies reporting clinical outcomes after acute ATR treated with PRP. RESULTS Eight studies were eligible and included 543 acute ATR. Four were randomized comparative studies. A total of 128 patients were treated surgically and 415 were treated conservatively, 271 received PRP injection. Five studies described the type of PRP used, which was variable. Only one study including 12 patients found significant outcomes in favor of the PRP group, with a 4-week earlier recovery of a normal range of motion and a 7-week earlier return to running. No difference in clinical or morphological evaluations, strength measurement, and functional outcomes was found in other studies both at short and long-term. PRP did not seem to modify the frequency of adverse events. CONCLUSIONS Data are not clearly in favor of a significant effect of the PRP use for treatment of ATR. There might be a slight effect on evolution during the first months. Its interest should be assessed in future studies with strong methodology.
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Affiliation(s)
- Pauline Daley
- Chu Nantes, Service De Médecine Physique Et Réadapatation Locomotrice Et Respiratoire, Nantes, France.,Chu Nantes, Service De Médecine Du Sport, Nantes, France
| | - Pierre Menu
- Chu Nantes, Service De Médecine Physique Et Réadapatation Locomotrice Et Respiratoire, Nantes, France.,Chu Nantes, Service De Médecine Du Sport, Nantes, France.,Irms, Institut Régional De Médecine Du Sport, Nantes, France.,Inserm, Umr 1229, RMeS, Regenerative Medicine and Skeleton, Université De Nantes, Oniris, Nantes, France
| | - Bastien Louguet
- Chu Nantes, Service De Médecine Du Sport, Nantes, France.,Irms, Institut Régional De Médecine Du Sport, Nantes, France
| | - Vincent Crenn
- Chu Nantes, Clinique Chirurgicale Orthopédique Et Traumatologique, Nantes, France
| | - Marc Dauty
- Chu Nantes, Service De Médecine Physique Et Réadapatation Locomotrice Et Respiratoire, Nantes, France.,Chu Nantes, Service De Médecine Du Sport, Nantes, France.,Irms, Institut Régional De Médecine Du Sport, Nantes, France.,Inserm, Umr 1229, RMeS, Regenerative Medicine and Skeleton, Université De Nantes, Oniris, Nantes, France
| | - Alban Fouasson-Chailloux
- Chu Nantes, Service De Médecine Physique Et Réadapatation Locomotrice Et Respiratoire, Nantes, France.,Chu Nantes, Service De Médecine Du Sport, Nantes, France.,Irms, Institut Régional De Médecine Du Sport, Nantes, France.,Inserm, Umr 1229, RMeS, Regenerative Medicine and Skeleton, Université De Nantes, Oniris, Nantes, France
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Effect of Platelet-Rich Plasma Augmentation on Endoscopy-Assisted Percutaneous Achilles Tendon Repair. J Clin Med 2022; 11:jcm11185389. [PMID: 36143034 PMCID: PMC9501121 DOI: 10.3390/jcm11185389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/10/2022] [Accepted: 09/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Achilles tendon ruptures are one of the most common sports injuries. Recently, platelet-rich plasma (PRP) has been widely used in tendon-related disorders to enhance tendon healing. However, studies regarding PRP treatment in Achilles tendon rupture show inconsistent results. The purpose of this study was to evaluate the effectiveness of PRP in patients with acute Achilles tendon rupture treated with endoscopy-assisted percutaneous repair. Methods: A total of 62 patients with acute Achilles tendon rupture treated with surgical repair from January 2014 to December 2018 were enrolled in this study. Surgical repair in conjunction with PRP augmentation after surgery was classified as the PRP group. Surgical repair without PRP augmentation was classified as the non-PRP group. All patients were followed up at least 2 years post-operation. The outcomes were evaluated on the basis of rate of return to sports, time to return to play, Achilles Tendon Total Rupture Score (ATRS), calf circumference ratio, ankle range of motion (ROM) and complications following surgery. Results: At 2-year follow-up, the ATRS score was not significantly different between groups (p = 0.8), but the ATRS score in both groups improved with time. Rate of return to sports and time to return to play were not different between the two groups (p = 1.00). Moreover, calf circumference ratio and ankle ROM were evaluated at 6-month, 12-month, 18-month and 24-month follow-ups. At 6 months, the PRP group had better ankle ROM (p = 0.003) and a higher calf circumference ratio (p = 0.011); however, at the 24-month evaluation, there were no between-group differences regarding calf circumference ratio, ankle dorsiflexion and plantarflexion (p > 0.05). Conclusion: We show that PRP augmentation in Achilles tendon surgery did not yield superior functional and clinical outcomes. Therefore, clinicians should inform patients of the above information when undergoing Achilles tendon surgery and offer correct expectations to family and patients regrading PRP treatment.
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Fletcher AN, Johnson AH. Biologic Adjuvants for Foot and Ankle Conditions. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Willits KR. In Nonsurgically Managed Acute Achilles Tendon Rupture, Platelet-Rich Plasma Did Not Improve Healing or Function at 12 Months Compared with Placebo. J Bone Joint Surg Am 2021; 103:934. [PMID: 33735147 DOI: 10.2106/jbjs.21.00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Kevin R Willits
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario Canada
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Platelet-Rich Plasma Applications for Achilles Tendon Repair: A Bridge between Biology and Surgery. Int J Mol Sci 2021; 22:ijms22020824. [PMID: 33467646 PMCID: PMC7830415 DOI: 10.3390/ijms22020824] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/08/2021] [Accepted: 01/10/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Resistance Exercises in Early Functional Rehabilitation for Achilles Tendon Ruptures Are Poorly Described: A Scoping Review. J Orthop Sports Phys Ther 2020; 50:681-690. [PMID: 33094667 PMCID: PMC8168134 DOI: 10.2519/jospt.2020.9463] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To (1) describe which resistance exercises are used in the first 8 weeks of treatment for acute Achilles tendon rupture and (2) assess the completeness of reporting of the exercise descriptions. DESIGN Scoping review. LITERATURE SEARCH We searched the MEDLINE, Embase, CINAHL, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases. STUDY SELECTION CRITERIA Randomized controlled trials, cohort studies, and case series (10 or more participants) that reported using resistance exercise in the immobilization period in the first 8 weeks of treatment for acute Achilles tendon rupture were included. DATA SYNTHESIS Completeness of exercise description was assessed with the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier exercise descriptor framework. RESULTS Thirty-eight studies were included. Fifty-one resistance exercises were extracted and categorized as isometric exercises (n = 20), heel raises (n = 6), strengthening with external resistance (n = 13), or unspecified (n = 12). A median of 8 (interquartile range, 6-10) of a possible 19 CERT items was reported. The amount of items described of the 13 Toigo and and Boutellier exercise descriptors ranged from 0 to 11. CONCLUSION A variety of resistance exercises targeted at the ankle plantar flexors were used as part of early functional rehabilitation after Achilles tendon rupture. However, most studies provided inadequate description of resistance exercise interventions. J Orthop Sports Phys Ther 2020;50(12):681-691. Epub 23 Oct 2020. doi:10.2519/jospt.2020.9463.
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Boesen AP, Boesen MI, Hansen R, Barfod KW, Lenskjold A, Malliaras P, Langberg H. Effect of Platelet-Rich Plasma on Nonsurgically Treated Acute Achilles Tendon Ruptures: A Randomized, Double-Blinded Prospective Study. Am J Sports Med 2020; 48:2268-2276. [PMID: 32485112 DOI: 10.1177/0363546520922541] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An acute Achilles tendon rupture (ATR) is a long-lasting and devastating injury. Possible biological augmentation to promote and strengthen tendon healing after an ATR would be desirable. PURPOSE To determine whether the application of a platelet-rich plasma (PRP) injection in nonsurgically treated ATRs may promote healing and thereby improve functional outcomes. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS A total of 40 men (aged 18-60 years) with an ATR incurred within 72 hours were included, and 38 were followed for 12 months. All patients were treated with an orthosis with 3 wedges for 8 weeks; full weightbearing from day 1 was allowed, combined with either 4 PRP or 4 placebo injections (a few drops of saline, <0.5 mL, under the skin) 14 days apart. All patients received the same instructions on an exercise program starting from week 9. Outcomes included the self-reported Achilles tendon Total Rupture Score (ATRS) as well as heel-rise work, heel-rise height, tendon elongation, calf circumference, and ankle dorsiflexion range of motion. RESULTS The mean ATRS score improved in both groups at all time points (P < .001), but there was no difference between the groups at any time points (12 months: 90.1 points in PRP group and 88.8 points in placebo group). No differences in all functional outcomes at any time points were seen between the groups. At 12 months, the injured leg did not reach normal functional values compared with the uninjured leg. CONCLUSION The application of PRP in nonsurgically treated ATRs did not appear to show any superior clinical and functional improvement. REGISTRATION NCT02417922 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Anders Ploug Boesen
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Orthopaedic Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | | | - Rudi Hansen
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Anders Lenskjold
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Malliaras
- Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Henning Langberg
- CopenRehab, Section of Social Medicine, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG. Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119884071. [PMID: 31803789 PMCID: PMC6878623 DOI: 10.1177/2325967119884071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines. PURPOSE To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture. RESULTS A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53). CONCLUSION Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.
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Affiliation(s)
- Jennifer A. Zellers
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marianne Christensen
- Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Inge Lunding Kjær
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
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Abstract
The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.
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Affiliation(s)
- Henrik C Bäcker
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Adrian J Yenchak
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - David P Trofa
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - J Turner Vosseller
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
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Abstract
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.
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Abstract
PURPOSE OF REVIEW Platelet-rich plasma has become an increasingly popular treatment option within the orthopedic community to biologically enhance and stimulate difficult-to-heal musculoskeletal tissues. This review evaluates the recent literature on platelet-rich plasma use in the treatment of foot and ankle pathologies. RECENT FINDINGS Recent literature has demonstrated platelet-rich plasma to have a possible benefit in the treatment of Achilles pathology, chronic plantar fasciitis, osteochondral lesions of the talus, ankle osteoarthritis, and diabetic foot ulcers. However, given the lack of standardization of platelet-rich plasma preparations and protocols and the predominance of low-quality studies, no definitive treatment indications exist. Platelet-rich plasma is a promising treatment option, but at present, there is only limited clinical evidence supporting its use in foot and ankle applications.
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Affiliation(s)
- Peter R Henning
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, 1400 S. Germantown Rd, Germantown, 38138, TN, USA
| | - Benjamin J Grear
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, 1400 S. Germantown Rd, Germantown, 38138, TN, USA.
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13
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Zhao E, Carney D, Chambers M, Ewalefo S, Hogan M. The role of biologic in foot and ankle trauma-a review of the literature. Curr Rev Musculoskelet Med 2018; 11:495-502. [PMID: 30054808 DOI: 10.1007/s12178-018-9512-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The use of biologics in orthopedics is becoming increasingly popular as an adjuvant in healing musculoskeletal injuries. Though many biologics involved in the management of foot and ankle injuries are used based on physician preference, reports of improved outcomes when combined with standard operative treatment has led to further clinical interest especially in foot and ankle trauma. RECENT FINDINGS The most recent studies have shown benefits for biologic use in patients predisposed to poor bone and soft tissue healing. Biologics have shown benefit in treating soft tissue injuries such as Achilles ruptures as well as the complications of trauma such as non-unions and osteoarthritis. Biologics have shown some benefit in improving functional and pain scores, as well as reducing time to heal in foot and ankle traumatic injuries, with particular success shown with patients that have risk factors for poor healing. As the use of biologics continues to increase, there is a need for high-level studies to confirm early findings of lower level reports.
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Affiliation(s)
- Emily Zhao
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Dwayne Carney
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Monique Chambers
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - Samuel Ewalefo
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - MaCalus Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA.
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Filardo G, Di Matteo B, Kon E, Merli G, Marcacci M. Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surg Sports Traumatol Arthrosc 2018; 26:1984-1999. [PMID: 27665095 DOI: 10.1007/s00167-016-4261-4] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 08/02/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied. METHODS A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies. RESULTS The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative). CONCLUSION Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders. LEVEL OF EVIDENCE Systematic review of level I-IV trials, Level IV.
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Affiliation(s)
- Giuseppe Filardo
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Berardo Di Matteo
- I Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Elizaveta Kon
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Giulia Merli
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Maurilio Marcacci
- Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
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Gil AB, Piva SR, Irrgang JJ. Considerations for Assessment and Applicability of Studies of Intervention. Clin Sports Med 2018; 37:427-440. [PMID: 29903384 DOI: 10.1016/j.csm.2018.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Evidence-based practice changed how health care professionals are taught medical practice. Despite all best intentions, many health care professionals have limited knowledge to assess the validity and usefulness of the medical literature. The goal of this article is to review the following basic considerations while appraising studies of intervention: (1) the hierarchy of evidence and the strengths and weaknesses of clinical studies, (2) the relevant elements of study design that impact validity of study results, and (3) the spectrum of efficacy and effectiveness of clinical studies and how these influence the applicability of study results to individual patients.
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Affiliation(s)
- Alexandra B Gil
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219-3130, USA.
| | - Sara R Piva
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219-3130, USA
| | - James J Irrgang
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219-3130, USA
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Lin MT, Chiang CF, Wu CH, Hsu HH, Tu YK. Meta-analysis Comparing Autologous Blood-Derived Products (Including Platelet-Rich Plasma) Injection Versus Placebo in Patients With Achilles Tendinopathy. Arthroscopy 2018; 34:1966-1975.e5. [PMID: 29685839 DOI: 10.1016/j.arthro.2018.01.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 01/18/2018] [Accepted: 01/18/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the effectiveness of autologous blood-derived products (ABP) injection with that of placebo (sham injection, no injection, or physiotherapy alone) in patients with Achilles tendinopathy. METHODS Electronic databases, including PubMed, Scopus, EMBASE, and Cochrane Library were searched up to June 2017. All published or unpublished randomized controlled trials (RCTs) were included. Two independent raters assessed the risk of bias of RCTs with the Cochrane Risk of Bias Tool. The primary outcome was Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Weighted mean differences (WMDs) were used for random effect meta-analysis. RESULTS Seven RCTs were enrolled in meta-analysis. The ABP injection and placebo revealed equal effectiveness in VISA-A score improvement at 4 to 6 weeks (short term, WMD 2.29, 95% confidence interval [CI]: -1.69, 6.27), 12 weeks (medium term, WMD 2.63, 95% CI: -1.72, 6.98), 24 weeks (long term, WMD 4.61, 95% CI: -1.25, 10.47), and 48 weeks (very long term, WMD 4.16, 95% CI: -6.82, 15.14). In meta-regression, there was no association between change in VISA-A score and duration of symptoms at 4 to 6 weeks (short term), 12 weeks (medium term), and 24 weeks (long term). CONCLUSIONS This meta-analysis revealed that ABP injection was not more effective than placebo (sham injection, no injection, or physiotherapy alone) in Achilles tendinopathy and that no association was found between therapeutic effects and duration of symptoms. LEVEL OF EVIDENCE Level I, meta-analysis of Level I studies.
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Affiliation(s)
- Meng-Ting Lin
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Fang Chiang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chueh-Hung Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Hui-Hsuan Hsu
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Yu-Kang Tu
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
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Ho G, Tantigate D, Kirschenbaum J, Greisberg JK, Vosseller JT. Increasing age in Achilles rupture patients over time. Injury 2017; 48:1701-1709. [PMID: 28457569 DOI: 10.1016/j.injury.2017.04.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. METHODS Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. RESULTS The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. CONCLUSION Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. LEVEL OF EVIDENCE Level III; Retrospective cohort study.
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Affiliation(s)
- Gavin Ho
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Direk Tantigate
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Josh Kirschenbaum
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Justin K Greisberg
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - J Turner Vosseller
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States.
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Fralinger DJ, Kaplan DJ, Weinberg ME, Strauss EJ, Jazrawi LM. Biological Treatments for Tendon and Ligament Abnormalities: A Critical Analysis Review. JBJS Rev 2016; 4:01874474-201606000-00005. [PMID: 27486722 DOI: 10.2106/jbjs.rvw.15.00079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The poor intrinsic healing potential of tendon and ligamentous tissue has driven the search for biological agents that can improve healing, most notably platelet-rich plasma (PRP) and autologous stem cells. Current evidence best supports the use of PRP as treatment for chronic, degenerative tendinopathies such as lateral epicondylitis of the elbow or patellar tendinopathy. It does not support the use of PRP to promote tendon or ligament-to-bone healing in rotator cuff repair or anterior cruciate ligament (ACL) reconstruction. Clinical evidence regarding the use of autologous stem cells as treatment for tendon and ligament abnormalities is currently limited. However, the initial results appear to be promising, particularly following rotator cuff repair. A major limitation in the evaluation of current data is the lack of standardization in the preparation and composition of PRP, which are often not reported. Future investigators should make an effort to report the method of preparation and final composition of PRP used. Autologous stem cells were most often harvested from bone marrow aspirate but were occasionally derived from dermal tenocyte cells. Recent studies have explored new sources for stem cells, including adipose tissue, peripheral blood, and human amniotic tissue. We expect that clinical data evaluating these treatments will soon emerge.
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Spennacchio P, Vascellari A, Cucchi D, Canata GL, Randelli P. Outcome evaluation after Achilles tendon ruptures. A review of the literature. JOINTS 2016; 4:52-61. [PMID: 27386448 DOI: 10.11138/jts/2016.4.1.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The optimal treatment and the best rehabilitation protocol after an acute Achilles tendon rupture (ATR) remain a matter of controversy in orthopaedic and sports medicine. The use of validated injury-specific outcome instruments is the only way to clarify these issues, in order to ensure that patients receive the best possible treatment. This article describes the most commonly reported outcome measures used to assess patients treated for ATR. On the basis of the available evidence, the Achilles tendon Total Rupture Score (ATRS) is the most appropriate outcome measure for evaluating the management of acute ATR.
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20
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Andia I, Maffulli N. Clinical Outcomes of Biologic Treatment for Chronic Tendinopathy. ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.oto.2015.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Şen B, Güler S, Çeçen B, Kumtepe E, Bağrıyanık A, Özkal S, Ali Özcan M, Özsan H, Şanlı N, Tatari MH. The Effect of Autologous Platelet Rich Plasma in the Treatment of Achilles Tendon Ruptures: An Experimental Study on Rabbits. Balkan Med J 2016; 33:94-101. [PMID: 26966624 DOI: 10.5152/balkanmedj.2015.15549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 06/03/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Achilles tendon ruptures are characterized by a long recovery period, high re-rupture rate and late return to work. To overcome these difficulties and augment tendon repair, many agents have been used. AIMS To determine the effect of autologous platelet rich plasma (PRP) in the treatment of Achilles tendon ruptures in rabbits. STUDY DESIGN Animal experimentation. METHODS The study included 14 New Zealand albino rabbits that were divided randomly into 2 groups, A and B, each containing seven rabbits. On day zero, all 28 Achilles tendons were tenotomized and repaired. In group A, the tendons were injected with PRP post-surgery, whereas those in group B were left untreated. On day 28, the right tendons in both groups were examined histopathologically via both light and electron microscopy, and the left tendons were subjected to biomechanical testing. RESULTS The histological and biomechanical findings in both light and electron microscopy in group A were better than those in group B, but the difference was not significant. According to Tang's scale, the mean value in Group A was 3.57, while it was 3.0 in Group B. The mean value of Group A for the length of collagen bands was 48.09 nm while the mean value of Group B was 46.58 nm (p=0.406). In biomechanical tests, although stiffness values were higher in group A, the difference between groups was not significant. In addition, maximum load values did not differ between groups A and B. CONCLUSION PRP had no effect on the healing process 28 days post-Achilles tendon rupture.
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Affiliation(s)
- Baran Şen
- Department of Orthopaedics and Traumatology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Serkan Güler
- Department of Orthopaedics and Traumatology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Berivan Çeçen
- Department of Biomechanics, Dokuz Eylül University Institute of Health Science, İzmir, Turkey
| | - Erdem Kumtepe
- Department of Biomechanics, Dokuz Eylül University Institute of Health Science, İzmir, Turkey
| | - Alper Bağrıyanık
- Department of Histology and Embriology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Sermin Özkal
- Department of Pathology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - M Ali Özcan
- Department of Hematology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Hayri Özsan
- Department of Hematology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Namık Şanlı
- Department of Hematology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - M Hasan Tatari
- Department of Orthopaedics and Traumatology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
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Heikkinen J, Lantto I, Flinkkilä T, Ohtonen P, Pajala A, Siira P, Leppilahti J. Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up. J Bone Joint Surg Am 2016; 98:85-92. [PMID: 26791028 DOI: 10.2106/jbjs.o.00496] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This prospective randomized trial with a mean fourteen-year follow-up compared simple end-to-end repair with fascial flap-augmented repair for acute Achilles tendon ruptures. METHODS From 1998 to 2001, sixty patients with acute Achilles tendon rupture were randomized to receive simple end-to-end repair or augmented repair; both groups were treated with postoperative bracing allowing free active plantar flexion. After a follow-up of thirteen years or more, fifty-five patients (twenty-eight in the nonaugmented-repair group and twenty-seven in the augmented-repair group) were reexamined. Outcome measures included the Leppilahti Achilles tendon score, isokinetic plantar flexion strength (peak torque and the work-displacement deficit at 10° intervals over the ankle range of motion), tendon elongation, and the RAND 36-item health survey. RESULTS After a mean of fourteen years of follow-up, the mean Leppilahti score was 87.1 points for the nonaugmented repairs and 91.5 points for the augmented repairs, with a mean difference of 4.3 points (95% confidence interval [CI], -0.1 to 8.8 points). The surgical technique did not have an impact on strength parameters, with a mean peak torque of 112.6 Nm after the nonaugmented repairs and 107.3 Nm after the augmented repairs (mean difference, 5.3 Nm [95% CI, -22.2 to 11.6 Nm]) and a median work-displacement deficit of 6.7% to 20.3% after the nonaugmented repairs and 12.8% to 18.0% after the augmented repairs (p = 0.9). Strength did not significantly change between the twelve-month and fourteen-year follow-up examinations. At a mean of fourteen years, the injured side showed a 12.2% to 18.0% median work-displacement deficit compared with the unaffected side (p < 0.001). RAND-36 scores indicated no between-group difference in health domains. CONCLUSIONS Augmented repair of total Achilles tendon ruptures provided no advantage over simple end-to-end repair. Achilles tendon ruptures result in a permanent calf muscle strength deficit, but its clinical relevance remains unclear. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Tapio Flinkkilä
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Ari Pajala
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Pertti Siira
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
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Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Kangas J, Siira P, Leppilahti J. Early functional treatment versus cast immobilization in tension after achilles rupture repair: results of a prospective randomized trial with 10 or more years of follow-up. Am J Sports Med 2015; 43:2302-9. [PMID: 26229048 DOI: 10.1177/0363546515591267] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are no long-term prospective controlled trials comparing postoperative regimens after Achilles tendon rupture repair. PURPOSE To compare ≥10-year outcomes of 2 postoperative regimens after Achilles tendon rupture repair: early weightbearing with early mobilization versus early weightbearing with early immobilization in tension. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 50 patients with acute Achilles tendon ruptures were randomized postoperatively to receive either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks (group 1) or Achilles tendon immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks (group 2). Patients were assessed at 3, 6, and 14 months and 11 years postoperatively. RESULTS There were 37 patients (74%) evaluated at a mean (±SD) of 11.0 ± 0.9 years. The mean Leppilahti score was 92.9 ± 5.6 in group 1 and 93.6 ± 7.2 in group 2 (P = .68). The mean isokinetic plantar flexion peak torque deficits or average work deficits in plantar flexion showed no differences between the groups with any angular velocity. Isokinetic strength changed minimally between 1 and 11 years compared with the unaffected ankle, but a mean deficit of 5% in peak torque and mean deficit of 8% in average work were still present after 11 years. On the contrary, isometric plantar flexion strength recovered significantly, with only a 2.4% difference at 11-year follow-up. CONCLUSION After the 11-year follow-up, early mobilization and immobilization in tension after Achilles rupture repair resulted in similar clinical outcomes and isokinetic strengths. Regardless of patient satisfaction with the operative treatment, calf muscle strength did not recover normally even at 11-year follow-up.
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Affiliation(s)
- Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tapio Flinkkila
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Jarmo Kangas
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pertti Siira
- Department of Physical Medicine and Rehabilitation, Oulu University Hospital, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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Andia I, Maffulli N. Muscle and tendon injuries: the role of biological interventions to promote and assist healing and recovery. Arthroscopy 2015; 31:999-1015. [PMID: 25618490 DOI: 10.1016/j.arthro.2014.11.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/30/2014] [Accepted: 11/13/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To summarize clinical studies after platelet-rich plasma (PRP) therapy for tendinopathy, plantar fasciopathy, and muscle injuries; to review PRP formulations used across studies; and to identify knowledge deficits that require further investigation. METHODS After a systematic review in PubMed, we identified clinical studies assessing PRP efficacy in tendon and muscle during the past decade. We standardized data extraction by grouping studies based on anatomic location; summarized patient populations, PRP formulations, and clinical outcomes; and identified knowledge deficits that require further investigation. RESULTS Overall, 1,541 patients had been treated with PRP in 58 clinical studies; of these, 26 addressed upper limb tendinopathies and 32 addressed the lower limb (810 patients and 731 patients treated with PRP, respectively). The quality of research is higher for the upper limb than for the lower limb (23 controlled studies, of which 17 are Level I, v 19 controlled studies, of which 6 are Level I, respectively). Patients have been treated mostly with leukocyte-platelet-rich plasma, except in the arthroscopic management of the rotator cuff. The safety and efficacy of PRP for muscle injuries has been addressed in 7 studies including 182 patients. Differences across results are mainly attributed to dissimilarities between tissues and different stages of degeneration, numbers of PRP applications, and protocols. CONCLUSIONS Given the heterogeneity in tendons and tendinopathies, currently, we are not able to decide whether PRP therapies are useful. Despite advances in PRP science, data are insufficient and there is a clear need to optimize protocols and obtain more high-quality clinical data in both tendinopathies and muscle injuries before making treatment recommendations. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
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Affiliation(s)
- Isabel Andia
- Regenerative Medicine Laboratory, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Dentistry, Salerno, Italy; Queen Mary University of London, London, England; Barts and The London School of Medicine and Dentistry, London, England; Centre for Sports and Exercise Medicine, Mile End Hospital, London, England.
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Allahverdi A, Sharifi D, Takhtfooladi MA, Hesaraki S, Khansari M, Dorbeh SS. Evaluation of low-level laser therapy, platelet-rich plasma, and their combination on the healing of Achilles tendon in rabbits. Lasers Med Sci 2015; 30:1305-13. [PMID: 25759233 DOI: 10.1007/s10103-015-1733-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/24/2015] [Indexed: 02/05/2023]
Abstract
Tendon repair is still one of the challenges for rehabilitation. Various treatments for tendon injuries have been used in recent decade. This study was established to investigate the effects of low-level laser therapy (LLLT), platelet-rich plasma (PRP) treatment alone, and using combined method on the healing of Achilles tendon in rabbits. Seventy-two healthy mature male white New Zealand rabbits were divided randomly into four groups of 18 animals each: control: partial tenotomy with no treatment, only 1 mL normal saline was injected on days 1, 8, and 15 at the site of splitting; PRP: partial tenotomy with PRP treatment on days 1, 8, and 15 at the site of splitting; LLLT: partial tenotomy with LLLT (K30 hand-held probe, AZOR, Technica, Russia, 650 nm, 30 mW, surface area = 1 cm(2), 60 S/cm(2), energy density = 1.8 J/cm(2)) for 15 consecutive days; LLLT + PRP: partial tenotomy with LLLT + PRP. At the end of trial, the rabbits were euthanatized and tendon specimens were harvested and were submitted for histopathological evaluation, hydroxyproline levels, and biomechanical measurement. The Tukey post hoc test was performed. The results for these parameters showed that PRP or LLLT alone has significant advantages over untreated animals (P < 0.05). Furthermore, it was found that the combined treatment with PRP and LLLT is even more efficient. There was no significant difference (P > 0.05) between the two groups of LLLT and PRP. However, the treatments combining PRP and LLLT showed significant results in comparison of PRP or LLLT alone (P < 0.05). Our results demonstrate that the healing time of injured tendon decreases by using the two therapies combined.
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Affiliation(s)
- Amin Allahverdi
- Young Researchers and Elites Club, Science and Research Branch, Islamic Azad University, Tehran, Iran,
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Lubowitz JH, Provencher MT, Brand JC, Rossi MJ. Thirty years brings major change. Arthroscopy 2015; 31:1-5. [PMID: 25554092 DOI: 10.1016/j.arthro.2014.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/10/2014] [Indexed: 02/02/2023]
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