The use of biologics for the elbow: a critical analysis review

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Elbow and Upper Extremity: An Orthoregeneration Network Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the elbow and upper extremity, including the tendons (lateral epicondylitis, medial epicondylitis, biceps tendonitis, triceps tendonitis), articular cartilage (osteoarthritis, osteochondral lesions), and bone (fractures, nonunions, avascular necrosis, osteonecrosis). Promising and established treatment modalities include hyaluronic acid; botulinum toxin; corticosteroids; leukocyte-rich and leukocyte-poor platelet-rich plasma; autologous blood; bone marrow aspirate comprising mesenchymal stromal cells (alternatively termed medicinal signaling cells and frequently mesenchymal stem cells [MSCs]) and bone marrow aspirate concentrate; MSCs harvested from adipose and skin (dermis) sources; vascularized bone grafts; bone morphogenic protein scaffold made from osteoinductive and conductive β-tricalcium phosphate and poly-ε-caprolactone with hydrogels, human MSCs, and matrix metalloproteinases; and collagen sponge. Autologous blood preparations such as autologous blood injections and platelet-rich plasma show positive outcomes for nonresponsive tendinopathy. In addition, cellular therapies such as tissue-derived tenocyte-like cells and MSCs show a promising ability to regulate degenerative processes by modulating tissue response to inflammation and preventing continuous degradation and support tissue restoration. LEVEL OF EVIDENCE: Level V, expert opinion.

[Treatment of lateral and medial epicondylopathy : Are platelet-rich plasma, shock wave therapy, etc. effective for both?]

Lateral and medial epicondylopathy (epicondylitis), which are common and in most cases self-limiting, frequently result in relevant reduction of quality of life and may also affect the ability to work. Recently, the use of orthobiologics, such as platelet-rich plasma (PRP), has been proposed to promote tendon regeneration and is supposed to be a valuable treatment option. However, scientific data are conflicting and the short- and long-time results are controversial. The use of stem cells is new approach and preliminary clinical data are promising. Shock wave therapy is widely used and part of the daily routine in treating lateral epicondylopoathy, although it is questionable for medial epicondylopathy.

Cell-based therapy of the elbow: evidence for lateral tendinopathy-a review on current treatments

PURPOSE

Cell-based therapies are on the rise in treating intra and extraarticular pathologies, trying to avoid surgical intervention and support local repair processes. Therefore, the aim was to summarize current evidence-based treatment options for a cell-based therapy around the elbow.

METHODS

Through a literature review up-to date treatment algorithms and therapies have been identified and have been rated according to their evidence level for clinical recommendation.

RESULTS

Regarding the four extraarticular anatomical regions of the elbow (anterior, medial, posterior and lateral) and the joint itself, the lateral elbow and its´ tendinopathies as well as the use of cell-based treatment options have been extensively studied and, therefore, allow for clear and evidence-based recommendations. The remaining three regions as wells as the intraarticular application do not show enough evidence for a clinical recommendation.

CONCLUSION

In conclusion the cell-based approach for treating elbow pathologies can only be recommended for the lateral elbow, as there has been shown sufficient evidence for the extraarticular application. It has to be mentioned, that the results from the lateral elbow maybe transferred to other extra-articular tendinopathies, as the lack of evidence may be due to the rare appearance of posterior, medial and anterior tendon affection. No recommendation can be given for intra-articular use.

LEVEL OF EVIDENCE

IV.

Cell-based therapies for the treatment of sports injuries of the upper limb

Introduction: The use of cell-based therapies in the management of sports injuries of the upper limb is increasingly popular despite the limited scientific evidence available for their use. We aim to evaluate the evidence for the use of cell-based therapies in these injuries and recommend areas for further research.Areas covered: In accordance with a published protocol (PROSPERO; Registration No. CRD42020193258), a comprehensive search of the literature was performed using the MEDLINE and EMBASE databases from inception to June 2020. All human studies reporting on the clinical, histological, or radiological outcomes following the use of cell-based therapies in the management of epicondylitis or rotator cuff pathology were included in this study. This resulted in 22 studies being included in this review, all of which underwent risk of bias assessments.Expert opinion: The evidence for the use of cell-based therapies in upper limb sports injuries is limited and generally of low quality. Given the heterogeneity in the cell types used, their harvesting methods and cell amounts, future research should be targeted at developing standardization of the reporting of these studies and more direct comparative studies looking at the efficacy of the different cell types.

Biologics in shoulder and elbow pathology

In recent years, orthobiologics have been of increasing clinical interest in the treatment of shoulder and elbow pathology. In some conditions, such as rotator cuff injury and lateral epicondylitis, there have been high-quality trials that support the use of platelet-rich plasma in reducing pain, restoring functionality, and improving clinical outcomes. However, as the numbers of both cellular-based biologics and the conditions being augmented by biologics continue to expand, there is a substantial need for high-quality investigations to support their routine use in most shoulder and elbow conditions. The purpose of this review is to summarize the current evidence of orthobiologics in the management of shoulder and elbow injury, as nonoperative treatment and as augments to operative treatment.

The use of dry needling vs. corticosteroid injection to treat lateral epicondylitis: a prospective, randomized, controlled study

BACKGROUND

Lateral epicondylitis (LE) is a common disease especially at middle age. Different types of treatments have been used to address LE. Corticosteroid (CS) injections and dry needling (DN) are utilized options in the treatment. However, the question of which one is better has not been entirely discussed in the literature. We hypothesized that the use of DN to treat LE would be at least as effective as using CS injections. We compared the pain relief afforded and improvements in functional disability after DN and CS injection.

METHODS

A total of 108 LE patients whose pain was not relieved by 3 weeks of first-line treatment were included in a randomized manner, using an online application into DN or CS groups (54 patients each). The minimum follow-up duration was 6 months. We recorded "Patient-Rated Tennis Elbow Evaluation" (PRTEE) scores before treatment and after 3 weeks and 6 months of treatment.

RESULTS

Seven patients were excluded for various reasons; thus, 101 patients were finally evaluated. Before treatment, the groups were similar in terms of age, symptom duration, and PRTEE score, but after treatment, DN-treated patients showed better improvement in the PRTEE score than CS-treated patients (P < .01). Both treatments were effective (both P < .01). From assessments at 3 weeks and 6 months post-treatment, PRTEE scores decreased over time. Four CS-treated patients (7.6%) developed skin atrophy and whitening. One DN-treated patient (2.04%) could not tolerate the pain of the intervention and withdrew from treatment.

CONCLUSION

DN and CS injection afforded significant improvements during the 6 months of follow-up. However, compared with CS injection, DN was more effective.

Platelet Concentrates in Musculoskeletal Medicine

Platelet concentrates (PCs), mostly represented by platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are autologous biological blood-derived products that may combine plasma/platelet-derived bioactive components, together with fibrin-forming protein able to create a natural three-dimensional scaffold. These types of products are safely used in clinical applications due to the autologous-derived source and the minimally invasive application procedure. In this narrative review, we focus on three main topics concerning the use of platelet concentrate for treating musculoskeletal conditions: (a) the different procedures to prepare PCs, (b) the composition of PCs that is related to the type of methodological procedure adopted and (c) the clinical application in musculoskeletal medicine, efficacy and main limits of the different studies.