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

Platelet-Poor versus Platelet-Rich Plasma for the Treatment of Muscle Injuries

ABSTRACT

Muscle injury in sport results in significant lost time and potential for reinjury for athletes. Autologous blood product, namely, platelet-rich plasma (PRP), has been investigated for possible augmentation of the treatment timeline with prevention of reinjury; however, conflicting results have been identified. A growing body of basic science and clinical literature is forming that supports the use of platelet-poor plasma (PPP) for muscle injury. The purpose of this study was to provide a background of the basic science of PRP versus PPP for muscle injury and to identify and review the clinical evidence for both autologous blood products, including the author's clinical experience utilizing the blood products. At the tissue level, PRP causes myoblast proliferation while PPP has led to myoblast induction, potentially identifying improved native muscle healing. Conflicting studies have been identified for the use of PRP for muscle injury. A growing body of positive results for PPP was identified, but high-quality comparative studies are needed.

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.

The Impact of Blood Morphological Parameters on Treatment Outcomes in Tennis Elbow Patients Receiving Platelet-Rich Plasma (PRP) Therapy: A Prospective Study

Platelet-rich plasma (PRP) therapy holds substantial promise for the treatment of tennis elbow, a complex and challenging musculoskeletal condition. The aim of the study was to assess whether there are correlations between the levels of individual morphotic elements determined in whole blood and the outcomes of tennis elbow treatment with PRP injection, as measured using patient-reported outcome measures (PROMs) such as the Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE). A prospective analysis was conducted on 107 patients (132 elbows) undergoing lateral epicondylitis treatment with (PRP) injections. Patients completed VAS, PRTEE, and QDASH questionnaires on the day of PRP administration and at established checkpoints (2, 4, 8, 12, 24, 52, and 104 weeks). Minimal clinically important difference (MCID) was employed to assess the treatment effects. Then, correlations were measured within each PROM, and the impact of the concentration of individual blood parameters on the MCID outcomes was assessed. Analyzing the relationships between the MCID+ and MCID- groups, significant correlations for the VAS and QDASH scales were observed. The level of individual morphotic elements in the blood may have influenced the treatment outcome, as measured using specific patient-reported outcome measures (PROMs). Regarding the VAS scale, factors favoring a positive treatment outcome included higher values of eosinophils (EOS) and basophils (BASO). For the QDASH scale, these factors were a lower value of mean corpuscular volume (MCV) and a higher mean corpuscular hemoglobin (MCH). The levels of certain blood parameters, such as EOS and BASO, in the current study influenced the classification of patients into MCID+ or MCID- groups, based on the VAS and QDASH scales.

Current concepts of natural course and in management of medial epicondylitis: a clinical overview

Medial epicondylitis (ME), called "golfer's elbow", is not frequent or serious disease but can cause symptoms that are bothersome in everyday life. Therefore knowledge about this condition may improve diagnostic-therapeutic process. In this article detailed information concerning pathophysiology and symptomatology of ME was described. Great attention was paid to issues related to the diagnosis of the disease both in terms of differentiation with other elbow disorders as well as examination techniques. Finally, current therapeutic options were presented in detail and their efficacy was discussed based on the available data.

The Potency of Platelet-Rich Plasma for Chronic Low Back Pain: A Systematic Review and Metaanalysis of Randomized Controlled Trial

Low back pain is one of the leading causes of disability in the world. Regenerative medicine can be one of the novel treatment breakthroughs in patients with low back pain, yet its use is still debatable. We performed a systematic evaluation and meta-analysis to determine the efficacy of platelet-rich plasma (PRP) treatment for patients with chronic low back pain. Comprehensive database searches were performed in four databases. This study was conducted and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses Guideline and registered to PROSPERO. We included and examined randomized controlled trials that looked into research employing PRP for patients with chronic low back pain. Outcomes of interest include clinical enhancement of pain, which is demonstrated in pain scores. Three studies were included comprising 138 patients with chronic low back pain. After 1, 3, and 6 months after injection, there was a substantial reduction in the pain score difference between the PRP and control groups, demonstrating PRP's superiority over the control group in the treatment of chronic low back pain. PRP injection significantly enhances chronic low back pain in the first, third, and sixth months after injection compared to controls.

Effect of platelet-rich plasma versus steroid injection in plantar fasciitis: a randomized clinical trial

BACKGROUND

Plantar fasciitis (PF) is a common orthopaedic problem, with heel pain worsening the quality of life. Although steroid injection is often used if the conservative treatment fails, Platelet-Rich Plasma (PRP) injection is gaining popularity due to its safety and long-lasting effect. However, the effect of PRP versus steroid injection in PF has not been studied yet in Nepal. Therefore, this study aimed to assess the effect of PRP compared with steroid injection in the treatment of PF.

METHODS

This study was a single-center, hospital-based, open-label, parallel-group randomized clinical trial to compare the effect of PRP injection with steroid injection in plantar fasciitis between August 2020 and March 2022. A total of 90 randomly selected participants aged 18 to 60 years suffering from plantar fasciitis with failed conservative treatment were intervened. The American Orthopaedic Foot and Ankle Society (AOFAS) and the Visual Analog Scale (VAS) scoring system were used to evaluate functional mobility and pain before and after the intervention for three and six months, respectively. Statistical analyses were performed using a Student's two-sample t-test. P-value < 0.05 was considered statistically significant.

RESULTS

The PRP injection showed a better outcome than the steroid injection in six months follow-up. The mean (± SD) VAS score was significantly decreased in the PRP group (1.97 + 1.13) than in the steroid group (2.71 ± 0.94) with the group difference of -0.73 (95% CI: -1.18 to -0.28) at six months. Similarly, there was a significant increase in the AOFAS scores in the PRP group (86.04 ± 7.45) compared to the steroid group (81.23 ± 9.60) at six months of follow-up with a group difference of 4.80 (95% CI: 1.15 to 8.45). There was also a significant reduction of plantar fascia thickness in the PRP group compared to that of the steroid group (3.53 ± 0.81 versus 4.58 ± 1.02) at six months of follow-up with the group difference of -1.04 (95% CI: -1.44 to -0.65).

CONCLUSION

The PRP injection showed better outcomes than steroid injection in plantar fasciitis treatment over the course of six months. Further research with a larger population and longer follow-up than six months is needed to generalize the findings and their long-term efficacy.

TRIAL REGISTRATION

NCT04985396. First registered on 02 August 2021. ( https://clinicaltrials.gov/ct2/show/NCT04985396 ).

Comparison of the Clinical Results of Platelet-Rich Plasma, Steroid and Autologous Blood Injections in the Treatment of Chronic Lateral Epicondylitis

BACKGROUND

The aim of our study is to compare the efficacy of PRP, steroids, and autologous blood injection in patients with chronic lateral epicondylitis.

METHOD

A total of 120 patients comprised our study. Three groups of 40 patients each received only one of the following: PRP, steroids, or autologous blood injections. Thereafter, VAS (visual analog scale), DASH (Disabilities of the Arm, Shoulder, and Hand), and Nirschl scores of those treated were evaluated in the second week, the fourth week, the third month, and the sixth month.

RESULTS

The baseline evaluation revealed no significant change in VAS, DASH, and Nirschl scores among the three groups (p > 0.050). At the second week evaluation, patients treated with steroids showed significant improvement compared to patients treated with PRP and autologous blood (p < 0.001). The fourth-week evaluation revealed the VAS, DASH, and Nirschl scores of the patients treated with steroids to have improved more significantly than those of patients treated with PRP and autologous blood (p < 0.001). The third month, when the results of all three groups were compared, revealed similar results (p > 0.050). The sixth-month evaluation, when the results of all three groups were compared, revealed the autologous blood and PRP applications provided significantly better results than the group treated with steroids (p < 0.001).

CONCLUSION

We concluded that steroid administration is effective in the short term, while PRP and autologous blood applications are more effective than steroid administration in the long term.

Percutaneous ultrasound-guided ulnar nerve release technique compared to open technique: A cadaveric study

Objectives: To evaluate the outcomes of a novel percutaneous ultrasound-guided technique for release of ulnar nerve entrapment at the elbow when compared to standard open release Methods: One single surgeon performed an ultrasound-guided percutaneous release of the cubital tunnel on a group of five cadaveric elbows and open release on five others. All procedures were timed, and incision lengths were recorded. Meticulous anatomic dissection was then performed to assess the complete release of the carpal tunnel and iatrogenic injuries. Results: No significant difference was found between the two groups in terms of complete release and iatrogenic injury, whereas Operative time was significantly shorter for the US-guided technique. Incomplete releases of the nerve were found only during the first two trials in each group, while the third, fourth, and fifth trials showed a complete ulnar nerve release in both series, highlighting a fast learning curve for both techniques. All of this through a significantly smaller incision in the US-guided technique. Conclusions: This study highlights the similar effects of these two techniques in terms of complete release of the ulnar nerve, with no clear superiority of one over the other in terms of morbidity rate. Both have a fast learning curve for an ultrasound-trained surgeon, with the US-guided technique being a less traumatic and quicker alternative procedure.

The use of platelet-rich plasma therapy in treating tennis elbow: A critical review of randomised control trials

Tennis elbow (TE) is a painful and debilitating condition of the elbow. Recently, the use of orthobiologics, such as platelet-rich-plasma (PRP), has been proposed to promote tendon regeneration. Despite their popularity, there is a paucity of updated reviews on the use of PRP compared with other treatment modalities for treating TE. The aim of this review is to summarise high quality studies that compare the use of PRP therapy with other therapies for TE and to identify areas where further research is warranted. This systematic review was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive literature search of PubMed, Scopus and Cochrane Library databases was undertaken in May 2021. Articles were screened for the following criteria: randomised control trials (RCTs) involving PRP in at least one of the treatment arms for tennis elbow. The quality of the RCTs included were analysed for their risk of bias using the modified Cochrane Collaboration Risk of Bias Assessment Tool for randomised trials. A total of 20 RCTs of which 1520 TE patients were analysed. The RCTs included in this review compared PRP with various treatment modalities routinely used in clinical practice such as physiotherapy, steroid injections, Autologous Whole Blood (AWB) and surgical interventions. With regards to the quality of RCTs, collectively, selection bias was found to be low risk however, performance bias in terms of blinding of participants and personnel performed poorly. Of the 20 RCTs, only 5 studies were classified as low risk of bias. In these 5 studies, 2 RCTs compared PRP with steroids and reported contrasting results, 1 RCT compared PRP with AWB injections which reported both to be similarly efficacious, 3 RCTs included a placebo group and only 1 reported superior effects with PRP. There are 2 main types of PRP classified according to the number of pro-inflammatory leukocyte i.e. leukocyte-rich and leukocyte-poor PRP. However, only 8 studies documented the formulation of PRP used. While the heterogeneity of PRP formulations could in-part explain the reported differences in outcomes, overall there is limited robust evidence to recommend PRP therapy for TE. Further research is required to establish the optimal formulation and administration of PRP injections. Proper documentation of TE patients need to be standardised before concrete recommendations on the use of PRP therapy may be offered.

Cell and Cell Free Therapies in Osteoarthritis

Osteoarthritis (OA) is the most common articular disease in adults and has a current prevalence of 12% in the population over 65 years old. This chronic disease causes damage to articular cartilage and synovial joints, causing pain and leading to a negative impact on patients' function, decreasing quality of life. There are many limitations regarding OA conventional therapies-pharmacological therapy can cause gastrointestinal, renal, and cardiac adverse effects, and some of them could even be a threat to life. On the other hand, surgical options, such as microfracture, have been used for the last 20 years, but hyaline cartilage has a limited regeneration capacity. In recent years, the interest in new therapies, such as cell-based and cell-free therapies, has been considerably increasing. The purpose of this review is to describe and compare bioregenerative therapies' efficacy for OA, with particular emphasis on the use of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). In OA, these therapies might be an alternative and less invasive treatment than surgery, and a more effective option than conventional therapies.

To Improve Pain and Function, Platelet-Rich Plasma Injections May Be an Alternative to Surgery for Treating Lateral Epicondylitis: A Systematic Review

PURPOSE

To determine whether platelet-rich plasma (PRP) injection for lateral epicondylitis offers patients comparable outcomes to lateral epicondylar surgery.

METHODS

Embase, Cochrane Library, and MEDLINE databases were searched using the terms lateral epicondylitis, lateral elbow pain, tennis elbow, lateral epicondylalgia, and elbow tendinopathy individually and combined with the terms platelet-rich plasma injections and lateral epicondylar surgery. We compared pain relief, function between the 2 treatment options, and identified whether PRP injection reduced the incidence of lateral epicondylar surgery. Studies must have compared PRP injections with lateral epicondylar surgery for the treatment of lateral epicondylitis; be of Level I, II, or III evidence; and be written in the English language.

RESULTS

Three studies (1 Level II and 2 Level III) met inclusion criteria. Two of the studies suggested that PRP injections offer similar relief as surgery in the short and mid-term, one study reported that PRP injections and surgery had similar outcomes in pain improvement and return to work, whereas 1 study reported that surgery may be a better long-term solution.

CONCLUSIONS

In comparison with lateral epicondylar surgery, PRP injections offer similar improvements in pain and function for patients suffering from lateral epicondylitis, especially in the short- and mid-term in 2 of the 3 included investigations. Therefore, PRP injections are an appropriate alternative for the treatment of lateral epicondylitis.

LEVEL OF EVIDENCE

Level III, Systematic Review of Level III or greater evidence.

Platelet-Rich Plasma versus Corticosteroid Injection for the Treatment of Lateral Epicondylitis: A Systematic Review of Systematic Reviews

BACKGROUND

Lateral epicondylitis (LE) is one of the most commonly reported musculoskeletal disorders in the upper extremity. The mechanism of LE is repetitive motion that causes a strain of the extensor tendons. This consequently causes pain and tendinosis at the tendinous attachment site on the lateral epicondyle. Most cases of LE are treated nonoperatively with a variety of interventions, such as injections.

PURPOSE

The aim of this systematic review (SR) is to synthesize the current evidence on the efficacy of platelet rich plasma (PRP) injections versus corticosteroid (CS) injections as treatment interventions for LE.

STUDY DESIGN

Systematic Review.

METHODS

Online databases were searched from database inception to February 24th, 2020 for relevant SR's evaluating PRP vs. CS injections as treatment methods for LE. Two independent researchers searched and screened for articles that were systematic reviews that directly compared PRP to CS injections for LE.

RESULTS

A total of five SR's were included in this review that were published between 2016 and 2020. CS injections were more efficacious for short-term pain relief, and PRP injections were more efficacious for long-term pain relief and improved function.

CONCLUSION

PRP injections appear to be a more effective long-term treatment option than CS injections for those with LE who did not respond to conservative management.

LEVEL OF EVIDENCE

1.

Platelet-rich plasma: a narrative review

The aim of this article was to synopsize platelet-rich plasma (PRP) use in musculoskeletal pathologies through evidence-based assessment of the preparation, classification, mechanism of action and applications of PRP, thereby answering which PRP type is best for each clinical indication.

The literature search was performed using Medline, EMBASE and Cochrane Reviews databases for papers containing the key terms “platelet-rich plasma” AND “orthopaedics” AND (“classification” OR “mechanism of action” OR “preparation” OR “clinical application”). Generated papers were evaluated for pertinence in following areas: preparation, classification, mechanism of action, clinical application within orthopaedics. Non-English papers were excluded. Included studies were evaluated for quality.

Sixty studies were included in our review. There are many commercial PRP preparation kits with differing component concentrations. There is no consensus on optimal component concentrations. Multiple PRP classifications exist but none have been validated. Platelet-rich plasma acts via growth factors (GFs) released from α-granules within platelets. Growth factors have been shown to be beneficial in healing. Grossly elevated concentrations of GFs may have inhibitory effects on healing. Multiple systematic reviews show efficacy of PRP in tendinopathies, early osteoarthritis, acute muscle injuries and in combination with rotator cuff repair and anterior cruciate ligament reconstruction.

The literature suggests leukocyte-rich PRP (L-PRP) is more beneficial in tendinopathies and pure PRP (P-PRP) is more beneficial in cartilage pathology. However, different PRP preparations have not been directly compared in any pathology. Classification of PRP type is frequently not stated in research. Standardization of PRP research parameters is needed to streamline findings and generate clear indications for PRP types to yield maximum clinical benefit.

Cite this article: EFORT Open Rev 2021;6:225-235. DOI: 10.1302/2058-5241.6.200017

Evidence-based indications of platelet-rich plasma therapy

Introduction: Platelet-rich plasma (PRP) is an autologous blood-derived product that contains platelet concentrations at least 2/3 times above the normal level and includes platelet-related growth factors. The concept of PRP began in the 1970s in the field of hematology to treat patients with thrombocytopenia. In the 1980s and 1990s, PRP began to be used in surgical procedures such as maxillofacial surgery and plastic surgery. Since then, PRP had been used in orthopedic procedures, cardiac surgery, sports injuries, plastic surgery, gynecology, urology, and more recently in medical esthetics. Areas covered: This review analyzes the mechanisms of action, current indications, clinical evidence, safety and future directions of PRP in the management of various medical conditions. The literature search methodology included using medical subject headings terms to search in PubMed. Articles used were screened and critically appraised by the coauthors of this review. Expert Opinion: Platelet-rich plasma is a therapeutic option used to treat many medical conditions. PRP could be used alone or in combination with other procedures. The effectiveness and safety of PRP has been demonstrated in many medical scenarios, however there is limited availability of large randomized clinical trials.

Biologics

Biologics are a growing field that has shown immense promise for the treatment of musculoskeletal conditions both in orthopedic sports medicine and interventional pain management. These procedures utilize injection of supraphysiologic levels of platelets and growth factors to invoke the body's own inflammatory cascade to augment the healing of many bony and soft tissue conditions. While many patients improve with conservative care, there is a need to address the gap between those that improve with rehabilitation alone and those who ultimately require operative management. Orthobiologic procedures have the potential to fill this void. The purpose of this review is to summarize the basic science, evidence for use, and post-injection rehabilitation concepts of platelet-rich plasma (PRP) and mesenchymal stromal cells (MSCs) as they pertain to joints, tendons, ligaments, and the spine.

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.

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.

Management of lateral epicondylitis

Lateral epicondylitis is the most common cause of lateral elbow pain. Although also known as tennis elbow, lateral epicondylitis often develops as a work-related condition and therefore constitutes a major public health issue. This article reviews the pathophysiological factors involved in lateral epicondylitis, as well as the tools available for establishing the diagnosis and ruling out other causes of lateral elbow pain. Finally, the non-operative and surgical treatment options are discussed in detail.

Efficacy of platelet-rich plasma for non-transfusion use: Overview of systematic reviews

INTRODUCTION

Platelet-rich plasma (PRP) is a blood component therapy with a supraphysiological concentration of platelets derived from allogenic or, more commonly, autologous blood. PRP has been used in different non-transfusion indications because of its role in the promotion of tissue repair and healing, in fields such as Traumatology, Dermatology and Dentistry.

OBJECTIVE

To provide a synthesis of the efficacy of PRP for different clinical situations.

METHODS

Systematic searches were carried out in MEDLINE, Embase, Cochrane Library and LILACS in July 2018 to identify systematic reviews (SRs) of randomized clinical trials (RCTs) focusing on PRP for non-transfusion use. Two authors independently screened all retrieved references in two stages (titles and abstracts at a first stage and full texts at a second stage). The methodological quality of SRs that met the eligibility criteria was appraised by AMSTAR 2. Conclusions were based on the most recent SRs with highest quality.

RESULTS

One thousand two hundred and forty references were retrieved. After checking the inclusion criteria, 29 SRs of RCTs related to three different fields (wound care, Orthopedics and Dentistry) were included. The results suggest the benefit of PRP for different clinical situations, such as diabetic wounds, acute lesions of musculoskeletal system, rotator cuff lesions, tendinopathies, knee and hip osteoarthritis, total knee arthroplasty, allogenic bone graft for dental implants and periodontal intrabony defects.

CONCLUSION

There is low to moderate quality evidence supporting the efficacy of PRP for specific clinical situations. The low quality of the evidence limits the certainty of these findings. Well-planned and well-conducted RCTs are still needed to further assess the efficacy of PRP.

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

There is significant interest in biologic treatment options to improve the healing environment and more rapidly decrease symptoms in many conditions around the elbow. Despite fairly widespread use of biologic agents such as platelet-rich plasma (PRP) in the elbow, there is a lack of clear evidence in the literature to support its use. The potential impact of these biologic agents must be evaluated with evidence from high-quality studies, particularly considering the high financial burden these treatments often impose on patients. The aim of this review is to provide an evidence-based summary of the biologic augmentation options available for use by the physician treating painful conditions of the elbow and to identify areas where further research is warranted.

Shock-wave therapy versus corticosteroid injection on lateral epicondylitis: a meta-analysis of randomized controlled trials

Background: Shock-wave (SW) therapy has been widely promoted and proven to be effective in ameliorating symptoms of lateral epicondylitis (LE) during recent years. Corticosteroid (CS) injection is another common treatment of LE, and several researches have documented its significant effect in the treatment of LE. Despite this, few studies have focused on comparing the use of SW and CS in the treatment of LE. The aim of this meta-analysis is to assess whether SW is superior to CS in managing LE, both in terms of ameliorating pain and improving functionality. Methods: A systematic search of the literature was conducted to identify relevant articles that were published in Pubmed, Medline, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov and OVID from the databases' inception to December 2018. All studies comparing the efficacy of SW and CS in terms of pain levels and functionality improvement were included. Data on the two primary outcomes were collected and analyzed using the Review Manager 5.3. Results: Four studies were included in the current meta-analysis. A significant difference in VAS score (SMD = 1.13, Cl 0.72-1.55 P < 0.00001, I² = 0) was noted between the SW group and the CS group. Furthermore, Significant difference was also seen in the term of grip strength (including HGS and GSS scoring system) (SMD = -1.42, Cl -1.85--0.98 P < 0.00001, I² = 0). Conclusions: In light of the better improvement in the terms of VAS and grip strength with follow-up more than 12 weeks, we assume that SW may be a superior alternative for the treatment of LE.

Long-term follow-up of platelet-rich plasma injections for refractory lateral epicondylitis

Background

Lateral epicondylitis (LE)¹ affects between 1 and 3% of the population. Recently, platelet-rich plasma (PRP)² has gained popularity.

Aim

Assess the long-term outcomes of PRP for patients with refractory LE.

Methods

We assessed 31 patients who had failed conservative management using the Oxford Elbow Score (OES).³.

Results

Mean follow-up: 5.2 years (range 4.2-6.1 years).87.1% exhibited minimum clinically important difference (MCID)⁴ in pain scores between pre-op and long-term. 90.3% displayed MCID in function and psycho-social domains.Two patients had a repeat injection and six underwent open release.

Discussion

PRP is successful in treating refractory LE in most patients and avoiding surgery.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Chronic lateral epicondylitis: challenges and solutions

Lateral epicondylitis (LE) is a significant source of pain and dysfunction resulting from repetitive gripping or wrist extension, radial deviation, and/or forearm supination. Although most cases are self-limiting over several years, controversy exists regarding the best treatment strategy for chronic LE. Nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), shockwave therapy, and injections with corticosteroids or biologics are all conservative treatment options for LE. For refractory cases, surgical options include open, arthroscopic, and percutaneous techniques. In this review, the current evidence behind these treatment strategies is presented. The data demonstrate that NSAIDs, PT, bracing, and shockwave therapy provide limited benefit for treating LE. Biologics such as platelet-rich plasma and autologous whole-blood injections may be superior to steroid injections in the long-term management of LE. Although the initial results are promising, larger comparative studies on stem cell injections are needed. For refractory LE, open, arthroscopic, and percutaneous techniques are all highly effective, with no method seemingly superior over another. Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work.