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Goldberg AJ, Masci L, O'Donnell P, Green R, Brooking D, Bassett P, Lowdell MW, Smith RKW. Autologous bone marrow derived mesenchymal stem cells are safe for the treatment of Achilles tendinopathy. Sci Rep 2024; 14:11421. [PMID: 38763976 PMCID: PMC11102920 DOI: 10.1038/s41598-024-61399-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/06/2024] [Indexed: 05/21/2024] Open
Abstract
Achilles tendinopathy is a disabling condition that affects more than 50% of runners. Pre-clinical studies in a large animal model of naturally-occurring tendinopathy similar to human Achilles tendinopathy has shown benefits of autologous bone marrow-derived mesenchymal stem cell (MSC) implantation. However, MSCs are advanced therapies medicinal products (ATMPs), with strict regulatory requirements. Guided by the regulator we carried out a first in man study to assess the safety and efficacy of autologous MSC injection in human patients with non-insertional Achilles tendinopathy. Ten patients, mean age 47 with mid-portion Achilles tendon pain and swelling for more than 6 months, underwent autologous cultured cell injections (median 12.2 × 106, range 5-19 × 106 cells) into their Achilles tendon. At 24 weeks follow-up, no serious adverse reactions or important medical events were observed. MOXFQ, EQ-5D-5L, and VISA-A scores improved clinically at 12 and 24 weeks. VAS pain improved increasingly at 6, 12 and 24 weeks. MOXFQ Pain and VISA-A Scores improved > 12 points from baseline to 24 weeks in 8 patients. Maximum anteroposterior tendon thickness as measured by greyscale US decreased by mean 0.8 mm at 24 weeks. This phase IIa study demonstrated the safety of autologous MSC injection for non-insertional Achilles tendinopathy and provides proof-of-concept of the technique in patients, all of whom had previously failed conservative treatments for chronic disease and leads the way for a larger randomised controlled trial.
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Affiliation(s)
- Andrew J Goldberg
- Division of Surgery, UCL Institute of Orthopaedics & Musculoskeletal Science, Royal Free Hospital, 9th Floor (East), 2QG, 10 Pond St, London, NW3 2PS, UK.
- Department of Research and Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, UK.
- MSK Lab, Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London, SW7 2AZ, UK.
- The London Ankle & Arthritis Centre, The Wellington Hospital, Wellington Place, London, NW8 9LE, UK.
| | - Lorenzo Masci
- Institute of Sport Exercise and Health, Tottenham Court Road, London, UK
| | - Paul O'Donnell
- Division of Surgery, UCL Institute of Orthopaedics & Musculoskeletal Science, Royal Free Hospital, 9th Floor (East), 2QG, 10 Pond St, London, NW3 2PS, UK
- Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Ruth Green
- Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Deirdre Brooking
- Department of Research and Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, UK
| | - Paul Bassett
- Statsconsultancy Ltd., 40 Longwood Lane, Amersham, Bucks, HP7 9EN, UK
| | - Mark W Lowdell
- Centre for Cell, Gene & Tissue Therapeutics, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
| | - Roger K W Smith
- Department of Veterinary Clinical Sciences and Services, The Royal Veterinary College, Hawkshead Lane, Hatfield, Hertfordshire, AL9 7TA, UK
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Biedermann BM, Fathi A, Kotlier JL, Lamb CJ, Ahmad A, Bolia IK, Mayfield C, Petrigliano FA, Liu JN. Results of Randomized Controlled Trials of Platelet-Rich Plasma in Lower-Extremity Tendinopathy Are Not Influenced by Industry Sponsorship. Arthroscopy 2024:S0749-8063(24)00301-3. [PMID: 38703920 DOI: 10.1016/j.arthro.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/22/2024] [Accepted: 04/02/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE To determine whether industry affiliation influences the results of randomized controlled trials (RCTs) studying the use of platelet-rich plasma (PRP) for the treatment of patellar or Achilles tendinopathy. METHODS The PubMed, Scopus, Cochrane, and MEDLINE databases were searched in July 2023 for RCTs investigating PRP for the treatment of patellar or Achilles tendinopathy published between 2009 and July 2023. Industry affiliation was determined by analyzing each study's funding or conflict-of-interest section. Author disclosures were searched in the American Academy of Orthopaedic Surgeons disclosure database and the Centers for Medicare & Medicaid Services open payments database. An industry-affiliated (IA) designation was given if an author had a relevant disclosure or if the company that funded the study manufactured PRP. Otherwise, a non-industry-affiliated (NIA) designation was given. Fisher exact analysis was used to determine whether PRP had a favorable effect, no significant effect, or an unfavorable effect on outcome. RESULTS Analysis was performed on 22 studies (10 IA and 12 NIA), with 17 studies (77.3%) reporting a conflict of interest or funding for the research, 4 (18.2%) reporting no conflict of interest, and 1 (4.5%) with no reporting. Of the 22 included studies, 8 (36.4%) reported favorable outcomes regarding PRP use and 14 (63.6%) reported no significant effect. Favorable outcomes were found in 4 of the 10 IA studies (40.0%), whereas no significant effect was reported in 6 (60.0%). The 12 NIA studies included 4 (33.3%) with favorable results and 8 (66.7%) with no significant effect. The comparison between industry affiliation and results reported was not statistically significant (P > .999). CONCLUSIONS The results of RCTs evaluating the use of PRP in lower-extremity tendinopathy were not influenced by industry sponsorship. CLINICAL RELEVANCE Most biomedical research is funded through industry sponsorship. Although this relation is necessary as technologies are developed, it is important to scrutinize studies for evidence of industry bias to understand how this bias may be affecting study results published in the literature.
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Affiliation(s)
- Brett M Biedermann
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A..
| | - Amir Fathi
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Jacob L Kotlier
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Chris J Lamb
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Aamir Ahmad
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Ioanna K Bolia
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Cory Mayfield
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Frank A Petrigliano
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Joseph N Liu
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
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Schneider N, Sinnott M, Patel N, Joseph R. The Use of Platelet-Rich Plasma and Stem Cell Injections in Musculoskeletal Injuries. Cureus 2024; 16:e59970. [PMID: 38854175 PMCID: PMC11162264 DOI: 10.7759/cureus.59970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
Injuries to the musculoskeletal (MSK) system can have a significant impact on an individual's activities of daily living, as this multifunctional unit is associated with physical movement. Treatment of MSK injuries often involves corticosteroid injections, supplements, pharmaceutical agents, and/or surgery. While these approaches have been shown to be effective for some patients over both the short and long term, they can be associated with limited relief, adverse effects, and/or decreases in activities of daily living. An unmet need exists to develop and/or implement more effective treatment approaches for MSK injuries. Treatment options being explored include platelet-rich plasma (PRP) and stem cell injections. This review outlines the current state of research evaluating PRP and stem cell injections in the treatment of various MSK injuries. A literature search was conducted using the PubMed database to identify the relevant published articles related to the use of PRP and/or stem cell injections for the treatment of MSK and cartilage injuries. PRP and stem cell injections have been shown to improve an individual's quality of life (QOL) and are associated with fewer side effects as compared to invasive standards of care in multiple MSK injuries such as plantar fasciitis, Achilles tendinopathy, acute muscle and tendon tears, ligament injuries, chondral and medial collateral ligament (MCL) knee injuries and arthritis, rotator cuff lesions, and avascular femoral necrosis. Specifically, these studies on PRP and stem cell injections suggest that both approaches are associated with a quicker return to activities of daily living while providing longer lasting relief without significant adverse events. The studies reviewed demonstrated PRP and stem cell approaches to be effective and safe for the treatment of certain MSK injuries, but as standardized protocols were not utilized across studies in the discussion of similar injuries, it was therefore difficult to compare their efficacy and safety. As such, further research is warranted to establish standardized research protocols across MSK injury studies to gain further insight into the efficacy, safety, and durability of PRP and stem cell injections.
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Affiliation(s)
- Nicole Schneider
- Sports Medicine Department, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, USA
| | - Michael Sinnott
- Sports Medicine Department, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Nikita Patel
- Sports Medicine Department, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, USA
| | - Roody Joseph
- Sports Medicine Department, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, USA
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Lim JJ, Belk JW, Wharton BR, McCarthy TP, McCarty EC, Dragoo JL, Frank RM. Most Orthopaedic Platelet-Rich Plasma Investigations Don't Report Protocols and Composition: An Updated Systematic Review. Arthroscopy 2024:S0749-8063(24)00243-3. [PMID: 38522650 DOI: 10.1016/j.arthro.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 02/28/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE To systematically review the literature to assess the heterogeneity of platelet-rich plasma (PRP) preparation and composition reporting for the treatment of musculoskeletal/orthopaedic pathologies. METHODS A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I and Level II studies from 2016 to 2022 that evaluated the use of PRP therapy for musculoskeletal pathologies. The search phrase used was "platelet-rich plasma clinical studies." Studies were assessed based on their reporting of the PRP preparation methods and reporting of PRP composition. RESULTS One hundred twenty-four studies (in 120 articles) met inclusion criteria for analysis. Of these studies, 15 (12.1%) provided comprehensive reporting, including a clear, well-described, and reproducible preparation protocol that future investigators can follow. Thirty-three studies (26.6%) quantitatively reported the final PRP product composition. CONCLUSIONS Among the studies using PRP for the treatment of musculoskeletal/orthopaedic pathologies, less than 20% provided a clear, well-described, and reproducible PRP preparation protocol, and only one-fourth of studies reported on the final PRP product composition. CLINICAL RELEVANCE A diverse current reporting of PRP composition between studies provides a high heterogeneity of the term "PRP," which becomes a limitation for a comparison of studies using PRP.
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Affiliation(s)
- Joseph J Lim
- University of Colorado Boulder, Boulder, Colorado, U.S.A..
| | - John W Belk
- University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | | | - Timothy P McCarthy
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Jason L Dragoo
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Rachel M Frank
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
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DeFoor MT, Cognetti DJ, Yuan TT, Sheean AJ. Treatment of Tendon Injuries in the Servicemember Population across the Spectrum of Pathology: From Exosomes to Bioinductive Scaffolds. Bioengineering (Basel) 2024; 11:158. [PMID: 38391644 PMCID: PMC10886250 DOI: 10.3390/bioengineering11020158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/28/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Tendon injuries in military servicemembers are one of the most commonly treated nonbattle musculoskeletal injuries (NBMSKIs). Commonly the result of demanding physical training, repetitive loading, and frequent exposures to austere conditions, tendon injuries represent a conspicuous threat to operational readiness. Tendon healing involves a complex sequence between stages of inflammation, proliferation, and remodeling cycles, but the regenerated tissue can be biomechanically inferior to the native tendon. Chemical and mechanical signaling pathways aid tendon healing by employing growth factors, cytokines, and inflammatory responses. Exosome-based therapy, particularly using adipose-derived stem cells (ASCs), offers a prominent cell-free treatment, promoting tendon repair and altering mRNA expression. However, each of these approaches is not without limitations. Future advances in tendon tissue engineering involving magnetic stimulation and gene therapy offer non-invasive, targeted approaches for improved tissue engineering. Ongoing research aims to translate these therapies into effective clinical solutions capable of maximizing operational readiness and warfighter lethality.
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Affiliation(s)
- Mikalyn T DeFoor
- San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
| | - Daniel J Cognetti
- San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
| | - Tony T Yuan
- Advanced Exposures Diagnostics, Interventions and Biosecurity Group, 59 Medical Wing, Lackland Air Force Base, San Antonio, TX 78236, USA
- Center for Biotechnology (4D Bio3), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew J Sheean
- San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
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Mao XF, Zhang XQ, Yao ZY, Mao HJ. Advances in mesenchymal stem cells therapy for tendinopathies. Chin J Traumatol 2024; 27:11-17. [PMID: 38052701 PMCID: PMC10859297 DOI: 10.1016/j.cjtee.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 10/13/2023] [Accepted: 11/07/2023] [Indexed: 12/07/2023] Open
Abstract
Tendinopathies are chronic diseases of an unknown etiology and associated with inflammation. Mesenchymal stem cells (MSCs) have emerged as a viable therapeutic option to combat the pathological progression of tendinopathies, not only because of their potential for multidirectional differentiation and self-renewal, but also their excellent immunomodulatory properties. The immunomodulatory effects of MSCs are increasingly being recognized as playing a crucial role in the treatment of tendinopathies, with MSCs being pivotal in regulating the inflammatory microenvironment by modulating the immune response, ultimately contributing to improved tissue repair. This review will discuss the current knowledge regarding the application of MSCs in tendinopathy treatments through the modulation of the immune response.
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Affiliation(s)
- Xu-Feng Mao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Ningbo University, Ningbo, 315010, Zhejiang province, China
| | - Xi-Qian Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Ningbo University, Ningbo, 315010, Zhejiang province, China
| | - Zhe-Yu Yao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Ningbo University, Ningbo, 315010, Zhejiang province, China
| | - Hai-Jiao Mao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Ningbo University, Ningbo, 315010, Zhejiang province, China.
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Arner JW, Kaeding CC, Bradley JP. Management of Patellar Tendinopathy. Arthroscopy 2024; 40:13-15. [PMID: 38123261 DOI: 10.1016/j.arthro.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 09/08/2023] [Indexed: 12/23/2023]
Abstract
Patellar tendinopathy is a common pathology typically seen in athletes involved in repetitive explosive jumping and running activities. Also known as jumpers' knee, it is commonly seen in high-level basketball players. Typically, athletes continue to play with symptoms, which can be aggravated and progress to partial patellar tendon tears. When partial patellar tendon tears occur, prolonged recovery and decreased performance is commonly seen. The pathology and treatment can be frustrating for both the athlete and medical provider. Patellar tendinopathy typically does not involve inflammation but rather microinjury to the tendon fibers, which leads to mucoid degeneration, necrosis, and loss of transitional fibrocartilage. When partial tendon tears do occur, the typical location is posteromedially adjacent to the patella. Treatment involves a stepwise approach starting with nonoperative means, including activity modification, nonsteroidal anti-inflammatories, and physical therapy focused on eccentrics. Extracorporeal shock wave treatments and injections with platelet-rich plasma or bone marrow aspirate concentrate should be considered, with evolving literature to support their use. Ultrasound percutaneous tendon scrapping with a needle supplemented with the aforementioned injections is an emerging treatment option that the authors have found to be helpful, although further studies are required. Surgical intervention is considered after failure of nonoperative treatments, and typically occurs in tears greater than 50% of the tendon thickness and in tendons with increased thickness (>8.8 mm). Open or arthroscopic debridement can be considered, with no studies showing superior outcomes with either technique; however, no high-quality comparison studies exist. The authors prefer an open technique where, much like a bone-patellar tendon-bone harvest, the unhealthy proximal tendon and bone are excised with then closure of the healthy tendon with absorbable sutures. Suture anchor repair may also be used when necessary. In a recent systematic review, surgical management of patellar tendinopathy has been shown to result in improved patient-reported outcomes with return to sport at high levels.1 Treatment for the difficult and sometimes frustrating pathology of patellar tendinopathy continues to evolve, with biologic and less-invasive ultrasound-based treatments showing promise, and surgical intervention providing reliable outcomes.
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Affiliation(s)
- Justin W Arner
- Department of Orthopaedic Surgery, Burke and Bradley Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A..
| | | | - James P Bradley
- Department of Orthopaedic Surgery, Burke and Bradley Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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Li XH, Xiao HX, Wang ZX, Tang XR, Yu XF, Pan YP. Platelet Concentrates Preconditioning of Mesenchymal Stem Cells and Combined Therapies: Integrating Regenerative Strategies for Enhanced Clinical Applications. Cell Transplant 2024; 33:9636897241235460. [PMID: 38506426 PMCID: PMC10956156 DOI: 10.1177/09636897241235460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/10/2024] [Accepted: 02/10/2024] [Indexed: 03/21/2024] Open
Abstract
This article presents a comprehensive review of the factors influencing the efficacy of mesenchymal stem cells (MSCs) transplantation and its association with platelet concentrates (PCs). It focuses on investigating the impact of PCs' composition, the age and health status of platelet donors, application methods, and environmental factors on the outcomes of relevant treatments. In addition, it delves into the strategies and mechanisms for optimizing MSCs transplantation with PCs, encompassing preconditioning and combined therapies. Furthermore, it provides an in-depth exploration of the signaling pathways and proteomic characteristics associated with preconditioning and emphasizes the efficacy and specific effects of combined therapy. The article also introduces the latest advancements in the application of biomaterials for optimizing regenerative medical strategies, stimulating scholarly discourse on this subject. Through this comprehensive review, the primary goal is to facilitate a more profound comprehension of the factors influencing treatment outcomes, as well as the strategies and mechanisms for optimizing MSCs transplantation and the application of biomaterials in regenerative medicine, offering theoretical guidance and practical references for related research and clinical practice.
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Affiliation(s)
- Xu-huan Li
- The 4th Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Han-xi Xiao
- The 4th Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Zu-xiu Wang
- The 4th Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Xin-rong Tang
- The 4th Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Xue-feng Yu
- The 4th Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yong-ping Pan
- The 4th Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
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Soler R, Rodas G, Rius-Tarruella J, Alomar X, Balius R, Ruíz-Cotorro Á, Masci L, Maffulli N, Orozco L. Safety and Efficacy of Bone Marrow-Derived Mesenchymal Stem Cells for Chronic Patellar Tendinopathy (With Gap >3 mm) in Patients: 12-Month Follow-up Results of a Phase 1/2 Clinical Trial. Orthop J Sports Med 2023; 11:23259671231184400. [PMID: 37711505 PMCID: PMC10498712 DOI: 10.1177/23259671231184400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/05/2023] [Indexed: 09/16/2023] Open
Abstract
Background In a previous study, the authors found that at 6 months after treatment with a 20 × 106 dose of bone marrow-derived mesenchymal stem cells (BM-MSCs), patients showed improved tendon structure and regeneration of the gap area when compared with treatment using leukocyte-poor platelet-rich plasma (Lp-PRP). The Lp-PRP group (n = 10), which had not seen tendon regeneration at the 6-month follow-up, was subsequently offered treatment with BM-MSCs to see if structural changes would occur. In addition, the 12-month follow-up outcomes of the original BM-MSC group (n = 10) were evaluated. Purpose To evaluate the outcomes of all patients (n = 20) at 12 months after BM-MSC treatment and observe if the Lp-PRP pretreated group experienced any type of advantage. Study Design Cohort study; Level of evidence, 2. Methods Both the BM-MSC and original Lp-PRP groups were assessed at 12 months after BM-MSC treatment with clinical examination, the visual analog scale (VAS) for pain during daily activities and sports activities, the Victorian Institute of Sport Assessment-Patella score for patellar tendinopathy, dynamometry, and magnetic resonance imaging (MRI). Differences between the 2 groups were compared with the Student t test. Results The 10 patients originally treated with BM-MSCs continued to show improvement in tendon structure in their MRI scans (P < .0001), as well as in the clinical assessment of their pain by means of scales (P < .05). Ten patients who were originally treated with Lp-PRP and then with BM-MSCs exhibited an improvement in tendon structure in their MRI scans, as well as a clinical pain improvement, but this was not significant on the VAS for sports (P = .139). Thus, applying Lp-PRP before BM-MScs did not yield any type of advantage. Conclusion The 12-month follow-up outcomes after both groups of patients (n = 20) received BM-MSC treatment indicated that biological treatment was safe, there were no adverse effects, and the participants showed a highly statistically significant clinical improvement (P < .0002), as well as an improvement in tendon structure on MRI (P < .0001). Preinjection of Lp-PRP yielded no advantages.
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Affiliation(s)
- Robert Soler
- Institut de Teràpia Regenerativa Tissular (ITRT), Centro Médico Teknon Hospital, Barcelona, Spain
| | - Gil Rodas
- Medical Department FC Barcelona, Barcelona, Spain
- Sports Medicine Unit, Clínic Hospital and Sant Joan de Déu Hospital, Barcelona, Spain
| | - Joan Rius-Tarruella
- Institut de Teràpia Regenerativa Tissular (ITRT), Centro Médico Teknon Hospital, Barcelona, Spain
| | - Xavier Alomar
- Diagnóstico por la Imagen, Clínica Creu Blanca, Barcelona, Spain
| | - Ramon Balius
- Consell Català de l’Esport, Generalitat de Catalunya, Barcelona, Spain
| | - Ángel Ruíz-Cotorro
- Servicios Médicos de la Real Federación Española de Tenis (RFET), Barcelona, Spain
- Director de la Clínica Tenis Teknon, Centro Médico Teknon, Barcelona, Spain
| | - Lorenzo Masci
- Institute of Sports Exercise and Health (ISEH), London, UK
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine, Surgery and Dentistry, Salerno, Italy
- Center of Sports and Exercise Medicine, Queen Mary University of London, London, UK
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Staffordshire, UK
| | - Lluís Orozco
- Institut de Teràpia Regenerativa Tissular (ITRT), Centro Médico Teknon Hospital, Barcelona, Spain
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10
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Sugrañes J, Jackson GR, Mameri ES, Schundler S, Obioha OA, Pascual TA, Chahla J. Current Concepts in Patellar Tendinopathy: An Overview of Imaging, Pathogenesis, and Nonoperative and Operative Management. JBJS Rev 2023; 11:01874474-202308000-00007. [PMID: 37590404 DOI: 10.2106/jbjs.rvw.23.00076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
» Approximately 1 in 3 high-impact athletes develops patellar tendinopathy (PT), with the proximal insertion of the patellar tendon being the most commonly affected anatomical site.» Nonoperative treatment options are effective in reducing pain and restoring functionality in most patients with PT. However, operative intervention should be considered when conservative management fails.» A comprehensive review of the literature on surgical procedures, including both open and arthroscopic approaches, was conducted with a specific focus on clinical outcomes and return to sports.» Both open surgery and arthroscopic surgery for PT have demonstrated favorable success rates and return-to-sport outcomes, with arthroscopic treatment potentially expediting the recovery process.
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Affiliation(s)
- Joan Sugrañes
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
- Department of Orthopaedics and Traumatology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Garrett R Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Enzo S Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
- Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Sabrina Schundler
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Obianuju A Obioha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Tomás A Pascual
- Department of Radiology, HIMAN Barrio Norte, Buenos Aires, Argentina
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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11
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Li C, Wang J, Yang W, Yu K, Hong J, Ji X, Yao M, Li S, Lu J, Chen Y, Yan S, Wu H, Ma C, Yu X, Jiang G, Liu A. 3D-printed hydrogel particles containing PRP laden with TDSCs promote tendon repair in a rat model of tendinopathy. J Nanobiotechnology 2023; 21:177. [PMID: 37268942 DOI: 10.1186/s12951-023-01892-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/11/2023] [Indexed: 06/04/2023] Open
Abstract
Long-term chronic inflammation after Achilles tendon injury is critical for tendinopathy. Platelet-rich plasma (PRP) injection, which is a common method for treating tendinopathy, has positive effects on tendon repair. In addition, tendon-derived stem cells (TDSCs), which are stem cells located in tendons, play a major role in maintaining tissue homeostasis and postinjury repair. In this study, injectable gelatine methacryloyl (GelMA) microparticles containing PRP laden with TDSCs (PRP-TDSC-GM) were prepared by a projection-based 3D bioprinting technique. Our results showed that PRP-TDSC-GM could promote tendon differentiation in TDSCs and reduce the inflammatory response by downregulating the PI3K-AKT pathway, thus promoting the structural and functional repair of tendons in vivo.
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Affiliation(s)
- Congsun Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Jie Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Weinan Yang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Kang Yu
- State Key Laboratory of Fluid Power and Mechatronic Systems, School of Mechanical Engineering, Hangzhou, Zhejiang, PR China
| | - Jianqiao Hong
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Xiaoxiao Ji
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
| | - Minjun Yao
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Sihao Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Jinwei Lu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Yazhou Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Shigui Yan
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Haobo Wu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Chiyuan Ma
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Xiaohua Yu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China.
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China.
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China.
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China.
| | - Guangyao Jiang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China.
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China.
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China.
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China.
| | - An Liu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China.
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China.
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China.
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China.
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12
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Pintore A, Notarfrancesco D, Zara A, Oliviero A, Migliorini F, Oliva F, Maffulli N. Intra-articular injection of bone marrow aspirate concentrate (BMAC) or adipose-derived stem cells (ADSCs) for knee osteoarthritis: a prospective comparative clinical trial. J Orthop Surg Res 2023; 18:350. [PMID: 37170296 PMCID: PMC10176826 DOI: 10.1186/s13018-023-03841-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND We determined whether autologous mesenchymal stem cells (MSCs) injections provide clinical and functional improvements in knee osteoarthritis (KOA) patients, and whether the results differ between autologous bone marrow cells (BMAC) and adipose-derived stromal cells (ADSCs). METHODS Between January 2021 and April 2022, 51 patients undergoing intra-articular injection of BMAC and 51 patients undergoing intra-articular injection of ADSCs were prospectively recruited. The Kellgren and Lawrence (K-L) classification was used to grade the severity of osteoarthritis. Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), and visual analog scale (VAS) were collected for all 102 patients in the previous week before the procedures, and at the one and 6 months from injection. RESULTS Knee KOOS scores, knee OKS scores, and VAS pain scores changed in similar ways in the two treatment groups. Both treatment groups demonstrated significant improvement pre-procedure to post-procedure in knee KOOS scores (p < 0.0001), knee OKS scores (p < 0.0001), and VAS pain scores (p < 0.0001). Patients with K-L grade 2 showed better functional and clinical outcomes than patients with K-L grades 3 and 4 (p < 0.0001). CONCLUSION Both intra-articular BMAC and ADSC injections significantly improved pain and functional outcomes at 6-month follow-up in patients with KOA. The difference between BMAC and ADCSs groups as tissue sources of MSCs was not statistically significant in terms of clinical and functional outcomes.
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Affiliation(s)
- Andrea Pintore
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | | | - Arnaldo Zara
- Casa di Cura Salus, 84091, Battipaglia, SA, Italy
| | - Antonio Oliviero
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
- Casa di Cura Salus, 84091, Battipaglia, SA, Italy
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
- Faculty of Medicine, School of Pharmacy and Bioengineering, Keele University, Thornburrow Drive, Stoke on Trent, England, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England, UK
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13
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Rodeo SA. Orthobiologics: Current Status in 2023 and Future Outlook. J Am Acad Orthop Surg 2023:00124635-990000000-00683. [PMID: 37130369 DOI: 10.5435/jaaos-d-22-00808] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 03/21/2023] [Indexed: 05/04/2023] Open
Abstract
Orthobiologic agents, including platelet-rich plasma, connective tissue progenitor cells derived from bone marrow, adipose, and other tissues, and purified cytokines and small peptides, have tremendous potential to target deficiencies in soft-tissue healing. The principal limitation currently is the variability in the composition and biologic activity of orthobiologic formulations, making it difficult to choose the optimal treatment for a specific tissue or pathology. Current data suggest that orthobiologics are "symptom-modifying," but there is little evidence that they can lead to true tissue regeneration ("structure-modifying"). A critically important need at this time is to identify sentinel markers of potency and biologic activity for different orthobiologic formulations so that we can match the treatment to the desired biologic effect for a specific tissue or pathology. Improved understanding of the underlying cellular and molecular mechanisms of tissue degeneration and repair will allow a precision medicine approach where we can choose the optimal orthobiologic treatment of specific orthopaedic problems. It is important for the clinician to be aware of the evolving regulatory status of orthobiologic treatments. Emerging therapies such as the use of exosomes and gene therapy approaches hold great promise as improved methods to both treat symptoms and affect tissue regeneration.
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Affiliation(s)
- Scott A Rodeo
- From the Sports Medicine Institute, Hospital for Special Surgery, New York, NY
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14
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The Efficiency and Safety of Platelet-Rich Plasma Dressing in the Treatment of Chronic Wounds: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Pers Med 2023; 13:jpm13030430. [PMID: 36983611 PMCID: PMC10053387 DOI: 10.3390/jpm13030430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/13/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023] Open
Abstract
Recently, many clinical trials have applied platelet-rich plasma (PRP) dressings to treat wounds that have stopped healing, which are also called chronic wounds. However, the clinical efficiency of PRP dressings in treating chronic wounds is still controversial. Therefore, we conducted this study to compare PRP dressings with normal saline dressings in treating chronic wounds. Relevant randomized controlled trials focusing on utilizing PRP dressings in treating chronic wounds were extracted from bibliographic databases. Finally, 330 patients with chronic wounds, reported in eight randomized controlled trials, were included in this study. In total, 169 out of 330 (51.21%) were treated with PRP dressings, and 161 out of 330 (48.79%) were treated with normal saline dressings. The pooled results showed that the complete healing rate of the PRP group was significantly higher than that of saline group at 8 weeks and 12 weeks, respectively. In addition, there were no significant differences in wound infection and adverse events. Compared with normal saline dressing, the PRP dressing could effectively enhance the prognosis of chronic wounds. Furthermore, the PRP did not increase wound infection rate or occurrence of adverse events as an available treatment for chronic wounds.
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15
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Maffulli N, Nilsson Helander K, Migliorini F. Tendon appearance at imaging may be altered, but it may not indicate pathology. Knee Surg Sports Traumatol Arthrosc 2023; 31:1625-1628. [PMID: 36800008 DOI: 10.1007/s00167-023-07339-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Abstract
Both in tendon repair following a tear and in tendinopathy, recovery from pain and restoration of (acceptable) function does not go hand in hand with the appearance of the affected tendon at imaging. The tendon may remain altered for a long while and possibly forever, indicating a possible dissociation between morphology and symptoms. The predictive value of asymptomatic abnormal findings remains limited, and interventions in such instances are inappropriate and not supported by current evidence. Once an initial imaging investigation has depicted the condition of the tendon, additional imaging investigations are unlikely to provide further information or change prognosis in patients in whom abnormalities compatible with a diagnosis of tendinopathy have been identified by either ultrasonography or MRI. Patient education and close clinical monitoring are recommended. This is applicable to the patellar tendon, Achilles tendon, rotator cuff, for both tendon repair and tendinopathy. Given the modest risk of sonographic abnormalities to develop in symptomatic tendinopathy, planning and trying to implement any form of intervention may not be warranted. The current evidence mostly arises from low-quality studies, with heterogeneous risk factors and populations, and caution must be maintained when interpreting the significance of such incidental findings in athletes.
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Affiliation(s)
- Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy.
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke-on-Trent, ST4 7QB, England.
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England.
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074, Aachen, Germany
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
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16
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Abadin AA, Orr JP, Lloyd AR, Henning PT, Pourcho A. An Evidence-Based Approach to Orthobiologics for Tendon Disorders. Phys Med Rehabil Clin N Am 2023; 34:83-103. [DOI: 10.1016/j.pmr.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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17
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Efficacy of Platelet-Rich Plasma Versus Placebo in the Treatment of Tendinopathy: A Meta-analysis of Randomized Controlled Trials. Clin J Sport Med 2023; 33:69-77. [PMID: 34342296 DOI: 10.1097/jsm.0000000000000961] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/28/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the efficacy of platelet-rich plasma (PRP) injections versus placebo in the treatment of tendinopathy. DATA SOURCES We performed a systematic literature search in MEDLINE, Embase, Scopus, CINAHL, Cochrane Library, and ClinicalTrials.gov through November 2020 to identify randomized controlled trials (RCTs) that evaluated the clinical efficacy of PRP versus placebo for the treatment of tendinopathy. Outcomes were analyzed on an intention-to-treat basis with random-effects models. MAIN RESULTS A total of 13 RCTs were included in this meta-analysis. The pooled analysis showed no significant difference in pain relief at 4 to 6 weeks (standard mean difference [SMD]: -0.18, 95% confidence intervals [CI]: -0.62 to 0.26), 12 weeks (SMD: -0.14, 95% CI: -0.55 to 0.26), and ≥24 weeks (SMD: -0.56, 95% CI: -1.16 to 0.05) or function improvement at 4 to 6 weeks (SMD: 0.11, 95% CI: -0.13 to 0.35), 12 weeks (SMD: 0.18, 95% CI: -0.13 to 0.49), and ≥24 weeks (SMD: 0.26, 95% CI: -0.14 to 0.66) for PRP compared with placebo in the treatment of tendinopathy. The sensitivity analysis indicated no significant difference in pain relief or function improvement at 12 weeks between PRP and placebo for different types of tendinopathies, treatment regimens, leukocyte concentrations, or cointerventions. CONCLUSIONS Platelet-rich plasma injection was not found to be superior to placebo in the treatment of tendinopathy, as measured by pain relief and functional improvement at 4 to 6, 12, and ≥24 weeks.
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18
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Barman A, Sinha MK, Sahoo J, Jena D, Patel V, Patel S, Bhattacharjee S, Baral D. Platelet-rich plasma injection in the treatment of patellar tendinopathy: a systematic review and meta-analysis. Knee Surg Relat Res 2022; 34:22. [PMID: 35509070 PMCID: PMC9066802 DOI: 10.1186/s43019-022-00151-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/07/2022] [Indexed: 01/01/2023] Open
Abstract
Abstract
Purpose
The objective of the study was to assess the efficacy of autologous platelet-rich plasma (PRP) injections in the treatment of patellar tendinopathy.
Methods
The PubMed, MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases were searched for clinical trials which compared PRP injection with other ‘active treatment’ interventions (‘Non-PRP’ injection and ‘No-injection’ treatments) or ‘No-active treatment’ interventions. Randomized and non-randomized clinical trials that had been published up to 15 November 2021, were included in the meta-analysis. The primary outcome, pain relief, was measured on a ‘visual analog scale.’ Secondary outcomes were knee functional activities and quality of life (QoL). The PRISMA guidelines were followed throughout the study.
Results
Eight comparative studies were identified for inclusion in the meta-analysis. Assessment of these studies revealed that there were no significant differences in pain relief, functional outcomes, and QoL in the short, medium, and long term between PRP injection and Non-PRP injection interventions. Similarly, comparison of PRP injection to the No-active treatment intervention showed no differences in short- and medium-term pain relief. However, when PRP injection was compared to the No-injection treatment intervention extracorporeal shock wave therapy (ECWT), the former was found to be more effective in terms of pain relief in the medium term (mean difference [MD] − 1.50; 95% confidence interval [CI] − 2.72 to − 0.28) and long term (MD − 1.70; 95% CI, − 2.90 to − 0.50) and functional outcomes in the medium term (MD 13.0; 95% CI 3.01–22.99) and long term (MD 13.70; 95% CI 4.62–22.78).
Conclusions
In terms of pain relief and functional outcomes, the PRP injection did not provide significantly greater clinical benefit than Non-PRP injections in the treatment of patellar tendinopathy. However, in comparison with ESWT, there was a significant benefit in favor of PRP injection.
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19
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Kasitinon D, Williams R, Gharib M, Flowers R, Raiser S, Jain NB. What's New in Orthopaedic Rehabilitation. J Bone Joint Surg Am 2022; 104:1961-1967. [PMID: 36126120 DOI: 10.2106/jbjs.22.00732] [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)
- Donald Kasitinon
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Reed Williams
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mahmood Gharib
- Department of Physical Medicine and Rehabilitation, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Ryan Flowers
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sara Raiser
- Department of Orthopaedics, Emory Healthcare, Atlanta, Georgia
| | - Nitin B Jain
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
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20
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Mirghaderi SP, Valizadeh Z, Shadman K, Lafosse T, Oryadi-Zanjani L, Yekaninejad MS, Nabian MH. Cell therapy efficacy and safety in treating tendon disorders: a systemic review of clinical studies. J Exp Orthop 2022; 9:85. [PMID: 36042110 PMCID: PMC9428081 DOI: 10.1186/s40634-022-00520-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/10/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Despite substantial animal evidence, cell therapy in humans remains in its infancy. The purpose of this study was to examine the potential therapeutic effects and safety of cell therapy in the treatment of tendon disorders. Methods According to the PRISMA guideline, a systematic review was performed on clinical studies concerning cell therapy in tendon disorders. A comprehensive search including the 5 databases of MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library until December 2021 was carried out and associated with hand searching. The quality of the eligible studies was assessed using the tools suggested by Cochrane recommendations. Qualitative synthesis was performed in 2 tables and discussed separately for rotator cuff, elbow, patella, Achilles, and gluteal tendons. Results Through 6017 records, 22 studies were included in the qualitative synthesis, including 658 patients. All the studies administered autologous cells, except one that used allogenic adipose-derived mesenchymal stem cells (Allogenic AD-MSC). Almost all studies demonstrated the safety of cell injection in their follow-up period with no serious side effects or immunologic reactions, with only a few related minor adverse events in some cases. The included studies showed the effectiveness of cell injection in tendinopathies of different sites, rotator cuff, elbow, patella, Achilles, and gluteal tendons. Among the rotator cuff studies, 4 comparative studies claimed that cell therapy is a more efficient treatment with a lower retear rate and pain level compared to the control group. However, one study found no differences between the groups. No controlled study has been performed on elbow tendinopathies, but 5 case series demonstrated the effectiveness of cell injection in elbow tendon disorders. For Achilles tendinopathies, only one randomized controlled trial (RCT) found that both cell therapy and control groups showed significant pain reduction and functional improvement with no statistical differences at the 6 months follow-up, but the cell therapy group had improved faster at earlier follow-ups. Patellar tendinopathy was studied in 2 RCTs, one did not show a significant difference and the other showed superior improvement compared to controls. Conclusion Cell therapy showed promising results and the available evidence suggests that it is safe at several sites of tendon disease. Based on available evidence, cell therapy should be suggested in specific conditions at each site. To approve cell therapy for tendon diseases, randomized clinical trials are required with a large sample size and long-term follow-ups. Level of evidence IV Supplementary Information The online version contains supplementary material available at 10.1186/s40634-022-00520-9.
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Affiliation(s)
- Seyed Peyman Mirghaderi
- Center of Orthopedic Trans-Disciplinary Applied Research (COTAR), Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Valizadeh
- Center of Orthopedic Trans-Disciplinary Applied Research (COTAR), Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Kimia Shadman
- Center of Orthopedic Trans-Disciplinary Applied Research (COTAR), Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Thibault Lafosse
- Alps Surgery Institute: Hand, Upper Limb, Brachial Plexus, and Microsurgery Unit (PBMA), Clinique Générale d'Annecy, Annecy, France
| | - Leila Oryadi-Zanjani
- Center of Orthopedic Trans-Disciplinary Applied Research (COTAR), Tehran University of Medical Sciences, Tehran, Iran.,Department of Orthopedic and Trauma Surgery, Shariati Hospital and School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mir Saeed Yekaninejad
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Hossein Nabian
- Center of Orthopedic Trans-Disciplinary Applied Research (COTAR), Tehran University of Medical Sciences, Tehran, Iran. .,Department of Orthopedic and Trauma Surgery, Shariati Hospital and School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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21
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Catapano M, Babu AN, Tenforde AS, Borg-Stein J, McInnis KC. Knee Extensor Mechanism Tendinopathy: Evaluation, Treatment, and Prevention. Curr Sports Med Rep 2022; 21:205-212. [PMID: 35703747 DOI: 10.1249/jsr.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Knee extensor mechanism tendinopathy, including patellar and quadriceps tendinopathy, is common among athletes and those involved in jumping sports. It is largely a clinical diagnosis that presents as anterior knee pain and stiffness with associated tenderness over the affected tendon. Imaging modalities, including ultrasound and/or magnetic resonance imaging, may be helpful with the diagnosis of difficult cases or in the planning of interventional procedures. Focused and structured rehabilitation using eccentric or heavy slow resistance exercise in conjunction with load management is important for recovery. Adjuvant therapies (e.g., injections or surgery) may be necessary in recalcitrant cases or those with insufficient response to rehabilitation efforts. Prevention strategies focus on improving biomechanics, landing mechanism and lower-extremity balance, flexibility, and strength.
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Affiliation(s)
| | | | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA
| | - Joanne Borg-Stein
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA
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22
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Kruse RC, Krill M, Solsrud E. Concurrent Bilateral Patellar Tendon Ultrasonic Debridement in a Collegiate Athlete - A Case Report. Curr Sports Med Rep 2022; 21:140-142. [PMID: 35522435 DOI: 10.1249/jsr.0000000000000952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Ryan C Kruse
- Department of Orthopedics and Rehabilitation, University of Iowa Sports Medicine, Iowa City, IA
| | - Michael Krill
- Department of Orthopedics and Rehabilitation, University of Iowa Sports Medicine, Iowa City, IA
| | - Emily Solsrud
- Carver College of Medicine, University of Iowa, Iowa City, IA
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23
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Frank RM, Bradsell H, Thompson SR. What's New in Sports Medicine. J Bone Joint Surg Am 2022; 104:667-674. [PMID: 35202043 DOI: 10.2106/jbjs.22.00089] [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)
- Rachel M Frank
- University of Colorado School of Medicine, Aurora, Colorado
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Ramires LC, Jeyaraman M, Muthu S, Shankar A N, Santos GS, da Fonseca LF, Lana JF, Rajendran RL, Gangadaran P, Jogalekar MP, Cardoso AA, Eickhoff A. Application of Orthobiologics in Achilles Tendinopathy: A Review. Life (Basel) 2022; 12:life12030399. [PMID: 35330150 PMCID: PMC8954398 DOI: 10.3390/life12030399] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 02/05/2023] Open
Abstract
Orthobiologics are biological materials that are intended for the regeneration of bone, cartilage, and soft tissues. In this review, we discuss the application of orthobiologics in Achilles tendinopathy, more specifically. We explain the concepts and definitions of each orthobiologic and the literature regarding its use in tendon disorders. The biological potential of these materials can be harnessed and administered into injured tissues, particularly in areas where standard healing is disrupted, a typical feature of Achilles tendinopathy. These products contain a wide variety of cell populations, cytokines, and growth factors, which have been shown to modulate many other cells at local and distal sites in the body. Collectively, they can shift the state of escalated inflammation and degeneration to reestablish tissue homeostasis. The typical features of Achilles tendinopathy are failed healing responses, persistent inflammation, and predominant catabolic reactions. Therefore, the application of orthobiologic tools represents a viable solution, considering their demonstrated efficacy, safety, and relatively easy manipulation. Perhaps a synergistic approach regarding the combination of these orthobiologics may promote more significant clinical outcomes rather than individual application. Although numerous optimistic results have been registered in the literature, additional studies and clinical trials are still highly desired to further illuminate the clinical utility and efficacy of these therapeutic strategies in the management of tendinopathies.
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Affiliation(s)
- Luciano C. Ramires
- Department of Orthopaedics and Sports Medicine, Centro Clínico Mãe de Deus, Porto Alegre 90110-270, Brazil;
| | - Madhan Jeyaraman
- Department of Orthopaedics, Faculty of Medicine—Sri Lalithambigai Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600095, India;
- Department of Orthopaedics, Apollo Hospitals, Greams Road, Chennai 600006, India;
| | - Sathish Muthu
- Department of Orthopaedics, Government Medical College and Hospital, Dindigul 624304, India
- Correspondence: (S.M.); (G.S.S.); (P.G.)
| | - Navaladi Shankar A
- Department of Orthopaedics, Apollo Hospitals, Greams Road, Chennai 600006, India;
| | - Gabriel Silva Santos
- Department of Orthopaedics, The Bone and Cartilage Institute, Indaiatuba 13334-170, Brazil; (L.F.d.F.); (J.F.L.)
- Correspondence: (S.M.); (G.S.S.); (P.G.)
| | - Lucas Furtado da Fonseca
- Department of Orthopaedics, The Bone and Cartilage Institute, Indaiatuba 13334-170, Brazil; (L.F.d.F.); (J.F.L.)
- Department of Orthopaedics, The Federal University of São Paulo, São Paulo 04024-002, Brazil
| | - José Fábio Lana
- Department of Orthopaedics, The Bone and Cartilage Institute, Indaiatuba 13334-170, Brazil; (L.F.d.F.); (J.F.L.)
| | - Ramya Lakshmi Rajendran
- Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea;
| | - Prakash Gangadaran
- Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea;
- BK21 FOUR KNU Convergence Educational Program of Biomedical Sciences for Creative Future Talents, Department of Biomedical Sciences, School of Medicine, Kyungpook National University, Daegu 41944, Korea
- Correspondence: (S.M.); (G.S.S.); (P.G.)
| | - Manasi P. Jogalekar
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94158, USA;
| | - Alfredo A. Cardoso
- Department of Oncology-Integrative Medicine-Pain Care, IAC—Instituto Ana Cardoso de Práticas Integrativas e Medicina Regenerative, Gramado 95670-000, Brazil;
| | - Alex Eickhoff
- Department of Orthopaedics, Centro Ortopédico Eickhoff, Três de Maio 98910-000, Brazil;
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Marigi EM, Buckley P, Razi F, Abbas MJ, Jildeh TR, Camp CL, Krych AJ, Okoroha KR. Patellar Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments. JBJS Rev 2022; 10:01874474-202203000-00008. [PMID: 35358114 DOI: 10.2106/jbjs.rvw.21.00168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Patellar tendinopathy is an attritional injury of the patellar tendon that is frequently identified in jumping athletes. Through repetitive or explosive movements, considerable loads and high peak strains are generated across the patellar tendon. » This leads to microinjury of tendon fibers, local mucoid degeneration, and loss of the fibrocartilaginous tissue that attaches tendon to bone. » Management of patellar tendinopathy often begins with nonoperative modalities: progressive tendon loading and eccentric rehabilitative exercise programs are the most effective. While a variety of additional treatment modalities are available, the comparative efficacy of these supportive treatments is not well differentiated at this time. » In this article, we analyze the existing literature regarding nonoperative treatment of patellar tendinopathy and provide additional insight on the effectiveness of current modalities.
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Challoumas D, Pedret C, Biddle M, Ng NYB, Kirwan P, Cooper B, Nicholas P, Wilson S, Clifford C, Millar NL. Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies. BMJ Open Sport Exerc Med 2021; 7:e001110. [PMID: 34900334 PMCID: PMC8634001 DOI: 10.1136/bmjsem-2021-001110] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives We performed a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) to provide insights into the effectiveness of available treatment modalities in patellar tendinopathy(PT). Methods Several databases were searched in May 2021 for RCTs assessing the effectiveness of any intervention compared with any other intervention, placebo or no treatment for pain and/or function in PT. The risk of bias and strength of evidence were assessed with the Cochrane Collaboration and GRADE (Grading of Recommendations, Assessment, Development and Evaluations)/GRADE-NMA tools. Results A total of 37 RCTs were eligible that assessed 33 different interventions and their combinations, most represented by single studies. Based on pairwise meta-analyses of two RCTs, extracorporeal shockwave therapy (ESWT) does not appear to be superior to sham ESWT (eccentric exercise in both groups) for short-term pain (mean differences (MD) +0.1, 95% CI (−0.8 to 1), p=0.84) or function (MD −1.8, 95% CI (–8 to 4.4), p=0.57). Based on a pairwise meta-analysis of three RCTs, isometric exercise appears as effective as isotonic exercise for immediate postintervention pain relief (MD −1.03, 95% CI (−2.6 to 0.5), p=0.19). Our NMA showed that topical glyceryl trinitrate (GTN) and hyaluronic acid injection, both combined with eccentric exercise and moderate, slow resistance exercise had the highest probability of being the most effective interventions (low/very low strength of evidence). Conclusions Promising interventions with inadequate evidence, such as topical GTN, hyaluronic acid injections and isometric and slow resistance exercise, should be further investigated through high-quality RCTs. Meanwhile, eccentric loading with or without adjuncts should remain the first-line treatment for all individuals with patellar tendinopathy.
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Affiliation(s)
- Dimitris Challoumas
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Carles Pedret
- Sports Medicine and Imaging Department, Clinica Mapfre de Medicina del Tenis, Barcelona, Spain
| | - Mairiosa Biddle
- Department of Trauma & Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nigel Yong Boon Ng
- Department of Trauma & Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Paul Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland.,Physiotherapy Department, Connolly Hospital Blanchardstown, Blanchardstown, Ireland
| | - Blair Cooper
- Department of Trauma & Orthopaedic Surgery, Ayr University Hospital, Ayr, UK
| | - Patrick Nicholas
- Department of Trauma & Orthopaedic Surgery, Ayr University Hospital, Ayr, UK
| | - Scott Wilson
- Department of Trauma & Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Chris Clifford
- Physiotherapy Department, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Neal L Millar
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.,Department of Trauma & Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
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Cell-Based Therapies for the Treatment of Shoulder and Elbow Tendinopathies: A Scoping Review. Stem Cells Int 2021; 2021:5558040. [PMID: 33995531 PMCID: PMC8096562 DOI: 10.1155/2021/5558040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Tendinopathies are a common cause of disability among the general population, and their management is challenging due to the degenerative nature of these disorders. The aim of this paper is to perform a scoping review of the available clinical evidence on the application of cell-based therapies for the management of elbow and rotator cuff tendinopathies, in order to summarize the current application methods and to shed light on the therapeutic potential and current limitations of these biologic approaches. Materials and Methods A scoping review of the literature was performed on the PubMed and Scopus databases using the following inclusion criteria: clinical reports of any level of evidence, written in English, with no time limitation, on the use of cell-based approaches to treat rotator cuff or elbow tendinopathies, including studies on biological augmentation during the surgical procedure. Exclusion criteria were as follows: case reports or mini case series (<5 patients), articles not written in English, and reviews. Relevant data were then extracted and collected in a single database with the consensus of the two observers to be analyzed for the purposes of the present manuscript. Results Seven papers dealing with rotator cuff tears were included. Four of them investigated the effect of injections, either MSCs alone or in combination with PRP, whereas three studies investigated the use of MSCs in combination with surgery. In all cases, an improvement was found in terms of clinical scores, with even evidence of tendon healing documented at second-look arthroscopy. Six papers dealt with elbow tendinopathies: three studies described the use of MSCs either with or without surgery, reporting significant clinical improvement and three studies analyzed the use of different types of cells (collagen-producing cells and autologous tenocytes) and, even in this case, clinical improvement was reported. Conclusion All the papers included suggested a beneficial role of cell-based approaches to treat common upper limb tendinopathies, with an overall satisfactory safety profile. However, the lack of high-level evidence and the presence of controversial issues, such as interproduct variability, harvest source, and application strategies, do not allow standardization of these novel biologic approaches, whose efficacy needs to be confirmed with properly designed randomized trials.
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