Platelet-Rich Plasma Is an Equal Alternative to Surgery in the Treatment of Type 1 Medial Epicondylitis

Novel Ultrasound-Guided Radiofrequency Ablation of the Medial Epicondylar Sensory Nerve for Recalcitrant Medial Epicondylosis: A Case-Based Technical Report

Recalcitrant medial epicondylosis (ME) is a chronic tendinopathy affecting the common flexor-pronator tendon origin which causes significant pain and functional limitations. Recalcitrant ME is difficult to manage with non-surgical treatment options. The medial epicondylar sensory nerve (MEsn) is a small sensory nerve that travels within the medial intermuscular septum to innervate the osseous-tendinous structures of the medial epicondyle. In this report, we describe a novel technique for the treatment of recalcitrant ME via radiofrequency ablation (RFA) of the MEsn under ultrasound guidance. The MEsn is localized under ultrasound in the medial distal arm, just proximal to the medial epicondyle. Patients with a positive prognostic block of the MEsn subsequently underwent RFA of the MEsn. We have performed this procedure on two patients who have demonstrated improvement in pain and function for up to nearly one year after the procedure. The relief from pain and improvement in function of these patients warrants further investigation and comparative trials with respect to conventional treatment options, as MEsn RFA may be a viable treatment option for recalcitrant ME.

Comparison of Clinical Outcomes of Platelet-Rich Plasma for Epicondylitis, Elbow: Simultaneous Lateral and Medial Versus Lateral Versus Medial

OBJECTIVE

Lateral and medial epicondylitis are relatively common diseases, but they do not improve quickly and are known to reduce patients' quality of life. Much research has been done on Platelet-Rich Plasma (PRP) as a treatment for lateral epicondylitis, but research on medial epicondylitis is lacking. The purpose of this study is to compare: (i) the pain intensity; and (ii) the functional outcome between the simultaneous treatment of medial and lateral epicondylitis and the treatment of only lateral or medial epicondylitis using PRP.

METHODS

In this retrospective study, 209 patients treated with PRP on epicondylitis between March 2018 and December 2021 were enrolled. Simultaneous treatment was underwent 68 patients (group I). Seventy patients were treated for lateral epicondylitis (group II). The remaining 71 patients were treated for medial epicondylitis (group III). The visual analogue scale for pain (VAS) and the Mayo elbow performance score (MEPS) were evaluated for clinical outcomes at the initial visit and 6 months after injection.

RESULTS

VAS for pain and MEPS showed significant improvement in all three groups compared to before treatment. There was no significant difference between three groups on -ΔVAS (P > 0.05). However, in case of ΔMEPS, group III showed significantly lower compared to groups II and III (P < 0.05). No patients showed worsening of symptoms or complications during the treatment.

CONCLUSION

PRP injection for the patient with elbow medial and lateral epicondylitis can be treated effectively simultaneously in terms of pain. From a functional point of view, the effect of simultaneous treatment may be lessened than in the case of only lateral and medial treatment.

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

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

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 ).

Surgical Techniques and Clinical Outcomes for Medial Epicondylitis: A Systematic Review

BACKGROUND

Medial epicondylitis (ME) is a pathological condition that arises in laborers and athletes secondary to repetitive wrist flexion and forearm pronation causing degeneration of the common flexor tendon. Although nonoperative management has demonstrated high rates of success, no standardized surgical technique has been established for situations when operative management is indicated.

PURPOSE/HYPOTHESIS

The purpose of this study was to perform a systematic review of the surgical treatment options for ME and evaluate the associated patient-reported outcomes (PROs). We hypothesized that surgical management of ME would vary across studies but no technique would prove to be superior.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Searches were conducted using PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature (CINAHL), SPORTDiscus, and Cochrane databases between 1980 and April 2020. All level 1 to 4 studies were identified that focused on surgical management and PROs in the setting of ME. Description of surgical technique and PROs were required for inclusion. Investigators independently dually abstracted and reviewed the studies for eligibility. Weighted means were calculated for demographic characteristics and available PROs.

RESULTS

Overall, 851 studies were identified according to the search criteria. A total of 16 studies met the inclusion and exclusion criteria and therefore were evaluated. Three surgical techniques were found: open (13 studies), arthroscopic (2 studies), and percutaneous (1 study). Descriptions of the open technique were subdivided into those with (7 studies) and without (6 studies) common flexor tendon repair. Analysis included 479 elbows; patients were primarily male (58.3%) with a weighted mean age of 47.2 years. Weighted mean follow-up was 4.6 years. Tennis and manual laborer were the most common sport and occupation, respectively. Surgical success ranged from 63% to 100%, with a low complication rate of 4.3%. Success rates for return to sports and work were 81%-100% and 66.7%-100%, respectively, and only 1 study reported a return to work rate <90%.

CONCLUSION

This systematic review demonstrates that surgical intervention for refractory ME often has a high success rate. Regardless of surgical technique performed, patients generally demonstrated an improvement in PROs, and an encouraging number returned to work with limited complications. Further investigation is necessary to determine superiority among open, arthroscopic, and percutaneous techniques.

The effect of leucocyte concentration of platelet-rich plasma on outcomes in patients with lateral epicondylitis: a systematic review and meta-analysis

HYPOTHESIS

The concentration of leukocytes influences the quality of platelet-rich plasma (PRP). However, there is no consensus on which type of PRP based on the concentration of leukocytes is the best for lateral epicondylitis (LE).

METHODS

We systematically searched the MEDLINE, Embase, and Cochrane Library databases until March 1, 2020. Studies involving randomized controlled trials, patients with LE, and treatment with PRP injections were included. PRP was classified into leukocyte-poor (LP) PRP and leukocyte-rich (LR) PRP. LR-PRP was defined as PRP with a white blood cell concentration exceeding that of whole blood (4.0-10.0 per μL³), whereas LP-PRP was defined as PRP with a lower white blood cell concentration than that of whole blood. The efficacy of PRP was assessed using the visual analog scale (VAS) and success rates.

RESULTS

Eleven randomized controlled trials (six involving LP-PRP and five involving LR-PRP) were eligible for inclusion in this review. Eight studies were included in the meta-analysis to evaluate the VAS score. Regarding short-term follow-up, there was no difference in the VAS scores between the LP-PRP and control groups (standard mean difference [SMD], 0.01; 95% confidence interval [CI], -0.29 to 0.30; P = 0.97), with no heterogeneity (I² = 0%). There was also no difference in the VAS scores between the LR-PRP and control groups (SMD, -0.19; 95% CI, -0.57 to 0.20; P = 0.34), with substantial heterogeneity (I² = 56.7%). Regarding long-term follow-up, there was no difference in the VAS scores between the LP-PRP and control groups (SMD, -0.73; 95% CI, -1.69 to 0.23; P = 0.134) with substantial heterogeneity (I² = 88.4%). The LR-PRP group had lower VAS scores than the control group (SMD, -1.06; 95% CI, -2.02 to -0.09; P = 0.032) with substantial heterogeneity (I² = 92%). In the LP-PRP group, there was no significant difference in the success rate (odds ratio, 1.08; 95% CI, 0.07-16.47; P = 0.956) with substantial heterogeneity (I² = 87.7%). In the LR-PRP group, however, the patients who received PRP had a higher success rate than those in the control group (odds ratio, 2.85; 95% CI, 1.67-4.85; P < 0.01) with substantial heterogeneity (I² = 82.9%).

CONCLUSION

LR-PRP may provide pain relief and successful outcomes for patients with LE compared with alternative local injections. Better results were observed with the use of LR-PRP than with the use of LP-PRP.

Effects of Platelet-Rich Plasma on Clinical Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background:

Many studies have documented the use of platelet-rich plasma (PRP) alongside anterior cruciate ligament (ACL) reconstruction (ACLR) in the management of ACL injury, but evidence on the benefits of PRP in improving the clinical outcomes of ACLR is inconsistent.

Purpose:

To help in our understanding, we undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) that evaluated the effects of PRP on patient-reported functional scores, the clinical assessments of knee function and structure, and complications.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

We searched 9 online databases for RCTs published in English or Chinese that examined the effects of PRP on ACLR. The primary outcome measures were visual analog scale (VAS) for pain and International Knee Documentation Committee (IKDC) scores. The secondary outcomes included KT-1000 arthrometer, pivot-shift test, Lysholm and Tegner scores, tunnel widening, graft characterization, and complications. Subgroup analyses were performed according to time of assessments. Fixed- and random-effects models were selected for data analysis.

Results:

A total of 14 studies were included. When PRP was injected to graft tunnels, the pooled VAS scores of the 2 groups were similar (P = .31), and the subgroup analysis found that VAS and IKDC only improved at 3 months postoperatively (P = .0003 and P < .00001, respectively). When PRP was used at the bone–patellar tendon–bone harvest sites, VAS was decreased in the first 6 months postoperatively (P < .00001), whereas IKDC score was not remarkably different (P = .07). After PRP injection, Lysholm scores at 3 months postoperatively was different between the 2 groups (P < .00001), but the Tegner scores (P = .86), KT-1000 measurements (P = .12), the positive rate of pivot-shift test (P = .64), the enlargement of tunnels (femoral, P = .91; tibial, P = .80), and the characterization of grafts (P = .05) were not different. No difference in complications was found in either group.

Conclusion:

PRP applied alongside ACLR could reduce postoperative pain and improve knee function in the short and medium terms but is ineffective in the long term. PRP does not improve knee stability and the enlargement of tunnels and does not accelerate the healing of grafts. Further studies would be required.