Intratendinous injections of platelet-rich plasma: feasibility and effect on tendon morphology and mechanics

Total Healing of a Partial Rupture of the Supraspinatus Tendon Using Barbotage Technique Associated with Platelet-Rich Plasma: A Randomized, Controlled, and Double-Blind Clinical Trial

The prevalence of partial rotator cuff tears (PRCTs) is high in the general population. Our hypothesis is that barbotage, when associated with platelet-rich plasma (PRP), is an effective method for healing these tears. The aim of this study was to compare the effects of barbotage with or without PRP on the healing of partial supraspinatus tendon tears (PSTTs). This study assessed the Western Ontario Rotator Cuff Index score and ultrasound (US) images at 6 weeks and 6 months after treatment. Patients in both groups showed clinical improvement, with no significant difference in scores at 6 weeks. However, at 6 months, the PRP group exhibited significant improvement (p = 0.019). Both groups experienced a reduction in ST tear size, but the PRP group demonstrated a significant enhancement at 6 weeks and 6 months. In conclusion, the US-guided barbotage technique, whether associated with PRP or saline solution, proved to be an effective treatment for clinical improvement and reduction in the size of PSTT. Better clinical improvement results were observed with PRP at 6 months. The combination of PRP with barbotage was superior in reducing the size of the ST tear at both 6 weeks and 6 months, resulting in complete healing in 79.3% of the tears.

Effect of platelet-rich plasma on the degenerative rotator cuff tendinopathy according to the compositions

Background

There are controversies about platelet-rich plasma (PRP) as an established treatment option for rotator cuff (RC) tendinopathy. The purpose of the study was to find the relation of cellular component with clinical efficacy in RC tendinopathy and to find the composition of PRP in treating RC tendinopathy.

Methods

A total 30 patients were recruited and divided into PRP and control groups. In the PRP group, 2 ml of PRP solution was injected to the hypoechoic lesion of degenerative supraspinatus via 22-gauge syringe with peppering technique. Patients in the control group were taught rotator cuff strengthening exercises. American Shoulder and Elbow Surgeons (ASES), Constant-Murley score, and numeric rating scale (NRS) were measured before, 6 weeks after, 12 weeks after, and 24 weeks after the procedure. PRP compositions were analyzed using the 1 ml of PRP solution.

Results

Linear regression analysis showed no significant difference of ASES and Constant-Murley scores between the groups at 6 weeks (P = 0.582 and 0.258) and at 12 weeks (P = 0.969 and 0.795) but showed a significant difference at 24 weeks (P = 0.050 and 0.048). Independent t test showed significant group difference of NRS at 6 weeks (P = 0.031) but not at 12 and 24 weeks (P = 0.147 and 0.935). 5.19 pg/ml in IL-1β and 61.79 μg/ml in TGF-β1 were acquired as cutoff values to predict meaningful improvement. The PRP subgroup above IL-1β or TGF-β1 cutoff value showed significant differences in all clinical outcomes compared with the exercise group while the PRP subgroup below the cutoff value showed no significant differences in linear regression analysis.

Conclusions

Our study can help to find the optimal PRP condition and to enhance the effect of PRP on RC tendinopathy.

Trial registration

All the patients were registered in our Institutional Ethics Committee (approval number 2014-05-009).

Platelet-Rich Plasma Diffusion in Achilles Tendon: Relationship with Therapeutic Outcomes

OBJECTIVE

The therapeutic efficacy of platelet-rich plasma in the treatment of Achilles tendinopathy is controversial. Among the variables which can explain the discrepant results, little attention has been paid to the distribution of platelet-rich plasma inside the tendon. The aim of the present study was to evaluate whether this factor is related to the clinical outcome of treatment.

SUBJECTS AND METHODS

Forty patients suffering from mid-portion Achilles tendinopathy were studied. At baseline, pain and function were measured by means of a visual analogue scale and the Victorian Institute of Sport Assessment-Achilles questionnaire. Thereafter, an ultrasound examination was performed, and platelet-rich plasma was injected. Immediately after injection, the plasma distribution was assessed visualizing the material in the tendon. The patients were re-evaluated at 3 and 6 months, computing pain and function values and the percentage of satisfactory outcomes in relation to the distance reached by the plasma from the point of injection.

RESULTS

The diffusion inside the tendon was longitudinal in all cases and cross-sectional only in 9. The mean distance from the tip of the needle increased significantly according to the severity of tendon damage. At follow-up, no relationship was found between plasma diffusion and clinical outcomes.

CONCLUSIONS

Platelet-rich plasma diffusion has no effect on clinical outcome, which mainly depends on the metabolic activation of the whole structure of the tendon.

Autologous fibrin scaffolds: When platelet- and plasma-derived biomolecules meet fibrin

The healing of vascularized mammalian tissue injuries initiate with hemostasis and clotting as part of biological defense system leading to the formation of a fibrin clot in which activated platelets are trapped to quickly stop bleeding and destroy microbials. In order to harness the therapeutic potential of biomolecules secreted by platelets and stemmed from plasma, blood deconstruction has allowed to yield autologous platelet-and plasma-derived protein fibrin scaffold. The autologous growth factors and microparticles stemmed from platelets and plasma, interact with fibrin, extracellular matrix, and tissue cells in a combinatorial, synergistic, and multidirectional way on mechanisms governing tissue repair. This interplay will induce a wide range of cell specifications during inflammation and repair process including but not limited to fibrogenesis, angiogenesis, and immunomodulation. As biology-as-a-drug approach, autologous platelet-and plasma-derived protein fibrin scaffold is emerging as a safe and efficacious natural human-engineered growth factor delivery system to repair musculoskeletal tissues, and skin and corneal ulcers and burns. In doing so, it acts as therapeutic agent not perfect but close to biological precision. However, this autologous, biocompatible, biodegradable, and long in vivo lasting strategy faces several challenges, including its non-conventional single dose-response effect, the lack of standardization in its preparation and application, and the patient's biological features. In this review, we give an account of the main events of tissue repair. Then, we describe the procedure to prepare autologous platelet-and plasma-derived protein fibrin scaffolds, and the rationale behind these biomaterials, and finally, we highlight the significance of strategic accuracy in their application.

The spread of Injectate after ultrasound-guided lateral elbow injection - a cadaveric study

Background

Injections into the tendinous portion of the common extensor origin are a common intervention in the treatment of Lateral Elbow Tendinopathy (LET). Clinical trials report a heterogeneous selection of injectate volumes and delivery techniques, with systematic reviews finding no clear consensus. The aim of this study was to assess the intratendinous distribution and surrounding tissue contamination of ultrasound-guided injections into the Common Extensor Tendon (CET) of the elbow.

Methods

Twenty cadaveric elbows were injected by a Consultant Radiologist under Ultrasound guidance. Elbows were randomised to equal groups of 1 or 3 mls of methylene blue injection, delivered using single shot or fenestrated techniques. Following injection, each cadaver underwent a dry arthroscopy and dissection of superficial tissues. The CET was excised, set and divided into 1 mm sections using microtome. Each slice was photographed and analysed to assess spread and pixel density of injectate in four colour graduations. The cross-sectional area of distribution was calculated and compared between groups.

Results

In all 20 cadaveric samples, contamination of the joint was noted on arthroscopy and dissection. Injectate spread through over 97% of the cross-sectional area. No differences were found in intratendinous spread of injectate between differing volumes or techniques.

Conclusion

This study found that commonly used injection volumes and techniques distribute widely throughout cadaveric CETs. There was no improvement when the volume was increased from 1 to 3 mls or between single shot of fenestrated injection techniques. It should be noted that joint contamination using these techniques and volumes may be inevitable.

Electronic supplementary material

The online version of this article (10.1186/s40634-018-0142-8) contains supplementary material, which is available to authorized users.

Platelet-rich plasma has beneficial effects in mice with osteonecrosis of the femoral head by promoting angiogenesis

Platelet-rich plasma (PRP) is autologous and multifunctional. Platelet concentrate from blood contains highly concentrated platelets and various types of cells, including growth factors. PRP promotes the recovery of cell proliferation and differentiation. Osteonecrosis of the femoral head is a disease caused by femoral head damage or an insufficient blood supply, which leads to the death of bone cells and abnormal bone marrow composition. The subsequent repair of bone cells may result in changes to the structure of femoral head, femoral head collapse and joint dysfunction. PRP may promote the repair of injured articular cartilage in patients with joint diseases through the removal of harmful inflammatory factors. In the present study, the therapeutic effects and primary mechanism of PRP action were investigated using a glucocorticoid-induced femoral head osteonecrosis mouse model. Dexamethasone (DEX) and phosphate-buffered saline were used as controls. The therapeutic efficacy of PRP to treat osteonecrosis in murine femoral heads was evaluated by assessing clinical arthritis scores. The present study indicated that mice with osteonecrosis of the femoral head treated with PRP exhibited downregulated expression of interleukin (IL)-17A, IL-1β, tumor necrosis factor-α, receptor activator of nuclear factor κ-B ligand, IL-6 and interferon-γ in the inflammatory tissue. In addition, the levels of hepatocyte growth factor, intercellular adhesion molecule-1, osteopontin, platelet-derived endothelial cell growth factor, vascular endothelial growth factor, platelet-derived growth factor, insulin-like growth factor-1 and transforming growth factor-β were increased following treatment with PRP. Joint tissue histological staining demonstrated that PRP alleviated osteonecrosis of the femoral head and reduced humoral and cellular immune responses that promoted beneficial effects on the histological parameters. Furthermore, the concentration of glucocorticoids were significantly decreased in the serum of PRP-treated mice with osteonecrosis compared with the DEX group (P<0.01). Notably, PRP promoted beneficial effects in mice with osteonecrosis of the femoral head by stimulating angiogenesis. Therefore, the present study indicated that treatment with PRP promotes beneficial effects by preventing joint inflammation, cartilage destruction and bone damage, and stimulating the repair of joint tissue in mice with osteonecrosis of the femoral head. These preclinical data suggest that PRP may be developed as a novel method of treating osteonecrosis of the femoral head.

Platelet-rich plasma exhibits beneficial effects for rheumatoid arthritis mice by suppressing inflammatory factors

Platelet-rich plasma (PRP) is a multifunctional blood product containing highly concentrated platelets, and various cell growth factors which promote cell proliferation and differentiation. PRP exhibited benefits in injurious articular cartilage repair and the removal of inflammatory factors in clinical studies. Rheumatoid arthritis (RA) is an autoimmune disease manifesting primarily as inflammatory arthritis, which is associated with notable morbidity in humans. In the present study, the therapeutic effects and primary mechanism of PRP on a type II collagen‑induced arthritis (CIA) mouse model was investigated. Inflammatory factors interleukin (IL)‑6, IL‑8, IL‑17, IL‑1β, tumor necrosis factor (TNF)‑α and interferon (IFN)‑γ were analyzed in PRP and PBS‑treated groups. Vascular endothelial growth factor (VEGF), platelet‑derived growth factor (PDGF), insulin‑like growth factor (IGF)‑1 and transforming growth factor (TGF)‑β expression in peripheral whole blood was additionally analyzed. The therapeutic efficacy of PRP for RA mice was evaluated using clinical arthritis scores. The results of the present study demonstrated that treatment with PRP alleviated arthritis, and reduced humoral and cellular immune responses, leading to beneficial effects on histological parameters as observed using joint tissue histological staining. CIA mice treated with PRP exhibited downregulated expression of IL‑6, IL‑8, IL‑17A, IL‑1β, TNF‑α, receptor activator for nuclear factor‑κB and IFN‑γ in inflammatory tissue. In addition, VEGF, PDGF, IGF‑1 and TGF‑β expression in peripheral whole blood was increased following treatment with PRP. The serum concentration of anti‑collagen antibody was decreased in PRP‑treated CIA mice. In conclusion, CIA mice treated with PRP exhibited beneficial effects, including decreased joint inflammation, cartilage destruction and bone damage, and increased repair of joint tissue. The results of the present study suggested that PRP may be an effective therapeutic agent for RA.

Optimisation of platelet concentrates therapy: Composition, localisation, and duration of action

Platelet concentrates (PC) generally refers to a group of products that are prepared from autologous blood intended to enhance healing activities. PC therapy is now very popular in treating musculoskeletal injuries; however, inconsistent clinical results urge the need to understand the working mechanism of PC. It is generally believed that the platelet-derived bioactive factors are the active constituents, and their bioavailability in the vicinity of the lesion sites determines the treatment efficacies. Therefore, the composition, localisation, and duration of the action of PC would be key determinants. In this review, we discuss how different preparations and delivery methods of PC would affect the treatment outcomes with respect to clinical evidence about PC therapy for osteoarthritis, tendinopathies, rotator cuff tears, anterior cruciate ligament injuries, and bone fractures. This review can be used as a quick guide for the use of PC therapy and provide insights for the further optimisation of the therapy in the near future.

Anaesthetics, steroids and platelet-rich plasma (PRP) in ultrasound-guided musculoskeletal procedures

This review aims to evaluate the role of anaesthetics, steroids and platelet-rich plasma (PRP) employed with ultrasound-guided injection in the management of musculoskeletal pathology of the extremities. Ultrasound-guided injection represents an interesting and minimally invasive solution for the treatment of tendon and joint inflammatory or degenerative diseases. The availability of a variety of new drugs such as hyaluronic acid and PRP provides expansion of the indications and therapeutic possibilities. The clinical results obtained in terms of pain reduction and functional recovery suggest that the use of infiltrative procedures can be a good therapeutic alternative in degenerative and inflammatory joint diseases.