|
1
|
Jeyaraman M, Jeyaraman N, Ramasubramanian S, Balaji S, Muthu S. Evidence-based orthobiologic practice: Current evidence review and future directions. World J Orthop 2024; 15:908-917. [DOI: 10.5312/wjo.v15.i10.908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/31/2024] [Accepted: 09/11/2024] [Indexed: 10/11/2024] Open
Abstract
The field of orthopedic and regenerative medicine is rapidly evolving with the increasing utilization of orthobiologic. These biologically derived therapies, including platelet-rich plasma, mesenchymal stem cells, bone marrow aspirate concentrate, stromal vascular fraction (SVF), and autologous chondrocyte implantation, are gaining traction for their potential to enhance the body's natural healing processes. They offer a promising alternative to traditional surgical interventions for musculoskeletal injuries and degenerative conditions. Current evidence suggests significant benefits of orthobiologics in treating conditions like osteoarthritis, tendon injuries, and spinal disorders, yet inconsistencies in treatment protocols and outcomes persist. The global market for orthobiologics is projected to grow substantially, driven by advancements in biologic therapies such as adipose-derived stem cells and SVF, and the demand for minimally invasive treatments. Despite their promise, regulatory and ethical challenges, as well as the need for high-quality, standardized research, remain significant obstacles. Future directions in the field include advancements in delivery systems, personalized medicine approaches, and the exploration of novel sources like induced pluripotent stem cells, aiming for more targeted and effective treatments. Collaborative efforts are crucial to overcoming these challenges and ensuring the safe and effective application of orthobiologics in clinical practice.
Collapse
Affiliation(s)
- Madhan Jeyaraman
- Department of Orthopedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600077, Tamil Nadu, India
- Department of Research Methods, Orthopedic Research Group, Coimbatore 641045, Tamil Nadu, India
| | - Naveen Jeyaraman
- Department of Orthopedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600077, Tamil Nadu, India
| | - Swaminathan Ramasubramanian
- Department of Orthopedic, Government Medical College, Omandurar Government Estate, Chennai 600002, Tamil Nadu, India
| | - Sangeetha Balaji
- Department of Orthopedic, Government Medical College, Omandurar Government Estate, Chennai 600002, Tamil Nadu, India
| | - Sathish Muthu
- Department of Research Methods, Orthopedic Research Group, Coimbatore 641045, Tamil Nadu, India
- Department of Orthopedics, Government Medical College and Hospital, Karur 639004, Tamil Nadu, India
- Department of Biotechnology, Faculty of Engineering, Karpagam Academy of Higher Education, Coimbatore 641021, Tamil Nadu, India
| |
Collapse
|
|
2
|
Jeyaraman M, Pai SN, Filippo M, Jeyaraman N, Venkatasalam R, Nallakumarasamy A, Khanna M, Patro BP, Sharma S, Rangarajan RV. Informed consent form for platelet rich plasma injections: evidence-based and legally guide for orthopaedic surgeons. Eur J Med Res 2024; 29:422. [PMID: 39152486 PMCID: PMC11330123 DOI: 10.1186/s40001-024-02019-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 08/08/2024] [Indexed: 08/19/2024] Open
Abstract
Regarding medico-legal malpractice suits, lawyers and insurers focus on informed consent documentation. Unfortunately, there is no standard protocol for obtaining informed consent for platelet-rich plasma (PRP) injections. The objective of the present study was to create a pre-designed, evidence-based informed consent form specifically for PRP injections. The current evidence on the medico-legal implications of PRP injections was accessed, as well as informed consent in general and specifically informed consent in PRP injections. Additionally, we interviewed orthopaedic surgeons and patients who had undergone PRP injections in the past year using a semi-structured approach. A legally valid and evidence-based informed consent form for PRP injections ensures rights, encouraging open communication and transparency between the patient and surgeon. Moreover, if a lawsuit arose, informed consent would be a critical document in surgeons' defence and would withstand scrutiny from lawyers and the judiciary. An evidence-based informed consent form for PRP injections was elaborated and reviewed by a legal expert to ensure adherence to legal proprieties. The final form of the informed consent for PRP injection was administered for one year and validated at our institution.
Collapse
Affiliation(s)
- Madhan Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu, 600077, India
- Department of Biotechnology, School of Engineering and Technology, Sharda University, Greater Noida, Uttar Pradesh, 201310, India
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, 226010, India
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli, Tamil Nadu, 620017, India
- Department of Regenerative Medicine, Orange Health Care, Chennai, Tamil Nadu, 600040, India
| | - Satvik N Pai
- Department of Orthopaedics, PES University Institute of Medical Sciences and Research, Bengaluru, Karnataka, 560083, India
| | - Migliorini Filippo
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
- Department of Life Sciences, Health, and Health Professions, Link Campus University, 00165, Rome, Italy.
| | - Naveen Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu, 600077, India
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, 226010, India
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli, Tamil Nadu, 620017, India
| | | | - Arulkumar Nallakumarasamy
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, 226010, India
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli, Tamil Nadu, 620017, India
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Karaikal, Puducherry, 609602, India
| | - Manish Khanna
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, 226010, India
| | - Bishnu Prasad Patro
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, 226010, India
- Department of Orthopaedics, All Indian Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Shilpa Sharma
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, 226010, India
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ravi Velamor Rangarajan
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, 226010, India
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli, Tamil Nadu, 620017, India
| |
Collapse
|
|
3
|
Wang S, Lyu B. Effectiveness of Injection Strategies on Patients With Patellar Tendonitis (Jumpers' Knee): A Network Meta-analysis of Randomized Controlled Trials. Sports Health 2024:19417381241263338. [PMID: 39101544 PMCID: PMC11569575 DOI: 10.1177/19417381241263338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
CONTEXT Patellar tendonitis (PT) is a common degenerative disease of the patellar tendon that seriously affects the sports careers of elite athletes and activities of daily living of sports enthusiasts. Injection therapy is a prevalent invasive treatment for PT. OBJECTIVE This work comprehensively analyzes various injection treatments for PT that consider agent type and characteristics, frequency, and assessment timepoints by meta-analysis. DATA SOURCES PubMed, Embase, and the Cochrane Library were sources of data. DATA SELECTION Randomized controlled trials (RCTs) analyzing the effect of various injection strategies on the treatment of patients with PT were considered. STUDY DESIGN Systematic review and meta-analysis. LEVEL OF EVIDENCE Level 2. DATA EXTRACTION First author, year of publication, research location, registration information, patient type, sample size, age, sex, intervention, control treatment, and follow-up period in each study were extracted. RESULTS Nineteen RCTs were included in the analysis. In the network meta-analysis of Victorian Institute of Sports Assessment-Patellar (VISA-P) outcomes, polidocanol (standardized mean difference (SMD), 6.52; 95% CI 4.75, 8.30; P < 0.01), tenocyte-like cells (SMD, 4.08; 95% CI 2.92, 5.25; P < 0.01), and leukocyte-poor platelet-rich plasma (LP-PRP) plus high-volume image-guided injection (HVIGI) (SMD, 1.56; 95% CI 0.62, 2.50; P < 0.01) were significantly superior to noninjection conservative treatment, mainly at the 6-month follow-up timepoint. For visual analog scale results, multiple dry needling (DN) (SMD, -1.78; 95% CI -2.56, -1.00; P < 0.01), LP-PRP (SMD, -0.71; 95% CI -1.31, -0.12; P = 0.02), and LP-PRP plus HVIGI (SMD, -1.31; 95% CI -2.22, -0.39; P < 0.01) were significantly superior to blank, which was also mainly at the 6-month timepoint. CONCLUSION Injection-related treatments: polidocanol, tenocyte-like cells, LP-PRP, and multiple DN showed potential short (1-3 months) or medium (6 months)-term treatment benefits. There is still no evidence for injection interventions with long-term therapeutic benefit.
Collapse
Affiliation(s)
- Shaowei Wang
- College of Physical Education, Hebei Normal University, Hebei, China
| | - Buwei Lyu
- Faculty of Public Physical Education, Hebei Normal University, Hebei, China
| |
Collapse
|
|
4
|
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.
Collapse
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
| |
Collapse
|
|
5
|
Giannini S, Vasta S, Giombini A, Fossati C, Riba U, Massazza G, Papalia R, Pigozzi F. Adductor longus and brevis lesion in an amateur soccer player: platelet rich plasma and multifractioned hyaluronic acid injections to enhance clinical recovery. J Sports Med Phys Fitness 2023; 63:1331-1336. [PMID: 37486253 DOI: 10.23736/s0022-4707.23.14938-3] [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: 07/25/2023]
Abstract
Groin pain is a common issue in athletes, with a particularly high incidence in male soccer players. Adductor muscles are the most involved site of the groin, accounting for up to one-fourth of muscle injuries of that region. Physical therapy and rehabilitation programs for adductor-related groin pain using active exercises are effective in getting athletes back to sport. However, the return-to-play time varies according to the injury severity. Minor lesions can recover in 1-2 weeks, while severer injuries require 8-12 weeks. To enhance tendon healing and shorten the return to play time, intrandentinous injections of Platelet Rich Plasma (PRP) have been proposed. An increasing body of evidence in literature have shown efficacy of platelet rich plasma in aiding the healing process in tendinopathies. Similarly, more recent evidences have proven hyaluronic (HA) acid to have anti-inflammatory, proliferative, repairing, and analgesic effects. This case report presents the clinical application of combined PRP and a multifractioned (a mixture of different molecular weights) HA in a 24-year-old athlete suffering from a hip adductor rupture.
Collapse
Affiliation(s)
- Silvana Giannini
- Villa Stuart Sports Clinic, FIFA Medical Centre of Excellence, Rome, Italy
| | - Sebastiano Vasta
- Department of Movement, Human and Health Sciences, "Foro Italico" University of Rome, Rome, Italy
- Unit of Orthopedics and Traumatology, Campus Bio-Medico University Hospital, Rome, Italy
| | - Arrigo Giombini
- Department of Movement, Human and Health Sciences, "Foro Italico" University of Rome, Rome, Italy -
| | - Chiara Fossati
- Department of Movement, Human and Health Sciences, "Foro Italico" University of Rome, Rome, Italy
- Center for Exercise Science and Sports Medicine, "Foro Italico" University of Rome, Rome, Italy
| | - Ugo Riba
- IRR Rehabilitation Center, Turin, Italy
| | - Giuseppe Massazza
- IRR Rehabilitation Center, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Rocco Papalia
- Unit of Orthopedics and Traumatology, Campus Bio-Medico University Hospital, Rome, Italy
| | - Fabio Pigozzi
- Villa Stuart Sports Clinic, FIFA Medical Centre of Excellence, Rome, Italy
- Department of Movement, Human and Health Sciences, "Foro Italico" University of Rome, Rome, Italy
- Center for Exercise Science and Sports Medicine, "Foro Italico" University of Rome, Rome, Italy
| |
Collapse
|
|
6
|
Stewart ZE, Lee K. Lower extremity ultrasound-guided interventions: tendon, ligament, and plantar fascia. Skeletal Radiol 2023; 52:991-1003. [PMID: 36326878 DOI: 10.1007/s00256-022-04212-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
Lower extremity tendinopathy and soft tissue injury are common clinical problems that can cause significant disability. Ultrasound-guided minimally invasive treatments using orthobiologics and image-guided percutaneous treatments continue to gain relevance with an ever-growing body of literature. We review the indications, technique, risks, and benefits according to the literature of common ultrasound-guided interventions utilized in the lower extremities.
Collapse
Affiliation(s)
- Zachary E Stewart
- Department of Radiology - Musculoskeletal Imaging and Intervention, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Yawkey Bldg Room 6033, Boston, MA, 02114, USA.
| | - Kenneth Lee
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
|
7
|
Pang L, Xu Y, Li T, Li Y, Zhu J, Tang X. Platelet-Rich Plasma Injection Can Be a Viable Alternative to Corticosteroid Injection for Conservative Treatment of Rotator Cuff Disease: A Meta-analysis of Randomized Controlled Trials. Arthroscopy 2023; 39:402-421.e1. [PMID: 35810976 DOI: 10.1016/j.arthro.2022.06.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 06/12/2022] [Accepted: 06/16/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE To explore whether platelet-rich plasma (PRP) injection can be a viable alternative to corticosteroid (CS) injection for conservative treatment of rotator cuff disease. METHODS This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, The Cochrane Library, and Web of Science were searched from January 1, 1990, to March 20, 2022, for English-language randomized controlled trials that compared PRP and CS injections for patients with rotator cuff disease. Two evaluators independently screened the literature, extracted data, and assessed the level of evidence and methodologic quality of the enrolled studies. The meta-analysis was conducted using RevMan software (version 5.3.3). RESULTS Thirteen nonsurgical randomized controlled trials with 725 patients were included. Compared with CS, PRP provided statistically worse short-term (<2 months) changes in American Shoulder and Elbow Surgeons (ASES) assessment scores, Simple Shoulder Test scores, and Disabilities of the Arm, Shoulder and Hand questionnaire scores but provided better medium-term (2-6 months) changes in Disabilities of the Arm, Shoulder and Hand scores, as well as long-term (≥6 months) changes in Constant-Murley scores, ASES scores, and Simple Shoulder Test scores. No statistically significant differences regarding pain reduction were found between the 2 groups. PRP injections led to worse short-term changes in forward flexion and internal rotation but better medium-term changes in forward flexion and external rotation. PRP showed significantly lower rates of post-injection failure (requests for subsequent injections or surgical intervention prior to 12 months) than CS. No outcome reached the minimal clinically important difference. After sensitivity analyses excluding studies with substantial clinical and/or methodologic heterogeneity, PRP showed better medium-term changes in ASES scores and visual analog scale scores and long-term changes in visual analog scale scores that reached the minimal clinically important difference. CONCLUSIONS Without the drawbacks of CS injection, PRP injection is not worse than CS injection in terms of pain relief and function recovery at any time point during follow-up. PRP injection may reduce rates of subsequent injection or surgery, and it might provide better improvements in pain and function in the medium to long term. PRP injection can be a viable alternative to CS injection for conservative treatment of rotator cuff disease. LEVEL OF EVIDENCE Meta-analysis of Level I and II studies.
Collapse
Affiliation(s)
- Long Pang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China; West China Medical School, Sichuan University, Chengdu, China
| | - Yang Xu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China; West China Medical School, Sichuan University, Chengdu, China
| | - Tao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yinghao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Zhu
- West China Hospital, Sichuan University, Chengdu, China.
| | - Xin Tang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
|
8
|
Thu AC. The use of platelet-rich plasma in management of musculoskeletal pain: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2022; 39:206-215. [PMID: 35673831 PMCID: PMC9273137 DOI: 10.12701/jyms.2022.00290] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 01/16/2023]
Abstract
Musculoskeletal pain is the most common pain reported by patients. Platelet-rich plasma (PRP) is widely used to treat musculoskeletal pain. However, the efficacy of PRP to treat this pain remains controversial. This review highlights the application of PRP in the treatment of musculoskeletal pain. PRP treatment appears to reduce pain and improve function in patients with musculoskeletal pain. However, there are limitations to the currently published studies. These limitations include the PRP preparation methods, type of activators, types of pathology to be treated, methods and times of administration, and association of PRP with other treatments.
Collapse
Affiliation(s)
- Aung Chan Thu
- Department of Physical Medicine and Rehabilitation, University of Medicine, Mandalay, Myanmar
- Corresponding author: Aung Chan Thu, MD, PhD Department of Physical Medicine and Rehabilitation, University of Medicine, 30th Street, Between 73rd & 74th Streets, Mandalay, Myanmar Tel: +95-9977277511 • E-mail:
| |
Collapse
|
|
9
|
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: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [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
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.
Collapse
Affiliation(s)
- Apurba Barman
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India.
| | - Mithilesh K Sinha
- Department of General Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Jagannatha Sahoo
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Debasish Jena
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Vikas Patel
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Suman Patel
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Souvik Bhattacharjee
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Debanjan Baral
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| |
Collapse
|
|
10
|
Peláez P, Damiá E, Torres-Torrillas M, Chicharro D, Cuervo B, Miguel L, del Romero A, Carrillo JM, Sopena JJ, Rubio M. Cell and Cell Free Therapies in Osteoarthritis. Biomedicines 2021; 9:1726. [PMID: 34829953 PMCID: PMC8615373 DOI: 10.3390/biomedicines9111726] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 12/18/2022] Open
Abstract
Osteoarthritis (OA) is the most common articular disease in adults and has a current prevalence of 12% in the population over 65 years old. This chronic disease causes damage to articular cartilage and synovial joints, causing pain and leading to a negative impact on patients' function, decreasing quality of life. There are many limitations regarding OA conventional therapies-pharmacological therapy can cause gastrointestinal, renal, and cardiac adverse effects, and some of them could even be a threat to life. On the other hand, surgical options, such as microfracture, have been used for the last 20 years, but hyaline cartilage has a limited regeneration capacity. In recent years, the interest in new therapies, such as cell-based and cell-free therapies, has been considerably increasing. The purpose of this review is to describe and compare bioregenerative therapies' efficacy for OA, with particular emphasis on the use of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). In OA, these therapies might be an alternative and less invasive treatment than surgery, and a more effective option than conventional therapies.
Collapse
Affiliation(s)
- Pau Peláez
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Elena Damiá
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Marta Torres-Torrillas
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Deborah Chicharro
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Belén Cuervo
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Laura Miguel
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Ayla del Romero
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Jose Maria Carrillo
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Joaquín J. Sopena
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| | - Mónica Rubio
- Bioregenerative Medicine and Applied Surgery Research Group, Department of Animal Medicine and Surgery, CEU Cardenal Herrera University, CEU Universities, C/Tirant lo Blanc, 7, Alfara del Patriarca, 46115 Valencia, Spain; (P.P.); (M.T.-T.); (D.C.); (B.C.); (L.M.); (A.d.R.); (J.M.C.); (J.J.S.); (M.R.)
- Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative Surgery, 08006 Barcelona, Spain
| |
Collapse
|
|
11
|
Abstract
The aim of this article was to synopsize platelet-rich plasma (PRP) use in musculoskeletal pathologies through evidence-based assessment of the preparation, classification, mechanism of action and applications of PRP, thereby answering which PRP type is best for each clinical indication. The literature search was performed using Medline, EMBASE and Cochrane Reviews databases for papers containing the key terms “platelet-rich plasma” AND “orthopaedics” AND (“classification” OR “mechanism of action” OR “preparation” OR “clinical application”). Generated papers were evaluated for pertinence in following areas: preparation, classification, mechanism of action, clinical application within orthopaedics. Non-English papers were excluded. Included studies were evaluated for quality. Sixty studies were included in our review. There are many commercial PRP preparation kits with differing component concentrations. There is no consensus on optimal component concentrations. Multiple PRP classifications exist but none have been validated. Platelet-rich plasma acts via growth factors (GFs) released from α-granules within platelets. Growth factors have been shown to be beneficial in healing. Grossly elevated concentrations of GFs may have inhibitory effects on healing. Multiple systematic reviews show efficacy of PRP in tendinopathies, early osteoarthritis, acute muscle injuries and in combination with rotator cuff repair and anterior cruciate ligament reconstruction. The literature suggests leukocyte-rich PRP (L-PRP) is more beneficial in tendinopathies and pure PRP (P-PRP) is more beneficial in cartilage pathology. However, different PRP preparations have not been directly compared in any pathology. Classification of PRP type is frequently not stated in research. Standardization of PRP research parameters is needed to streamline findings and generate clear indications for PRP types to yield maximum clinical benefit. Cite this article: EFORT Open Rev 2021;6:225-235. DOI: 10.1302/2058-5241.6.200017
Collapse
Affiliation(s)
- Thomas Collins
- Trauma & Orthopaedics, Wythenshawe Hospital, Wythenshawe, UK
| | | | | |
Collapse
|
|
12
|
Challoumas D, Millar NL. Do we need to improve the reporting of evidence in tendinopathy management? A critical appraisal of systematic reviews with recommendations on strength of evidence assessment. BMJ Open Sport Exerc Med 2021; 7:e000920. [PMID: 33692904 PMCID: PMC7907875 DOI: 10.1136/bmjsem-2020-000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2021] [Indexed: 11/23/2022] Open
Abstract
Objective To critically appraise the quality of published systematic reviews (SRs) of randomised controlled trials (RCTs) in tendinopathy with regard to handling and reporting of results with special emphasis on strength of evidence assessment. Data sources Medline from inception to June 2020. Study eligibility All SRs of RCTs assessing the effectiveness of any intervention(s) on any location of tendinopathy. Data extraction and synthesis Included SRs were appraised with the use of a 12-item tool devised by the authors arising from the Preferred Reporting Items in Systematic Reviews and Meta-Analyses statement and other relevant guidance. Subgroup analyses were performed based on impact factor (IF) of publishing journals and date of publication. Results A total of 57 SRs were included published in 38 journals between 2006 and 2020. The most commonly used risk-of-bias (RoB) assessment tool and strength of evidence assessment tool were the Cochrane Collaboration RoB tool and the Cochrane Collaboration Back Review Group tool, respectively. The mean score on the appraisal tool was 46.5% (range 0%–100%). SRs published in higher IF journals (>4.7) were associated with a higher mean score than those in lower IF journals (mean difference 26.4%±8.8%, p=0.004). The mean score of the 10 most recently published SRs was similar to that of the first 10 published SRs (mean difference 8.3%±13.7%, p=0.54). Only 23 SRs (40%) used the results of their RoB assessment in data synthesis and more than half (n=30; 50%) did not assess the strength of evidence of their results. Only 12 SRs (21%) assessed their strength of evidence appropriately. Conclusions In light of the poor presentation of evidence identified by our review, we provide recommendations to increase transparency and reproducibility in future SRs.
Collapse
Affiliation(s)
- Dimitris Challoumas
- Institute of Infection, Immunity and Inflammation College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Neal L Millar
- Institute of Infection, Immunity and Inflammation College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
|
13
|
Oudelaar BW, Huis In 't Veld R, Ooms EM, Schepers-Bok R, Nelissen RGHH, Vochteloo AJH. Efficacy of Adjuvant Application of Platelet-Rich Plasma After Needle Aspiration of Calcific Deposits for the Treatment of Rotator Cuff Calcific Tendinitis: A Double-Blinded, Randomized Controlled Trial With 2-Year Follow-up. Am J Sports Med 2021; 49:873-882. [PMID: 33566629 DOI: 10.1177/0363546520987579] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Needle aspiration of calcific deposits (NACD) is a frequently used treatment for rotator cuff calcific tendinitis (RCCT). However, a substantial number of patients experience recurrent or persisting shoulder symptoms after NACD. PURPOSE To compare the effects of adjuvant application of platelet-rich plasma (PRP) after NACD (NACP+PRP) with those of conventional NACD with corticosteroids (NACD+corticosteroids) on pain, shoulder function, and quality of life (QoL). STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In a single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic RCCT were randomly allocated to receive NACD+corticosteroids or NACD+PRP. Pain, shoulder function, and QoL were assessed at baseline; 6 weeks; and 3, 6, 12, and 24 months after treatment using a numeric rating scale for pain (NRS); the Constant-Murley score (CMS); the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH); the Oxford Shoulder Score (OSS); and the EuroQol 5-dimension scale (EQ-5D). Additionally, resorption of calcific deposits and the integrity of rotator cuff tendons were assessed by using standard radiographs and ultrasound examination, respectively. The results were analyzed using noninferiority analysis for NRS scores and a mixed model for repeated measures. RESULTS Eighty patients were included (48 female; mean age, 49 ± 6 years; 41 patients in the NACD+PRP group). Both groups showed improvement of clinical scores at the 2-year follow-up (P < .001 for all clinical scores). NACD+PRP was found to be noninferior to NACD+corticosteroids with regard to the mean decrease of NRS scores (4.34 vs 3.56; P = .003). Mixed-model analysis showed a significant difference in favor of NACD+PRP (CMS, P < .001; DASH, P = .002; OSS, P = .010; EQ-5D, P < .001). However, clinically relevant differences in favor of NACD+PRP were only seen at the 6-month follow-up for NRS and CMS scores, whereas at the 6-week follow-up a clinically relevant difference in favor of NACD+corticosteroids was found for all clinical scores except for the NRS. Full resorption of calcific deposits was present in 84% of the NACD+PRP group compared with 66% in the NACD+corticosteroids group (P = .081). In the NACD+PRP group, 10 (24%) patients required a second NACD procedure compared with 19 (49%) patients in the NACD+corticosteroids group (P = .036). Six complications, of which 5 were frozen shoulders, occurred in the NACD+PRP group compared with 1 complication in the NACD+corticosteroids group (P = .11). CONCLUSION NACD+PRP resulted in worse clinical scores at the 6-week follow-up but better clinical scores at the 6-month follow-up compared with NACD+corticosteroids. At the 1- and 2-year follow-ups, the results were comparable between groups. Furthermore, PRP seemed to reduce the need for additional treatments but was associated with more complications. In conclusion, NACD+corticosteroids had a favorable early effect on pain and function combined with low comorbidity. Thus, it remains the treatment of choice for patients with RCCT. REGISTRATION NCT02173743 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Bart W Oudelaar
- Centre for Orthopaedic Surgery OCON, Hengelo, the Netherlands
| | | | - Edwin M Ooms
- Centre for Orthopaedic Surgery OCON, Hengelo, the Netherlands
| | | | - Rob G H H Nelissen
- Department of Orthopaedic Surgery, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | | |
Collapse
|
|
14
|
Krogh TP, Kjær SG, Blegvad‐Nissen J, Jensen P, Ellingsen T, Fredberg U. Ultrasound‐guided injection therapy with platelet‐rich plasma in recreational athletes with patellar tendinopathy: A randomized, single blinded, placebo‐controlled trial with 3 months follow‐up. TRANSLATIONAL SPORTS MEDICINE 2021. [DOI: 10.1002/tsm2.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Thøger Persson Krogh
- Diagnostic Centre University Research Clinic for Innovative Patient PathwaysSilkeborg Regional Hospital Silkeborg Denmark
- Center for Sports Medicine Regional Hospital of Northern Denmark Hjørring Denmark
| | - Søren Geill Kjær
- Diagnostic Centre University Research Clinic for Innovative Patient PathwaysSilkeborg Regional Hospital Silkeborg Denmark
| | - Jesper Blegvad‐Nissen
- Diagnostic Centre University Research Clinic for Innovative Patient PathwaysSilkeborg Regional Hospital Silkeborg Denmark
| | - Pia Jensen
- Diagnostic Centre University Research Clinic for Innovative Patient PathwaysSilkeborg Regional Hospital Silkeborg Denmark
| | - Torkell Ellingsen
- Diagnostic Centre University Research Clinic for Innovative Patient PathwaysSilkeborg Regional Hospital Silkeborg Denmark
- Research Unit of Rheumatology Department of Clinical Research University of Southern DenmarkOdense University Hospital Odense Denmark
| | - Ulrich Fredberg
- Diagnostic Centre University Research Clinic for Innovative Patient PathwaysSilkeborg Regional Hospital Silkeborg Denmark
- Research Unit of Rheumatology Department of Clinical Research University of Southern DenmarkOdense University Hospital Odense Denmark
- Institute of Sports Medicine Copenhagen Bispebjerg Hospital Copenhagen Denmark
| |
Collapse
|
|
15
|
Park YB, Kim JH, Ha CW, Lee DH. Clinical Efficacy of Platelet-Rich Plasma Injection and Its Association With Growth Factors in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized Double-Blind Controlled Clinical Trial As Compared With Hyaluronic Acid. Am J Sports Med 2021; 49:487-496. [PMID: 33523756 DOI: 10.1177/0363546520986867] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although platelet-rich plasma (PRP) has potential as a regenerative treatment for knee osteoarthritis, its efficacy varies. Compositional differences among types of PRP could affect clinical outcomes, but the biological characterization of PRP is lacking. PURPOSE To assess the efficacy of intra-articular PRP injection in knee osteoarthritis as compared with hyaluronic acid (HA) injection and to determine whether the clinical efficacy of PRP is associated with its biological characteristics. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 110 patients with symptomatic knee osteoarthritis received a single injection of leukocyte-rich PRP (1 commercial kit) or HA. Clinical data were assessed at baseline and at 6 weeks and 3 and 6 months after injection. The primary endpoint was an improvement in the International Knee Documentation Committee (IKDC) subjective score at 6 months, and the secondary endpoints were improvements in scores based on the Patient Global Assessment, the visual analog scale (VAS) for pain, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Samsung Medical Center patellofemoral score. Cell counts and concentrations of growth factors and cytokines in the injected PRP were assessed to determine their association with clinical outcomes. RESULTS PRP showed significantly improvement in IKDC subjective scores at 6 months (11.5 in the PRP group vs 6.3 in the HA group; P = .029). There were no significant differences between groups in other clinical outcomes. The Patient Global Assessment score at 6 months was better in the PRP group (P = .035). The proportion of patients who scored above the minimal clinically important difference (MCID) for VAS at 6 months was significantly higher in the PRP group (P = .044). Within the PRP group, the concentrations of platelet-derived growth factors were high in patients with a score above the MCID for VAS at 6 months. The incidence of adverse events did not differ between the groups (P > .05). CONCLUSION PRP had better clinical efficacy than HA. High concentrations of growth factors were observed in patients who scored above the MCID for clinical outcomes in the PRP group. These findings indicate that concentration of growth factors needs to be taken into consideration for future investigations of PRP in knee osteoarthritis. REGISTRATION NCT02211521 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jun-Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Republic of Korea
| | - Chul-Won Ha
- Department of Orthopedic Surgery, Samsung Medical Center, Seoul, Republic of Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, Republic of Korea.,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Dong-Hyun Lee
- Department of Orthopedic Surgery, Himchan Hospital, Busan, Republic of Korea
| |
Collapse
|
|
16
|
IN-SEASON REHABILITATION PROGRAM USING BLOOD FLOW RESTRICTION THERAPY FOR TWO DECATHLETES WITH PATELLAR TENDINOPATHY: A CASE REPORT. Int J Sports Phys Ther 2020; 15:1184-1195. [PMID: 33344034 DOI: 10.26603/ijspt20201184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background and Purpose Patellar tendinopathy is an overuse injury experienced primarily by athletes; especially athletes who participate in sports that involve frequent jumping. Therapeutic exercise is the primary conservative treatment for patients with this condition. However, some patients with patellar tendinopathy may be unable to tolerate the loading that occurs during exercise. The use of blood flow restriction (BFR) therapy for patients with patellar tendinopathy may allow the athlete to exercise with a lower load while still experiencing the physiological benefits associated with training at a higher intensity. The purpose of this case report was to detail the outcomes from a rehabilitation program utilizing BFR for two collegiate decathletes with patellar tendinopathy. Study Design Case ReportCase Descriptions and Interventions: Two NCAA Division III freshmen collegiate decathletes with a history of left knee pain prior to college and who had been complaining of increasing pain during the initial month of track practices. Findings from the musculoskeletal examinations included left sided lower extremity weakness, pain during functional testing, pain when palpating the left patellar tendon, and VISA-P scores less than 80. Ultrasound imaging at baseline revealed thickened tendons on the left with hypoechoic regions. Both athletes participated in 20 therapy sessions consisting of therapeutic exercises performed with BFR. Outcomes Both athletes experienced improvements in pain scores, increases in lower extremity strength, improved functional test performance, higher VISA-P scores, and improvements in tendon size and appearance as measured by diagnostic ultrasound. Conclusion Both athletes experienced improvements with the BFR-based therapeutic exercise program and were able to compete throughout the track season. The use of BFR may allow patients who are unable to tolerate exercise due to pain an alternative approach during rehabilitation. Future research should compare therapeutic exercise programs for this condition with and without BFR. Level of Evidence Level V.
Collapse
|
|
17
|
Sánchez-Sánchez JL, Calderón-Díez L, Herrero-Turrión J, Méndez-Sánchez R, Arias-Buría JL, Fernández-de-las-Peñas C. Changes in Gene Expression Associated with Collagen Regeneration and Remodeling of Extracellular Matrix after Percutaneous Electrolysis on Collagenase-Induced Achilles Tendinopathy in an Experimental Animal Model: A Pilot Study. J Clin Med 2020; 9:jcm9103316. [PMID: 33076550 PMCID: PMC7602800 DOI: 10.3390/jcm9103316] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/21/2020] [Accepted: 10/12/2020] [Indexed: 01/04/2023] Open
Abstract
Percutaneous electrolysis is an emerging intervention proposed for the management of tendinopathies. Tendon pathology is characterized by a significant cell response to injury and gene expression. No study investigating changes in expression of those genes associated with collagen regeneration and remodeling of extracellular matrix has been conducted. The aim of this pilot study was to investigate gene expression changes after the application of percutaneous electrolysis on experimentally induced Achilles tendinopathy with collagenase injection in an animal model. Fifteen Sprague Dawley male rats were randomly divided into three different groups (no treatment vs. percutaneous electrolysis vs. needling). Achilles tendinopathy was experimentally induced with a single bolus of collagenase injection. Interventions consisted of 3 sessions (one per week) of percutaneous electrolysis or just needling. The rats were euthanized, and molecular expression of genes involved in tendon repair and remodeling, e.g., Cox2, Mmp2, Mmp9, Col1a1, Col3a1, Vegf and Scx, was examined at 28 days after injury. Histological tissue changes were determined with hematoxylin–eosin and safranin O analyses. The images of hematoxylin–eosin and Safranin O tissue images revealed that collagenase injection induced histological changes compatible with a tendinopathy. No further histological changes were observed after the application of percutaneous electrolysis or needling. A significant increase in molecular expression of Cox2, Mmp9 and Vegf genes was observed in Achilles tendons treated with percutaneous electrolysis to a greater extent than after just needling. The expression of Mmp2, Col1a1, Col3a1, or Scx genes also increased, but did not reach statistical significance. This animal study demonstrated that percutaneous electrolysis applied on an experimentally induced Achilles tendinopathy model could increase the expression of some genes associated with collagen regeneration and remodeling of extracellular matrix. The observed gene overexpression was higher with percutaneous electrolysis than with just needling.
Collapse
Affiliation(s)
- José Luis Sánchez-Sánchez
- Department of Physical Therapy, Universidad de Salamanca, 37007 Salamanca, Spain; (J.L.S.-S.); (L.C.-D.); (R.M.-S.)
| | - Laura Calderón-Díez
- Department of Physical Therapy, Universidad de Salamanca, 37007 Salamanca, Spain; (J.L.S.-S.); (L.C.-D.); (R.M.-S.)
- Physical Therapy Department, Mutua Accidentes Laborales, FREMAP, 37007 Salamanca, Spain
| | - Javier Herrero-Turrión
- Instituto de Neurociencias de Castilla y León, Universidad de Salamanca, 37007 Salamanca, Spain;
- Instituto Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca, 37007 Salamanca, Spain
| | - Roberto Méndez-Sánchez
- Department of Physical Therapy, Universidad de Salamanca, 37007 Salamanca, Spain; (J.L.S.-S.); (L.C.-D.); (R.M.-S.)
| | - José L. Arias-Buría
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, 28922 Madrid, Spain;
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, 28922 Madrid, Spain
| | - César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, 28922 Madrid, Spain;
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, 28922 Madrid, Spain
- Correspondence: ; Tel.: +34-91-488-88-84
| |
Collapse
|
|
18
|
The Effectiveness of Minimally Invasive Techniques in the Treatment of Patellar Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:8706283. [PMID: 32963575 PMCID: PMC7492866 DOI: 10.1155/2020/8706283] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/14/2020] [Accepted: 08/25/2020] [Indexed: 01/22/2023]
Abstract
The aim was to determine the effectiveness of minimally invasive techniques (MIT) in patients with patellar tendinopathy. Database searches were performed for randomized controlled trials (RCTs) in electronic databases (WOS, Cochrane Central, SportDiscus, and Medline via PubMed and PEDro). The inclusion criteria used were published in English or Spanish and involving adults with patellar tendinopathy (pain on the inferior pole of the patella for a minimum of 3 months), with at least one group receiving MIT. The quality of the relevant RCTs was evaluated using the PEDro scale. The primary outcome was functionality using the VISA-p questionnaire. Secondary outcome was focused on pain. A total of 1164 studies were screened for possible inclusion in our systematic review. Finally, 10 RCTs were included with a total of 326 individuals. Five RCTs were included in the meta-analysis. The quality assessment revealed that all the studies included were considered to possess high methodological quality. All studies analyzing MIT such as platelet-rich plasma (PRP), dry needling, or skin-derived tenocyte-like cells, when combined with exercise, proved to be effective for patellar tendinopathy. Moreover, the PRP technique with doses greater than 4 mL together and combined with an exercise program lasting over 6 weeks obtained better results in functionality and pain than other treatments in the short term. However, in the long term, dry needling and skin-derived tenocyte-like cells are more effective than PRP. Although the infiltration of drugs was effective at posttreatment, these improvements were not maintained over time and may have secondary effects. Although there are no RCTs analyzing the effectiveness of MIT like percutaneous needle electrolysis, there has been an increasing number of publications achieving excellent results in the last years. However, it is necessary to develop RCTs analyzing not only the effect but also comparing the effectiveness between different MIT such as dry needling and percutaneous needle electrolysis.
Collapse
|
|
19
|
The Clinical Use of Platelet-Rich Plasma in Knee Disorders and Surgery-A Systematic Review and Meta-Analysis. Life (Basel) 2020; 10:life10060094. [PMID: 32630404 PMCID: PMC7344495 DOI: 10.3390/life10060094] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/14/2020] [Accepted: 06/23/2020] [Indexed: 12/16/2022] Open
Abstract
In recent years, the interest in biological treatment of knee lesions has increased, especially the application of platelet-rich plasma is of particular note. The number of articles evaluating platelet-rich plasma (PRP) efficacy in the recovery of knee disorders and during knee surgery has exponentially increased over the last decade. A systematic review with meta-analyses was performed by assessing selected studies of local PRP injections to the knee joint. The study was completed in accordance with 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A multistep search of PubMed, Embase, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov was performed to identify studies on knee surgery and knee lesion treatment with PRP. Of the 4004 articles initially identified, 357 articles focusing on knee lesions were selected and, consequently, only 83 clinical trials were analyzed using the revised Cochrane risk-of-bias tool to evaluate risk. In total, seven areas of meta-analysis reported a positive effect of PRP. Among them, 10 sub-analyses demonstrated significant differences in favor of PRP when compared to the control groups (p < 0.05). This study showed the positive effects of PRP, both on the recovery of knee disorders and during knee surgery; however further prospective and randomized studies with a higher number of subjects and with lower biases are needed.
Collapse
|
|
20
|
Mariani E, Pulsatelli L. Platelet Concentrates in Musculoskeletal Medicine. Int J Mol Sci 2020; 21:ijms21041328. [PMID: 32079117 PMCID: PMC7072911 DOI: 10.3390/ijms21041328] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/29/2020] [Accepted: 02/06/2020] [Indexed: 12/02/2022] Open
Abstract
Platelet concentrates (PCs), mostly represented by platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are autologous biological blood-derived products that may combine plasma/platelet-derived bioactive components, together with fibrin-forming protein able to create a natural three-dimensional scaffold. These types of products are safely used in clinical applications due to the autologous-derived source and the minimally invasive application procedure. In this narrative review, we focus on three main topics concerning the use of platelet concentrate for treating musculoskeletal conditions: (a) the different procedures to prepare PCs, (b) the composition of PCs that is related to the type of methodological procedure adopted and (c) the clinical application in musculoskeletal medicine, efficacy and main limits of the different studies.
Collapse
Affiliation(s)
- Erminia Mariani
- Laboratorio di Immunoreumatologia e rigenerazione tissutale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy;
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
- Correspondence: ; Tel.: +39-051-6366803
| | - Lia Pulsatelli
- Laboratorio di Immunoreumatologia e rigenerazione tissutale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy;
| |
Collapse
|
|
21
|
Schwitzguebel AJ, Kolo FC, Tirefort J, Saffarini M, Lädermann A. Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: Response. Am J Sports Med 2020; 48:NP9-NP10. [PMID: 31877106 DOI: 10.1177/0363546519879690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
|
22
|
Systematic Comparison of the Effect of Four Clinical-Grade Platelet Rich Hemoderivatives on Osteoblast Behaviour. Int J Mol Sci 2019; 20:ijms20246243. [PMID: 31835696 PMCID: PMC6941155 DOI: 10.3390/ijms20246243] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/09/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023] Open
Abstract
Hemoderivatives have utilized in an empirical manner, driven by clinical considerations, leading to the development of a plethora of manufacturing protocols. The purpose of this study was to investigate the composition and bioactivity of four common clinical-grade hemoderivates prepared using standardised methods. Four different hemoderivatives were obtained from sheep blood and divided into two groups: A-PRF/i-PRF (fresh) and P-PRP/L-PRP (anticoagulated). Thrombus (CLOT) was used as a control. Thrombocyte quantification, growth factor composition (IGF-I, VEGF, PDGF-BB, BMP-2), cell viability, migration and mineralization assay were evaluated. Platelet recovery was superior for L-PRP followed by P-PRP. A significant cumulative release of IGF-I and PDGF-BB was noted for A-PRF and L-PRP groups at early time points. Similar release profiles of BMP-2 and VEGF were noted in all protocols. Cell viability and migration assay have demonstrated a detrimental effect when the concentration was ≥60%. Moreover, at Day 21, i-PRF have demonstrated superior mineralisation properties when compared to all groups. A negative impact of A-PRF was demonstrated at high concentrations. Despite its low content in growth factors, i-PRF was the best performing blood product for inducing osteoblast mineralisation, and therefore could be the candidate of choice for utilisation in bone tissue engineering applications.
Collapse
|
|
23
|
Platelet-rich plasma for sports-related muscle, tendon and ligament injuries: an umbrella review. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 17:465-478. [PMID: 31846610 DOI: 10.2450/2019.0274-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Platelet-rich plasma (PRP) has been used in different non-transfusion indications due to its role in tissue regeneration and healing. The aim of this overview of systematic reviews (umbrella review) is to provide a summary of the existing research syntheses related to PRP use for sports-related muscle, tendon and ligament injuries. MATERIALS AND METHODS Literature searches were performed in MEDLINE, Embase, and Cochrane Library to identify systematic reviews focusing on PRP use for sports-related muscle, tendon and ligament injuries. The methodological quality of included studies was assessed using the checklist for systematic reviews and research syntheses developed by the Joanna Briggs Institute and the GRADE assessment. RESULTS Twenty-two studies met the inclusion criteria. Five studies evaluated PRP use for acute muscle injury, and 17 evaluated PRP use for tendon and ligament injury. Studies were heterogeneous in terms of the dose and number of PRP injections, and the control groups. Three of the 5 reviews evaluating acute muscle injury concluded that PRP had no effect on the outcomes considered. One review shows superior efficacy of rehabilitation exercise compared to PRP. One review shows that PRP may result in an earlier return to sport for acute grade I-II injury. Eight out of the 17 reviews evaluating PRP for tendon and ligament injuries show a statistically significant (p<0.05) difference in pain and/or function outcome measures favouring PRP compared to controls, although most of the observed differences were small. Adverse events data and quality of life outcomes were rarely analysed or reported in the included studies and were considered clinically insignificant. DISCUSSION In most of the included reviews, the available evidence was judged to be of low/very low quality due to risk of bias, inconsistency and imprecision, thus making the level of certainty of these findings low and not adequate to support the general use of PRP in this setting.
Collapse
|
|
24
|
Mehrabani D, Seghatchian J, Acker JP. Platelet rich plasma in treatment of musculoskeletal pathologies. Transfus Apher Sci 2019; 58:102675. [DOI: 10.1016/j.transci.2019.102675] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
|
25
|
Rodeo SA, Bedi A. 2019-2020 NFL and NFL Physician Society Orthobiologics Consensus Statement. Sports Health 2019; 12:58-60. [PMID: 32379537 DOI: 10.1177/1941738119889013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Scott A Rodeo
- Hospital for Special Surgery, Co-Chief Emeritus, Sports Medicine Institute, Hospital for Special Surgery, New York, New York.,Weill Cornell Medical College, New York, New York.,New York-Presbyterian Hospital, New York, New York.,New York Giants, East Rutherford, New Jersey
| | - Asheesh Bedi
- Sports Medicine, Sports Medicine & Shoulder Surgery, MedSport, Department of Orthopaedic Surgery, Michigan Medicine, University of Michigan Athletics, Ann Arbor, Michigan.,Detroit Lions, Detroit, Michigan
| |
Collapse
|
|
26
|
Pachito DV, Latorraca CDOC, Riera R. Efficacy of platelet-rich plasma for non-transfusion use: Overview of systematic reviews. Int J Clin Pract 2019; 73:e13402. [PMID: 31408240 DOI: 10.1111/ijcp.13402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/05/2019] [Accepted: 08/07/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Platelet-rich plasma (PRP) is a blood component therapy with a supraphysiological concentration of platelets derived from allogenic or, more commonly, autologous blood. PRP has been used in different non-transfusion indications because of its role in the promotion of tissue repair and healing, in fields such as Traumatology, Dermatology and Dentistry. OBJECTIVE To provide a synthesis of the efficacy of PRP for different clinical situations. METHODS Systematic searches were carried out in MEDLINE, Embase, Cochrane Library and LILACS in July 2018 to identify systematic reviews (SRs) of randomized clinical trials (RCTs) focusing on PRP for non-transfusion use. Two authors independently screened all retrieved references in two stages (titles and abstracts at a first stage and full texts at a second stage). The methodological quality of SRs that met the eligibility criteria was appraised by AMSTAR 2. Conclusions were based on the most recent SRs with highest quality. RESULTS One thousand two hundred and forty references were retrieved. After checking the inclusion criteria, 29 SRs of RCTs related to three different fields (wound care, Orthopedics and Dentistry) were included. The results suggest the benefit of PRP for different clinical situations, such as diabetic wounds, acute lesions of musculoskeletal system, rotator cuff lesions, tendinopathies, knee and hip osteoarthritis, total knee arthroplasty, allogenic bone graft for dental implants and periodontal intrabony defects. CONCLUSION There is low to moderate quality evidence supporting the efficacy of PRP for specific clinical situations. The low quality of the evidence limits the certainty of these findings. Well-planned and well-conducted RCTs are still needed to further assess the efficacy of PRP.
Collapse
Affiliation(s)
- Daniela Vianna Pachito
- Hospital Sírio-Libanês, Núcleo de Avaliação de Tecnologias de Saúde, São Paulo, Brazil
- Disciplina de Economia e Gestão da Saúde, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Rachel Riera
- Hospital Sírio-Libanês, Núcleo de Avaliação de Tecnologias de Saúde, São Paulo, Brazil
- Evidence Based Health Program, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| |
Collapse
|
|
27
|
Chen PC, Wu KT, Chou WY, Huang YC, Wang LY, Yang TH, Siu KK, Tu YK. Comparative Effectiveness of Different Nonsurgical Treatments for Patellar Tendinopathy: A Systematic Review and Network Meta-analysis. Arthroscopy 2019; 35:3117-3131.e2. [PMID: 31699265 DOI: 10.1016/j.arthro.2019.06.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 06/05/2019] [Accepted: 06/13/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the functional improvement and pain reduction of different nonsurgical treatments for patellar tendinopathy (PT), a systematic review with network meta-analysis was performed. METHODS Studies were comprehensively searched for without language restrictions in the CENTRAL, MEDLINE, EMBASE, Web of Science, Physiotherapy Evidence Database, and SPORTDiscus databases from inception to May 2018. Randomized controlled trials about nonsurgical treatments for PT were included. The outcome measurements were the Victorian Institute of Sports Assessment (VISA) scale and pain scores (such as the visual analog scale or Numerical Rating Scale). Study quality was evaluated using the Physiotherapy Evidence Database score. Direct comparisons were performed using pairwise meta-analysis, whereas network meta-analysis was performed using a frequentist method in a multivariate random-effects model. RESULTS Eleven studies with 430 affected patellar tendons were included in the systematic review. The summary mean difference of improvement in the VISA scale versus the control group for corticosteroid injection was -23.00 (95% confidence interval [CI] -36.73 to -9.27), for leukocyte-rich platelet-rich plasma (LR-PRP) was 13.22 (95% CI 2.37-24.07), for focused extracorporeal shockwave therapy (ESWT) was -1.28 (95% CI -6.25 to 3.68), for radial ESWT was -6.68 (95% CI -20.20 to 6.84), for ultrasound was -0.70 (95% CI -11.23 to 9.83), for autologous blood injection was -0.60 (95% CI -9.30 to 8.10), for dry needling was 17.51 (95% CI -2.57 to 37.60), for topical glyceryl trinitrate was -0.90 (95% CI -13.07 to 11.27), and for skin-derived tendon-like cells was 10.40 (95% CI -1.59 to 22.39). LR-PRP (Surface Under the Cumulative Ranking curve [SUCRA] = 87.5%) or dry needling (SUCRA = 90.5%) was most likely to be ranked the best in terms of improvement on the VISA scale. Compared with the control group, the summary mean difference of the change in pain score for corticosteroid injection was 0.80 (95% CI -3.48 to 5.08), for LR-PRP was -1.87 (95% CI -3.28 to -0.46), for focused ESWT was 0.13 (95% CI -0.68 to 0.93), for radial ESWT was 0.03 (95% CI -1.92 to 1.98), for ultrasound was -0.20 (95% CI -1.49 to 1.09), for autologous blood injection was 0.60 (95% CI -0.73 to 1.93), for dry needling was -0.37 (95% CI -2.71 to 1.97), and for topical glyceryl trinitrate was -0.50 (95% CI -2.55 to 1.55). The treatment most likely to be ranked the best in terms of change in pain score was LR-PRP (SUCRA = 94.9%). CONCLUSIONS The network meta-analysis demonstrated that LR-PRP has the greatest functional improvement and pain reduction for PT compared with other treatment options. However, the treatment effect estimates can be biased by the possible intransitivity and should not be overestimated. LEVEL OF EVIDENCE Level I, meta-analysis of Level I studies.
Collapse
Affiliation(s)
- Po-Cheng Chen
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuan-Ting Wu
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Yi Chou
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Medical Mechatronic Engineering Program, Cheng Shiu University, Kaohsiung, Taiwan
| | - Yu-Chi Huang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Lin-Yi Wang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsung-Hsun Yang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ka-Kit Siu
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
|
28
|
Variability of the Composition of Growth Factors and Cytokines in Platelet-Rich Plasma From the Knee With Osteoarthritis. Arthroscopy 2019; 35:2878-2884.e1. [PMID: 31604507 DOI: 10.1016/j.arthro.2019.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 03/31/2019] [Accepted: 04/07/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the composition and concentration of growth factors and cytokines in platelet-rich plasma (PRP) with knee osteoarthritis and to explore the association of the concentration of growth factors and cytokines with the platelet count of PRPs. METHODS Patients who visited outpatient clinic with symptomatic knee osteoarthritis (Kellgren-Lawrence grades 1 to 3) and had no blood dyscrasia were enrolled from October 2014 to March 2015. PRPs were obtained using a commercial system. Concentrations of growth factors and cytokines were measured with an enzyme-linked immunosorbent assay. Anabolic factors (platelet-derived growth factor [PDGF]-AA, -BB, and -AB, transforming growth factor-β, vascular endothelial growth factor [VEGF], epidermal growth factor [EGF], basic fibroblast growth factor [bFGF], and insulin-like growth factor 1), catabolic factors (interleukin [IL]-1β and matrix metalloproteinase 13), and catabolic blockers (IL-1 receptor antagonist) were included. The degree of variation was determined by coefficient of variation (CoV). RESULTS 105 patients were included. Growth factors and cytokines showed wide variation. bFGF showed the highest variation (CoV 78.45), and transforming growth factor-β1 showed the lowest variation (CoV 5.30). Platelet count in PRP showed a positive correlation with PDGF-BB and -AB, and VEGF (r = 0.270, P = .005; r = 0.231, P = .018; and r = 0.200, P = .041, respectively) and was negatively correlated with IL-1β (r = -0.220, P = .025). CONCLUSION Growth factors and cytokines in PRPs obtained from patients with knee osteoarthritis show a wide variation; the highest variation was shown in bFGF. Platelet counts associated positively with PDGF-AB and -BB and VEGF and negatively with IL-1β. CLINICAL RELEVANCE This information leads to the concept that variation and association of specific factors needs to be taken into consideration for future investigations of PRPs in clinical application in patients with knee osteoarthritis.
Collapse
|
|
29
|
Abstract
There is good scientific rationale to support the use of growth factors to promote musculoskeletal tissue regeneration. However, the clinical effectiveness of platelet-rich plasma (PRP) and other blood-derived products has yet to be proven. Characterization and reporting of PRP preparation protocols utilized in clinical trials for the treatment of musculoskeletal disease is highly inconsistent, and the majority of studies do not provide sufficient information to allow the protocols to be reproduced. Furthermore, the reporting of blood-derived products in orthopaedics is limited by the multiple PRP classification systems available, which makes comparison of results between studies challenging. Several attempts have been made to characterize and classify PRP; however, no consensus has been reached, and there is lack of a comprehensive and validated classification. In this annotation, we outline existing systems used to classify preparations of PRP, highlighting their advantages and limitations. There remains a need for standardized universal nomenclature to describe biological therapies, as well as a comprehensive and reproducible classification system for autologous blood-derived products. Cite this article: Bone Joint J 2019;101-B:891–896.
Collapse
Affiliation(s)
- L. A. Rossi
- Department of Orthopaedic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - I. R. Murray
- Resident in Orthopaedic Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
- Department of Trauma and Orthopaedics, University of Edinburgh, Edinburgh, UK
| | - C. R. Chu
- Department of Orthopedic Surgery, Stanford University, Stanford, California, USA
- VA Palo Alto, Palo Alto, California, USA
| | - G. F. Muschler
- Director of the Joint Preservation Center, and Director of the Regenerative Medicine Laboratory, Cleveland Clinic, Cleveland, Ohio, USA
| | - S. A. Rodeo
- Tissue Engineering, Regeneration, and Repair Program, Hospital for Special Surgery, New York, New York, USA
- Orthopaedic Surgery, Weill Medical College of Cornell University, New York, New York, USA
- The Hospital for Special Surgery, New York, New York, USA
- New York Giants Football, New York, New York, USA
| | - N. S. Piuzzi
- Cleveland Clinic, Cleveland, Ohio, USA
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
|
30
|
Schwitzguebel AJ, Kolo FC, Tirefort J, Kourhani A, Nowak A, Gremeaux V, Saffarini M, Lädermann A. Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: A Double-Blinded, Randomized Controlled Trial. Am J Sports Med 2019; 47:1885-1892. [PMID: 31161947 DOI: 10.1177/0363546519851097] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of platelet-rich plasma (PRP) for the treatment of rotator cuff tears remain inconclusive, as it is administered either as an adjuvant to surgical repair or as a primary infiltration without targeting the index lesion, which could dilute its effect. PURPOSE To determine whether PRP infiltrations are superior to saline solution infiltrations (placebo) at improving healing, pain, and function when injected under ultrasound guidance within isolated interstitial supraspinatus tears. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In this single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic isolated interstitial tears of the supraspinatus, confirmed by magnetic resonance arthrography, were randomized to PRP or saline injections. Each patient received 2 injections with a 1-month interval. The primary outcome was the change in lesion volume, calculated on magnetic resonance arthrography, at 7 months. The secondary outcomes were improvements in shoulder pain and the Single Assessment Numerical Evaluation (SANE) score at >12 months. RESULTS Preoperative patient characteristics did not differ between the 2 groups. At 7 months, there were no significant differences between the PRP and control groups in terms of a decrease in lesion size (-0.3 ± 23.6 mm3 vs -8.1 ± 84.7 mm3, respectively; P = .175); reduction of pain on a visual analog scale (VAS) (-2.3 ± 3.0 vs -2.0 ± 3.0, respectively; P = .586); and improvement in SANE (16.7 ± 20.0 vs 14.9 ± 29.0, respectively; P = .650), Constant (8.6 ± 13.0 vs 10.7 ± 19.0, respectively; P = .596), and American Shoulder and Elbow Surgeons (19.5 ± 20.0 vs 21.9 ± 28.0, respectively; P = .665) scores. At >12 months, there were no significant differences between the PRP and control groups in terms of a reduction of pain on a VAS (-3.3 ± 2.6 vs -2.3 ± 3.2, respectively; P = .087) or improvement in the SANE score (24.4 ± 27.5 vs 23.4 ± 24.9, respectively; P = .846). At 19.5 ± 5.3 months, the incidence of adverse effects (pain >48 hours, frozen shoulder, extension of lesion) was significantly higher in the PRP group than the control group (54% vs 26%, respectively; P = .020). CONCLUSION PRP injections within interstitial supraspinatus tears did not improve tendon healing or clinical scores compared with saline injections and were associated with more adverse events. REGISTRATION NCT02672085 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Adrien J Schwitzguebel
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland.,Division of Physical Medicine and Rehabilitation, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Jérôme Tirefort
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Abed Kourhani
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alexandra Nowak
- Division of Physical Medicine and Rehabilitation, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Gremeaux
- Division of Physical Medicine and Rehabilitation, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| |
Collapse
|
|
31
|
Milano G, Sánchez M, Jo CH, Saccomanno MF, Thampatty BP, Wang JHC. Platelet-rich plasma in orthopaedic sports medicine: state of the art. J ISAKOS 2019. [DOI: 10.1136/jisakos-2019-000274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
|
32
|
Oudelaar BW, Peerbooms JC, Huis In 't Veld R, Vochteloo AJH. Concentrations of Blood Components in Commercial Platelet-Rich Plasma Separation Systems: A Review of the Literature. Am J Sports Med 2019; 47:479-487. [PMID: 29337592 DOI: 10.1177/0363546517746112] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) has proven to be a very safe therapeutic option in the treatment of tendon, muscle, bone, and cartilage injuries. Currently, several commercial separation systems are available for the preparation of PRP. The concentrations of blood components in PRP among these separation systems vary substantially. PURPOSE To systematically review and evaluate the differences between the concentrations of blood components in PRP produced by various PRP separation systems. STUDY DESIGN Systematic review. METHODS MEDLINE/PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE were searched for studies that compared the concentrations of blood components and growth factors in PRP between various separation systems and studies that reported on the concentrations of blood components and growth factors of single separation systems. The primary outcomes were platelet count, leukocyte count, and concentration of growth factors (eg, platelet-derived growth factor-AB [PDGF-AB], transforming growth factor-β1 [TGF-β1], and vascular endothelial growth factor [VEGF]). Furthermore, the preparation protocols and prices of the systems were compared. RESULTS There were 1079 studies found, of which 19 studies were selected for inclusion in this review. The concentrations of platelets and leukocytes in PRP differed largely between, and to a lesser extent within, the studied PRP separation systems. Additionally, large differences both between and within the studied PRP separation systems were found for all the growth factors. Furthermore, preparation protocols and prices varied widely between systems. CONCLUSION There is a large heterogeneity between PRP separation systems regarding concentrations of platelets, leukocytes, and growth factors in PRP. The choice for the most appropriate type of PRP should be based on the specific clinical field of application. As the ideal concentrations of blood components and growth factors for the specific fields of application are yet to be determined for most of the fields, future research should focus on which type of PRP is most suitable for the specific field.
Collapse
Affiliation(s)
- Bart W Oudelaar
- OCON Centre for Orthopaedic Surgery, Hengelo, the Netherlands
| | - Joost C Peerbooms
- Department of Orthopaedic Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | | |
Collapse
|
|
33
|
Abate M, Di Carlo L, Verna S, Di Gregorio P, Schiavone C, Salini V. Synergistic activity of platelet rich plasma and high volume image guided injection for patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc 2018; 26:3645-3651. [PMID: 29605861 DOI: 10.1007/s00167-018-4930-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 03/26/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Platelet rich plasma and high volume image guided injections of saline have been used in the treatment of patellar tendinopathy with positive results. As the different mechanisms of action do not interfere each other, it can be hypothesized that they can be used in combination. Aim of this study was twofold: first, to evaluate the efficacy of these two treatments in the management of patellar tendinopathy; second, to verify whether the combination of these therapies could provide further advantages. METHODS Fifty-four patients suffering from patellar tendinopathy were enrolled. After clinical (VAS and VISA-P) and sonographic evaluation, two ultrasound guided injections (2 weeks apart) of platelet rich plasma, high-volume image-guided injections of saline, or both in association were performed. The VAS and VISA-P scores obtained from the three treatments groups (18 patients in each group) were compared across the different follow-up times (3 and 6 months). RESULTS In the short term both treatments showed comparable efficacy, whereas in the medium term the positive effects of high-volume image-guided injections gradually diminished and platelet rich plasma showed greater efficacy. Better results (reduced pain, improved function and increased number of subjects who exhibited optimal recovery [> 20 points in VISA-P score]) were observed when both procedures were associated. CONCLUSIONS The contemporaneous administration of platelet rich plasma and high volume image guided injections of saline treatments, which influence tendon repair by means of different mechanisms, grants a greater improvement for patellar tendinopathy. This finding has clinical relevance, given that this condition has a substantial impact on sports and work performance. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Michele Abate
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy.
| | - Luigi Di Carlo
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
| | - Sandra Verna
- Immunohaematology and Transfusional Medicine Service, "SS. Annunziata" Hospital, Chieti Scalo, Chieti, Italy
| | - Patrizia Di Gregorio
- Immunohaematology and Transfusional Medicine Service, "SS. Annunziata" Hospital, Chieti Scalo, Chieti, Italy
| | - Cosima Schiavone
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
| | - Vincenzo Salini
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
| |
Collapse
|
|
34
|
|
|
35
|
Kolber MJ, Purita J, Paulus C, Carreno JA, Hanney WJ. Platelet-Rich Plasma: Basic Science and Biological Effects. Strength Cond J 2018. [DOI: 10.1519/ssc.0000000000000402] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
|
36
|
Kolber MJ, Purita J, Paulus C, Carreno JA, Hanney WJ. Platelet Rich Plasma: Postprocedural Considerations for the Sports Medicine Professional. Strength Cond J 2018. [DOI: 10.1519/ssc.0000000000000403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
|
37
|
Martínez-Martínez A, Ruiz-Santiago F, García-Espinosa J. Platelet-rich plasma: myth or reality? RADIOLOGIA 2018; 60:465-475. [PMID: 30274850 DOI: 10.1016/j.rx.2018.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/10/2018] [Accepted: 08/20/2018] [Indexed: 01/06/2023]
Abstract
Platelet-rich plasma (PRP) is a preparation for therapeutic purposes that is increasingly accepted for various musculoskeletal disorders, due to its theoretical potential to repair tissues with poor healing capacity. Several randomised clinical trials have investigated the capacity of PRP to repair tendons, ligaments, muscles and cartilage, and to date there is level 1a evidence to support its use for lateral epicondylitis, osteoarthritis of the knee, plantar fasciitis and rotator cuff tendinopathy; and level 1b for patellar tendinopathy and osteoarthritis of the hip. Retrospective cohort studies and case series describe promising results with PRP for treating other musculoskeletal disorders. Since its side effects are fewer than those of the control groups, the treatment is considered practically harmless and is being increasingly used. Further randomised clinical trials are necessary to establish future indications, and to confirm effectiveness and safety.
Collapse
Affiliation(s)
- A Martínez-Martínez
- Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España.
| | - F Ruiz-Santiago
- Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - J García-Espinosa
- Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| |
Collapse
|
|
38
|
Andia I, Maffulli N. How far have biological therapies come in regenerative sports medicine? Expert Opin Biol Ther 2018; 18:785-793. [PMID: 29939773 DOI: 10.1080/14712598.2018.1492541] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Regular engagement in sports produces many health benefits, but also exposes to increased injury risk. The quality of medical care available is crucial not only for sports trauma but also to avoid overuse syndromes and post-traumatic degenerative conditions. AREAS COVERED We provide background information on some clinical needs in sport injuries and describe the main families of biological products used in clinical practice. We also discuss limitations of the current clinical experience. EXPERT OPINION Sport and exercise impairment affects different segments of the population with different needs. The exceptional demands of elite athletes and subsequent media coverage have created hype around regenerative therapies. Statistical evidence, whether weak (cell products) or moderate (PRPs), is not enough to drive medical decisions because of the heterogeneity of the biological products available and their application procedures. Moreover, the specific needs of the different segments of the population along with the available clinical evidence for each musculoskeletal condition should be considered in the decision-making process. There is urgent need to develop regenerative protocols combined with post-intervention rehabilitation, and gather meaningful clinical data on the safety and efficacy of these interventions in the different populations segments.
Collapse
Affiliation(s)
- Isabel Andia
- a Regenerative Medicine Laboratory, BioCruces Health Research Institute, Cruces University Hospital , Barakaldo , Spain
| | - Nicola Maffulli
- b Department of Musculoskeletal Disorders , University of Salerno School of Medicine and Dentristry , Salerno , Italy.,c Centre for Sport and Exercise Medicine , Queen Mary University of London, Barts and the London School of Medicine and Dentistry , London , England
| |
Collapse
|
|
39
|
Andia I, Martin JI, Maffulli N. Advances with platelet rich plasma therapies for tendon regeneration. Expert Opin Biol Ther 2018; 18:389-398. [DOI: 10.1080/14712598.2018.1424626] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Isabel Andia
- Regenerative Medicine Laboratory, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Jose Ignacio Martin
- Regenerative Medicine Laboratory, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
- Interventional Imaging. Department of Radiology, Cruces University Hospital, Barakaldo, Spain
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Dentristry, Salerno, Italy
- Barts and the London School of Medicine and Dentistry Centre for Sports and Exercise Medicine, Queen Mary University of London, London, England
| |
Collapse
|