Elbow – Tendon/Ligament Disorders – PRP

Background:

Studies have demonstrated the potential of platelet-rich plasma (PRP) to heal damaged tissue. To date, there are no published reports of clinical outcomes of partial ulnar collateral ligament  (UCL) tears of the elbow treated with PRP.

Hypothesis:

Platelet-rich plasma will promote the healing of partial UCL tears and allow a return to play.

Study Design:

Case series; Level of evidence, 4.

Methods:

Thirty-four athletes with a partial-thickness UCL tear confirmed on magnetic resonance imaging were prospectively followed. All patients had failed at least 2 months of nonoperative treatment and an attempt to return to play. Baseline questionnaires, including the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) and Disabilities of the Arm, Shoulder and Hand (DASH) measures, were completed by each patient before injection. Baseline ultrasound measurement of the humeral-ulnar joint space was assessed with 10 lb of valgus stress on the elbow. Each patient received a single type 1A PRP injection at the UCL under ultrasound guidance. The same treating physician at a single institution performed all injections with the same PRP preparation used. Patients completed a course of guided physical therapy and were allowed to return to play based on their symptoms and physical examination findings. Outcome scores, including KJOC and DASH scores, were collected after return to play and were compared with baseline scores. Ultrasound measurements were collected at final follow-up and compared with preinjection values.

Results:

At an average follow-up of 70 weeks (range, 11-117 weeks), 30 of 34 athletes (88%) had returned to the same level of play without any complaints. The average time to return to play was 12 weeks (range, 10-15 weeks). The average KJOC score improved from 46 to 93 (P \ .0001). The average DASH score improved from 21 to 1 (P \ .0001). The sports module of the DASH questionnaire improved from 69 to 3 (P \ .0001). Medial elbow joint space opening with valgus stress decreased from 28 to 20 mm at final follow-up (P \ .0001). The difference in medial elbow joint space opening (stressed vs nonstressed) decreased from 7 to 2.5 mm at final follow-up (P \ .0001). One player had persistent UCL insufficiency and underwent ligament reconstruction at 31 weeks after injection.

Conclusion:

The results of this study indicate that PRP is an effective option to successfully treat partial UCL tears of the elbow in athletes.

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Background:

Tendinopathy is very common in the general population. There are increasing numbers of clinical studies referring to platelet-rich plasma (PRP) and platelet-poor plasma (PPP) as treatments for tendinopathy.

Purpose:

To perform a meta-analysis of the outcomes of the PRP groups by preparation method and injection technique in tendinopathy. To determine the clinical effectiveness of the preparations and to evaluate the effect of controls used in the studies reviewed.

Study Design:

Systematic review and meta-analysis.

Methods:

The PubMed, EMBASE, CINAHL, and Medline databases were searched in March 2012, April 2014, and August 2015, and randomized controlled trials using autologous blood, PRP, PPP, or autologous conditioned plasma in tendinopathy with outcome measures of pain and follow-up time of 3 months were included in this review. Trials including surgery, tendon tears, and muscle or ligament injuries were excluded. Study quality was assessed using the Cochrane Collaboration risk-of-bias tool by 2 reviewers. Data were pooled using random-effects meta-analysis. The primary outcome measure was a change in pain intensity. Where more than 1 pain scale was included, a functional score was selected ahead of a visual analog scale score.

Results:

A total of 18 studies (1066 participants) were included. Eight studies were deemed to be at low risk of bias. The most significant outcomes in the PRP groups were seen in those treated with highly cellular leukocyte-rich PRP (LR-PRP) preparations: GPS kit (standardized mean difference [SMD], 35.75; 95% CI, 28.40-43.10), MyCells kit (SMD, 31.84; 95% CI, 17.56-46.13), Prosys kit (SMD, 42.99; 95% CI, 37.73-48.25), and unspecified LR-PRP (SMD, 34.62; 95% CI, 31.69-37.55). When the LR-PRP system types were grouped, there was a strongly positive effect (SMD, 36.38; 95% CI, 34.00-38.77) when compared with leukocyte-poor PRP (SMD, 26.77; 95% CI, 18.31-35.22). In assessing the control groups, there was no clear difference between different types of control injections: saline (SMD, 14.62; 95% CI, 10.74-18.50), local anesthetic (SMD, 15.00; 95% CI, 7.66-22.34), corticosteroid (SMD, 23.82; 95% CI, 10.74-18.50), or dry needling (SMD, 25.22; 95% CI, 21.27-29.16).

Conclusion:

There is good evidence to support the use of a single injection of LR-PRP under ultrasound guidance in tendinopathy. Both the preparation and intratendinous injection technique of PRP appear to be of great clinical significance.

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Purpose:

The purpose of this prospective, randomized study was to compare the efficacy of autologous platelet- rich plasma (PRP) injections and arthroscopic lateral release in treating chronic lateral epicondylitis (LE).

Methods:

Patients who had a clinical diagnosis of LE confirmed by ultrasound (US) were included in this study. A total of 101 patients received arthroscopic release (n 1⁄4 50) or US-guided PRP injections (n 1⁄4 51). Outcomes were assessed using a visual analog scale for pain, the Patient-Rated Tennis Elbow Evaluation (PRTEE), and a calibrated hand dynamometer for grip strength.

Results:

Both patient groups experienced significant improvement in all measures. Between-group comparisons showed a significantly higher value in the PRP group only for grip strength at week 8 (P 1⁄4 .0073); all other significant differences were in favor of arthroscopy: overall pain (P 1⁄4 .0021), night pain (P 1⁄4 .0013), and PRTEE score (P 1⁄4 .0013) at week 104 and grip strength at weeks 24, 52, and 104 (all P < .0001). Consumption of rescue pain medication was not significantly different between the groups.

Conclusions:

The present findings suggest that (1) PRP injections and arthroscopic extensor carpi radialis brevis release are both effective in the short and medium term; (2) PRP patients experienced a significant worsening of pain at 2 years; (3) arthroscopic release ensured better long-term outcomes in terms of pain relief and grip strength recovery; and (4) both procedures were safe and well accepted by patients.

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Introduction

There are various therapeutic approaches to the treatment of lateral epicondylitis, a highly prevalent musculoskeletal disorder. Recently, injection therapy with autologous conditioned plasma (ACP) has shown promise as a new approach.

Methods

Set up as a prospective, double-blind, randomized controlled clinical trial, this study involved 50 patients with lateral epicondylitis. Following external randomization, 25 patients received one round of injection therapy with ACP (platelet rich plasma, PRP), while the remaining 25 patients received a placebo of 0.9 % NaCl. All patients were re-evaluated with respect to lateral epicondylitis of the elbow at four-weeks and six-months post-injection.

Results

Out of 50 patients, 36 qualified for reevaluation, 18 patients from the ACP therapy group and 18 from the placebo group. The initial Disability of the Arm, Shoulder and Hand (DASH) score for all reevaluated patients was 36.4 in the ACP group, and 41.0 in the placebo group; both groups exhibited decreased DASH scores at the four-week and six-month post-injection follow-up (6 months: ACP 30.1, placebo 25.8). The decrease of the DASH score after 4 weeks was greater and qualified as statistically significant in the placebo group (p = 0.041), compared to the DASH score decrease in the ACP treatment group, which was statistically non-significant. Additionally, the difference between the DASH scores of the treatment and placebo groups was statistically non-significant four weeks and six months after treatment.

Discussion

The results of this study suggest a therapeutic effect in both the ACP and placebo groups, with no evidence for a therapeutically significant difference between ACP and placebo treatments. It is hypothesized that, in accordance with the study protocols, injection with a local anaesthetic prior to ACP therapy may have an influence on the therapeutic effect of ACP. Future studies have to confirm recent findings that demonstrated a minimizing, or even inhibiting, action of
local anaesthetics on the effects of ACP/PRP.

Conclusion

The effect of ACP/PRP injections needs to be investigated in future studies under standardized conditions.

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Objective:

To determine whether ultrasound (US)-guided percutaneous needle tenotomy followed by a platelet-rich plasma (PRP) injection would result in pain reduction, functional improvement, or structural alterations in patients with chronic, recalcitrant tendinopathy.

Design:

Part A was a retrospective observational study. Part B was a prospective observational study.

Setting:

Outpatient academic sports medicine center.

Participants:

Patients were required to have chronic (3 months), recalcitrant tendinopathy treated with US-guided percutaneous tenotomy and PRP injection between January 2007 and October 2009. Fifty-one subjects met the inclusion criteria. Forty-one (80%) participated in part A of the study, whereas 34 subjects (67%) participated in part B.

Methods:

In part A, subjects completed a survey obtaining anthropomorphic, demographic, pain, and functional data. Subjects’ platelet, hemoglobin, and white blood cell concentrations from their whole-blood and PRP samples were also obtained. In part B, subjects returned to the clinic after US-guided percutaneous needle tenotomy and PRP injection for a diagnostic US, which was compared with their preprocedure diagnostic US.

Main Outcome Measures:

The main outcome measures included changes in pain, function, and tendon characteristics.

Results:

The tendinopathy location was in the upper extremity in 10 subjects (24.4%), was in the lower extremity in 31 subjects (75.6%), and had been present for a mean of 40 months. The mean postprocedure follow-up was 14 months, and the maximum benefits occurred 4 months postprocedure. There were mean functional and worst-pain improvements of 68% and 58%, respectively. Eighty-three percent of subjects were satisfied with their outcomes and would recommend the procedure to a friend. Although no tendons demonstrated a normal sonographic appearance after the procedure, 84% of subjects had an improvement in echotexture, 64% had a resolution of intratendinous calcifications, and 82% had a decrease in intratendinous neovascularity. None of the variables analyzed in this study demonstrated a significant correlation with pain or functional outcome measures.

Conclusions:

In this case series, we found US-guided percutaneous needle tenotomy followed by PRP injection to be a safe and effective treatment for chronic, recalcitrant tendinopathy, and this treatment was associated with sonographically apparent improvements in tendon morphology. However, because of the intrinsic limitations of the study design and the heterogeneity of treated tendons, further research is required to corroborate our findings.

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Background:

Platelet-rich plasma (PRP) has shown to be a general stimulation for repair.

Purpose:

To determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Patients:

The trial was conducted in 2 teaching hospitals in the Netherlands. One hundred patients with chronic lateral epicondylitis were randomly assigned in the PRP group (n 5 51) or the corticosteroid group (n 5 49). A central computer system carried out randomization and allocation to the trial group. Patients were randomized to receive either a corticosteroid injection or an autologous platelet concentrate injection through a peppering technique. The primary analysis included visual analog scores and DASH Outcome Measure scores (DASH: Disabilities of the Arm, Shoulder, and Hand).

Results:

Successful treatment was defined as more than a 25% reduction in visual analog score or DASH score without a reintervention after 1 year. The results showed that, according to the visual analog scores, 24 of the 49 patients (49%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was significantly different (P \ .001). Furthermore, according to the DASH scores, 25 of the 49 patients (51%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was also significantly different (P 5 .005). The corticosteroid group was better initially and then declined, whereas the PRP group progressively improved.

Conclusion:

Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection. Future decisions for application of the PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.

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Aim of the work:

This randomized controlled study was designed to compare the effectiveness of local injection of autologous platelet rich plasma (PRP) and local steroid in reducing pain and improving function in a cohort of patients with tennis elbow (TE) and plantar fasciitis (PF).

Patients and methods:

The study population comprised two groups; Group 1 patients with TE (n = 30) and Group 2 patients with PF (n = 30). In each group patients were allocated randomly to receive either a steroid or PRP injections. All patients filled in visual analog scale (VAS), disability of arm, shoulder and hand (DASH) score for TE and foot health status questionnaire (FHSQ) for PF at base line and after 6 weeks.

Results:

Relative to TE group of patients significant differences were observed between VAS and DASH scores at base line and 6 weeks after treatment in both groups (p < 0.001). While no significant differences were observed relative to VAS and DASH score changes between both groups (p > 0.05). In PF patients comparison of VAS and FHSQ at base line and 6 weeks after treatment between control group and PRP group showed significant differences for VAS (p = 0.005 and p < 0.001, respectively), and for FHSQ (p = 0.03 and p < 0.001, respectively). While highly significant difference were observed between both groups regarding VAS and FHSQ changes (p = 0.001).

Conclusion:

Local injection of autologous PRP proved to be a promising form of therapy for TE and PF. It is both safe and effective in relieving pain and improving function and superior to local steroids in PF.

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Background:

Elbow epicondylar tendinosis is a common problem that usually resolves with nonoperative treatments. When these measures fail, however, patients are interested in an alternative to surgical intervention.

Hypothesis:

Treatment of chronic severe elbow tendinosis with buffered platelet-rich plasma will reduce pain and increase function in patients considering surgery for their problem.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

One hundred forty patients with elbow epicondylar pain were evaluated in this study. All these patients were initially given a standardized physical therapy protocol and a variety of other nonoperative treatments. Twenty of these patients had significant persistent pain for a mean of 15 months (mean, 82 of 100; range, 60-100 of 100 on a visual analog pain scale), despite these interventions. All patients were considering surgery. This cohort of patients who had failed nonoperative treatment was then given either a single percutaneous injection of platelet-rich plasma (active group, n = 15) or bupivacaine (control group, n = 5).

Results:

Eight weeks after the treatment, the platelet-rich plasma patients noted 60% improvement in their visual analog pain scores versus 16% improvement in control patients (P = .001). Sixty percent (3 of 5) of the control subjects withdrew or sought other treatments after the 8-week period, preventing further direct analysis. Therefore, only the patients treated with platelet-rich plasma were available for continued evaluation. At 6 months, the patients treated with platelet-rich plasma noted 81% improvement in their visual analog pain scores (P = .0001). At final follow-up (mean, 25.6 months; range, 12-38 months), the platelet-rich plasma patients reported 93% reduction in pain compared with before the treatment (P < .0001).

Conclusion:

Treatment of patients with chronic elbow tendinosis with buffered platelet-rich plasma reduced pain significantly in this pilot investigation. Further evaluation of this novel treatment is warranted. Finally, platelet-rich plasma should be considered before surgical intervention.

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Background:

Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow.

Purpose:

To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study.

Results:

Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .094). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .027). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .036). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P\.001). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P = .012). No significant complications occurred in either group.

Conclusion:

Treatment of chronic tennis elbow with leukocyte-enriched PRP is safe and results in clinically meaningful improvements compared with an active control group.

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