Kobe returns to Germany for another Knee Arthritis Treatment

KobeTeam.com

Kobe Bryant returned to Germany this past week to be treated with a blood derived treatment (Orthokine) again for his knee.  He has had this treatment in the past at least twice before.  It involves drawing blood and incubating it over a 24 hour period and then reinjecting a component of blood that has anti-inflammatory properties.  It is similar but not exactly the same as platelet-rich plasma therapy.  It would be most interesting to learn about how this has helped him over the years and in what specific ways. He clearly has thousands of miles of basketball on his knees and is also recovering from multiple other injuries.  We do not, however, have any data about the status of his knee cartilage or joint before or after any of these treatments.  Here is a detailed description of the "Orthokine" treatment.  

Kobe has with his travel and his wallet voted in favor of this treatment.  It will be quite interesting to see how he plays this year in the NBA.   It will also be instructive to follow Kobe's future medical interventions as a way of measuring the value of the one he just had in Germany.

AM

TotalTendon

Kobe Bryant goes to Germany Again

Kobe Bryant recently went to Germany again to be treated with "Orthokine".  From his recent instagram post, it looks like he also received accupuncture.  (See below)  The  combination of treatments may make it difficult to determine which one could be responsible for any improvement he may feel.

Sports Illustrated also just published an article about Kobe's treatment.

No details about the condition of his knee prior to the treatment.  Many clinicians and researchers are working on a variation of this treatment----platelet-rich plasma.  

AM

Platelet Rich Plasma Significantly Improves Outcomes for Tennis Elbow in a 230 Patient Study

The American Journal of Sports Medicine (AJSM) has just published the largest study evaluating platelet-rich plasma.  The 230 patient study was conducted over the course of more than five years and represents the work of dozens of clinicians and researchers.  Overall, it is clear from the data that the use of PRP to treat chronic tennis elbow results in significant reductions in pain and elbow tenderness compared to an active control of needling of the elbow without PRP.  It is also safe and cost effective compared to cortisone and surgery.  This type of study is time consuming and expensive but will help guide patient and physicians decisions about how to best treat chronic tennis elbow.

Here is a lay press article on the article from Healio.

Read the full AJSM Abstract below.

AM
Total Tendon


Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow
A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients

1. Allan K. Mishra, MD*,†, 
2. Nebojsa V. Skrepnik, MD, PhD‡,
3. Scott G. Edwards, MD§, 
4. Grant L. Jones, MD‖, 
5. Steven Sampson, DO¶,
6. Doug A. Vermillion, MD#, 
7. Matthew L. Ramsey, MD**, 
8. David C. Karli, MD, MBA†† and 
9. Arthur C. Rettig, MD‡‡

1. ^†Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California
2. ^‡Tucson Orthopaedic Institute, Tucson, Arizona
3. ^§Division of Hand and Elbow Surgery, Georgetown University Hospital, Washington, District of Columbia
4. ^‖Department of Orthopaedic Surgery, The Ohio State University, Columbus, Ohio
5. ^¶The Orthohealing Center and The Orthobiologic Institute, Los Angeles, California
6. ^#Orthopaedic Research Clinic, Anchorage, Alaska
7. ^**Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
8. ^††The Steadman Clinic, Vail, Colorado
9. ^‡‡Methodist Sports Medicine, Indianapolis, Indiana
10. Investigation performed at Department of Orthopaedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California

1. *Allan K. Mishra, MD, Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, 1300 Crane Street, Menlo Park, CA 94025 (e-mail: am@totaltendon.com).

Abstract

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.

The Biomet Biologics GPS device was used to prepare the PRP for this study.

Kobe Bryant Tears Achilles Tendon

Kobe Bryant last night in made a cut on the basketball court he has made a million times and felt like "somebody kicked" him.  He unfortunately sustained an achilles tendon tear.   See the video below of the injury:



He will likely have surgery in the near future.  The surgical takes about an hour.  Rehabilitation typically takes anywhere from 9-12 months.  Some surgeons are augmenting achilles repairs with platelet-rich plasma pointing to anecdotal evidence suggesting PRP could accelerate recovery.

Here is a video of how to clinically diagnosis an achilles tendon tear:



Below are some pictures that outline the steps in an Achilles tendon repair  
Torn tendon, suture repair, closure

If anyone can come back from this injury, Kobe can.  The NBA and all of basketball are wishing him the the best for his surgery if needed and for his full recovery.

AM
TotalTendon

PRP beats Placebo for Knee Arthritis

The American Journal of Sports Medicine recently published the results of another study supporting the use of Platelet Rich Plasma for arthritis.  In this very well done study, two different doses of PRP were given to patients and then compared to a saline injection.  One group recieved a single injection of PRP, another two PRP injections spaced 3 weeks apart and the third group a single injection of saline or sterile salt water.  The third group served the placebo control. 

Statistically significant improvements in pain and function were noted in the PRP groups within 2-3 weeks and lasted 6 months.  The saline treated group noted worsening of symptoms.  There were no significant differences between the two PRP groups with both showing improvement. 

Overall, this prospective, randomized trial adds to the mounting evidence that specific forms of PRP can be helpful for patients with knee osteoarthritis.  See abstract below for details. 

The use of PRP for knee osteoarthritis is rapidly evolving.  There are now 37 articles on PubMed discussing that specific topic.  (Link to abstracts)  Over the course of 2013, more presentations and papers will help clarify the role of PRP for this very common problem.

AM
Total Tendon

Treatment With Platelet-Rich Plasma Is More Effective Than Placebo for Knee Osteoarthritis: A Prospective, Double-Blind, Randomized Trial.

Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A.
Am J Sports Med. 2013 Jan 8. [Epub ahead of print]
SourceDepartment of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

BACKGROUND:Specific growth factors have been proposed as therapeutic proteins for cartilage repair. HYPOTHESIS:Platelet-rich plasma (PRP) provides symptomatic relief in early osteoarthritis (OA) of the knee. STUDY DESIGN:Randomized controlled trial; Level of evidence, 1. METHODS:A total of 78 patients (156 knees) with bilateral OA were divided randomly into 3 groups. Group A (52 knees) received a single injection of PRP, group B (50 knees) received 2 injections of PRP 3 weeks apart, and group C (46 knees) received a single injection of normal saline. White blood cell (WBC)-filtered PRP with a platelet count 3 times that of baseline (PRP type 4B) was administered in all. All the groups were homogeneous and comparable in baseline characteristics. Clinical outcome was evaluated using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire before treatment and at 6 weeks, 3 months, and 6 months after treatment. They were also evaluated for pain by a visual analog scale, and overall satisfaction with the procedure and complications were noted. RESULTS:Statistically significant improvement in all WOMAC parameters was noted in groups A and B within 2 to 3 weeks and lasting until the final follow-up at 6 months, with slight worsening at the 6-month follow-up. The mean WOMAC scores (pain, stiffness, physical function, and total score) for group A at baseline were 10.18, 3.12, 36.56, and 49.86, respectively, and at final follow-up were 5.00, 2.10, 20.08, and 27.18, respectively, showing significant improvement. Similar improvement was noted in group B (mean WOMAC scores at baseline: 10.62, 3.50, 39.10, and 53.20, respectively; mean WOMAC scores at final follow-up: 6.18, 1.88, 22.40, and 30.48, respectively). In group C, the mean WOMAC scores deteriorated from baseline (9.04, 2.70, 33.80, and 45.54, respectively) to final follow-up (10.87, 2.76, 39.46, and 53.09, respectively). The 3 groups were compared with each other, and no improvement was noted in group C as compared with groups A and B (P < .001). There was no difference between groups A and B, and there was no influence of age, sex, weight, or body mass index on the outcome. Knees with Ahlback grade 1 fared better than those with grade 2. Mild complications such as nausea and dizziness, which were of short duration, were observed in 6 patients (22.2%) in group A and 11 patients (44%) in group B. CONCLUSION:A single dose of WBC-filtered PRP in concentrations of 10 times the normal amount is as effective as 2 injections to alleviate symptoms in early knee OA. The results, however, deteriorate after 6 months. Both groups treated with PRP had better results than did the group injected with saline only.

Platelet Rich Plasma and Knee Arthritis

Knee arthritis is a very common problem for patients worldwide.  With the aging of the population this will become one of the most important medical issues to address with biologic therapies.

Conflicting results have recently been published about the use of platelet rich plasma in the treatment of knee arthritis.  Filardo, Kon et al found no significant differences between PRP and hyaluronic acid injections.  (see full abstract).  Conversely, Cerza et al did find significantly better clinical outcomes when patients were treated with PRP vs hyaluronic acid injections. (see full abstract) The version of PRP used in these two studies were different.  The first study also used three injections and the second four weekly injections.  Clearly, more research is needed to clarify the value of PRP for knee arthritis and determine the optimal formulations and techniques.

AM
TotalTendon

See the video below for a brief description of knee arthritis

Regenokine featured on ABC's Nightline

ABC's Nightline newsmagazine, in a story by Ron Claibourne, discussed Regenokine.  This therapy was developed in Germany and focuses on incubating blood in glass beads to concentrate an anti-inflammatory protein known as IL-1 RA.  (Long name:  Interleukin Receptor Antagonist)  It has been used to treat osteoarthritis and back pain.

The story features Tracy McGrady and how it helped him return to an elite level in the NBA after a knee injury.  Kobe Bryant, Alex Rodriguez and Fred Couples are also discussed in the story as successes.  This treatment and technology are promising but more level one evidence is needed to confirm its value.

Blood derived treatments such as this or platelet rich plasma have now been used for more than a decade with superior safety profiles.  Data continues to emerge suggesting these types of treatments have significant clinical value at a reasonable cost.

Allan Mishra, MD
@BloodCure

Meta-analysis of Viscosupplementation for Knee Osteoarthritis Reveals Little Benefit

In the study outlined below, treatment with viscosupplementation (typically various forms of hyaluronic acid) was studied in over 12,500 patients.  This is an injection therapy used in patients with knee osteoarthritis.  It is usually reserved for patients that fail other forms of treatment.  Here is the conclusion of this study of studies:  "In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."

Clearly, the data shows this treatment does not provide transformative value.  We need better options for patients with mild to moderate knee osteoarthritis.  Biologic therapies such as platelet rich plasma and autologous stem cells are evolving but still need significantly better studies to be used for knee osteoarthritis widely.  

It is often NOT discussed but patients with knee osteoarthritis can often benefit from weight reduction and leg strengthening via an exercise bike program.  Perhaps we should focus on these patient driven solutions first.

AM

Total Tendon

Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review and Meta-analysis 

Anne W.S. Rutjes, PhD; Peter Jüni, MD; Bruno R. da Costa, MSc; Sven Trelle, MD; Eveline Nüesch, PhD; and Stephan Reichenbach, MD, MScBackground: Viscosupplementation, the intra-articular injection of hyaluronic acid, is widely used for symptomatic knee osteoarthritis.

Purpose: To assess the benefits and risks of viscosupplementation for adults with symptomatic knee osteoarthritis.

Data Sources: MEDLINE (1966 to January 2012), EMBASE (1980 to January 2012), the Cochrane Central Register of Controlled Trials (1970 to January 2012), and other sources.

Study Selection: Randomized trials in any language that compared viscosupplementation with sham or nonintervention control in adults with knee osteoarthritis.

Data Extraction: Primary outcomes were pain intensity and flare-ups. Secondary outcomes included function and serious adverse events. Reviewers used duplicate abstractions, assessed study quality, pooled data using a random-effects model, examined funnel plots, and explored heterogeneity using meta-regression.

Data Synthesis: Eighty-nine trials involving 12 667 adults met inclusion criteria. Sixty-eight had a sham control, 40 had a follow-up duration greater than 3 months, and 22 used cross-linked forms of hyaluronic acid. Overall, 71 trials (9617 patients) showed that viscosupplementation moderately reduced pain (effect size, −0.37 [95% CI, −0.46 to −0.28]). There was important between-trial heterogeneity and an asymmetrical funnel plot: Trial size, blinded outcome assessment, and publication status were associated with effect size. Five unpublished trials (1149 patients) showed an effect size of −0.03 (CI, −0.14 to 0.09). Eighteen large trials with blinded outcome assessment (5094 patients) showed a clinically irrelevant effect size of −0.11 (CI, −0.18 to −0.04). Six trials (811 patients) showed that viscosupplementation increased, although not statistically significantly, the risk for flare-ups (relative risk, 1.51 [CI, 0.84 to 2.72]). Fourteen trials (3667 patients) showed that viscosupplementation increased the risk for serious adverse events (relative risk, 1.41 [CI, 1.02 to 1.97]).

Limitations: Trial quality was generally low. Safety data were often not reported.

Conclusion: In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events.

Link to Abstract