Treatment of Patellar Tendinopathy with Platelet Rich Plasma

"Clinically Meaningful Improvements"

Statistically Significant Improvement (Pain and VISA Scores) 

Gosens et al, worldwide leaders in platelet rich plasma research have shown in their latest article how previous treatments influence outcomes.  This is a critical component to understanding outcomes.  This data suggests that previous treatment with cortisone or surgery may slow a healing response.  As the clinical research evolves, these crucial factors must be taken into consideration.  

See the recently published abstract below.

Allan Mishra @bloodcure  Total Tendon

Int Orthop. 2012 Apr 27. 

Pain and activity levels before and after platelet-rich plasma injection treatment of patellar tendinopathy: a prospective cohort study and the influence of previous treatments.

Gosens T, Den Oudsten BL, Fievez E, van 't Spijker P, Fievez A.

Source

Department of Orthopaedics and Traumatology, St Elisabeth Hospital Tilburg, Tilburg, The Netherlands, 

Abstract

PURPOSE:

The aim of this study was to evaluate the outcome of patients with patellar tendinopathy treated with platelet-rich plasma injections (PRP). Additionally, this study examined whether certain characteristics, such as activity level or previous treatment affected the results.

METHODS:

Patients (n = 36) were asked to fill in the Victorian Institute of Sports Assessment - Patellar questionnaire (VISA-P) and visual analogue scales (VAS), assessing pain in activities of daily life (ADL), during work and sports, before and after treatment with PRP. Of these patients, 14 had been treated before with cortisone, ethoxysclerol, and/or surgical treatment (group 1), while the remaining patients had not been treated before (group 2).

RESULTS:

Overall, group 1 and group 2 improved significantly on the VAS scales (p < .0.05). However, group 2 also improved on VISA-P (p = .0.003), while group 1 showed less healing potential (p = 0.060). Although the difference between group 1 and group 2 at follow-up was not considered clinically meaningful, over time both groups showed a clinically significant improvement.

CONCLUSION:

After PRP treatment, patients with patellar tendinopathy showed a statistically significant improvement. In addition, these improvements can also be considered clinically meaningful. However, patients who were not treated before with ethoxysclerol, cortisone, and/or surgical treatment showed the improvement.

Elbow Ligament Injuries, Tommy John Surgery and Platelet Rich Plasma

Baseball players especially pitchers create tremendous forces across the inside part of their elbows when throwing.  The inside part of the elbow is supported by a stout ligament---the ulnar collateral ligament.  Repetitive trauma in the form of pitching or an acute severe injury such as an elbow dislocation can result in a complete tear of this important stabilizing ligament.  Pitchers who sustain a complete tear are typically treated with "Tommy John" surgery---reconstruction of the ulnar collateral ligament.  


In athletes with partial injuries to this ligament, however, platelet rich plasma is emerging as an alternative treatment to surgery.  In a study presented at the American Academy of Orthopedic Surgery (2012) by Dr. Scott Crow et al, the value of PRP as a treatment for this injury was discussed.  94% of athletes returned to play within 10 weeks when treated with PRP.    


"...researchers followed 17 athletes with a partial UCL tear. All patients had failed conservative treatment, including rest and physical therapy. Baseline questionnaires, including the Kerlan-Jobe Shoulder and Elbow Score (KJOC Score) and Disability of the Arm, Shoulder, and Hand Score (DASH Score) were completed for each patient prior to the PRP injection. Each patient underwent a single PRP injection at the ulnar collateral ligament under ultrasound guidance.
At an average follow-up of 18 weeks (range 12-46 weeks), 16 of 17 athletes had returned to play. The average time to return to play was 10 weeks (range 8-12 weeks). The average KJOC Score improved from 47 to 93, p=.0001. The average DASH Score improved from 24 to 3, p=.003. The Sports Module of the DASH questionnaire improved from 74 to 6, p=.0001.
"There is little information in the literature regarding non-surgical treatment of UCL tears. Our results show that PRP may be an option to return players to the field without having to place them under the knife," said Crow."  See Full Press Release

Allan Mishra, MD

Total Tendon

Platelet rich plasma is being studied worldwide (US, Europe, India) as a potential treatment for knee osteoarthritis.  The evidence is immature but it does suggest PRP may have a role in the management of this very common problem.

In the study outlined below, PRP was compared to a standard treatment of hyaluronic acid.  

"Statistically significantly better results in the Western Ontario and McMaster Universities Osteoarthritis Index and Numeric Rating Scale scores were recorded in a group of patients who received PRP injections after a 3- and 6-mo follow-up."

AM

TotalTendon

Am J Phys Med Rehabil. 2012 May;91(5):411-7.

Treatment of knee joint osteoarthritis with autologous platelet-rich plasma in comparison with hyaluronic Acid.

Spaková T, Rosocha J, Lacko M, Harvanová D, Gharaibeh A.

Source

From the Associated Tissue Bank of Faculty of Medicine UPJS and University Hospital of L. Pasteur (TS, JR, DH); and Department of Orthopaedics and Traumatology, Faculty of Medicine, P. J. Safárik University and University Hospital of L. Pasteur, Kosice, Slovakia (ML, AG).

Abstract

OBJECTIVE:

This study aimed to find a simple, cost-effective, and time-efficient method for the preparation of platelet-rich plasma (PRP), so the acquired benefits will be readily available for multiple procedures in smaller outpatient clinics and to explore the safety and efficacy of the application of PRP in the treatment of degenerative lesions of articular cartilage of the knee.

DESIGN:

The study was designed as a prospective, cohort study with a control group. A total of 120 patients with Grade 1, 2, or 3 osteoarthritis according to the Kellgren and Lawrence grading scale were enrolled in the study. One group of patients was treated using three intra-articular applications of PRP, and the second group of patients was given three injections of hyaluronic acid. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index and the 11-point pain intensity Numeric Rating Scale.

RESULTS:

On average, a 4.5-fold increase in platelet concentration was obtained in the PRP group. No severe adverse events were observed. Statistically significantly better results in the Western Ontario and McMaster Universities Osteoarthritis Index and Numeric Rating Scale scores were recorded in a group of patients who received PRP injections after a 3- and 6-mo follow-up.

CONCLUSIONS:

Our preliminary findings support the application of autologous PRP as an effective and safe method in the treatment of the initial stages of knee osteoarthritis. Further studies are needed to confirm these results and to investigate the persistence of the beneficial effects 

Dwight Howard of the Orlando Magic today will undergo back surgery to treat a herniated disc.  I underwent a similar procedure 3.5 years ago.  Below is a video of that procedure.

Monitoring Brain Tumors without Surgery

Glioblastoma is one of thethe most common and most lethal forms of brain cancer.  Monitoring the potential for it to spread or invade is a critical component of treatment.  A novel method of sampling spinal fluid for genetic markers called microRNAs has recently been developed that holds significant promise.  This is an excellent example of how medicine is in the process of being radically transformed by genetic tests. 

See press release below.

AM


Researchers discover non-surgical test for brain cancer



Test will allow for patients with brain tumors to be diagnosed and monitored without the need for surgery


Boston – In a breakthrough for the way brain cancer is diagnosed and monitored, a team of researchers, lead by Anna M. Krichevsky, PhD, of the Center of Neurologic Diseases at Brigham and Women's Hospital (BWH) in Boston and Santosh Kesari, MD, PhD, director of Neuro-Oncology at UC San Diego Moores Cancer Center, have demonstrated that brain tumors can be reliably diagnosed and monitored without surgery. Previously, an accurate non-surgical test to detect brain tumors was unavailable and methods of monitoring a brain tumor's progression or response to treatment were not reliable. The results from this pilot study are published in the online edition of Neuro-Oncology.


"We are excited about the potential that this test has to ease the process of detecting and monitoring brain tumors," said Krichevsky. "The test needs to be further developed before it is used in a clinical setting, but I expect it could be particularly valuable for patients who are not surgical candidates due to the tumor's size or location, or due to an underlying medical condition."


In a study of 118 patients with different types of brain cancers, researchers showed that microRNA profiling of cerebrospinal fluid can be used to determine the presence of glioblastoma, the most common and lethal type of brain tumor. The test utilizes microRNAs, tiny RNA molecules that provide excellent biomarkers for various conditions, and whose levels can be accurately measured in body fluids simply and inexpensively. The same process can be used to detect the presence of cancer that started in another part of the body and spread to the brain, and furthermore, the process can also be used to monitor the tumor as it is treated.


A patent related to the test is pending. The study was funded by National Institutes of Health grants [R01CA138734-01A1, K08CA124804, and ARRA 3P30CA023100-25S8, the Sontag Foundation and the James S. McDonnell Foundation.

Link to full press release.

Platelet-rich Fibrin Matrix NOT helpful in Rotator Cuff Repair Surgery

Platelet-rich plasma comes in a variety of forms.  Platelet-rich fibrin matrix (PRFM) is prepared by spinning blood and adding calcium to create a type of gel that can hold suture.  In the study below, this gel was used in combination with a standard arthroscopic rotator cuff repair.  No differences were seen in healing as measured by ultrasound at 6 and 12 weeks when the PRFM was added.  There was also some suggestion that platelet rich fibrin matrix had a negative effect on healing.

It is crucial to understand that this data is specific to PRFM and not all types of platelet rich plasma.  Most patients and even many providers fail to realize the importance of formulation and indications.  PRP in the near future will become even more complex as newer formulations become available and as data matures.

AM
Total Tendon

The Effect of Platelet-Rich Fibrin Matrix on Rotator Cuff Tendon Healing: A Prospective, Randomized Clinical Study

1. Scott A. Rodeo, MD, 
2. Demetris Delos, MD,
3. Riley J. Williams, MD, 
4. Ronald S. Adler, MD, PhD, 
5. Andrew Pearle, MD and 
6. Russell F. Warren, MD

+

1. Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York
2. Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York
3. Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York
4. Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York
5. Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York
6. Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York

Abstract

Background: There is a strong need for methods to improve the biological potential of rotator cuff tendon healing. Platelet-rich fibrin matrix (PRFM) allows delivery of autologous cytokines to healing tissue, and limited evidence suggests a positive effect of platelet-rich plasma on tendon biology.

Purpose: To evaluate the effect of platelet-rich fibrin matrix on rotator cuff tendon healing.

Study Design: Randomized controlled trial; Level of evidence, 2.

Methods: Seventy-nine patients undergoing arthroscopic rotator cuff tendon repair were randomized intraoperatively to either receive PRFM at the tendon-bone interface (n = 40) or standard repair with no PRFM (n = 39). Standardized repair techniques were used for all patients. The postoperative rehabilitation protocol was the same in both groups. The primary outcome was tendon healing evaluated by ultrasound (intact vs defect at repair site) at 6 and 12 weeks. Power Doppler ultrasound was also used to evaluate vascularity in the peribursal, peritendinous, and musculotendinous and insertion site areas of the tendon and bone anchor site. Secondary outcomes included standardized shoulder outcome scales (American Shoulder and Elbow Surgeons [ASES] and L’Insalata) and strength measurements using a handheld dynamometer. Patients and the evaluator were blinded to treatment group. All patients were evaluated at minimum 1-year follow-up. A logistic regression model was used to predict outcome (healed vs defect) based on tear severity, repair type, treatment type (PRFM or control), and platelet count.

Results: Overall, there were no differences in tendon-to-bone healing between the PRFM and control groups. Complete tendon-to-bone healing (intact repair) was found in 24 of 36 (67%) in the PRFM group and 25 of 31 (81%) in the control group (P = .20). There were no significant differences in healing by ultrasound between 6 and 12 weeks. There were gradual increases in ASES and L’Insalata scores over time in both groups, but there were no differences in scores between the groups. We also found no difference in vascularity in the peribursal, peritendinous, and musculotendinous areas of the tendon between groups. There were no differences in strength between groups. Platelet count had no effect on healing. Logistic regression analysis demonstrated that PRFM was a significant predictor (P = .037) for a tendon defect at 12 weeks, with an odds ratio of 5.8.

Conclusion: Platelet-rich fibrin matrix applied to the tendon-bone interface at the time of rotator cuff repair had no demonstrable effect on tendon healing, tendon vascularity, manual muscle strength, or clinical rating scales. In fact, the regression analysis suggests that PRFM may have a negative effect on healing. Further study is required to evaluate the role of PRFM in rotator cuff repair.

Platelet Rich Plasma Helps Heal Patellar Tendon Graft Site after ACL Surgery

In a prospective, randomized controlled trial, platelet rich plasma was found to improve patellar tendon graft site healing and decrease pain in the immediate post operative period.  See abstract below:

AM
TotalTendon

From the American Journal of Sports Medicine

Patellar Tendon Healing With Platelet-Rich Plasma: A Prospective Randomized Controlled Trial

1. Adriano Marques de Almeida, MD, MS (adrianoalmeida@usp.br),
2. Marco Kawamura Demange, MD, PhD, 
3. Marcel Faraco Sobrado,
4. Marcelo Bordalo Rodrigues, MD, 
5. André Pedrinelli, MD, PhD and
6. Arnaldo José Hernandez, MD, PhD

+Author Affiliations

1. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil
2. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil
3. São Paulo University Medical School, São Paulo, Brazil
4. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil
5. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil
6. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil

Abstract

Background: The patellar tendon has limited ability to heal after harvesting its central third. Platelet-rich plasma (PRP) could improve patellar tendon healing.

Hypothesis: Adding PRP to the patellar tendon harvest site would improve donor site healing and improve clinical outcome at 6 months after anterior cruciate ligament (ACL) reconstruction with a patellar tendon graft.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Twenty-seven patients were randomly divided to receive (n = 12) or not receive (n = 15) PRP in the patellar tendon harvest site during ACL reconstruction. The primary outcome was magnetic resonance imaging (MRI) assessment of patellar tendon healing (gap area) after 6 months. Secondary outcomes were questionnaires and isokinetic testing of ACL reconstruction with a patellar tendon graft comparing both groups.

Results: Patellar tendon gap area was significantly smaller in the PRP group (4.9 ± 5.3 mm²; 95% confidence interval [CI], 1.1-8.8) than in the control group (9.4 ± 4.4 mm²; 95% CI, 6.6-12.2; P = .046). Visual analog scale score for pain was lower in the PRP group immediately postoperatively (3.8 ± 1.0; 95% CI, 3.18-4.49) than in the control group (5.1 ± 1.4; 95% CI, 4.24-5.90; P = .02). There were no differences after 6 months in questionnaire and isokinetic testing results comparing both groups.

Conclusion: We showed that PRP had a positive effect on patellar tendon harvest site healing on MRI after 6 months and also reduced pain in the immediate postoperative period. Questionnaire and isokinetic testing results were not different between the groups at 6 months.