Platelet Rich Plasma effective in treating Chronic Achilles Tendonitis

In the study outlined below, patients with chronic achilles tendinosis (also known as achilles tendonitis) severe enough to consider surgery were treated with platelet rich plasma.  Clinical success was found in 93% of patients treated with PRP (28/30).  This is an uncontrolled study but did show efficacy in a very difficult group of patients.  

Allan Mishra (@bloodcure)

TotalTendon

Foot Ankle Int. 2012 May;33(5):379-85.

Platelet rich plasma treatment for chronic achilles tendinosis.

Monto RR.

Source

Abstract

BACKGROUND:

Chronic Achilles tendinosis is a relatively common but difficult orthopedic condition to treat. In this study, autologous platelet rich plasma (PRP), a concentrated bioactive blood component rich in cytokines and growth factors, was evaluated to determine its potential long-term efficacy in treating chronic cases of Achilles tendinosis resistant to traditional nonoperative management.

METHODS:

Thirty patients with chronic Achilles tendinosis who did not respond to a minimum of 6 months of traditional nonoperative treatment modalities were treated with a single ultrasound guided injection of PRP. AOFAS scoring was completed for all patients pretreatment and at 0, 1, 2, 3, 6, 12, and 24 months post-treatment. MRI and/or ultrasound studies were completed for all patients pre-treatment and at 6 months post-treatment. Prior to the PRP treatment all of the patients in this study were considering surgical Achilles repair for their severe symptoms.

RESULTS:

The average AOFAS score increased from 34 (range, 20 to 60) to 92 (range, 87 to 100) by 3 months after PRP treatment and remained elevated at 88 (range, 76 to 100) at 24 months post-treatment. Pretreatment imaging abnormalities present in the Achilles tendon on MRI and ultrasound studies resolved in 27 of 29 patients at 6 months post-treatment. Clinical success was achieved in 28 of 30 patients.

CONCLUSION:

Platelet-rich plasma was used effectively to treat chronic recalcitrant cases of Achilles tendinosis.

Platelet Rich Plasma better than Prolotherapy for Biceps Tendonitis

In an abstract published by the American Journal of Sports Medicine of a Korean language article, platelet rich plasma was found to be more effective than prolotherapy for proximal biceps tendinitis.  In the study 100 patients were studied in a case-control fashion and then followed for 12 months.  No significant differences were noted between the groups in the first months.  However, significant differences were found between the groups at 3, 6 and 12 months in visual analog pain scores, Korean Shoulder Society score, UCLA score and Constant shoulder score (p < 0.05).  The conclusion of the study was "PRP therapy is more effective treatment than prolotherapy"

The details of this study are not known.  It does provide some data to support the use of PRP for this common problem.  If anyone out there can find and translate this article it would be most helpful.  This dramatically speaks to the importance of finding these articles (in any language) and then coordinating the information for patients and providers.


AM
TotalTendon

"Comparative Studies of Platelet-Rich Plasma (PRP) and Prolotherapy for Proximal Biceps Tendintis"
Moon et al
Department of Orthopaedic Surgery; Gwangju, Korea
Journal of the Korean Orthopedic Association
Quoted in Vol. 40:6 June 2012 of the American Journal of Sports Medicine

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

Shockwave Therapy and Knee Osteoarthritis

Extracorporeal shockwave therapy is the external application of high intensity sound energy.  This type of treatment has been applied to kidney stones, fractures, tendonitis and now osteoarthritis.   Two preclinical studies published today suggest this technique may be promising.

Two different models of knee osteoarthritis were utilized.  One involves cutting the ACL, the other creates a cartilage defect in the knee.  Both of these studies suggest shockwave therapy may have value in the treatment of knee osteoarthritis.  Appropriate human clinical trials still need to be conducted.


AM

Here are the two studies:

Clin Orthop Relat Res. 2012 Jun 6. 

Does Extracorporeal Shock Wave Therapy Enhance Healing of Osteochondritis Dissecans of the Rabbit Knee?: A Pilot Study.

Lyon R, Liu XC, Kubin M, Schwab J.

Conclusions

Shockwave therapy "accelerated the healing rate and improved cartilage and subchondral bone quality in the OCD (osteochondritis dissecans) rabbit model.

Link to full abstract

Journal of Surgical Research

Extracorporeal shockwave therapy shows time-dependent chondroprotective effects in osteoarthritis of the knee in rats

Ching-Jen Wang, MD

, 

Yi-Chih Sun, BS

, 

To Wong, MD

, 

Shan-Ling Hsu, MD

, 

Wen-Yi Chou, MD

, 

Hsueh-Wen Chang, PhD

• Conclusion

  "Extracorporeal shockwave therapy is effective in preventing osteoarthritis of the knee in rats. The beneficial effects of ESWT appear to be time-dependent beginning at 4 weeks after treatment."
  Link to full abstract
  
  
  
  

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

Kobe Bryant Regenokine Orthokine Treatment Explained

Kobe Bryant (LA Lakers) is having another Orthokine or Regenokine treatment after averaging 29 points per game in his 15th season in the NBA.  Is it because of a blood derived treatment he had done on his knee?  Other elite athletes such as Alex Rodriguez (NY Yankees) and Fred Couples (PGA Golfer)  have been treated with Orthokine in Germany.  But what is Orthokine?  That is a question that needs to be answered.

Orthokine is a form of autologous conditioned serum (ACS) that contains a high concentration of a molecule called IL-1 RA.  This stands for interleukin-1 receptor antagonist (IL-1 RA).  Interleukin-1 (IL-1) is an important mediator of inflammation and tissue damage.  Balancing IL-1 with IL-1 RA is important.  Read more about IL-1/IL-1 RA

Orthokine to the best of my knowledge is only available in Germany and has mainly been used to treat knee osteoarthritis.  A study of 376 patients was done comparing Orthokine (ACS) with hyaluronic acid (HA) and saline injections for knee osteoarthritis.  The "effects of ACS were significantly superior to those of HA and saline for all outcome measures and time points."  See Abstract of Article

From the available evidence, it appears as though this is a reasonable treatment.  I do not, however, know many of the details.  This treatment is not available in the United States.  It is produced by incubating a patient's blood in a sterile container with beads over a period of 6-8 hours or more.  The IL-1 RA and other growth factors are concentrated and injected back into the patient.

This is different than platelet rich plasma (PRP) in that PRP is made at the point of care and can be delivered back to the patient within 15-20 minutes.  No incubation period is needed.  

Allan Mishra, MD

@BloodCure

Sports Press about Kobe and the treatment:  
http://www.hoopsworld.com/kobe-readying-for-german-knee-procedure

Platelet Rich Plasma Helpful for Jaw Osteonecrosis

The paper outlined below suggests platelet rich plasma may be helpful for patients with osteonecrosis of the jaw induced by bisphosphonates.  Bisphosphonates are a class of drugs that help prevent bone loss and are used to treat osteoporosis.  Further data will be be required to confirm these findings.  

AM

TotalTendon

Int J Oral Maxillofac Surg. 2012 May 28.

Use of platelet-rich plasma in the treatment of bisphosphonate-related osteonecrosis of the jaw.

Bocanegra-Pérez S, Vicente-Barrero M, Knezevic M, Castellano-Navarro JM, Rodríguez-Bocanegra E, Rodríguez-Millares J,Pérez-Plasencia D, Ramos-Macías A.

Source

Hospital Universitario Insular de las Palmas de Gran Canaria, Universidad de Las Palmas de Gran Canaria, Spain.

Abstract

Platelet-rich plasma is a concentrate of growth factors and osteoconductive proteins, which can play a major role in bone biology by accelerating and enhancing bone repair and regeneration. This paper describes the results of using platelet-rich plasma in the management of bisphosphonate-associated necrosis of the jaw. Eight patients with a diagnosis of bisphosphonate-associated necrosis of the jaw were surgically treated for debridement and removal of necrotic bone, followed by application of autologous platelet concentrate enriched with growth factors and primary suture of the wound. Patients underwent periodic clinical and radiological follow-up examinations. All patients showed clinical improvement and oral lesions resolved 2-4 weeks after treatment. After an average 14-month follow up period, patients remained asymptomatic. Although not conclusive, the combination of necrotic-bone curettage and platelet-rich-plasma to treat refractory osteonecrosis of the jaw yielded promising results.