Tuesday, August 21, 2012

Steroid Injections may Deplete Tendon Stem Cell Pools

Steroid injections are commonly used for a number of musculoskeletal conditions.  There is increasing evidence to suggest this is not a good idea especially for tendon related problems such as tennis elbow or rotator cuff tendinopathy.  Clinical studies only confirm short term pain relief for cortisone injections.  Basic science studies are now revealing that such injections may deplete tendon stems cells pools or increase the risk of tendon rupture.  (See Abstract Below)

Platelet rich plasma has been shown to be superior to cortisone injection in a double blind randomized trial at least for tennis elbow.  When discussing the value of evolving biologic therapies it is crucial to compare them to commonly used treatments.  In the case of cortisone for tendon related injuries and disorders at least for now PRP is the superior choice based on basic science and clinical publications for tennis elbow.  (Gosens et al Study)

Allan Mishra, MD


 2012 Aug 8. 

The effects of dexamethasone on human patellar tendon stem cells: Implications for dexamethasone treatment of tendon injury.



Injection of Dexamethasone (Dex) is commonly used in clinics to treat tendon injury such as tendinopathy because of its anti-inflammatory capabilities. However, serious adverse effects have been reported as a result of Dex treatment, such as impaired tendon healing and tendon rupture...... Dex treatment depletes the stem cell pool and leads to the formation of non-tendinous tissues (e.g., fatty and cartilage-like tissues), which make tendon susceptible to rupture. 

© 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. 
Copyright © 2012 Orthopaedic Research Society.

Wednesday, August 15, 2012

Orthopedic Innovation

Innovation within medicine more often arises via persistence and determination than from dramatic breakthroughs.  In fact, many paradigm shifting advancements are not initially embraced by the medical establishment.  In orthopedics, total joint replacement and arthroscopy are two excellent examples.  Sir John Charnley deserves much of the credit for the modern development of hip replacement surgery.  His initial designs used Teflon and those implants typically failed early.  He redesigned his implant to use a novel liner that significantly improved  its longevity.  Use of other materials and techniques over several decades via the hard work of many have led us to the point where we complain when a total hip lasts less than 10 or even 15 years.  (Read more)

Arthroscopy, one of the first minimally invasive types of surgery, at its beginning took longer and was more complicated than open surgery.  The first examination of joint via a "scope" was close to 100 years ago.    Over the last 30 years, it has become the standard of care for evaluating and treating many joint injuries such as ACL reconstruction and Rotator Cuff Repair.  This innovation is the result of contributions of thousands of researchers, surgeons and their patients.  It is also led to less invasive surgery for spine disorders.  (See Spine Surgery Video) (Read more/source)

We are now about a decade into "Biologic Orthopedics".  Therapies such as Platelet Rich Plasma, Stem Cells, Genetic Engineering, and Genome Sequencing are revolutionizing how we evaluate and treat patients.  As we surf the choppy waters of innovation, however, we will not always embrace ideal ideas.  Some "innovations" will fade as fads but others will emerge as commonplace treatments that significant improve the lives of millions of patients.  We need to balance our approach to novel methods of helping our patients.  We must seek their safety and benefit first.   In doing so, we are obligated to consider emerging biologic treatment options because they may be the best and most appropriate.

Allan Mishra, MD

Sunday, August 05, 2012

Medicare (CMS) Announces Payment Coverage for Platelet Rich Plasma For Wound Healing

Platelet Rich Plasma has been used for years to treat chronic wounds.  In a landmark decision, the Centers for Medicare and Medicaid Services (CMS) announced coverage for PRP that is being used in clinical trials for wound healing.  This is a crucial first step for a broad range of biologic therapies.  If government payers are willing to support these types of treatments when they are backed up with appropriate data, more innovative treatments will arise.  This is good news for patients and the providers who are developing novel options for difficult problems.

Full Story Link

Allan Mishra, MD



Thursday, August 02, 2012

Can Platelet Rich Plasma Heal Difficult Meniscus Tears?

Meniscus tears are very common and come in a variety of types and occur in different zones of the knee.  The peripheral part of the meniscus is known as the red-red zone because it has the best blood supply.  The central portion is known as the red-white zone becuase of its moderate blood supply and the white-white zone has a poor blood supply.  Typically, tears in this white-white zone are surgical resected because of their poor healing capacity.  Newer mechanical techniques are being developed to suture these tears together.  And, now biologic enhancement with platelet-rich plasma has been formally proposed as a way to improve the chances of such a tear healing.  Data will need to be developed but it is clear we will need both better devices to suture the meniscus AND biologic stimulation in order for white-white tears to heal.

See video below about meniscus tears and the abstract of an article proposing PRP to help heal meniscus tears. 


A novel hypothesis: The application of platelet-rich plasma can promote the clinical healing of white-white meniscal tears.

Wei LC, Gao SG, Xu M, Jiang W, Tian J, Lei GH.
Med Sci Monit. 2012 Aug 1;18(8):HY47-50.

The white-white tears (meniscus lesion completely in the avascular zone) are without blood supply and theoretically cannot heal. Basal research has demonstrated that menisci are unquestionably important in load bearing, load redistribution, shock absorption, joint lubrication and the stabilization of the knee joint. It has been proven that partial or all-meniscusectomy results in an accelerated degeneration of cartilage and an increased rate of early osteoarthritis. Knee surgeons must face the difficult decision of removing or, if possible, retaining the meniscus; if it is possible to retain the meniscus, surgeons must address the difficulties of meniscal healing. Some preliminary approaches have progressed to improve meniscal healing. However, the problem of promoting meniscal healing in the avascular area has not yet been resolved. The demanding nature of the approach as well as its low utility and efficacy has impeded the progress of these enhancement techniques. Platelet-rich plasma (PRP) is a platelet concentration derived from autologous blood. In recent years, PRP has been used widely in preclinical and clinical applications for bone regeneration and wound healing. Therefore, we hypothesize that the application of platelet-rich plasma for white-white meniscal tears will be a simple and novel technique of high utility in knee surgery. 

SourceDepartment of Orthopaedics, Xiangya Hospital, Central South University, ChangSha, Hunan, China and Department of Orthopaedics, First People's Hospital of ShaoYang City, ShaoYang, Hunan, China.

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