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

Dramatic Rise in Platelet Rich Plasma References

Over the last decade, there has been a dramatic rise in the number of PubMed and Google references about platelet-rich plasma.  This represents worldwide interest in this point-of-care biologic treatment for a variety of research and clinical applications.

Patients are already seeing the benefits of this research and new breakthroughs will come from expected and unexpected sources.

AM

Platelet Rich Plasma PubMed and Google Reference Growth Charts from Allan Mishra

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.

Platelet-rich Plasma Update from Toronto, ISAKOS 2013

The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) is a gathering of several thousand professionals that is presently taking place in Toronto, Canada.  Today, a platelet-rich plasma (PRP), Instructional Course Lecture was offered to over 100 participants.  Lectures about how to use or not use PRP were given by Dr. Rogerio Silva, Dr. Allan Mishra, Dr. Nicola Maffuli and Dr. Steven Arnoczky.  At least ten other PRP lectures were given at the conference including Dr. Mandeep Dhillion from India presenting his excellent study showing the value of PRP for knee osteoarthritis.  Basic science papers by Dr. Joon Lee et al from Korea also showed a chondro-protective effect of PRP after acute ACL tears.  It is becoming increasingly difficult to keep up with the dramatic rise in PRP related presentations and papers.  Overall, it is clear that there is increasing worldwide interest in this point-of-care, blood-derived bioactive treatment.  As the data matures we will better understand how to use PRP to help care for patients.  Presently, there is excellent level one support for its use in chronic tennis elbow.

AM

Platelet Rich Plasma Update, JBJS Webinar

Worldwide interest in Platelet-Rich Plasma is increasing significantly.  471 new publications have appeared on PubMed about platelet-rich plasma in just the last year, making it quite challenging to keep up with the published literature.  There has also been a dramatic rise in Google "hits" for PRP to over 1.3 million.  (See the graphs below)   New data recently accepted for publication to the American Journal of Sports Medicine confirms the value of PRP in the treatment of chronic tennis elbow.  See American College of Surgeons Report on the paper.

Tonight the Journal of Bone and Joint Surgery will be holding a webinar on the topic.  Over 1000 professionals have already signed up for the event.  This is totally unprecedented for a major, elite journal to sponsor a discussion on a single specific biologic orthopedic topic.  Follow Dr. Mishra:  @BloodCure for real time updates about tonight's webinar.

Or, consider joining the Biologic Orthopedic Society Group on LinkedIN to participate in a discussion about the webinar and other biologic orthopedic topics.

AM

TotalTendon

DNA Structure Discovered 60 Years Ago

One of the world's most important scientific papers was published in the journal Nature on April 25, 1953, 60 years ago today.  The entire paper was just one page!  In the short communication, James Watson and Francis Crick not only detailed the definitive structure of DNA (deoxyribonucleic acid)  but also proposed the unzipping mechanism by which the molecule could replicate itself.  They initially announced they had found "the secret of life" at the Eagle Pub in Cambridge, England.    (See the DNA diagram from the actual paper to the right)

These two brilliant men figured out the chemical structure of DNA without doing any experiments.  They started by carefully digested and then synthesizing the world's literature.  They attended conferences and sought data anywhere they could find it.  They were ridiculed for building stick models instead of conducting costly and time consuming lab investigations.  The solution to the beautiful double helix structure of DNA arose via the collaboration of biologist Watson and physicist Crick.  Neither one of them had an elite understanding of chemistry.  They even challenged and eventually proved wrong the triple helix structure proposed by famous chemist Linus Pauling.  

Sixty years later, their discovery and the subsequent research on recombinant DNA and genomic sequencing has transformed our lives.  Today, we take for granted our ability to "grow" human insulin in bioreactors and target specific cancers with molecular designer drugs.  It is appropriate to pause for just a moment today and thank the two dreamers who via their hard work and intuition discovered the structure of DNA.  Let's hope we can find and encourage many more dreamers like Watson and Crick.

AM

References:  Watson and Crick,  Nature April 1953

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

Compound Tibia Fractures, Kevin Ware NCAA hoops

You may have heard about the nasty compound shin bone fracture sustained by Louisville's Kevin Ware in the NCAA Regional Final game on Sunday.  These fractures are also known as open tibia fractures.  In this post, I'll outline some of the details of this serious injury to help everyone understand it better.

For a compound or open fracture to occur without any contact is very rare.  I did a search on PubMed yesterday and couldn't find even a case report of one.  So, we need to try to better understand why his shin bone or tibia failed.  Is it because he jumped and then landed with a dramatic twisting force?  That is one possibility.  Another one is that he may have had some underlying weakness of his bone prior to the injury.  It occurred to me that these young men play a ton of hoops especially toward the end of the year with their conference tournaments and then immediately thereafter they participate in the NCAA tourney.  Did he have some stress injury to the bone due to playing so many games that may have predisposed it to failure?  Is it possible that he had a metabolic bone problem that resulted in it being weak?  Finally, was it simply one of worst cases of bad luck in a basketball history?  We may never know.

It is crucial that he was treated immediately by an elite trauma team.  Indy has some of the best in the country.  What he likely had to have done was a wash out of the area where the bone poked through the skin and then an insertion of a titanium nail to stabilize the bone.  He also sustained injuries to the skin and muscle around the bone.  These are known as soft tissue injuries.  These will also need to heal.  In addition to the surgery, he was likely given intravenous antibiotics to help prevent the onset of infection.

Mr. Ware's type of fracture usually takes several months to heal properly.  Occasionally, additional growth factors are given at the time of surgery to improve the chances the fracture consolidates.  Or, external devices that deliver ultrasound or electrical stimulation are used to enhance or accelerate the bone healing.  Even if everything initially is done perfectly as it seems to have been in this case, there is still a risk of bone not healing (delayed or non-union) or the possibility of late infection.

It is great to see Mr. Ware up and sending out pictures.  This young man dealt with a severe injury that was witnessed by millions of people on live TV with incredible courage and poise.  Hopefully his recovery will be uneventful and speedy.  I know we all would love to see him back on the court as soon as possible.


AM

View an excellent story about the injury from Dr. Jon LaPook and Scott Pelley from the CBS Evening News.

References

Melvin et al.  “Open Tibial Shaft Fractures:  I.  Evaluation and Initial Wound Management”

Journal of the American Academy of Orthopeadic Surgeons

Melvin et al.  “Open Tibial Shaft Fractures: II.  Definitive Management and Limb Salvage”

Journal of the American Academy of Orthopeadic Surgeons