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.


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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

Large Randomized Trial Confirms Value of Platelet Rich Plasma for Tennis Elbow Patients

84% of patients with chronic tennis elbow who had failed other non-operative treatments were successfully treated using platelet-rich plasma (PRP) in a large randomized trial.  The results will be presented today at the American Academy of Orthopedic Surgery Meeting in Chicago.

The study was a randomized, double-blind, multi-center controlled trial of 230 patients.  Patients received needling of their elbow tendons with and without PRP.  At 24 weeks the PRP patients reports a 71.5% improvement in their pain compared to 56.1 in the control group. (P = 0.027)  Patients treated with PRP also had less elbow tenderness at each follow up point. (See Graph Below)  Overall, 84% of the PRP patients were successfully treated compared to 68.3% of the control group. (P = 0.012)

This is the largest study done to date using PRP.  There are now over 340 patients who have been treated with the same system (Biomet GPS PRP) and techniques confirming the value of PRP as a treatment for chronic tennis elbow.  Importantly, there is also a decade long experience using PRP with an excellent safety profile.  PRP with this newly released data can now be confidently used for chronic tennis elbow patients prior to considering surgical intervention.

American College of Surgeons Article on the presentation.

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Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients with Chronic Tennis Elbow:

A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients

AAOS 2013

Allan K. Mishra,  MD; Nebojsa V. Skrepnik, MD, PhD; Scott G. Edwards, MD; Grant L. Jones, MD; Steven Sampson, DO; Doug A. Vermillion, MD; Matthew L. Ramsey, MD; David C. Karli, MD, MBA; Arthur C. Rettig, MD 

Platelet Rich Plasma better than Shock Wave for Jumpers' Knee

Jumpers' knee also known as patellar tendinitis is a common problem for basketball and volleyball players among other athletes.  Patients treated with platelet-rich plasma for this condition when compared to shock wave treatment improved more at six and 12 months after treatment.  See abstract below.

This paper adds to the mounting data suggesting PRP is a valuable treatment for chronic tendon related problems such as Jumpers' knee.

MRI of Patellar Tendinopathy

Also Known as Jumpers' Knee

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TotalTendon

Am J Sports Med. 2013 Feb 13. [Epub ahead of print]

Platelet-Rich Plasma Versus Focused Shock Waves in the Treatment of Jumper's Knee in Athletes.

Vetrano M, Castorina A, Vulpiani MC, Baldini R, Pavan A, Ferretti A.

Source

Physical Medicine and Rehabilitation Unit, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.

Abstract

BACKGROUND:Tendinopathies represent a serious challenge for orthopaedic surgeons involved in treatment of athletes. PURPOSE:To compare the effectiveness and safety of platelet-rich plasma (PRP) injections and focused extracorporeal shock wave therapy (ESWT) in athletes with jumper's knee. STUDY DESIGN:Randomized controlled trial; Level of evidence, 1. METHODS:Forty-six consecutive athletes with jumper's knee were selected for this study and randomized into 2 treatment groups: 2 autologous PRP injections over 2 weeks under ultrasound guidance (PRP group; n = 23), and 3 sessions of focused extracorporeal shock wave therapy (2.400 impulses at 0.17-0.25 mJ/mm(2) per session) (ESWT group; n = 23). The outcome measures were Victorian Institute of Sports Assessment-Patella (VISA-P) questionnaire, pain visual analog scale (VAS), and modified Blazina scale. A reviewer who was blinded as to the group allocation of participants performed outcome assessments before treatment and at 2, 6, and 12 months after treatment. Nonparametric tests were used for within-group (Friedman/Wilcoxon test) and between-group (Kruskal-Wallis/Fisher test) testing, and the significance level was set at .05. RESULTS:The 2 groups were homogeneous in terms of age, sex, level of sports participation, and pretreatment clinical status. Patients in both groups showed statistically significant improvement of symptoms at all follow-up assessments. The VISA-P, VAS, and modified Blazina scale scores showed no significant differences between groups at 2-month follow-up (P = .635, .360, and .339, respectively). The PRP group showed significantly better improvement than the ESWT group in VISA-P, VAS scores at 6- and 12-month follow-up, and modified Blazina scale score at 12-month follow-up (P < .05 for all). CONCLUSION:Therapeutic injections of PRP lead to better midterm clinical results compared with focused ESWT in the treatment of jumper's knee in athletes.

Stem Cells from the Rotator Cuff and Biceps Tendon

In a landmark study, Dr. Pietro Randelli and his colleagues found a population of cells within the rotator cuff and biceps tendon with stem cell like "characteristics (ie, they were self-renewing in vitro, clonogenic, and multipotent), as they could be induced to differentiate into different cell types-namely, osteoblasts, adipocytes, and skeletal 

muscle cells."

The full implications of this paper are difficult to predict but this work could enable entirely new approaches to tendon repair within and outside of the shoulder.  The authors should be congratulated on this truly important work.  See the full abstract below for details.

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Am J Sports Med. 2013 Feb 7. [Epub ahead of print]

Isolation and Characterization of 2 New Human Rotator Cuff and Long Head of Biceps Tendon Cells Possessing Stem Cell-Like Self-Renewal and Multipotential Differentiation Capacity.

Randelli P, Conforti E, Piccoli M, Ragone V, Creo P, Cirillo F, Masuzzo P, Tringali C, Cabitza P, Tettamanti G, Gagliano N, Anastasia L.

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Source

IRCCS Policlinico San Donato, San Donato Milanese, Italy.

Abstract

BACKGROUND:Stem cell therapy is expected to offer new alternatives to the traditional therapies of rotator cuff tendon tears. In particular, resident, tissue-specific, adult stem cells seem to have a higher regenerative potential for the tissue where they reside. HYPOTHESIS:Rotator cuff tendon and long head of the biceps tendon possess a resident stem cell population that, when properly stimulated, may be induced to proliferate, thus being potentially usable for tendon regeneration. STUDY DESIGN:Controlled laboratory study. METHODS:Human tendon samples from the supraspinatus and the long head of the biceps were collected during rotator cuff tendon surgeries from 26 patients, washed with phosphate-buffered saline, cut into small pieces, and digested with collagenase type I and dispase. After centrifugation, cell pellets were resuspended in appropriate culture medium and plated. Adherent cells were cultured, phenotypically characterized, and then compared with human bone marrow stromal cells (BMSCs), as an example of adult stem cells, and human dermal fibroblasts, as normal proliferating cells with no stem cell properties. RESULTS:Two new adult stem cell populations from the supraspinatus and long head of the biceps tendons were isolated, characterized, and cultured in vitro. Cells showed adult stem cell characteristics (ie, they were self-renewing in vitro, clonogenic, and multipotent), as they could be induced to differentiate into different cell types-namely, osteoblasts, adipocytes, and skeletal muscle cells. CONCLUSION:This work demonstrated that human rotator cuff tendon stem cells and human long head of the biceps tendon stem cells can be isolated and possess a high regenerative potential, which is comparable with that of BMSCs. Moreover, comparative analysis of the sphingolipid pattern of isolated cells with that of BMSCs and fibroblasts revealed the possibility of using this class of lipids as new possible markers of the cell differentiation status. CLINICAL RELEVANCE:Rotator cuff and long head of the biceps tendons contain a stem cell population that can proliferate in vitro and could constitute an easily accessible stem cell source to develop novel therapies for tendon regeneration.

Steroid Shots NOT helpful for Tennis Elbow

For years now, physicians of all types have recommended steroid injections for tennis elbow.  There has been some debate about the value of these injections.  It is time to declare there is no significant value and they may actually be harmful.  A new study published today by the Journal of the American Medical Association (JAMA) evaluated 165 patients in a prospective, randomized fashion.  In this study, patients were given a corticosteroid injection or a placebo injection.  Physical therapy was also added.  Reuters Health ran a story about the study today.  Here are some excerpts:  

(Reuters Health) - "Getting a cortisone injection won't cure tennis elbow any better than a drug-free saline shot, according to a new study - and it might actually slow recovery."

"Among those who'd received a cortisone shot, 83 percent reported they had completely recovered from tennis elbow by one year. That compared to 96 percent of those who'd received a placebo injection, according to findings published Tuesday in the Journal of the American Medical Association."

"This evidence does not support the clinical practice of using corticosteroid injection to facilitate active rehabilitation," the study team wrote."

Read the full article by Genevra Pittman from Reuters.  

It is clear form published peer reviewed data that cortisone injections have little or no value in the treatment of tennis elbow.  Data suggests a platelet rich plasma injection is significantly better option than cortisone.   Or, try a simple stretching and strengthening program.  Always also consult with a physician also to make sure you have a proper diagnosis.

Simple Tennis Elbow Stretches

Simple Tennis Elbow Strengthening Exercises

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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.

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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.

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See the video below for a brief description of knee arthritis

Systemic Effects of Platelet Rich Plasma

In a well done study, researchers have shown when athletes are given an intratendinous injection of leukocyte-enriched platelet rich plasma (PRP), they will have elevated levels of growth factors in their blood up to four days after the procedure.  (see abstract below)

Vascular-endothelial growth factor  (VEGF), a molecule known to enhance angiogenesis (new blood vessel formation), was elevated in all 25 patients after injection.  This is very interesting and important data suggesting PRP may trigger a systemic response.  It also helps explain why PRP may be a useful treatment for tendon related injuries and disorders.   Several controlled studies confirm PRP can be an effective treatment for chronic tennis elbow and this study may reveal one of the mechanisms of action.
Tennis Elbow Study 1,  Tennis Elbow Study 2

It would be quite interesting and important to also measure growth factors in athletes who have received a saline injection or dry needling of their tendons to see if the act of introducing a needle into a damaged tendon produces a similar or different systemic response.

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Am J Sports Med. 2012 Dec 4.

The Systemic Effects of Platelet-Rich Plasma Injection.

Wasterlain AS, Braun HJ, Harris AH, Kim HJ, Dragoo JL.

Source

Department of Orthopaedic Surgery, Stanford University, Stanford, California.

Abstract

BACKGROUND:Platelet-rich plasma (PRP) is an autologous blood product used to treat acute and chronic tendon, ligament, and muscle injuries in over 86,000 athletes in the United States annually. The World Anti-Doping Agency (WADA) banned intramuscular PRP injections in competitive athletes in 2010 because of concerns that it may increase performance-enhancing growth factors. The ban on PRP was removed in 2011 because of limited evidence for a systemic ergogenic effect of PRP, but the growth factors within PRP remain prohibited. PURPOSE:To quantify the effect of PRP injection on systemic growth factors with performance-enhancing effects and to identify molecular markers to detect treated athletes. STUDY DESIGN:Descriptive laboratory study. METHODS:Six ergogenic growth factors monitored by WADA-human growth hormone (hGH), insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), basic fibroblast growth factor (bFGF or FGF-2), vascular endothelial growth factor (VEGF), and platelet-derived growth factor-BB (PDGF-BB)-were measured in 25 patients before (baseline) and at 0.25, 3, 24, 48, 72, and 96 hours after intratendinous leukocyte-rich PRP injection. Eating and exercise were prohibited for 3 hours before testing. Growth factors were quantified by enzyme-linked immunosorbent assay, and the change relative to each patient's baseline was calculated. RESULTS:Relative to serum, PRP contained significantly more bFGF (226 vs 5 pg/mL), VEGF (1426 vs 236 pg/mL), and PDGF-BB (26,285 vs 392 pg/mL), but IGF-1 and hGH were not elevated. Serum levels increased significantly for IGF-1 at 24 and 48 hours, for bFGF at 72 and 96 hours, and for VEGF at 3, 24, 48, 72, and 96 hours after PRP injection. Additionally, VEGF was increased in all 25 patients after PRP treatment. CONCLUSION:Serum IGF-1, VEGF, and bFGF levels are significantly elevated after PRP injection, supporting a possible ergogenic effect of PRP. An indirect marker for hGH doping, the product of IGFBP-3 × IGF-1, also significantly increased after PRP. Platelet-rich plasma appears to trigger an increase in circulating growth factors through activating biological pathways rather than by serving as a vehicle for the direct delivery of presynthesized growth factors. Elevated VEGF was observed in all patients after PRP, and ≥88% of patients had elevated VEGF at each time point from 3 to 96 hours after PRP, suggesting that VEGF may be a sensitive molecular marker to detect athletes recently treated with PRP. CLINICAL RELEVANCE:This is the first and only adequately powered study of the systemic effects of PRP. We present evidence that PRP contains and may trigger systemic increases in substances currently banned in competitive athletes. Finally, we provide evidence that VEGF could serve as a useful molecular marker to detect athletes treated with PRP.