Dr Weglein and Dr Garcia teaching at TOBI ( the Orthobiologic institute)
Over the years, TOBI has become best known for world-renowned faculty. TOBI annual events bring together field experts publishing the research in orthopedic biologics and regenerative medicine. This event has enjoyed consistent annual growth, as global thought-leaders return for annual updates and the year\'s best networking opportunities to collaborate on projects and advance the field. Newcomers to the field come to learn from the best.
Effect of High-Volume Injection, Platelet-Rich Plasma, and Sham Treatment in Chronic Midportion Achilles Tendinopathy: A Randomized Double-Blinded Prospective Study
Background: Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse.
Purpose: To determine whether eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment-Achilles [VISA-A]). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up.
Conclusion: Treatment with HVI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVI may be more effective in improving outcomes of chronic AT than PRP in the short term.
Purpose: To compare the short-term effect of prolotherapy and conservative terapy for the Tietze synrome.
Patients And Methods: From 2013 to 2014, twenty-one patients underwent prolotherapy (group 1) and thirteen underwent conservative therapy with analgesics (group 2). A visual analogue score (VAS) was recorded for measurement of pain intensity in all patients before (Pre VAS) and after injection first day (VAS1), first week (VAS2) and fourth week (VAS3). Group 2 were received systemic nonsteroidal anti-inflammatory drug. VAS score was recorded similarly at the same times (Pre VAS, VAS1, VAS2, VAS3), and clinical affects were compared between the two groups.
Results: The mean VAS score (mm) before prolotherapy was 7.10 in patients who received prolotherapy, and 7.14 mm in patients who treated nonsteroidal anti-inflammatory drug. The mean VAS after the fist injection was 2.19 mm and dropped to 1.52 mm after the third injection. The mean VAS after the nonsteroidal anti-inflammatory drug treatment dropped 2.62 mm and during the same scores to 3 weeks later. There was no significant difference between the group 1 and group 2 in the age, sex and comorbidity. Also there was no significant difference between the group 1 and group 2 in clinical and radiological evidence. The prolotherapy group showed a faster recovery, including significantly reduced clinic findings (p: 0.001). Third VAS is significant finding for the prolotherapy group.
Conclusion: Prolotherapy could be performed safely and is a method with a favorable long term treatments for t he Tietze Syndrome. It may be the ideal procedure for patients with drugs side effects and advers events especially for those with limited liver and kidney reserve or significant comorbidities.
A Houston research team has uncovered a possible treatment for severe brain injuries that could dramatically improve the outlook for tens of thousands of trauma patients - from those injured on Houston highways, to soldiers wounded on faraway battlefields.
About 275,000 people across the country each year are wheeled into emergency rooms with severe traumatic brain injuries; about a fourth don\'t survive. Those who do often suffer permanent disabilities, in part because swelling in the brain in the days and weeks after the injury cuts off blood flow, killing neurons.
In a new clinical trial conducted at Memorial Hermann Hospital, researchers from UTHealth have shown it\'s possible to reduce brain inflammation by harvesting stem cells from a trauma patient\'s bone marrow and re-infusing them into the bloodstream within 48 hours of injury. The results are promising, said Dr. Charles Cox, who\'s been working on the experimental treatment for more than 15 years.
Background: The study was conducted to analyse the clinical outcomes following a single injection of platelet rich plasma, produced using autologous blood by standard double centrifugation technique in patients with plantar fasciitis who have not had relief using conservative methods.
Methods: Between June 2013 and June 2015, 26 consecutive patients (Mean age 45.92) (11 males/15 females) who had symptoms for a minimum of 3 months and had failed conservative management options such as rest, anti-inflammatories and physiotherapy were given a single injection of PRP in the medial calcaneal tubercle.
Results: The outcomes were measured using Visual analogue scale and Foot function index at pre injection, and at 1, 6 and 12 months post injection and results tabulated. All patients reported an improvement in VAS and FFI scores consistently. One superficial infection was encountered.
Conclusions: Single injection of platelet rich plasma improves pain and function in the foot in patients suffering from plantar fasciitis when conservative management has failed. The synergism between various autologous growth factors may play a role in tendon healing.
Introduction: Knee Osteoarthrosis is one of the most debilitating diseases. Prolotherapy includes intraarticular injection of various drugs to decrease inflammation. Injection of Intradiscal O2-O3 has reduced pain and disability of patients with low back pain due to prolapsed lumbar disk.
Objective: To compare the effect of intraarticular injection of Ozone and steroids in improvement of clinical and cellular healing of knee osteoarthritis.
Methods:in a randomized clinical trial, 70 patients with knee osteoarthrosis were included in the study. In Ozone group, 5 ml (35 μg/ml) of Ozone and in steroid group 5ml (50 mg) Triamcinolone were injected intraarticular. At 1,2,and 6 month patients were followed for pain scale, disability index and IL-1β and TNF-α serum levels were measured.
Results: At 1 month after injection pain scale and disability index and IL-1β and TNF-α were decreased in both groups. However, at 2 and 6 month pain scale and disability index were significantly lower in Ozone group compare to steroid group (p<0.05). Besides, serum level of IL-1β and TNF-α were also significantly lower at 2 and 6 month in Ozone group compare to steroid group (p<0.05).
Conclusion: Intraarticular Ozone induces significantly longer improvement of pain and disability in knee osteoartherosis compare to steroid injection. In addition, serum inflammatory cytokines are also lower in Ozone group compared to steroid group along with clinical improvements.
Autologous platelet-rich plasma versus corticosteroid in the management of elbow epicondylitis: A randomized study
Introduction: Elbow epicondylar tendinitis is a common problem for patients whose activities require strong gripping or repetitive wrist movements in the day-to-day activities of life. Histologic specimens from chronic cases confirm that tendinitis is not an acute inflammatory condition but rather a failure of the normal tendon repair mechanism associated with angiofibroblastic degeneration. Tendon regeneration may be improved by injecting autologous growth factors obtained from the patient\'s own blood. Autologous growth factors can be injected with autologous whole blood or platelet-rich plasma (PRP).
Materials and Methods: A randomized study with 83 patients was done. The study population comprised two groups. Group A (n = 50) treated with local steroid injection and Group B (n = 33) treated with autologous PRP. Patients were allocated randomly using computer-generated random number table. The base-line evaluation was done using visual analog score (VAS) and modified Mayo performance index for elbow (MAYO). Re-evaluation was after 1, 2, and 6 months of the procedure. Statistical analysis was done using independent t-test.
Results: Six months after treatment with PRP, patient\'s with elbow epicondylitis had a significant improvement in their VAS (P < 0.05) and MAYO (P < 0.05) in contrast to steroid, whereas no statistical difference was found between the two groups at 1 and 2 months after intervention.
Conclusion: Treatment of patients with epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection.
Purpose of Review: Osteoarthritis and overuse tendinopathy are common chronic conditions of high societal and patient burden. The precise etiology of pain and disability in both conditions is multifactorial and not well understood. Patients are often refractory to conservative therapy. The development of new therapeutic options in both conditions is a public health priority. Prolotherapy is an injection-based outpatient regenerative therapy for chronic musculoskeletal conditions, including osteoarthritis and tendinopathy. The authors reviewed the basic science and clinical literature associated with prolotherapy for these conditions.
Recent Findings: Systematic review, including meta-analysis, and randomized controlled trials suggest that prolotherapy may be associated with symptom improvement in mild to moderate symptomatic knee osteoarthritis and overuse tendinopathy.
Summary: Although the mechanism of action is not well understood and is likely multifactorial, a growing body of literature suggests that prolotherapy for knee osteoarthritis may be appropriate for the treatment of symptoms associated with knee osteoarthritis in carefully selected patients who are refractory to conservative therapy and deserves further basic and clinical science investigation for the treatment of osteoarthritis and tendinopathy.
Platelet-rich plasma versus dry needling of myofascial meridian trigger points in the treatment of plantar fasciitis
Background: Plantar fasciitis (PF) is the most common cause of heel pain, which results from repetitive trauma with degenerative changes in the plantar tissue. Platelet-rich plasma (PRP) and dry needling showed promising results as regards pain resolution and healing effect, and hence our aim was to compare their efficacy in the treatment of chronic PF.
Patients and methods : Thirty patients diagnosed with unilateral PF were subjected to full clinical assessment for foot function using the foot function index (FFI) and assessment of trigger points along the meridians. Ultrasonographic examination of plantar fascia thickness, echogenicity, and power Doppler was carried out. Patients were divided randomly into two groups of 15 each: group A received a single injection of PRP at the plantar fascia, and group B was treated with dry needling protocol in myofascial meridians trigger points along the superficial back line. Follow-up after 6 and 12 weeks included clinical re-evaluation, FFI determination, and ultrasonography. Our results showed a significant improvement in the clinical outcome of the FFI in group B (P<0.03) and a highly significant improvement in the clinical outcome within the PRP group by the 12th week (P<0.009). A significant decrease in thickness, heterogeneity, and Doppler signals (P<0.04, P<0.003, and P<0.03, respectively) was observed within the PRP group at the 12th week.
Conclusion: PRP injection is a promising line of treatment for chronic PF with documented ultrasonographic healing effect. Dry needling is a simple and safe technique for treating pain associated with PF, yet it is more invasive and less effective compared with PRP injection.
Purpose: To assess the short-term results of repeated intra-articular platelet rich plasma (PRP) injections into the knee in patients with early osteoarthritis (OA) and to determine a better treatment protocol.
Methods: This is a retrospective study in 191 knees (127 patients) with minimum of 12 months follow-up. We compared the clinical results of three types of injection method, once a month, twice monthly, and three injections at monthly interval. The outcomes were assessed using Visual Rating Scale (VRS), functional score, knee score, range of motion (ROM), WOMAC Stiffness/Pain/Function score, IKDC score, before the first injection and at 12 months post treatment.
Results: There were significant improvements in all scores after treatment as compared to the pre-treatment values (p < 0.05), except Knee score after 1st and 2nd injection and ROM in three groups. The parameters of Visual Rating Scale (VRS), functional score, and WOMAC Stiffness/Pain/Function score showed significant differences among the three groups in favour of the three injections group (p < 0.05). At 12 months, the effects began to decline in one injection and two injections groups, and the data in one injection group showed significant difference compared to two injection group (p < 0.001). Three injections group had higher scores and more improvement at 12 months after treatment when compared to the other two groups.
Conclusion: PRP injection appears to be effective in early symptomatic OA knees. The results after treatment are encouraging with significant reduction in pain and improvement in knee function at 12 months after treatment when compared to the pre-treatment status. Three injections per month yielded significantly better results in short-term follow-up.
Increased risk for knee replacement surgery after arthroscopic surgery for degenerative meniscal tears: a multi-center longitudinal observational study using data from the osteoarthritis initiative.
Objective: The primary objective was to assess whether patients with knee osteoarthritis and whom undergo arthroscopic meniscectomy have an increased risk for future knee replacement surgery.
Results: 335 participants underwent arthroscopic meniscectomy during follow up, of which 63 (18.8%) underwent knee replacement surgery in the same knee. Of the 335 propensity score matched participants 38 (11.1%) underwent knee replacement surgery during follow up. Results from the Cox-proportional hazards model demonstrated that the hazard ratio of knee replacement surgery was 3.03 (95% CI (1.67-5.26)) for participants who underwent arthroscopic meniscectomy relative to the propensity score matched participants who did not undergo arthroscopic meniscectomy.
Conclusions: In patients with knee osteoarthritis arthroscopic knee surgery with meniscectomy is associated with a three fold increase in the risk for future knee replacement surgery.
Objective: The aim of the present study was to evaluate the effect of PRP on the repair of spinal cord injury in rat model.
Material and methods: Rats were randomly divided into three groups with six rats in each group. Then, spinal cord injury was performed under general anesthesia using \"weight dropping\" method. Control group included rats receiving normal saline, group two received PRP 1 week after injury; group three received PRP 24 h after injury. The motor function was assessed weekly using the Basso, Beattie, and Bresnahan (BBB) locomotor rating scale. Anterograde tracing was performed for evaluation of axon regeneration.
Result: Motor recovery was significantly better in the rats treated with PRP 24 h after injury than the control group. In the rats treated with PRP 1 week after injury and rats treated with PRP 24 h after injury, the average numbers of BDA-labeled axons were statistically different from the control group.
Conclusion: Our experimental study demonstrated positive effects of platelet rich plasma on nerve regeneration after spinal cord injury.
Introduction: Articular cartilage damage is a major cause of pain and functional disability which can occur as a result of injury, disease process such as osteoarthritis, or both. While surgical approaches may provide definitive treatment, they are not typically indicated for mild to moderate damage, may be contraindicated in patients with risk factor, and carry a risk of both operative and anesthetic complications. Nonoperative care may not be definitive in advanced cases, however it can provided definitive treatment in more mild to moderate disease. When excluding biologic options, nonoperative treatments do not reverse the disease process or damage, however there are a variety of options which have been shown to provide significant improvement in terms of pain and function, and many treatments delay and can potentially stall progression of articular cartilage damage. In this chapter, we provide an evidence based approach to the various nonoperative options for the treatment of articular cartilage disease, including exercise, weight loss, physical therapy, braces, oral medications, topical medications, supplements, corticosteroid injections, viscosupplementation, and prolotherapy.
The influence of platelet rich plasma on synovial fluid volumes, protein concentrations, and severity of pain in patients with knee osteoarthritis
Knee pain is commonly seen in orthopedic and rehabilitation outpatient clinical settings. Patients with knee osteoarthritis (OA) are often complicated with joint soreness, swelling, weakness, and pain. These complaints are often caused by the excessive amount of synovial fluid (SF) accumulated in the bursae around the knee joint. This study was aimed to evaluate the effectiveness of platelet rich plasma (PRP) in treating patients with minor to moderate knee osteoarthritis (OA) combined with supra-patellar bursitis using a proteomic approach and clinical evaluation tool. In this study, 24 elderly patients with minor to moderate knee OA combined with supra-patellar bursitis were recruited. Musculoskeletal ultrasound was used for accurate needle placement for the aspiration of SF followed by subsequent PRP injections. Three monthly PRP injections were performed to the affected knees for a total of 3 months. Approximately after the 2nd PRP injection, significant decreases in SF total protein concentrations, volumes, and Lequesne index values were observed. SF proteins associated with chelation and anti-aging physiological functions such as matrilin, transthyretin, and complement 5 increased at least 2-fold in concentrations. Proteins associated with inflammation, such as apolipoprotein A-I, haptoglobin, immunoglobulin kappa chain, transferrin, and matrix metalloproteinase decreased at least 2-fold in concentrations. Therefore, at least two monthly PRP injections may be beneficial for treating patients with minor to moderate knee OA combined with supra-patellar bursitis.
Safety and Efficacy of Intra-articular Injection of Platelet-Rich Plasma in Patients With Ankle Osteoarthritis
Background: An intra-articular injection of platelet-rich plasma (PRP) may be an effective treatment for osteoarthritis (OA). However, its efficacy in ankle OA has not been investigated yet. The purpose of this study was to assess the safety and efficacy of an intra-articular injection of PRP in patients with ankle OA during a 24-week period.
Methods: Twenty ankles of 20 patients with varus-type ankle OA who received intra-articular injections of PRP were evaluated. PRP was extracted from whole blood by using the double-spin technique. Three injections of 2-mL PRP were administered to the ankle at an interval of 2 weeks under ultrasonographic guidance. Adverse events and efficacy were assessed at 4, 12, and 24 weeks after the last injection. Clinical outcomes were assessed by using the visual analog scale (VAS) for pain, the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q)
Results: No serious adverse effects were observed during the follow-up period. The VAS and JSSF scale scores significantly decreased from baseline to 4, 12, and 24 weeks after treatment (P < .001). The mean score in the pain-related subscale of the SAFE-Q significantly improved from baseline to 12 weeks after treatment (P = .04). Overall, the amount of pain reduction was maximal at 12 weeks after the last injection, and the effect was reduced at 24 weeks. The patients with late-stage OA had worse scores in all outcomes than those with early-stage OA.
Conclusion: Intra-articular injections of PRP resulted in no serious adverse effects and significantly reduced pain in the patients with ankle OA. PRP treatment can be safe and effective and may be an option in the treatment of ankle OA.
Background: Platelet rich plasma (PRP) has been a breakthrough in the field of medicine especially in the field of orthopaedics for enhancing bone and soft tissue healing. Plantar Fasciitis is a very common problem in the field of orthopaedics and are very difficult to treat and a challenge to orthopaedicians. The aim of our study was to find out the efficacy of autologous PRP in relieving pain in patients with plantar fasciitis.
Methods: In this study, 25 patients with plantar fasciitis (age above 18 years) were selected. The pain intensity was assessed with visual analogue score initially and during follow up. All subjects were given single autologous intra-lesional PRP injection and the results were assessed using difference in VAS.
Results: The mean pain score at presentation was 8.08. The mean pain scores at subsequent intervals of 1,2,4,6 months after injection were 4.32, 2.60, 1.88 & 2.00 respectively. (P<0.05 which is statistically significant). The maximum pain relief was seen at 4th month post PRP injection and the pain relief was sustained till the last follow up.
Conclusions: From our study we have found that Intra-lesional autologous PRP is effective in relieving pain in patients with plantar fasciitis. PRP is biological and can be a safe adjuvant in the treatment of Plantar Fasciitis.
Evaluation of new concept of platelet-rich plasma periarticular injections for pain reduction in patients with temporomandibular joint dysfunctions: a pilot study
Background: A number of conservative methods are used in the treatment of temporomandibular joint (TMJ) dysfunction pain syndrome. Platelet-rich plasma (PRP) is a natural concentrate of autologous blood growth factor. Periarticular application of PRP and creating of oedema around the TMJ can be very simple approach for treating of TMJ pain instead of intraarticular application.
Objective: The symptoms of sacroiliac joint (SIJ) disorders are usually detected in the buttock and groin, and occasionally referred to the thigh and leg. However, lumbar disorders also cause symptoms in these same body regions. The presence of a characteristic, symptomatic pattern in the legs would be useful for diagnosing SIJ disorders. This study aimed to identify specific leg symptoms in patients with SIJ pain originating from the posterior sacroiliac ligament and determine the rate of occurrence of these symptoms.
Patients and Methods: The source population consisted of 365 consecutive patients from February 2005 to December 2007. One hundred patients were diagnosed with SIJ pain by a periarticular SIJ injection (42 males and 58 females, average age 46 years, age range, 18-75 years). A leg symptom map was made by subtracting the symptoms after a periarticular SIJ injection from the initial symptoms, and evaluating the rate of each individual symptom by area.
Results: Ninety-four patients reported pain at or around the posterior-superior iliac spine (PSIS). Leg symptoms comprised pain and a numbness/tingling sensation; ≥60% of the patients had these symptoms. Pain was mainly detected in the back, buttock, groin, and thigh areas, while numbness/tingling was mainly detected in the lateral to posterior thigh and back of the calf.
Conclusions: Leg symptoms associated with SIJ pain originating from the posterior sacroiliac ligament include both pain and numbness, which do not usually correspond to the dermatome. These leg symptoms in addition to pain around the PSIS may indicate SIJ disorders.
Role of Ultrasound Guided Platelet-Rich Plasma (PRP) Injection in Treatment of Lateral Epicondylitis
Background: Lateral epicondylitis is referred to a degenerative disorder that affects the common extensor tendon (CET) where it attaches to the lateral epicondyle of the humerus. Nowadays, one of minimally invasive interventions is platelet-rich plasma (PRP) injection that had been explored in some controlled clinical studies to show its effectiveness in treating lateral epicondylitis through inducing inflammation rather than suppressing it.
Objectives: The aim of our study was to investigate the effectiveness of ultrasound guided platelet-rich plasma (PRP) injection in treating chronic lateral epicondylitis in addition to identifying the potential sonographic morphological changes in the common extensor tendon (CET) after PRP injection.
Results: Statistical analysis showed high significant improvement in all ultrasound findings of common extensor tendon (CET) including echotexture, thickness, cross section, partial tear and calcification in majority of patients.
Conclusion: We concluded that US-guided platelet-rich plasma (PRP) injection for treatment of lateral epicondylitis was a safe, minimally invasive and effective procedure in improving the sonographic and pathological changes of common extensor tendon (CET).