Purpose
Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to ...systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied.
Methods
A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies.
Results
The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative).
Conclusion
Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders.
Level of evidence
Systematic review of level I–IV trials, Level IV.
Purpose The aim of our study is to compare the efficacy of platelet-rich plasma (PRP) and viscosupplementation (hyaluronic acid HA) intra-articular injections for the treatment of knee cartilage ...degenerative lesions and osteoarthritis (OA). Methods The study involved 150 patients affected by cartilage degenerative lesions and early and severe OA. Fifty symptomatic patients were treated with 3 autologous PRP intra-articular injections and were evaluated prospectively at enrollment and at 2- and 6-month follow-up. The results obtained were compared with 2 homogeneous groups of patients treated with HA injections. One group was treated with injections of high–molecular weight HA; the other group was treated with low–molecular weight (LW) HA. International Knee Documentation Committee and EQ VAS scores were used for clinical evaluation; adverse events and patient satisfaction were also recorded. Results At 2 months' follow-up, the PRP and LW HA groups showed a similar improvement, with higher results compared with the high–molecular weight HA group ( P < .005). At 6 months' follow-up, better results were observed in the PRP group ( P < .005). PRP and LW HA treatments offered similar results in patients aged over 50 years and in the treatment of advanced OA. PRP showed a better performance compared with HA in younger patients affected by cartilage lesions or early OA. Conclusions Autologous PRP injections showed more and longer efficacy than HA injections in reducing pain and symptoms and recovering articular function. Better results were achieved in younger and more active patients with a low degree of cartilage degeneration, whereas a worse outcome was obtained in more degenerated joints and in older patients, in whom results similar to those of viscosupplementation have been observed. Level of Evidence Level II, prospective comparative study.
Purpose The aim of this systematic review was to address the treatment of chondral and osteochondral knee lesions through the use of scaffolds, by showing surgical options and results of this ...scaffold-based repair approach for the healing of the articular surface. Methods All studies published in English addressing cartilage scaffold-based treatment were identified, including those that fulfilled the following criteria: (1) Levels I to IV evidence addressing the outlined areas of interest, (2) measures of functional or clinical outcome, (3) knee cartilage lesions, and (4) minimum of 2 years of follow-up. Results The analysis showed a progressively increasing number of articles per year from 1995 to February 2012. The number of selected articles was 51, with 40 focusing on 2-step procedures and 11 focusing on 1-step procedures. The evaluation of evidence level showed 3 randomized studies, 10 comparative studies, 33 case series, and 5 case reports. Conclusions Regenerative scaffold-based procedures are emerging as a therapeutic option for the treatment of chondral lesions, but well-designed studies are lacking. Systematic long-term evaluation of these techniques and randomized studies are necessary to confirm the potential of this treatment approach, especially compared with the available traditional treatments. Different 1-step scaffold-based strategies are emerging to simplify the procedure and reduce costs. Level of Evidence Level IV, systematic review of Level I to IV studies
Platelet rich plasma (PRP), a blood-derived product rich in growth factors, is a promising treatment for cartilage defects but there is still a lack of clinical evidence. The aim of this study is to ...show, through a randomized double blind prospective trial, the efficacy of this procedure, by comparing PRP to Hyaluronic Acid (HA) injections for the treatment of knee chondropathy or osteoarthritis (OA).
109 patients (55 treated with HA and 54 with PRP) were treated and evaluated at 12 months of follow-up. The patients were enrolled according to the following inclusion criteria: age > 18 years, history of chronic (at least 4 months) pain or swelling of the knee and imaging findings of degenerative changes of the joint (Kellgren-Lawrence Score up to 3). A cycle of 3 weekly injections was administered blindly. All patients were prospectively evaluated before and at 2, 6, and 12 months after the treatment by: IKDC, EQ-VAS, TEGNER, and KOOS scores. Range of motion and knee circumference changes were measured over time. Adverse events and patient satisfaction were also recorded.
Only minor adverse events were detected in some patients, such as mild pain and effusion after the injections, in particular in the PRP group, where a significantly higher post-injective pain reaction was observed (p=0.039). At the follow-up evaluations, both groups presented a clinical improvement but the comparison between the two groups showed a not statistically significant difference in all scores evaluated. A trend favorable for the PRP group was only found in patients with low grade articular degeneration (Kellgren-Lawrence score up to 2).
Results suggest that PRP injections offer a significant clinical improvement up to one year of follow-up. However, conversely to what was shown by the current literature, for middle-aged patients with moderate signs of OA, PRP results were not better than those obtained with HA injections, and thus it should not be considered as first line treatment. More promising results are shown for its use in low grade degeneration, but they still have to be confirmed.
Purpose Regenerative scaffold-based procedures are emerging as a potential therapeutic option for the treatment of chondral and osteochondral lesions. In general, we can summarize most of the recent ...developments to reach clinical application into 2 major trends: the use of different cell sources or the application of biomaterials as a cell-free approach. The aim of this systematic review was to analyze both preclinical and clinical studies on these new trends to understand how the available evidence supports the use of cell sources or justifies the cell-free approach for the scaffold-based treatment of cartilage lesions. Methods The research was performed using the PubMed database by looking at studies published in the English language referring to chondral or osteochondral defect repair with scaffold-based procedures until the end of 2013. The following strings were used: (“cartilage”MeSH AND “tissue scaffolds”MeSH). Results The search showed an increasing number of published articles each year for both scaffold-based approaches, identifying a total of 305 articles. Among clinical trials, 116 used cell-based scaffold treatments and 11 used scaffolds alone. In the preclinical setting, a scaffold/cell combination was the most used treatment approach (133 v 45 articles), with mesenchymal stem cells (MSCs) being the favorite cell type. Bone marrow was the most used cell source, but other sources are gaining interest. Among articles comparing scaffolds with or without cells, the majority reported superior results for cells (71 of 89 articles). In the clinical setting, most of the articles analyzed chondrocyte-based scaffolds, with only 7 studies using MSCs; all cells were from bone marrow. Despite the lower number of articles, cell-free scaffolds are gaining popularity, with a recent increase in published studies showing promising results. Conclusions This systematic review underlined the difficulties in understanding the real need for cells to increase the scaffold-based cartilage healing potential because of the heterogeneity of products used as well as the design of the published studies. Scaffold and cell combinations were the most investigated option in the preclinical setting, showing generally superior results, but in the clinical setting, both strategies remain used. In particular, although chondrocytes are the most commonly used cell type, research showed increasing interest in the potential of MSCs for cartilage regeneration. However, the difficulties in managing cell cultures, together with the development of a new generation of materials able to exploit the intrinsic tissue regeneration ability, justifies the clinical use of cell-free scaffolds, with increasing literature and promising preliminary results. Level of Evidence Level IV, systematic review of Level I to IV studies.
Abstract Cartilage injuries have a high incidence and a high impact on society. In an attempt to fulfill patients' expectations and successfully treat this pathology, various techniques have been ...developed over the years. Treatments proposed for cartilage lesions are described with their rationale and indications, ranging from conservative measures to surgical approaches, reparative or regenerative. Among the numerous and heterogeneous procedures proposed over time to treat cartilage defects none has clearly proven to lead to a hyaline articular surface nor to offer better clinical results. Regenerative procedures have been introduced as ambitious techniques that aim to overcome the limitations of the more traditional reparative approaches and restore the articular surface with a hyaline-like tissue; improvement in tissue engineering with new scaffolds as well as new regenerative options involving growth factors or MSCs are currently being investigated as promising solutions to further improve the treatment of cartilage lesions. However, the current literature findings are not conclusive. Randomized controlled trials are necessary to evaluate new regenerative approaches, to show clearly advantages and disadvantages with respect to the more traditional procedures, besides their potential, limits, and indications to improve the treatment of patients affected by chondral and osteochondral lesions. Since clear and commonly accepted treatment algorithms are not available in the literature, the massively increasing number of controversial results may be confusing for the orthopaedic surgeon who has to choose the proper management of patients with cartilage lesions. Thus, the results obtained through the study of the authors' 20 years' experience in cartilage treatment were analyzed to give some indications on the potential and limits of different treatment approaches available in clinical practice.
Background:
Meniscal allograft transplant (MAT) is an effective treatment for relieving symptoms and improving knee function in patients who experience symptomatic unicompartmental knee pain after a ...previous meniscectomy. However, the literature contains a paucity of studies assessing the survival rate and prognostic factors of soft tissue MAT.
Purpose:
To report the survivorship of a large, single-center cohort of consecutive patients treated with arthroscopic MAT using soft tissue technique and to investigate variables that could potentially influence failures and outcomes.
Study design:
Case series; Level of evidence, 4.
Methods:
Consecutive MAT procedures totaling 364 performed in a single institution between June 2004 and April 2019 were screened and assessed for eligibility. Subjective clinical scores (Lysholm score, Tegner activity scale, and visual analog score) were collected preoperatively and at 2, 5, 7, and 10 years of follow-up. Two survival analyses were performed using Kaplan-Meier curves, with surgical failure (defined as any graft revision) and clinical failure (defined as a Lysholm score <65 points) used as endpoints. Univariate analyses were performed using reoperations, surgical failure, clinical failure, and different demographic and surgical characteristics as endpoints.
Results:
A total of 324 consecutive patients were evaluated at a mean follow-up 5.7 ± 3.0 years. Of these, 189 (58%) underwent an associated surgical procedure. A total of 22 patients (6.8%) were considered to have experienced surgical failure, and no predictors of surgical failure were identified based on the relevant variables. When all patients were considered, a significant improvement in all of the patient-reported outcome measures was present between the preoperative assessment and the last follow-up (P < .001), with no significant decrease over time. Moreover, 70 (21.6%) patients were considered to have experienced clinical failure; the need for concurrent cartilage procedures (odds ratio, 0.16; P = .001) and anterior cruciate ligament (ACL) reconstruction (odds ratio, 0.40; P = .059) were predictors of failure. Finally, a lower survival rate was reported in female patients compared with male patients (49% vs 69%, respectively; P = .007) and in patients who required cartilage surgery (P = .014). In particular, patients who required cartilage surgery showed nearly half the survival rate compared with those with required no cartilage procedures at 10-year follow-up (36.4% vs 71%, respectively; P = .029).
Conclusion:
Female sex and the need to combine MAT with a cartilage procedure or ACL reconstruction could result in an increased rate of clinical failure at midterm follow-up.
Background:
Long-term patient-reported outcome measures (PROMs) and predictors of success or failure after anterior cruciate ligament (ACL) reconstruction are not fully understood, especially when ...combined with a lateral extra-articular reconstruction.
Purpose:
To assess the long-term PROMs, revision rate, and predictors of success or failure after ACL reconstructions using an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular reconstruction.
Study Design:
Case series; Level of evidence, 4.
Methods:
The study cohort consisted of 267 consecutive patients (mean age, 30.7 years) who underwent ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular augmentation between November 2007 and May 2009. The number of subsequent ACL revisions and reoperations were recorded. Subjective clinical status was assessed with PROMs—specifically, the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and visual analog scale for pain—at a minimum follow-up of 10 years.
Results:
Overall, 3% of patients underwent ACL revision, with a 10-year survival rate of 96.3%. High sport activity (hazard ratio, 6.9; P = .285) and concomitant meniscal lesion (hazard ratio, 2.6; P = .0487) were predictors of ACL revision or new meniscectomy. The mean ± SD Lysholm score was 94.1 ± 10.8, while that for the visual analog scale for pain was 0.2 ± 0.9 at rest and 2.1 ± 2.6 during activity. KOOS subscale scores were as follows: 95.7 ± 8.1 for Pain, 92.5 ± 10.5 for Symptoms, 98.4 ± 7.4 for Activities of Daily Living, 90.7 ± 17.2 for Sport, and 91.2 ± 17.1 for Quality of Life; respectively, 88%, 99%, 81%, 89%, and 91% of patients achieved the Patient Acceptable Symptom State. Female sex and chondropathy with Outerbridge grade ≥2 were predictors of worse KOOS subscales. Overall, 82% of patients returned to sport, and 57% were still participating at the 10-year evaluation.
Conclusion:
ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring autografts and a lateral extra-articular reconstruction provided satisfactory results in terms of function, symptoms, sports, and quality of life in 80% to 90% of patients after 10 years. Long-term survivorship was 96%. Sport participation declined from 82% postoperatively to 57% at long-term follow-up. A concomitant medial meniscal lesion was a predictor of higher risk of ACL failure or new meniscal lesion, while advanced chondropathy and female sex were predictors of higher pain, lower function, and poor quality of life scores.
Background:
Meniscal allograft transplant (MAT) is considered an effective procedure for reducing pain and improving knee function. Nevertheless, the current knowledge regarding the results of MAT is ...limited to short- to mid-term follow-up studies, especially for arthroscopic techniques.
Purpose:
To evaluate the long-term clinical outcomes, reoperations, and failures with a minimum follow-up of 10 years after fresh-frozen MAT performed arthroscopically with soft tissue fixation.
Study Design:
Case series; Level of evidence, 4.
Methods:
A total of 46 patients (age, 36.6 ± 10.6 years; 36 male, 10 female) who underwent medial MAT (n = 27) or lateral MAT (n = 19) with a minimum 10-year follow-up were evaluated with the Lysholm score, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale for pain, and Tegner score. Surgical failure was defined as the need for partial or total graft removal (meniscectomy or knee replacement), and clinical failure was defined as the need for partial or total graft removal in addition to a poor Lysholm score (<65 points) at final follow-up. Survival analysis was performed with Kaplan-Meier curve, and clinical scores were analyzed based on the Patient Acceptable Symptom State (PASS) for MAT.
Results:
10-year survival and clinical data were available for 38 patients. Because 6 meniscectomies were required, the rate of survival free from surgical failure was 91% at 5 years and 86% at 10 years. Lower survival was reported in lateral MAT (73%) compared with medial MAT (96%). Because a further 4 patients had poor Lysholm scores, the rate of survival free from surgical and clinical failure was 87% at 5 years and 70% at 10 years. The average Lysholm score at final follow-up was 82 ± 20, and 60% to 82% of patients achieved PASS of the various KOOS subscales. The Tegner score and the KOOS Sport score significantly decreased from mid-term to long-term evaluation (P < .001 and P < .05, respectively). Other KOOS subscales and the Lysholm score remained stable at long-term evaluation. No significant differences were found between isolated MAT or combined MAT regarding subjective scores, surgical failures, or clinical failures.
Conclusion:
Up to 10 years after surgery, 86% of fresh-frozen MATs with soft tissue fixation were still in situ, and satisfactory clinical results were present for about 70% of patients. Decline of clinical outcomes from midterm to long term was noted only in sports-related scores. A higher number of overall reoperations was noted in female patients, whereas a higher risk of failure was present in the patients with lateral MAT.
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