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.

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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.

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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.

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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.

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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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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.