Biologic Orthopedics Journal

Regenerative Rehabilitation for Lateral Epicondylalgia

2022-08-03T23:12:46+00:00

Lateral epicondylalgia (LE) is a common condition of the elbow that causes significant pain and disability resulting in economic burden and loss of function. Causes of LE include overuse leading to local tendinopathy, neuropathic mechanisms, and impairments in regions proximal and distal to the elbow such as the wrist, cervical spine, and shoulder girdle. Physical therapy and other forms of conservative rehabilitation are often utilized successfully and include interventions such as exercise, joint, and soft tissue manipulation, and various modalities such as ultrasound and extracorporeal shockwave therapy. However, despite the reported benefits of exercise and other rehabilitative interventions, most research regarding treatment efficacy has focused on functional outcomes without understanding the cellular and molecular effects. Moreover, inconsistencies in the literature remain regarding best-practice management for LE. Nevertheless, recent investigations have provided insight into the corrective processes that may occur with commonly employed rehabilitative procedures. This article will give an overview of the pathophysiological process associated with LE followed by a detailed discussion of the current understanding of the cellular and molecular mechanisms that may occur with conservative rehabilitation. The purpose of this paper is to present the current evidence regarding conservative rehabilitation to exemplify how these interventions may serve as an adjunct to biological therapies.

Extracorporeal Shockwave Treatment for Low Back Pain

2022-08-23T20:08:33+00:00

Low back pain is a common symptom in patients with chronic musculoskeletal conditions, affecting several individuals. In most cases, low back pain can often prove to be nonspecific or even multifactorial. Current treatment approach is based on surgical and noninvasive interventions, including pharmacological, psychological, physiotherapeutic, or complementary strategies. Extracorporeal shock wave therapy (ESWT) is a type of noninvasive mechanotherapy that has become popular in recent years due to its applicability in the treatment of various musculoskeletal disorders, especially in the lumbar spine of individuals with osteopo-rosis, sacroiliitis, and even spinal cord disorders. The objective of this manuscript is to review the scientific evidence supporting the application of this therapy in the management of low back pain, and give a brief description of the treatment techniques used in clinical settings. The articles included in this descriptive review were selected from databases using the Google Scholar tool, from which a total of 13 applicable studies matching the topic were included. Despite the need for more clinical trials, shock waves have been applied in medical health for many years with satisfactory results. Its application in the treatment of lumbar spine disorders has been shown to be advantageous in the management of pathological progression, such as the natural wear and tear process of musculoskeletal structures. In this sense, shockwave therapy may represent a viable alternative for the treatment of lumbar spine disorders; however, its therapeutic effects and
mechanisms require further elucidation.

The Utility of Photobiomodulation as a Supplement to Orthobiologic Interventions

2022-11-09T18:53:09+00:00

Several mechanisms may influence recovery and act as a complementary intervention to regenerative medicine. One area of consideration that may improve clinical outcomes in patients receiving regenerative medicine treatments is the utilization of supplementary interventions referred to as regenerative rehabilitation. One such intervention may be the use of light therapy also known as photobiomodulation (PBM). Terms synonymous with PBM include low-level light therapy (LLLT), low-power laser irradiation or cold laser. As a musculoskeletal intervention, PBM is administered via a mechanism that creates light through optical amplification. These interventions describe a form of PBM or light therapy that uses specific param-eters to target tissues through direct or indirect contact with or without heat or structural tissue alterations. PBM may improve treatment outcomes based on synergistic effects that are thought to modulate inflammation and facilitate cellular repair. This manuscript provides an overview of the current evidence supporting the use of PBM as a complementary intervention to regenerative medicine with a focus on managing conditions related to the musculoskeletal system.

The Effects of Platelet-Rich Plasma in Conjunction with Rehabilitation for Lower Extremity Musculoskeletal Pathologies

2022-06-12T15:00:57+00:00

Background: Platelet-rich plasma (PRP) has been considered for its role in facilitating the body’s own healing processes, with the potential to complement rehabilitation in the management of lower extremity
musculoskeletal pathologies.
Methods: Eligible studies were randomized clinical trials and quasi-experimental trials with completed data analysis; published in English; recruited participants aged >18 years; had at least two groups, with one intervention group receiving PRP injection alone or PRP injection and rehabilitation, and the comparison group receiving either rehabilitation alone or a control group receiving saline and rehabilitation; included at least one outcome measure of pain, disability, quality of life, or return to play. An electronic search was conducted using PubMed, Embase, Cochrane, Pedro, and clinicaltrials.gov. Methodological quality was assessed using the Cochrane Collaboration Risk of Bias (RoB) tool. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the quality of evidence. Meta-analyses were conducted across outcomes in each pathology when possible.
Results: Twenty-one studies assessed Achilles rupture, Achilles tendinopathy, lateral ankle sprain, high ankle sprain, hamstring injury, knee osteoarthritis, acute muscle injury, patellar tendinopathy, and plantar fasciitis, with an average RoB score of 9.9 out of 12. Meta-analyses for Achilles rupture (n = 270) revealed a nonsignificant effect on disability in the short and long term (high level of evidence) when comparing PRP, immobilization, and exercise/physical therapy to placebo, immobilization, and exercise/physical therapy. Meta-analyses for Achilles tendinopathy revealed a nonsignificant effect on pain (n = 64) in the short term, and disability in the short (n = 138) as well as long term (n = 192) (very low to low level of evidence) when comparing PRP and exercise to placebo and exercise.
Conclusions: While individual studies demonstrated significant findings across outcomes, the non-significant pooled results and inability to perform further meta-analyses made it difficult to provide definitive recommendations for the addition of PRP to exercise for lower extremity musculoskeletal pathologies. Future studies should standardized PRP exercise rehabilitation protocols with better dosage parameters, consider larger sample sizes, and have short and long term follow-up periods consistent with the Cochrane Collaboration.

Platelet-Rich Plasma and Rehabilitation for Upper Extremity Musculoskeletal Pathologies

2022-05-27T01:33:12+00:00

Background: Platelet-rich plasma (PRP) is considered in clinical practice for its role in facilitating the body’s own healing processes, with the potential to complement physical therapy in managing musculoskeletal pathologies of the upper extremity.

Methods: Eligible studies must be randomized with clinical/quasi-experimental trials with complete data analysis, and published in English. They have to recruit participants aged >18 years; have at least two groups, with one intervention group receiving PRP injection alone or PRP injection and rehabilitation, and the comparison group receiving either rehabilitation alone or a control group receiving saline and rehabilitation; and finally include at least one outcome measure of pain, disability, or quality of life. An electronic search was conducted using PubMed, Embase, Cochrane, Pedro, and clinicaltrials.gov. Methodological quality was assessed using the Cochrane Collaboration Risk of Bias (RoB) tool. The grading of recommendations assessment, development, and evaluation approach was used to provide an overall assessment of the quality of evidence. Meta-analyses were conducted across outcomes within each pathology when possible.

Results: A total of 13 studies assessing adhesive capsulitis, carpal tunnel syndrome, lateral epicondylal-gia, rotator cuff tendinopathy, subacromial impingement syndrome, and shoulder osteoarthritis were included with an average RoB score of 8.77 out of 12 across all studies. Meta-analyses for rotator cuff tendinopathy (n = 49) revealed a significant effect on pain (cm) (mean difference [MD] -2.53; 95% confidence interval [CI]: −5.02, −0.04; I2 statistic = 51%; P = 0.05), quality of life (MD 16.82; 95% CI: 0.40, 33.25; I2 = 0%; P = 0.04), and disability (standardized mean difference [SMD]: −0.64; 95% CI: −1.24, −0.04; I2 = 0%; P = 0.04) favoring PRP and physical therapy as long-term follow-up (moderate level of evidence). All other meta-analyses for adhesive capsulitis and carpal tunnel demonstrated nonsignificant effects.

Conclusions: This systematic review demonstrated that PRP is a beneficial adjunct to physical therapy for reducing pain and improving disability and quality of life (moderate level of evidence) when compared to placebo plus physical therapy for the management of rotator cuff tendinopathy.

Ultrasound-Guided Posterior Iliac Crest Aspiration

2021-09-13T10:30:43+00:00

Background: Bone Marrow Aspirate (BMA) contains growth factors and signaling entities essential for local cellular repair. BMA and concentrated BMA injections (BMC) are used for orthopedic procedures, such as in treating cartilaginous and bony defects. Several techniques exist for harvesting BMA. A technique termed ultrasound-guided posterior iliac crest aspiration (UPICA) is of special interest. This case series was
undertaken to determine if practitioners can effectively perform the UPICA technique in a clinical setting.

Methods: In accordance with the UPICA technique, ultrasound guidance was used to localize the posterior iliac crest. Following local anesthesia, aspiration was performed using 10 mL syringes at multiple depths. The periosteum was entered once. A needle was advanced 0.5 cm with each new depth. At each penetration level, 10 mL was drawn before rotating 90 degrees and aspirating an additional 10 mL. Following aspiration at various depths, approximately 60 mL of BMA was obtained. The inclusion criteria for this study were patients with diagnosed glenohumeral osteoarthritis, knee osteoarthritis, hip osteoarthritis, or rotator cuff tears whose condition had failed to improve with conservative care. The UPICA technique was performed in each case by the senior author (BG).

Results: For the 10 cases, the average patient age was 72 (SD 7.6; range 58–81) years old. The sample included 8 males and 2 females. The mean total nucleated cell count (TNCC)/mL BMA was 9.7E+06 (SD 2.9E+06), while the TNCC/mL bone marrow concentrate (BMC) was 43.9E+06 (SD 29.5E+06), a 4.3 (SD 2.3)-fold increase in concentration. The mean cell colony forming units-fibroblasts (CFU-f)/mL BMA was 520 (SD 155) with a mean CFU-f/mL BMC of 4899 (SD 2887) resulting in a 9.6 (SD 4.6)-fold increase in concentration. The viability for the BMA was 97.5 (SD 2.3) %, and the BMC was 94.9 (SD 4.55) %.

Conclusions: Utilizing the UPICA technique, similar yields for the BMC CFU-f/mL counts were obtained to those reported previously by other clinicians. Additionally, the results demonstrated the ability of the bone marrow concentration system to successfully concentrate the BMA. Based on these findings, the research team endorses the UPICA technique as a viable method for bone marrow aspiration.

The Effect of Combined Bone Marrow Aspirate, Lipoaspirate, and Platelet-Rich Plasma Injections on Pain, Function, and Perceived Change Amongst Individuals with Glenohumeral Osteoarthritis

2022-08-02T13:55:27+00:00

Purpose: This study was conducted to investigate the efficacy of a combined minimally processed bone marrow aspirate (BMA), adipose graft, and leukocyte-rich platelet-rich plasma (PRP) intra-articular injection series on pain, function, and global rating of change (GROC) among patients with glenohumeral osteoarthritis (GHOA) and record any complications or adverse events associated with the protocol.

Methods: Ten adults (mean age 65 years) previously recalcitrant to conservative care with clinical and radiographic evidence of GHOA were included. At the initial visit, patients were assessed for eligibility of treatment. All patients were assessed pre- and post-treatment with numerical pain rating and patient-specific functional scales (PSFS). All study participants were treated with 4–6 ml of PRP, 6 ml adipose graft, and 12 ml of BMA, which were administered via a landmark-based anterior intra-articular injection. Patients were requested to return twice over 4-week intervals for booster PRP injections. At each follow-up, the GROC and prior outcome measures were completed.

Results: Patients returned after an average of 27 days for first (F1) and 68 days for the second (F2) PRP injection. Friedman Chi Square analysis indicated significant improvements in best and worse pain and PSFS from baseline initial visit to F1 and F2 (P ≤ .002). Post-hoc Wilcoxon signed-rank testing with Bonferroni correction (α = 0.017) identified significant improvements from baseline to F1 and F2 for the PSFS (P ≤ 0.012). Improvements in best and worse pain were significant at F2 (P ≤ 0.016), not F1 (P ≥ 0.02), compared to baseline. Effect sizes were large, ranging from r = 0.57 to 0.84 for pain and function. Improvements in pain, GROC, and PSFS met minimum clinically important differences at F2 based on previously validated clinimetrics. The only adverse events reported are related to administration of injectate that was temporary and managed in all cases with over-the-counter analgesics.

Conclusion: A minimally processed adipose graft with BMA and three PRP injections improved pain and function among individuals with GHOA who were recalcitrant to conservative care. Although significant functional improvement at both follow-up points occurred, clinically important and significant changes in pain did not occur until F2. A one-group design and multimodal approach limit generalization of results.

Level of Evidence: IV

Optimal Injection Volume in Treatment of Tendinopathy

2022-07-07T05:48:50+00:00

Background: Tendinopathy, a pathology of tendons characterized by inflammation and or degeneration, is a prevalent cause of disease and disability in active and working patients. Within the past decade, orthobiologic injections such as Platelet Rich Plasma (PRP) have become increasingly popular within the musculoskeletal physician’s practice for treatment of chronic tendinopathies. However, there is a lack of standardization of PRP preparation and injection protocols, leading to gaps in our knowledge regarding the optimal administration dosages to maximize treatment efficacy.

Purpose: This review aims to compile and evaluate the existing data for PRP injection volumes for various tendinopathies in hopes of contributing to standardization of PRP protocols, with a further goal of minimiz-ing waste of a costly therapeutic.

Study Design: Systematic Review

Methods: In June 2020, comprehensive electronic database searches were conducted by a medical librarian in Medline via PubMed, EMBASE (embase.com), CINAHL (EbscoHost), CENTRAL and Scopus according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data was extracted from studies meeting inclusion criteria on injection volumes and outcomes and grouped based on anatomic injection location.

Results: Twenty-eight studies were identified for inclusion in which ultrasound-guided intra-tendinous PRP injections were administered to patients to treat various tendinopathies. For all tendon locations, the mini-mum volume of injectate reported achieved positive clinical outcomes in patients compared to baseline. Conclusions: Despite its many benefits—tendon healing, pain relief, increased function—PRP can pose a significant financial burden to patients, with patients often having to pay for the full cost out-of-pocket due to lack of insurance coverage. This study provides evidence that PRP can be effective at smaller volumes, minimizing waste and the out-of-pocket cost to the patient. In addition, this study further stresses the impor-tance of protocol standardization.

Clinical Relevance: Though more data is needed, it is apparent that the minimum amount of injectate used clinically for various anatomic locations is enough for overall positive outcomes, and therefore can be the recommended dose given. As such, the authors have incorporated the minimum injection volume into their practice using the following volumes: Rotator Cuff-1 mL, Lateral or Medial Epicondyle-1.5 mL, Gluteal or Hamstring-3 mL, Patella-2 mL, Achilles-3 mL. Unfortunately, without more data available in the literature, the authors cannot make stronger recommendations at this time.

What is known about the subject: Among intralesional injections for the treatment of tendinopathy, PRP has shown positive results in multiple trials and has made its way into many musculoskeletal physicians’ practice. However, there is a significant lack of standardization in PRP protocols.

What this study adds to existing knowledge: While other reviews have highlighted the discrepancies amongst PRP protocols, our review is the first to examine injection volume and its effect on outcomes. We were able to suggest a minimum injectate amount for positive outcomes, either pain relief or improvement in the tendon appearance on imaging.

Is Discontinuation of Oral Anticoagulation Therapy Necessary for Orthobiologic Interventions?

2022-05-24T12:39:34+00:00

N/A viewpoint submission