Meta-analysis of Viscosupplementation for Knee Osteoarthritis Reveals Little Benefit

In the study outlined below, handling alongside viscosupplementation (typically diverse forms of hyaluronic acid) was studied inward over 12,500 patients.  This is an injection therapy used inward patients alongside articulatio genus osteoarthritis.  It is commonly reserved for patients that neglect other forms of treatment.  Here is the determination of this study of studies:  "In patients alongside articulatio genus osteoarthritis, viscosupplementation is associated alongside a modest as well as clinically irrelevant create goodness as well as an increased run a jeopardy for serious adverse events."

Clearly, the information shows this handling does non render transformative value.  We withdraw ameliorate options for patients alongside mild to moderate articulatio genus osteoarthritis.  Biologic therapies such every bit platelet rich plasma and autologous stalk cells are evolving only nonetheless withdraw significantly ameliorate studies to endure used for articulatio genus osteoarthritis widely.  

It is oft NOT discussed only patients alongside articulatio genus osteoarthritis tin hand the axe oft create goodness from weight reduction as well as leg strengthening via an practice wheel program.  Perhaps nosotros should focus on these patient driven solutions first.

AM

Total Tendon

Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review as well as Meta-analysis 

Anne W.S. Rutjes, PhD; Peter Jüni, MD; Bruno R. da Costa, MSc; Sven Trelle, MD; Eveline Nüesch, PhD; as well as Stephan Reichenbach, MD, MScBackground: Viscosupplementation, the intra-articular injection of hyaluronic acid, is widely used for symptomatic articulatio genus osteoarthritis.

Purpose: To assess the benefits as well as risks of viscosupplementation for adults alongside symptomatic articulatio genus osteoarthritis.

Data Sources: MEDLINE (1966 to Jan 2012), EMBASE (1980 to Jan 2012), the Cochrane Central Register of Controlled Trials (1970 to Jan 2012), as well as other sources.

Study Selection: Randomized trials inward whatsoever linguistic communication that compared viscosupplementation alongside sham or nonintervention command inward adults alongside articulatio genus osteoarthritis.

Data Extraction: Primary outcomes were hurting intensity as well as flare-ups. Secondary outcomes included share as well as serious adverse events. Reviewers used duplicate abstractions, assessed study quality, pooled information using a random-effects model, examined funnel plots, as well as explored heterogeneity using meta-regression.

Data Synthesis: Eighty-nine trials involving 12 667 adults met inclusion criteria. Sixty-eight had a sham control, forty had a follow-up duration greater than iii months, as well as 22 used cross-linked forms of hyaluronic acid. Overall, 71 trials (9617 patients) showed that viscosupplementation moderately reduced hurting (effect size, −0.37 [95% CI, −0.46 to −0.28]). There was of import between-trial heterogeneity as well as an asymmetrical funnel plot: Trial size, blinded outcome assessment, as well as publication condition were associated alongside final result size. Five unpublished trials (1149 patients) showed an final result size of −0.03 (CI, −0.14 to 0.09). Eighteen large trials alongside blinded outcome assessment (5094 patients) showed a clinically irrelevant final result size of −0.11 (CI, −0.18 to −0.04). Six trials (811 patients) showed that viscosupplementation increased, although non statistically significantly, the run a jeopardy for flare-ups (relative risk, 1.51 [CI, 0.84 to 2.72]). Fourteen trials (3667 patients) showed that viscosupplementation increased the run a jeopardy for serious adverse events (relative risk, 1.41 [CI, 1.02 to 1.97]).

Limitations: Trial lineament was to a greater extent than oft than non low. Safety information were oft non reported.

Conclusion: In patients alongside articulatio genus osteoarthritis, viscosupplementation is associated alongside a modest as well as clinically irrelevant create goodness as well as an increased run a jeopardy for serious adverse events.

Link to Abstract

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Steroid Injections may Deplete Tendon Stem Cell Pools

Steroid injections are normally used for a number of musculoskeletal conditions.  There is increasing bear witness to advise this is non a expert consider particularly for tendon related problems such equally lawn tennis elbow or rotator cuff tendinopathy.  Clinical studies exclusively confirm brusque term hurting relief for cortisone injections.  Basic scientific discipline studies are straight off revealing that such injections may deplete tendon stems cells pools or increase the ask a opportunity of tendon rupture.  (See Abstract Below)

Platelet rich plasma has been shown to hold out superior to cortisone injection inwards a double blind randomized case at to the lowest degree for lawn tennis elbow.  When discussing the value of evolving biologic therapies it is crucial to compare them to normally used treatments.  In the illustration of cortisone for tendon related injuries as well as disorders at to the lowest degree for straight off PRP is the superior alternative based on basic scientific discipline as well as clinical publications for lawn tennis elbow.  (Gosens et al Study)

Allan Mishra, MD

@Bloodcure
TotalTendon

J Orthop Res. 2012 Aug 8. 

The effects of dexamethasone on human patellar tendon stalk cells: Implications for dexamethasone handling of tendon injury.

Zhang J, Keenan C, Wang JH.

Source

Abstract

Injection of Dexamethasone (Dex) is normally used inwards clinics to process tendon injury such as tendinopathy because of its anti-inflammatory capabilities. However, serious adverse effects accept been reported equally a final result of Dex treatment, such equally impaired tendon healing as well as tendon rupture...... Dex handling depletes the stalk jail cellular telephone puddle as well as leads to the formation of non-tendinous tissues (e.g., obese as well as cartilage-like tissues), which brand tendon susceptible to rupture. 

© 2012 Orthopaedic Research Society. Published past times Wiley Periodicals, Inc. 

Copyright © 2012 Orthopaedic Research Society.

See Full Abstract

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Platelet Rich Plasma Significantly Improves Outcomes for Tennis Elbow inward a 230 Patient Study

The American Journal of Sports Medicine (AJSM) has merely published the largest study evaluating platelet-rich plasma.  The 230 patient study was conducted over the course of education of to a greater extent than than 5 years together with represents the locomote of dozens of clinicians together with researchers.  Overall, it is clear from the information that the purpose of PRP to process chronic lawn tennis elbow results inward important reductions inward hurting together with elbow tenderness compared to an active command of needling of the elbow without PRP.  It is every bit good security together with toll effective compared to cortisone together with surgery.  This type of study is fourth dimension consuming together with expensive but volition assistance guide patient together with physicians decisions nearly how to best process chronic lawn tennis elbow.

Here is a lay press article on the article from Healio.

Read the total AJSM Abstract below.

AM
Total Tendon


Platelet-Rich Plasma Significantly Improves Clinical Outcomes inward Patients With Chronic Tennis Elbow
A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients

1. Allan K. Mishra, MD*,†, 
2. Nebojsa V. Skrepnik, MD, PhD‡,
3. Scott G. Edwards, MD§, 
4. Grant L. Jones, MD‖, 
5. Steven Sampson, DO¶,
6. Doug A. Vermillion, MD#, 
7. Matthew L. Ramsey, MD**, 
8. David C. Karli, MD, MBA†† and 
9. Arthur C. Rettig, MD‡‡

1. ^†Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California
2. ^‡Tucson Orthopaedic Institute, Tucson, Arizona
3. ^§Division of Hand together with Elbow Surgery, Georgetown University Hospital, Washington, District of Columbia
4. ^‖Department of Orthopaedic Surgery, The Ohio State University, Columbus, Ohio
5. ^¶The Orthohealing Center together with The Orthobiologic Institute, Los Angeles, California
6. ^#Orthopaedic Research Clinic, Anchorage, Alaska
7. ^**Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
8. ^††The Steadman Clinic, Vail, Colorado
9. ^‡‡Methodist Sports Medicine, Indianapolis, Indiana
10. Investigation performed at Department of Orthopaedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California

1. *Allan K. Mishra, MD, Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, 1300 Crane Street, Menlo Park, CA 94025 (e-mail: am@totaltendon.com).

Abstract

Background: Elbow tenderness together with hurting amongst resisted wrist extension are mutual manifestations of lateral epicondylar tendinopathy, every bit good known every bit lawn tennis elbow. Previous studies bring suggested platelet-rich plasma (PRP) to live a security together with effective therapy for lawn tennis elbow.

Purpose: To evaluate the clinical value of tendon needling amongst PRP inward patients amongst chronic lawn tennis elbow compared amongst an active command group.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: A total of 230 patients amongst chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at to the lowest degree three months of symptoms together with had failed conventional therapy. There were no differences inward patients randomized to have PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the quest of attention together with contained both concentrated platelets together with leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled amongst or without PRP. Patients together with investigators remained blinded to the handling grouping throughout the study.

Results: Patient outcomes were followed for upwards to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% inward their hurting scores compared amongst 47.4% inward the active command grouping (P = .094). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% inward their hurting scores compared amongst 56.1% inward the command grouping (P = .027). The percent of patients reporting important elbow tenderness at 12 weeks was 37.4% inward the PRP grouping versus 48.4% inward the command grouping (P = .036). At 24 weeks, 29.1% of the PRP-treated patients reported important elbow tenderness versus 54.0% inward the command grouping (P < .001). Success rates for patients amongst 24 weeks of follow-up were 83.9% inward the PRP grouping compared amongst 68.3% inward the command grouping (P= .012). No important complications occurred inward either group.

Conclusion: Treatment of chronic lawn tennis elbow amongst leukocyte-enriched PRP is security together with results inward clinically meaningful improvements compared amongst an active command group.

The Biomet Biologics GPS device was used to produce the PRP for this study.

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Why patients are seeking out platelet rich plasma too other biologic treatments.

Platelet rich plasma (PRP) as well as adult stalk prison theater mobile telephone treatments derived from os marrow are rapidly evolving into the mainstream of medicine.  As you lot tin run into from the nautical chart above, the expose of hits for "platelet rich plasma" is ascent dramatically.  There are likewise over 7400 PRP references on PubMed.org.  Let's explore why.

Patients are seeking out less invasive treatments.  When presented alongside the selection of surgical physical care for or an business office procedure, patients typically volition select the business office procedure.  Surgery ofttimes carries important to a greater extent than run a hazard as well as sure as shooting to a greater extent than cost.

Patients desire to render to sports, move or life equally apace equally possible.
Botox as well as Lasik eye surgical physical care for render patients alongside almost immediate improvement for wrinkles as well as vision.  Patients forthwith facial expression other specialities to deliver similar almost instantaneous success.   Elite athletes are especially interested inwards returning to the highest degree of component equally apace equally possible.  They cause got been 1 of the primary drivers of PRP as well as other biologic treatments.

Patients are dissatisfied alongside the surgical treatments nosotros cause got been offering them.
This is peculiarly truthful when it comes to genu arthritis.  Presently, at that spot is rattling lilliputian definitive evidence supporting the purpose of many mutual treatments as well as at that spot is a Grand Canyon size hole inwards our mightiness to effectively care tens of millions of patients.  Biologic therapies volition probable create sum this void inside the side yesteryear side v years.

Patients intuitively sympathise the regenerative abilities of your ain blood as well as os marrow.  Evidence is mounting across a several specialties supporting the purpose of blood as well as os marrow to care for a multifariousness of conditions.  A novel written report volition commence this autumn evaluating the utility of giving Alzheimer's patients blood transfusions from salubrious volunteers nether 30.  (Stanford Blood-Alzheimer's study)

Patients are willing to live on treated without perfect supporting data.

Patients create non ofttimes sympathise the require for large clinical trials as well as are impatient alongside the fourth dimension as well as endeavour it takes to generate meaningful clinical data.  The purpose of their ain blood (PRP) or os marrow but brand feel to them as well as they are willing as well as ofttimes eager to essay a novel handling instead of undergo surgery.

We are shortly scrambling to figure out how to develop, execute as well as pay for the clinical trials needed to best sympathise how to utilize biologic orthopedic therapies.  The practiced word is:  hundreds of clinicians, researchers as well as medical device professionals are working diligently on dozens of novel handling options.

Please post whatever comments nigh why you lot may yell back patients as well as clinicians are using PRP, stalk cells or other biologic treatments.

AM   (@ on Twitter)
TotalTendon
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