Regenerative Approaches to Tendon and Ligament Conditions.

Tendon and ligament injuries and degenerative conditions of these soft tissues have poor healing potential and healing is often incomplete. Biocellular and orthobiologic approaches including PRP and stem cell therapies are reviewed. A review of some of the regenerative medicine science and difficulties facing physicians exploring these methods is presented. A series of cases are reviewed demonstrating the application of these principles. Clinical experience with many of these biocellular interventions is outpacing validation in basic science studies. Clinical experience dictates the need for repeated clinical and imaging evaluation and the need for repeated intervention or change in strategies when needed.

A call for a standard classification system for future biologic research: the rationale for new PRP nomenclature.

Autologous cell therapies including platelet-rich plasma (PRP) and bone marrow concentrate (BMC) are increasingly popular options for soft tissue and joint-related diseases. Despite increased clinical application, conflicting research has been published regarding the efficacy of PRP, and few clinical publications pertaining to BMC are available. Preparations of PRP (and BMC) can vary in many areas, including platelet concentration, number of white blood cells, presence or absence of red blood cells, and activation status of the preparation. The potential effect of PRP characteristics on PRP efficacy is often not well understood by the treating clinician, and PRP characteristics, as well as the volume of PRP delivered, are unfortunately not included in the methods of many published research articles. It is essential to establish a standard reporting system for PRP that facilitates communication and the interpretation and synthesis of scientific investigations. Herein, the authors propose a new PRP classification system reflecting important PRP characteristics based on contemporary literature and recommend adoption of minimal standards for PRP reporting in scientific investigations. Widespread adoption of these recommendations will facilitate interpretation and comparison of clinical studies and promote scientifically based progress in the field of regenerative medicine.

How effective are injection treatments for lateral epicondylitis?

OBJECTIVE: To compare the effectiveness, after 3 months, of a single injection of platelet-rich plasma (PRP), glucocorticoid (GC), or saline in reducing pain in lateral epicondylitis. DESIGN: Randomized, controlled, 3-group trial (RCT). Patients and outcome assessors were blinded to intervention group. Sample size was calculated to show a clinically important difference in patient-reported pain intensity at 12 months with 17 patients per group. SETTING: Tertiary study at the Rheumatology Unit at the Diagnostic Centre of the Region Hospital Silkeborg, Denmark. PARTICIPANTS: Patients were referred to the Rheumatology Unit by general practitioners or other rheumatology or orthopedic departments. Inclusion criteria (verified by 1 physician) were lateral epicondylitis symptoms for ≥3 months (pain on the lateral side of the elbow and at the lateral epicondyle on palpation and during resisted dorsiflexion of the wrist), an ultrasound (US) color Doppler flow of ≥ grade 2 (range, 0-4). Exclusion criteria were age <18 years, treatment with GC injection within 3 months, inflammatory diseases, and conditions causing chronic pain. The 60 included patients had a mean age of 45 years, 52% were women, 58% had ≥1 previous injection, and 58% used analgesics. INTERVENTION: The patients were randomized to a single US-guided injection of PRP, GC, or saline, administered by the 1 physician who had made the diagnosis. All patients were blindfolded during blood collection and injection. They all received an injection of 10 to 15 mL of lidocaine into the peritendon before the procedure. The PRP injection was of approximately 3.5 mL of autologous platelets (collected and centrifuged for 15 minutes from 27 mL of whole blood) buffered with 8.4% sodium bicarbonate, and immediately peppered into the common tendon origin. The GC injection (1 mL triamcinolon, 40 mg/mL + 2 mL lidocaine, 10 mg/mL) was delivered through 1 site. The saline injection (3 mL saline, 0.9%) was peppered in the same manner as the PRP injection. After treatment, the patients were asked to use the arm minimally for 3 days and then gradually to return to normal use. MAIN OUTCOME MEASURES: The pain intensity scale of the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire was the main outcome measure (least to most pain = 0-50 points). The secondary end points included changes in functional disability using the functional section of the PRTEE, (least to most disability = 0-100 points), US changes in color Doppler signal and tendon thickness, and adverse events, which included pain after the injection. After 3 months, if the patient was unsatisfied with the result of treatment, he or she could be released from the study to seek other management. MAIN RESULTS: Ten, 11, and 13 patients (58% of the total) dropped out of the PRP, GC, and saline groups, respectively, at the 3-month follow-up, thus evaluations were only made at 1 and 3 months. At 1 month, the mean reduction in pain for the PRP group versus the saline group was 1.2 (95% confidence interval [CI], -5.0 to 7.3); for the GC group versus the saline group was -8.1 (95% CI, -14.3 to -1.9); and for the GC group versus the PRP group, -9.3 (95% CI, -15.4 to -3.2). At 3 months, the mean reduction in pain for no group was significantly greater than for others (PRP vs the saline group, -2.7; 95% CI, -8.8 to 3.5; GC vs the saline group, -3.8; 95% CI, -9.9 to 2.4; GC vs the PRP group, -1.1; 95% CI, -7.2 to 5.0). The PRTEE disability scores at 1 month also favored the GC group versus saline, but no differences were found between any groups at 3 months. The improvement in Doppler grades at 3 months favored the GC group versus the saline group and the PRP group (P<0.0001 for both comparisons). Mean reduction in tendon thickness was greater for the GC group versus the saline group (P<0.0001) and the PRP group (P=0.002). PRP injections were found to be more painful than GC and saline injections. No adverse events leading to hospitalization, and no reports of infections resulting from the injections, occurred. CONCLUSIONS: The dropout rate of 58% at 3 months showed that none of PRP, glucocorticoid, or saline injections adequately reduced the pain and disability of lateral epicondylitis.

Freiberg's Infraction in an Adolescent Dancer: Condition Often Mistaken for a Stress Fracture.

Freiberg's infraction is not widely seen but can occur among young athletes. Its symptoms and radiographic signs may mimic stress fractures, as in the 12-year-old female dancer described here. This condition, an osteochondrosis that most commonly affects the second metatarsal, is diagnosed with plain radiography. Treatment typically involves immobilization or off-loading to eliminate pain, use of orthoses, and a gradual return to weight-bearing activity.

Nonsurgical sports medicine training in the United States: a survey of sports medicine fellowship graduates.

OBJECTIVE: To survey graduates of nonsurgical sports medicine fellowship training programs about the quality and content of their educational curriculum. DESIGN: Survey. PARTICIPANTS: Participants were year 2000 active members of the American Medical Society for Sports Medicine (AMSSM) and American Osteopathic Academy of Sports Medicine (AOASM) and all other attendees at the 2000 AOASM and AMSSM annual meetings. The survey also was sent to candidates sitting for the 1999 CAQ examination from the American Board of Family Practice, American Board of Internal Medicine, American College of Emergency Physicians, and American Academy of Pediatrics. RESULTS: A total of 1608 surveys were distributed; 612 were returned for a return rate of 43%. Of respondents, 294 were fellowship trained, and 318 considered themselves to be sports medicine physicians but were not fellowship trained. Sections of the survey completed only by fellowship-trained physicians and focusing on training curriculum are reported in this article. Categories of survey questions included clinical experience, curriculum, academic activities, research, teaching experiences, primary care skills, procedures, types of athletes seen during training, supervision, and benefits. General attitudes about fellowship training also were surveyed: 99% of graduates were satisfied with their training and would do a fellowship again, and 98% felt they their training prepared them for a career in sports medicine. Orthopaedic experiences and physical examination skills were rated the highest. Research experience, work with disabled athletes, and selected areas of nonorthopaedic medical training, such as sports ophthalmology and sports psychology, were rated the lowest. CONCLUSIONS: Overall, fellowship training in sports medicine seems to be satisfactory to fellowship graduates. Strengths and weaknesses in training programs were identified.