Skin-derived fibroblasts for the treatment of refractory Achilles tendinosis: preliminary short-term results

BACKGROUND

Chronic Achilles tendinosis is a common musculoskeletal disorder often refractory to conservative management. Our study aimed to assess the safety and efficacy of the use of autologous skin-derived collagen-producing cells in the treatment of refractory Achilles tendinosis.

METHODS

We conducted a randomized, double-blind study on forty Achilles tendons in thirty-two patients (eight with bilateral involvement) who had a clinical and radiographic diagnosis of Achilles tendinosis. The patients ranged from twenty-two to sixty-seven years old and had a mean age of 45.2 years. The patients with unilateral involvement were randomized into the treatment group (twelve patients) and control group (twelve patients). The eight patients with bilateral involvement were individually randomized into treatment and control groups, with eight Achilles tendons in each group. Achilles tendons in the treatment group were injected under ultrasound guidance with laboratory-expanded, skin-derived fibroblasts suspended in autologous plasma. The control group received ultrasound-guided injection of a local anesthetic and physiotherapy. The Victorian Institute of Sport Assessment (VISA) questionnaire and visual analog scale (VAS) scores were used as the main outcome measures for both groups.

RESULTS

Significant differences in the mean VISA and VAS scores were detected between the treatment and the control groups for the patients with unilateral involvement at six months (p < 0.001 for both). With use of the Mann-Whitney U Test, significant differences in the VISA score were observed at the second visit and at the three-month and six-month visits (p = 0.02, p = 0.007, and p < 0.001 respectively). The VAS scores also showed significant differences at the second visit and at the six-month evaluation (p = 0.014 and p < 0.001, respectively). The eight patients with bilateral involvement were analyzed separately; with the number of patients studied, no significant differences in the VISA or VAS scores were observed between the treatment group and the control group.

CONCLUSIONS

These preliminary short-term results demonstrate that the injection of skin-derived fibroblasts for the treatment of Achilles tendinosis is safe. However, larger studies with a longer duration of follow-up are required to determine the long-term effectiveness before wider clinical application is considered.

Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections

BACKGROUND

Growth factor technologies are increasingly used to enhance healing in musculoskeletal injuries, particularly in sports medicine. Two such products; platelet-rich plasma (PRP) and autologous blood, have a growing body of supporting evidence. No previous trial has directly compared the efficacy of these two methods.

HYPOTHESIS

Growth factor administration improves tissue regeneration in patients who have failed to respond to conservative therapy.

STUDY DESIGN

A prospective, double-blind, randomised trial.

METHODS

Elbow tendinopathy patients who had failed conservative physical therapy were divided into two patient groups: PRP injection (N=80) and autologous blood injection (ABI) (N=70). Each patient received two injections at 0 and 1 month. Patient-related tennis elbow evaluation (PRTEE) was recorded by a blinded investigator at 0, 1, 3 and 6 months. The main outcome measure was PRTEE, a validated composite outcome for pain, activities of daily living and physical function, utilising a 0-100 scale.

RESULTS

At 6 months the authors observed a 66% success rate in the PRP group versus 72% in the ABI group, p=NS. There was a higher rate of conversion to surgery in the ABI group (20%) versus the PRP group (10%).

CONCLUSION

In patients who are resistant to first-line physical therapy such as eccentric loading, ABI or PRP injections are useful second-line therapies to improve clinical outcomes. In this study, up to seven out of 10 additional patients in this difficult to treat cohort benefit from a surgery-sparing intervention.

Enumeration of functional T-cell subsets by fluorescence-immunospot defines signatures of pathogen burden in tuberculosis

Background

IFN-γ and IL-2 cytokine-profiles define three functional T-cell subsets which may correlate with pathogen load in chronic intracellular infections. We therefore investigated the feasibility of the immunospot platform to rapidly enumerate T-cell subsets by single-cell IFN-γ/IL-2 cytokine-profiling and establish whether immunospot-based T-cell signatures distinguish different clinical stages of human tuberculosis infection.

Methods

We used fluorophore-labelled anti-IFN-γ and anti-IL-2 antibodies with digital overlay of spatially-mapped colour-filtered images to enumerate dual and single cytokine-secreting M. tuberculosis antigen-specific T-cells in tuberculosis patients and in latent tuberculosis infection (LTBI). We validated results against established measures of cytokine-secreting T-cells.

Results

Fluorescence-immunospot correlated closely with single-cytokine enzyme-linked-immunospot for IFN-γ-secreting T-cells and IL-2-secreting T-cells and flow-cytometry-based detection of dual IFN-γ/IL-2-secreting T-cells. The untreated tuberculosis signature was dominated by IFN-γ-only-secreting T-cells which shifted consistently in longitudinally-followed patients during treatment to a signature dominated by dual IFN-γ/IL-2-secreting T-cells in treated patients. The LTBI signature differed from active tuberculosis, with higher proportions of IL-2-only and IFN-γ/IL-2-secreting T-cells and lower proportions of IFN-γ-only-secreting T-cells.

Conclusions

Fluorescence-immunospot is a quantitative, accurate measure of functional T-cell subsets; identification of cytokine-signatures of pathogen burden, distinct clinical stages of M. tuberculosis infection and long-term immune containment suggests application for treatment monitoring and vaccine evaluation.

Posterior ankle impingement syndrome: a clinical review with reference to horizontal jump athletes

Posterior ankle impingement syndrome is the term attributed to the clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. In this review article, we discuss the anatomy, aetiology, clinical and radiological features of posterior ankle impingement syndrome and consider the conservative and surgical management and the guidelines used for post operative rehabilitation. Finally we provide illustrative cases and review the biomechanical features of this condition in horizontal jump athletes.

Cell therapy in tendon disorders: what is the current evidence?

BACKGROUND

Various types of tissue-derived cells are being experimented with for the treatment of tendinopathy, tendon repair, and use in tissue engineering.

PURPOSE

The aim of this systematic review is to explore the current evidence with a view to evaluate the potential of this therapeutic intervention.

STUDY DESIGN

Systematic review.

METHODS

A review of the literature was conducted using PubMed. Search criteria included keywords "tendinopathy," "tendinitis," "tendinosis," "epicondylitis," "stem cell," and "cell therapy." Articles not written in English language were excluded.

RESULTS

A total number of 379 articles were identified and a critical appraisal of the relevant articles was undertaken, which encompassed human and animal research. The review included articles related to various tissue-derived cells such as tendon progenitors, adipose tissue, synovium, muscle, bone marrow, and skin. The utility of cell therapy in tissue engineering and rotator cuff repair was also assessed.

CONCLUSION

With the limitation of the available evidence, the literature suggests that cell therapy is applicable and may be effective for the treatment of tendinopathy. However, further research into the precise biological mechanisms, long-term implications, and cost-effectiveness is needed.

Imaging of impingement lesions in the ankle

Ankle impingement and instability are well-recognized complications of ankle sprain. Ankle impingement is an important cause of chronic ankle pain in active populations, particularly in the professional athlete. Depending on anatomical location and the structures involved, impingement syndromes are classified into anterolateral, anterior, posterior, posteromedial, and anteromedial types. Clinically, impingement syndromes are characterized by painful limitation of full-ankle movement. Ankle impingement results from repetitive subclinical trauma due to overuse injuries, which, in the subacute or chronic situation, lead to abnormal osseous and soft-tissue thickening within the ankle joint. Various imaging techniques can be used in the diagnosis of ankle impingement. Usually, radiography is the initial imaging technique performed to rule out bony trauma and identify potential anatomical bony abnormalities. Use of computed tomography and isotope bone scanning is largely superseded by magnetic resonance imaging, although with variable sensitivity and specificity. Arthrographic techniques, using computed tomography or magnetic resonance, are useful for exquisite demonstration of capsular recesses and synovial abnormalities. Imaging-guided injection techniques can be used in the management of impingement for pain ablation and to aid clinical diagnosis, especially in hind foot pain.

CT-guided injection for ganglion impar blockade: a radiological approach to the management of coccydynia

AIM

To evaluate the role of computed tomography (CT) in needle placement for ganglion impar blocks, and to determine the efficacy of CT-guided ganglion impar blocks in the management of coccydynia.

MATERIALS AND METHODS

The results of ganglion impar blockade in eight patients with coccydynia secondary to trauma or unknown cause were reviewed. The diagnosis of coccydynia was based on clinical history, location of pain, and response to previous diagnostic and therapeutic procedures. The eight patients were treated with CT-guided ganglion impar blocks to manage their coccyx pain after conservative procedures, including oral medication and cushions, failed to provide relief. All patients were subjected to ganglion impar blocks under a thin-section CT-guided technique for needle placement, using a mixture of bupivacaine and triamcinolone. The patients were followed-up for a period of 6-months.

RESULTS

Eight patients were treated in this study with a total of 11 injections. A technical success of 100% was achieved in all cases with accurate needle placement without any complications and all the patients tolerated the procedure well. Out of eight, three patients (37%) had complete relief of pain on the follow-up intervals up to 6 months. Three out of eight patients (37%), had partial relief of symptoms and a second repeat injection was given at the 3 month interval of the follow-up period. At the end of the 6-month follow-up period, six out of eight patients (75%) experienced symptomatic relief (four complete relief and two partial relief) without any additional resort to conventional pain management. Twenty-five percent (two out of eight) did not have any symptomatic improvement. The mean visual analogue score (VAS) pre-procedure was 8 (range 6-10) and had decreased to 2 (range 0-5) in six out of eight patients.

CONCLUSION

CT can be used as an imaging method to identify the ganglion and guide the needle in ganglion impar blockade. The advantages of CT-guided injection over those performed under fluoroscopy may include accurate and confident needle placement in the sacro-coccygeal region, ease of wide area coverage, lesser risk of complications due to inadvertent injections into the major pelvic structures, and increased likelihood of reaching the ganglion impar, especially in cases with anatomical variation in the ganglion impar location. These factors may have implications in the overall success rate of ganglion impar blockade.

Glenoid rim fracture in contact athletes with absorbable suture anchor reconstruction

Absorbable suture anchors are widely used in arthroscopic shoulder reconstruction procedures and provide a good solution for stabilization in athletes. In our practice we identified a group of 3 patients who had participated in contact sports and in whom traumatic instability developed. Subluxation of the shoulder followed repair by use of absorbable suture anchors. Each patient had a new injury characterized by a glenoid rim fracture that was not amenable to further arthroscopic reconstruction and was revised by use of a modified Latarjet procedure. All patients successfully returned to contact sports. We conclude that resorption defects resulting from the use of absorbable anchors contribute to an increased risk of rim fracture.

Treatment of lateral epicondylitis using skin-derived tenocyte-like cells

OBJECTIVES

To culture collagen-producing cells derived from skin fibroblasts and o evaluate prospectively the safety and potential use of this cell preparation for treatment of refractory lateral epicondylitis in a pilot study.

DESIGN

Prospective clinical pilot study.

SETTING

Institution-based clinical research.

PATIENTS

A total of 12 patients (5 men and 7 women; mean age 39.1 years) with clinical diagnosis of refractory lateral epicondylitis.

INTERVENTIONS

Laboratory-prepared collagen-producing cells derived from dermal fibroblasts were injected into the sites of intrasubstance tears and fibrillar discontinuity of the common extensor origin under ultrasonography guidance.

MAIN OUTCOME MEASURES

The outcome assessment was performed over 6 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale was used to assess pain severity and functional disability. Tendon healing response was measured using four criteria on ultrasonography: tendon thickness, hypoechogenicity, intrasubstance tears and neovascularity.

RESULTS

Cell cultures rich in collagen-producing cells was successfully prepared. After injection, the median PRTEE score decreased from 78 before the procedure to 47 at 6 weeks, 35 at 3 months and 12 at 6 months after the procedure (p<0.05). The healing response on ultrasonography showed median decrease in: (1) number of tears, from 5 to 2; (2) number of new vessels, from 3 to 1; and (3) tendon thickness, from 4.35 to 4.2 (p<0.05). Of the 12 patients, 11 had a satisfactory outcome, and only one patient proceeded to surgery after failure of treatment at the end of 3 months.

CONCLUSIONS

Skin-derived tenocyte-like cells can be cultured in the laboratory to yield a rich preparation of collagen-producing cells. Our pilot study suggests that these collagen-producing cells can be injected safely into patients and may have therapeutic value in patients with refractory lateral epicondylitis.

Persistent symptoms following non operative management in low grade MCL injury of the knee - The role of the deep MCL

Incomplete injuries (grade I or II) to the medial collateral ligament (MCL) of the knee are common and usually self limiting. Some patients complain of chronic medial knee pain following injury. We highlight the importance of anatomical investigation of these patients and evaluate a successful treatment technique. A consecutive case series of 34 patients with chronic pain following grade I/II MCL injury were reviewed. Injury prevented sporting activity, and examination revealed thickening and tenderness of the MCL. The knee was assessed by MRI. All patients had radiological evidence of injury to the superficial and deep MCL, with thickening, scarring and tearing. Patients were treated with ultrasound guided injection of local anaesthetic and steroid into the deep MCL and clinically reassessed. They were allowed to return to sport immediately. They were assessed for recurrence of symptoms with a postal questionnaire. Four were excluded from follow up. Four were lost. All patients reported an immediate and sustained resolution their medial knee pain. At mean follow up of 20.4 months (range 11-38 months) all were back to their pre-injury level of work. Twenty five (96%) had immediate and sustained return to sporting activity. Twenty one (81%) reported no change in level of sporting function. In patients with persistent medial joint pain following grade I/II MCL sprain, pain from the deep MCL must be considered. MRI will confirm the diagnosis, exclude coexistent pathology and localise the lesion within the deep MCL. A single corticosteroid injection provides an excellent clinical outcome 20 months post injection.

A role delineation study of health educators in the United States: methodological innovations

This paper focuses on methodological innovations used in the National Health Educator Competencies Update Project (CUP) in the United States. The CUP was a six-year research study designed to delineate the role of the health educator in the USA. Individuals who self-identified as health educators were included in the study. To provide context, the background for the research is presented, followed by a brief overview of the research process. Some of the key methodological innovations discussed are: selecting a representative sample when the total population of those working as health educators was not easily identified or readily accessible; assessing response methodology preferences through pilot studies; enhancing the response rate through accurate, up-to-date mailing lists and incentives; and exploring new approaches to large-scale data analyses. Insights gained are included for other researchers who may wish to undertake similar studies or draw from the CUP dataset for secondary analyses.

Efficacy and safety of vertebroplasty for treatment of painful osteoporotic vertebral fractures: a randomised controlled trial [ACTRN012605000079640]

Background

Vertebroplasty is a promising but as yet unproven treatment for painful osteoporotic vertebral fractures. It involves radiographic-guided injection of various types of bone cement directly into the vertebral fracture site. Uncontrolled studies and two controlled quasi-experimental before-after studies comparing volunteers who were offered treatment to those who refused it, have suggested an early benefit including rapid pain relief and improved function. Conversely, several uncontrolled studies and one of the controlled before-after studies have also suggested that vertebroplasty may increase the risk of subsequent vertebral fractures, particularly in vertebrae adjacent to treated levels or if cement leakage into the adjacent disc has occurred. As yet, there are no completed randomised controlled trials of vertebroplasty for osteoporotic vertebral fractures. The aims of this participant and outcome assessor-blinded randomised placebo-controlled trial are to i) determine the short-term efficacy and safety (3 months) of vertebroplasty for alleviating pain and improving function for painful osteoporotic vertebral fractures; and ii) determine its medium to longer-term efficacy and safety, particularly the risk of further fracture over 2 years.

Design

A double-blind randomised controlled trial of 200 participants with one or two recent painful osteoporotic vertebral fractures. Participants will be stratified by duration of symptoms (< and ≥ 6 weeks), gender and treating radiologist and randomly allocated to either the treatment or placebo. Outcomes will be assessed at baseline, 1 week, 1, 3, 6, 12 and 24 months. Outcome measures include overall, night and rest pain on 10 cm visual analogue scales, quality of life measured by the Assessment of Quality of Life, Osteoporosis Quality of Life and EQ-5D questionnaires; participant perceived recovery on a 7-point ordinal scale ranging from 'a great deal worse' to 'a great deal better'; disability measured by the Roland-Morris Disability Questionnaire; timed 'Up and Go' test; and adverse effects. The presence of new fractures will be assessed by radiographs of the thoracic and lumbar spine performed at 12 and 24 months.

Discussion

The results of this trial will be of major international importance and findings will be immediately translatable into clinical practice.

Trial registration

Australian Clinical Trial Register # [ACTRN012605000079640]

MR imaging appearances of acromioclavicular joint dislocation

The key structures involved in dislocation of the acromioclavicular joint (ACJ) are the joint itself and the strong accessory coracoclavicular ligament. ACJ dislocations are classified with the Rockwood system, which comprises six grades of injury. Treatment planning requires accurate grading of the ACJ disruption, but correct classification can be difficult with clinical assessment. Magnetic resonance (MR) imaging has a well-established role in evaluation of ACJ pain. MR imaging performed in the coronal oblique plane parallel to the distal clavicle allows assessment of the acromioclavicular and coracoclavicular ligaments owing to its in-plane orientation in relation to these structures. This technique enables distinction between grade 2 and grade 3 injuries, which can be difficult with conventional clinical and radiographic evaluation. In addition, diagnosis of grade 1 injuries is possible by demonstration of a ruptured superiodorsal acromioclavicular ligament. Resultant thickening of the acromioclavicular or coracoclavicular ligament allows identification of chronic ACJ injuries.

Upright positional MRI of the lumbar spine

Supine magnetic resonance imaging (MRI) is routinely used in the assessment of low back pain and radiculopathy. However, imaging findings often correlate poorly with clinical findings. This is partly related to the positional dependence of spinal stenosis, which reflects dynamic changes in soft-tissue structures (ligaments, disc, dural sac, epidural fat, and nerve roots). Upright MRI in the flexed, extended, rotated, standing, and bending positions, allows patients to reproduce the positions that bring about their symptoms and may uncover MRI findings that were not visible with routine supine imaging. Assessment of the degree of spinal stability in the degenerate and postoperative lumbar spine is also possible. The aim of this review was to present the current literature concerning both the normal and symptomatic spine as imaged using upright MRI and to illustrate the above findings using clinical examples.

Magnetic resonance imaging findings of injuries to the calf muscle complex

OBJECTIVE

The objective was to describe the imaging findings following acute injury to the calf musculature.

DESIGN AND PATIENTS

We retrospectively reviewed 59 MR examinations in patients who sustained injuries to the calf muscle from April 2001 to September 2004 (48 men, 11 women), with an average age of 31 and 47 years respectively (range in men 20-53; range in women 33-63). Attention was directed to the frequency of muscle involvement, the location of the injury within the musculotendinous unit and the extent of the injury.

RESULTS AND CONCLUSIONS

A total of 79 separate sites of strain injury were identified (39 solitary, 20 dual). Of the 39 isolated strains, injury to the gastrocnemius was most common (19 out of 39; 48.7%), preferentially involving the medial head in 18 cases and the lateral head in 1 case. The soleus was also commonly involved (18 out of 39; 46.2%), with 2 cases (5.1%) of distal avulsions of the plantaris. Of the 20 dual injuries, a combination of gastrocnemius injury with soleus injury was the most frequent finding (12 out of 20; 60%). Dual injuries of both heads of the gastrocnemius muscles were demonstrated in 4 cases (20%), with the soleus and tibialis posterior injured in 3 cases (15%). A combination of soleus and flexor hallucis longus injury was seen in 1 case (5%).

CONCLUSION

This retrospective study utilizing MRI demonstrates that the medial head of the gastrocnemius is the most commonly injured muscle of the calf, closely followed by the soleus, the latter finding rarely reported in the sonographic literature. Dual injuries of the calf muscle complex occur much more commonly than previously reported and may be of prognostic significance.

Prevalence and diagnostic significance of fluid–fluid levels in soft-tissue neoplasms

AIM

To report the prevalence of fluid-fluid levels (FFLs) in soft-tissue tumours as demonstrated by magnetic resonance imaging (MRI) and the potential diagnostic relevance of this finding.

MATERIALS AND METHODS

A retrospective analysis was performed of 726 consecutive patients (361 women, 365 men, mean age 47.6 years+/-20.1 SD) presenting with a soft-tissue mass over a 7-year period. All subjects underwent MRI and final diagnosis was based on biopsy/surgical resection, or clinical follow-up and characteristic imaging findings. The patients were divided according to the presence or absence of FFLs on T2-weighted (T2W) axial MRI and histological diagnosis (non-neoplastic, neoplastic benign, neoplastic malignant). Cases with FFLs were sub-categorized depending upon the proportion of tumour containing FFLs: <1/3, 1/3-2/3 and >2/3, in order to determine whether the proportion of FFLs was useful for differential diagnosis.

RESULTS

Twenty-four of the 726 (3.3%: confidence interval 2.1-4.9%) soft-tissue masses contained FFLs. One of the 24 (4.1%) was non-neoplastic (one ganglion), 12 (50.0%) were benign neoplasms (nine haemangiomas, two schwannomas, one hamartoma) and 11 (45.9%) were malignant neoplasms (one leiomyosarcoma, one liposarcoma, one malignant fibrous histocytoma, one mxyofibrosarcoma, two primitive neuroectodermal tumours, two synovial sarcomas, one spindle cell sarcoma, and two sarcomas not otherwise specified). The presence of FFLs did not help to differentiate benign from malignant neoplasms. Of the 12 benign neoplasms, 66.7% contained over two-thirds FFLs, the majority of which were haemangiomas. Of the 10 malignant neoplasms, all contained less than two-thirds FFLs: 20% had less than one-third, 80% had one to two-thirds FFLs.

CONCLUSIONS

The prevalence of FFLs in soft-tissue tumours referred to a specialist orthopaedic oncology unit is 3.3%. However, the presence of FFLs does not reliably distinguish benign from malignant neoplasms, although all lesions with more than two-thirds FFLs were benign.

MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players

OBJECTIVE

To describe magnetic resonance imaging (MRI) findings in the lumbar spine in asymptomatic elite adolescent tennis players, to serve as the baseline for a future prospective longitudinal cohort study.

DESIGN

Observational study.

SETTING

Institutional, national tennis centre.

PARTICIPANTS

33 asymptomatic elite adolescent tennis players, mean (SD) age, 17.3 (1.7) years (18 male, 15 female).

METHODS

Sagittal T1, T2, STIR, and axial T2 weighted MRI images were reviewed for the presence of abnormalities by two radiologists in consensus. Abnormalities included disc degeneration, disc herniation, pars lesions (fracture or stress reaction), and facet joint arthropathy.

RESULTS

Five players (15.2%) had a normal MRI examination and 28 (84.8%) had an abnormal examination. Nine players showed pars lesions (10 lesions; one at two levels) predominately at the L5 level (9/10, L5; 1/10, L4). Three of the 10 lesions were complete fractures; two showed grade 1 and one grade 2 spondylolisthesis, both of which resulted in moderate narrowing of the L5 exit foramen. There were two acute and five chronic stress reactions of the pars. Twenty three patients showed signs of early facet arthropathy occurring at L5/S1 (15/29 joints) and L4/5 (12/29 joints). These were classified as mild degeneration (20/29) and moderate degeneration (9/29), with 20/29 showing sclerosis and 24/29 showing hypertrophy of the facet joint. Synovial cysts were identified in 14 of the 29 joints. Thirteen players showed disc desiccation and disc bulging (mild in 13; moderate in two) most often at L4/5 and L5/S1 levels (12 of 15 discs).

CONCLUSIONS

Abnormalities were frequent, predominately in the lower lumbar spine, almost exclusively at L4/5 and L5/S1 levels. Pars injuries and facet joint arthroses were relatively common.