Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial

Arthroscopic rotator cuff repair combined with platelet-rich plasma products can reduce the rate of retearing and improve clinical outcomes: A meta-analysis of randomized controlled trials

BACKGROUND

Although several studies on the potential benefits of protein-rich plasma (PRP) therapy for rotator cuff injuries have been published, the results have been conflicting. Therefore, this study aimed to determine whether PRP is beneficial for the prevention of retears after arthroscopic rotator cuff repair (ARCR).

METHODS

Two reviewers conducted independent literature searches based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) comparing a PRP treatment group with a control group were included. The quality of evidence was assessed using the Cochrane Collaboration Risk of Bias Tool. Clinical outcomes were compared using the risk ratio (RR) for dichotomous variables and weighted mean difference (WMD) for continuous variables. Statistical significance was set at P < .05.

RESULTS

This review included 21 RCTs (1359 patients). Significant results were noted in favor of PRP treatment compared with controls based on retearing rates (16.5% vs 23.6%, respectively; P = .002) and the Constant score in the short term (WMD: 1.98; 95% confidence interval [CI], 0.27-3.70; I2 = 0%; P = .02), medium term and long term (WMD: 2.56 [95% CI: 1.57-3.55]; I2 = 2%; P < .001); the University of California, Los Angeles score in the short term (WMD: 1.14 [95% CI: 0.43-1.85]; I2 = 25%; P = .002) but not in the medium and long term (WMD: 0.66 [95% CI: -0.16 to 1.48]; I2 = 57%; P = .11); and the visual analog scale score in the short term (WMD: -0.63 [95% CI: -0.83 to-0.43]; I2 = 41%; P < .001), medium and long term (WMD: -0.12 [95% CI: -0.19 to-0.05]; I2 = 0%; P = .008). There was no significant difference in American Shoulder and Elbow Surgeons scores between the treatment and control groups in the short term (WMD: -0.48 [95% CI: -2.80 to 1.85]; I2 = 22%; P = .69) or medium and long term (WMD: 0.92 [95% CI: -1.56 to 3.39]; I2 = 40%; P = .47).

CONCLUSION

Intraoperative use of PRP reduces the risk of rotator cuff repair failure, improves clinical outcomes, and reduces recurrence rates.

Leukocyte-Poor Platelet-Rich Plasma as an Adjuvant to Arthroscopic Rotator Cuff Repair Reduces the Retear Rate But Does Not Improve Functional Outcomes: A Double-Blind Randomized Controlled Trial

BACKGROUND

Whether the use of PRP as an adjuvant of rotator cuff repairs leads to improved tendon healing and better functional outcomes remains unclear in clinical evidence.

PURPOSE

The main purpose of this study was to assess whether the use of leukocyte-poor platelet-rich plasma (LP-PRP) as an adjuvant to arthroscopic rotator cuff repair (ARCR) decreases the rate of retears compared with a control group. The secondary objective was to analyze whether LP-PRP improves patient-reported outcomes.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This was a double-blind randomized controlled trial at a single center. A consecutive series of 96 patients with rotator cuff tears <3 cm were enrolled and randomly allocated to the control group (double-row suture-bridge ARCR alone [n = 48]) and the PRP group (double-row suture-bridge repair, followed by 1 LP-PRP injection during surgery [n = 48]). The visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and the Pittsburgh Sleep Quality Index (PSQI) were administered preoperatively and at 6- and 12-month follow-up. Magnetic resonance imaging (MRI) was performed to evaluate tendon integrity at 6-month follow-up. Both patients and assessors were blinded to the intervention received during surgery.

RESULTS

The mean patient age was 56.1 ± 2.98 years. Of the 96 patients, 90 had MRI performed at 6 months after surgery (94% radiological follow-up). The retear rate in the PRP group was 15.2% (7/46 [95% CI, 6%-28%]), which was lower than that in the control group of 34.1% (15/44 [95% CI, 20%-49%]) (P = .037). Therefore, the risk ratio of ruptures in patients exposed to LP-PRP was 0.44 (95% CI, 0.2-0.9; P = .037). Overall, the ASES, VAS, SANE, and PSQI scores showed a statistical improvement after surgery (P < .001). There were no significant differences in functional scores between the groups. Most of the patients exceeded the minimal clinically important difference for the ASES, SANE, and VAS without significant differences between the groups.

CONCLUSION

In patients with rotator cuff tears <3 cm undergoing double-row suture-bridge repair, a 5-mL dose of LP-PRP injected at the tendon-bone interface significantly reduced the retear rate. However, the use of LP-PRP in terms of postoperative pain and patient-reported outcomes failed to show clinically meaningful effects.

REGISTRATION

NCT04703998 (ClinicalTrials.gov identifier).

Efficacy of platelet-rich plasma in rotator cuff repair: systematic review and meta-analysis

OBJECTIVE

To analyze the efficacy and safety after the application of platelet-rich-plasma (PRP) as an adjuvant in arthroscopic rotator cuff repairs.

MATERIAL AND METHODS

A bibliographic search of the literature of prospective studies with level of evidence one or two was carried out from January 2004 to December 2021, including studies that compare the functional and re-tear results after arthroscopic cuff repair rotator with or without PRP.

RESULTS

A total of 281 articles were identified, of which 14 met the inclusion criteria. The overall re-rupture rate was 24%. In the PRP group, a decrease in the re-rupture rate and better functional results were demonstrated, although these differences were not significant.

CONCLUSIONS

Adjuvant treatment with PRP has shown promising results, although there is not yet enough evidence to provide a clear advantage for routine use in clinical practice.

[Translated article] Efficacy of platelet-rich plasma in rotator cuff repair: Systematic review and meta-analysis

OBJECTIVE

To analyse the efficacy and safety after the application of platelet-rich-plasma (PRP) as an adjuvant in arthroscopic rotator cuff repairs.

MATERIAL AND METHODS

A bibliographic search of the literature of prospective studies with level of evidence one or two was carried out from January 2004 to December 2021, including studies that compare the functional and re-tear results after arthroscopic cuff repair rotator with or without PRP.

RESULTS

A total of 281 articles were identified, of which 14 met the inclusion criteria. The overall re-rupture rate was 24%. In the PRP group, a decrease in the re-rupture rate and better functional results were demonstrated, although these differences were not significant.

CONCLUSIONS

Adjuvant treatment with PRP has shown promising results, although there is not yet enough evidence to provide a clear advantage for routine use in clinical practice.

Effect of Platelet-Rich Plasma Dosing for Healing after Arthroscopic Cuff Repair Compared with Surgery Alone: A Systematic Review and Meta-Analysis

INTRODUCTION

Platelet-rich plasma (PRP) has been used for arthroscopic rotator cuff repairs (aRCR), but no studies have addressed the impact of platelet concentration. The primary aim was to evaluate whether the PRP cell concentration has an effect on tendon healing after aRCR compared with surgery alone. The secondary aim was to assess the functional and pain outcomes.

MATERIALS AND METHODS

A systematic review was performed with searches in the MEDLINE (PubMed), Scopus, Web of Science, and Cochrane (Central) databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Metanalytic procedures were performed for randomized controlled trials (RCTs), and a subgroup analysis was used for studies with target (approximately 10 6 cells·μL -1 ) or below-target PRP cellular concentrations (app. 5 × 10 5 cells·μL -1 ) regarding the primary outcome of tendon healing.

RESULTS

This review included 10 studies (8 RCTs) with 342 patients in the aRCR + PRP group and 344 patients with isolated aRCR. The risk of bias was low to intermediate (6/4, respectively). Meta-analysis of the RCT revealed that the aRCR + high-concentration PRP group had an approximately 3.9-fold higher chance of healing than the non-PRP group (odds ratio, 3.89; 95% confidence interval, 1.78-8.44; P = 0.0007). No significant difference in healing was found between the aRCR + low-concentration PRP and non-PRP groups (odds ratio, 2.21; 95% confidence interval, 0.66-7.45; P = 0.2). The Constant-Murley score and University of California Los Angeles scores were significantly improved in the aRCR + PRP groups with more than 12 months of follow-up, and no significant differences were found consistently for the American Shoulder and Elbow Society and visual analog scale scores.

CONCLUSIONS

This study highlights that a PRP cell concentration close to the target (10 6 cells·μL -1 ) of patients with aRCR may improve their healing and functional outcomes and that dosing may be potentially useful in therapy.

Top 50 most impactful publications on massive rotator cuff tears

Background

Bibliometric analysis is a useful tool for measuring the scholarly impact of a topic and its more and less heavily studied aspects. The purpose of this study is to use bibliometric analysis to comprehensively analyze the 50 articles with the highest citation indices in studies evaluating the treatment and outcomes of massive rotator cuff tears (mRCTs).

Methods

This cross-sectional study identified articles within the Scopus database published through December 2022. Keywords used were "massive rotator cuff tear." Articles were sorted in chronological order. The year published and number of citations were recorded. A citation index (CI) was calculated for each article by dividing the number of citations by number of years published [1 citation/1 year published (2021) = CI of 1]. Of these, the 50 articles with the highest CIs were carried forward for evaluation. Frequencies and distributions were assessed for data of each variable collected.

Results

These search methods produced 625 articles regarding mRCT research (ranging from January 1986 to December 2022). Four of the top 10 most impactful articles were published in the 2010s. The level of evidence (LOE) published with the greatest frequency was level of evidence 4 (41%). The journal Arthroscopy published the highest number within the top 50 (26%) followed by the Journal of Bone and Joint Surgery and the American Journal of Sports Medicine (20% each). Clinical studies composed 88% of the top 50. Case series (38%) predominated, while systematic reviews (20%) and randomized control trials (8%) were less prevalent. The majority of studies concentrated on the clinical outcomes of certain interventions (62%), mainly comparing multiple interventions.

Conclusion

Despite the relatively high prevalence of mRCTs (40% of all tears), this topic comprises only a small proportion of all rotator cuff research. This analysis has identified gaps within and limitations of the findings concerning mRCTs for researchers to propose research questions targeting understudied topics and influence the future treatment and outcomes of this clinically difficult diagnosis.

Platelet-rich plasma infusion as an adjunct treatment for persistent thin lining in frozen embryo transfer cycles: first US experience report

PURPOSE

To study effect of intrauterine infusion of platelet-rich plasma (PRP) on endometrial growth in the setting of thin endometrial lining in patients with prior cancelled or failed frozen embryo transfer (FET) cycles.

MATERIALS AND METHODS

Single-arm cohort study of forty-six patients (51 cycles) with endometrial lining thickness (EMT) < 6 mm in prior cancelled or failed FET cycles requesting intrauterine PRP treatment in upcoming FET cycle. The primary outcomes were final EMT in FET cycle and change in EMT after PRP. The secondary outcomes were overall pregnancy rate, clinical pregnancy rate, miscarriage rate, ongoing pregnancy, and live birth rates.

RESULTS

The mean pre-PRP EMT in all FET cycles was 4.0 ± 1.1 mm, and mean post-PRP EMT (final) was 7.1 ± 1.0 mm. Of 51 cycles, 33 (64.7%) reached ≥ 7 mm after PRP administration. There was a significant difference between pre-PRP EMT and post-PRP EMT in all FET cycles, with mean difference of 3.0 ± 1.5 mm. Three cycles were cancelled for failure to reach adequate lining. Total pregnancy rate was 72.9% in our cohort of 48 cycles that proceeded to transfer. Clinical pregnancy rate was 54.2% (26/48 FET cycles); clinical miscarriage rate was 14.3% (5/35 pregnancies). Twenty six women had live birth (18 with EMT ≥ 7 mm and 8 with EMT < 7 mm). Response to PRP was not correlated with any pre-cycle characteristics.

CONCLUSION

We demonstrate a significant improvement in lining thickness and pregnancy rates in this challenging cohort of women after PRP infusion, with no adverse events. Cost-effectiveness of PRP with benefits and alternatives should be carefully considered.

Efficacy of platelet-rich plasma and platelet-rich fibrin in arthroscopic rotator cuff repair: A systematic review and meta-analysis

OBJECTIVE

Basic scientific studies have demonstrated positive effects of platelet-rich therapies, such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF), on tendon repair. However, clinical evidence indicating improved prognosis is controversial. In this study, we aimed to determine whether augmentation of arthroscopic rotator cuff repair with PRP and PRF improves outcomes compared to arthroscopic repair alone.

LITERATURE SURVEY

PubMed, Embase, and Cochrane library databases were comprehensively searched for randomized controlled trials (RCTs) published until June 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. No language restriction was applied.

METHODOLOGY

The primary outcomes were the rate of repeat tears after arthroscopic rotator cuff repair (retear rate) and clinical function scores (Constant-Murley Score, University of California, Los Angeles Score), and the extracted data were assessed for quality. Statistical analyses were performed using Review manager 5.3, and p < .05 was considered statistically significant.

SYNTHESIS

Ten RCTs with 628 patients were included. The results showed that augmenting surgery with PRP reduces retear rates compared to surgery alone (risk ratio [RR] = 0.40, 95% confidence interval [CI] 0.23-0.69, p = .001), whereas PRF has no effect on retear rates (p = .92). Regarding clinical function, PRP improves Constant-Murley scores (mean difference [MD] = 2.03, 95% CI 0.13-3.93, p = .04) and University of California, Los Angeles scores (MD = 1.30, 95% CI 0.36-2.24, p = .007), whereas PRF improves only Constant-Murley scores (MD = 3.93, 95% CI 1.50-6.36, p = .002). However, these differences were small and below the minimum clinically important difference threshold.

CONCLUSIONS

This study showed that compared to arthroscopic rotator cuff repair alone, the application of PRP in arthroscopic rotator cuff repair reduces retear rate and improves clinical function scores, whereas the application of PRF has no clinically meaningful benefit. The small number and heterogeneity of studies as well as methodological limitations and risk of bias limit confidence in the true effect.

Patient-reported outcome tools and baseline scores vary by country and region for arthroscopic repair of massive rotator cuff tears: a systematic review

Background

Different patient-reported outcome (PRO) tools are used in patients with arthroscopic rotator cuff repair (ARCR) which complicates outcome comparisons. The purpose of this systematic review was to compare PRO usage and baseline scores across world regions and countries in patients with ARCR of massive rotator cuff tears (MRCT).

Methods

A systematic review was performed on ARCR for MRCT. The search was conducted from September to November of 2022 using the MEDLINE database for articles published in the last 15 years. Thirty-seven articles were included after initial screening and full-text review. In each article, PRO usage, baseline scores, and country of origin were collected. PRO usage was reported in percentages and baseline scores were normalized for each region to facilitate comparisons. Normalization was performed using the PRO means from each article. These averages were converted to fractions using the worst and best possible scores. These were combined into a single numerical value, expressed as a decimal from 0 to 1, using the total sample size for each tool per region. Values closer to 0 represent worse functional outcomes.

Results

Thirty-two percent (n = 12) of articles were from Asia, 43.2% (n = 16) from Europe, 5.4% (n = 2) from the Middle East, and 18.9% (n = 7) from North America. The most commonly reported PRO tools were American Shoulder and Elbow Surgeons (ASES) in 19 papers, Constant-Murley Score (CMS) in 26 papers, Visual Analog Scale for pain (VAS) in 19 papers, and University of California in Los Angeles (UCLA) in 11 papers. ASES was reported in 51% of articles with 63% being from Asia (n = 12) compared to 21% from North America (n = 4). CMS was reported in 70% of studies with 58% being from Europe. Upon normalization, the preoperative score ranged from 0.30 to 0.44. Europe (0.39), and North America (0.40) showed similar scores. The lowest and highest scores were seen in the Middle East (0.3) and Asia (0.44) respectively.

Conclusion

There is no standardized method to report outcomes in patients undergoing ARCR for MRCT. Great variation in usage exists in PROs which complicates data comparison between world regions. With normalization, baseline scores where similar among Asia, North America, and Europe, and lowest in the Middle East.

Platelet-rich plasma in the pathologic processes of tendinopathy: a review of basic science studies

Tendinopathy is a medical condition that includes a spectrum of inflammatory and degenerative tendon changes caused by traumatic or overuse injuries. The pathological mechanism of tendinopathy has not been well defined, and no ideal treatment is currently available. Platelet-rich plasma (PRP) is an autologous whole blood derivative containing a variety of cytokines and other protein components. Various basic studies have found that PRP has the therapeutic potential to promote cell proliferation and differentiation, regulate angiogenesis, increase extracellular matrix synthesis, and modulate inflammation in degenerative tendons. Therefore, PRP has been widely used as a promising therapeutic agent for tendinopathy. However, controversies exist over the optimal treatment regimen and efficacy of PRP for tendinopathy. This review focuses on the specific molecular and cellular mechanisms by which PRP manipulates tendon healing to better understand how PRP affects tendinopathy and explore the reason for the differences in clinical trial outcomes. This article has also pointed out the future direction of basic research and clinical application of PRP in the treatment of tendinopathy, which will play a guiding role in the design of PRP treatment protocols for tendinopathy.

A network meta-analysis of arthroscopic rotator cuff repair

OBJECTIVE

Rotator cuff tear is a common shoulder injury that often leads to serious limitations in daily life. Herein, a network Meta-analysis using frequency theory was performed to evaluate the clinical outcomes of five rotator cuff repair techniques, including single-row repair, double-row repair, suture bridge repair, platelet-rich plasma therapy, and bone marrow stimulation, thus guiding clinical decision-making on rotator cuff repair.

METHODS

PubMed, EMbase, The Cochrane Library, and Web of Science were searched for randomized controlled trials and cohort studies comparing rotator cuff repair techniques published from inception to May 2022. Combined analysis and quality assessment were performed using software STATA15.1 and Review Manager5.3.

RESULTS

A total of 51 articles were finally included, including 27 randomized controlled trials and 24 cohort studies. Results from the network Meta-analysis showed that: (1) In terms of the American Shoulder and Elbow Surgeons score, platelet-rich plasma therapy, double-row repair, bone marrow stimulation, and single-row repair were significantly better than suture bridge repair. (2) In terms of Constant score, bone marrow stimulation was significantly better than double-row repair, single-row repair, and suture bridge repair. (3) In terms of visual analog scale score, platelet-rich plasma therapy was significantly better than double-row repair and suture bridge repair. (4) In terms of the Shoulder Rating Scale of the University of California at Los Angeles score, platelet-rich plasma therapy and double-row repair were relatively better but not significantly different from the other treatments. (5) In terms of the risk of re-tear, the re-tear rate of platelet-rich plasma therapy and double-row repair was significantly lower than that of single-row repair and suture bridge repair.

CONCLUSION

Based on the results of network Meta-analysis and surface under the cumulative ranking, platelet-rich plasma therapy, bone marrow stimulation, and double-row repair have good overall rehabilitation effects. It is recommended to choose appropriate repair techniques as per the actual clinical situation.

Transosseous-Equivalent/Suture Bridge Technique in Combination With Platelet-Rich Plasma Application Yield Optimal Clinical Outcomes in Arthroscopic Rotator Cuff Repair: A Bayesian Network Analysis of Randomized Controlled Trials

PURPOSE

To assess the clinical evidence defining the optimal combination of arthroscopic suture technique and platelet-rich products (PRP), and application for arthroscopic rotator cuff repair (ARCR).

METHODS

All level of evidence (LOE) I randomized controlled trials (RCT) focusing on arthroscopic suture technique and/or PRP application in ARCR were included. The exclusion criteria were LOE II or worse, studies with other interventions, studies reported none of the predetermined clinical outcomes; studies unable to extract any precise data; studies from the same patient group of included studies. A pair-wise meta-analysis and Bayesian network analysis were performed on each comparison. The intervention options were ranked by Bayesian network analysis.

RESULTS

27 studies comprising 1,947 individuals met the inclusion criteria. The application of transosseous equivalent/suture bridge repair (SB) with PRP (SB+PRP) significantly reduced retear rate (risk ratio [RR], 0.29; 95% confidence interval [CI], [0.15, 0.55].) and increased Constant-Murley score (mean difference, 1.90; 95% CI, [0.14, 3.74]), compared to SB repair. Single-row repair (SR) with PRP usage (SR+PRP) significantly reduced retear rate (RR, 0.27; 95% CI, [0.12, 0.55]) and pain visual analog scale (VAS) (mean difference: -0.84; 95% CI [-1.39, -0.46].), increased University of California, Los Angeles (UCLA) shoulder score (mean difference: 1.48; 95% CI [0.50, 2.58]) and Constant-Murley score (mean difference: 4.53; 95% CI [2.65, 6.38]), compared to SR repair. The ranking for outcomes demonstrated SB+PRP resulted in the best retear rate, UCLA shoulder score, with the second-best postoperative pain, Constant-Murley score, while SR+PRP resulted in the best postoperative pain, Constant-Murley score, with the second-best retear rate and UCLA score.

CONCLUSION

Arthroscopic rotator cuff repair utilizing SB+PRP yields optimal retear rate and UCLA shoulder score, with the second-best postoperative pain and Constant-Murley shoulder outcome score, while SR+PRP yields the best in these two parameters.

LEVEL OF EVIDENCE

Level I, Bayesian network analysis of level I RCT.

The Effect of PRP Augmentation of Arthroscopic Repairs of Shoulder Rotator Cuff Tears on Postoperative Clinical Scores and Retear Rates: A Systematic Review and Meta-Analysis

The aim of this review and meta-analysis is to assess recent clinical trials concerning the combination of operative treatment of rotator cuff tears and the administration of PRP and its effect on clinical scores and postoperative retear rates. The trials were used to compare the combination of PRP treatment and arthroscopic rotator cuff repair to arthroscopy alone. Twenty-five clinical trials were reviewed. A risk-of-bias assessment was made for all randomized clinical trials included, using the Cochrane collaboration’s tool as well as a quality assessment for all non-randomized studies utilizing the Newcastle−Ottawa scale. The PRP-treated patients showed statistically significant improvement postoperatively compared to control groups concerning the Constant−Murley (mean difference 2.46, 95% CI 1.4−3.52, p < 0.00001), SST (mean difference 0.32, 95% CI 0.02−0.63, p = 0.04), and UCLA (mean difference 0.82, 95% CI 0.23−1.43, p = 0.07) scores. A statistically significant decrease of retear rates in the PRP-treated patients, with a risk ratio of 0.78 (95% CI 0.65−0.94, p = 0.01), was found. We believe that the results presented have positive aspects, especially concerning the retear risk, but are yet inconclusive concerning clinical results such as shoulder pain and function.

Platelet-rich plasma does not improve clinical results in patients with rotator cuff disorders but reduces the retear rate. A systematic review and meta-analysis

PURPOSE

To assess whether the use of Platelet-rich plasma (PRP) produces a clinical benefit in patients with rotator cuff disorders, treated either conservatively or surgically.

METHODS

A systematic review was performed according to PRISMA guidelines on three databases (PubMed, Cochrane Library, Web of Science) to identify randomised controlled trials (RCTs) on the use of PRP in patients with rotator cuff disorders, treated either conservatively or surgically. A meta-analysis was performed on articles reporting results for Constant, UCLA, VAS, SST scores and retear rate. The RoB 2.0 and the modified Coleman Methodology Score were used to assess methodological quality.

RESULTS

A total of 36 RCTs (20 surgical, 16 conservative) were included, for a total of 2,443 patients. Conservative treatment showed high heterogeneity and no clear consensus in favour of PRP. The meta-analysis of the studies with surgical treatment showed no benefit in using PRP in any of the clinical outcomes, either at the short or medium/long-term follow-up. However, the retear rate was lower with PRP augmentation (p < 0.001). The overall quality of the studies was moderate to high, with the surgical studies presenting a lower risk of bias than the conservative studies.

CONCLUSION

The use of PRP as augmentation in rotator cuff surgical repair significantly reduces the retear rate. However, no benefits were documented in terms of clinical outcomes. PRP application through injection in patients treated conservatively also failed to present any clear advantage. While there are many studies in the literature with several RCTs of moderate to high quality, the high heterogeneity of products and studies remains a significant limitation to fully understanding PRP potential in this field.

LEVEL OF EVIDENCE

Level I.

Effect of Bone Marrow Aspirate Concentrate and Platelet-Rich Plasma Augmentation on the Rate of Revision Rotator Cuff Repair

Background:

The application of orthobiologics at the time of arthroscopic rotator cuff repair (RCR) has received an increasing amount of clinical interest despite a relative scarcity of human clinical studies on their efficacy.

Purpose:

To utilize a national administrative database to determine the association of bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) applied at the time of RCR with revision surgery rates.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The Mariner data set from the PearlDiver patient records repository was utilized to identify patients undergoing RCR using Current Procedural Terminology (CPT) code 29827. Patients receiving BMAC or PRP at the time of RCR were then identified using CPT coding. For comparison purposes, a matched cohort was created consisting of patients who underwent RCR without biologic augmentation in a 5:1 fashion for each biologic separately. Cases were matched according to age, sex, tobacco use, biceps tenodesis, distal clavicle excision, and subacromial decompression. All groups were then queried for revision RCR or conversion to reverse shoulder arthroplasty. Revision rates were compared utilizing a multivariate binomial logistic regression analysis. Adjusted odds ratios (ORs) and 95% CIs were calculated.

Results:

A total of 760 patients who underwent biologic augmentation during RCR were identified, including 646 patients in the PRP group and 114 patients in the BMAC group. They were compared with 3800 matched controls without documented biologic application at the time of surgery. Compared with matched controls, patients who received BMAC at the time of surgery experienced a significantly lower incidence of revision surgery at 2 years (OR, 0.36; 95% CI, 0.15-0.82; P = .015). There was no significant difference in revision rates between PRP and matched controls (OR, 0.87; 95% CI, 0.62-1.23; P = .183).

Conclusion:

The application of BMAC at the time of RCR was associated with a significant decrease in the incidence of revision surgery. There was no apparent effect of PRP on the incidence of revision surgery after primary RCR. Higher-level clinical studies considering surgical factors are needed to more clearly define the role of biologic adjuvants in RCR.

Long-term outcomes of teres major transfer for irreparable posterosuperior rotator cuff tears in patients aged <65 years

Background

Massive rotator cuff tears are defined as irreparable when tendon-to-bone or tendon-to-tendon continuity with the adducted arm cannot be restored and severe muscle fatty infiltration is present. Tendon transfer is a palliative procedure that improves shoulder function and relieves pain.

Methods

We reviewed the records of patients aged <65 years, whose irreparable posterosuperior rotator cuff tears had been managed with teres major tendon transfer at our institution. Their 5- and 10-year clinical and radiographic follow-up records were examined to assess long-term outcomes. Patients' Constant Score, Disabilities of the Arm, Shoulder, and Hand score, and the visual analog scale for pain were calculated before the procedure and at 5 and 10 years.

Results

There were 24 consecutive patients aged <65 years (mean, 59; 12 men and 12 women) who had received no prior treatment except rehabilitation. All patients underwent teres major tendon transfer due to the failure of conservative treatment. The mean Constant Score was 26 preoperatively and 68 and 66 at 5 and 10 years, respectively (P = .0001 and P = .25). The mean Disabilities of the Arm, Shoulder, and Hand scores were 62.2 preoperatively and 7.8 and 9.3 at 5 and 10 years, respectively (P = .0009 and P = .1). The mean visual analog scale scores at rest were 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (P = .0003 and P = .1). Based on Hamada's classification, at 5 years, 3 patients showed grade 2 changes, and another had grade 3 changes; at 10 years, 7 patients showed grade 2 changes, and one showed grade 3 changes. Complications (8%) developed after the 10-year evaluation and included pain in 1 patient and secondary rupture of the transfer in another.

Discussion

Improving shoulder function and reducing pain in relatively young patients with irreparable posterosuperior cuff tears involves replacing the lost muscle with a muscle-tendon transfer. The chief aims of the procedure are to restore the balance with the subscapularis muscle, achieve joint stability, keep the humeral head in the glenoid cavity, and improve shoulder abduction and external rotation. Teres major tendon transfer can achieve these goals. Altogether, 22 of our 24 patients experienced improved daily activity function and pain relief that became stable after 5 years. Teres major transfers are useful surgical procedures, particularly in younger patients and in those with high functional demands, providing good and stable long-term results.

Clinical perspectives for repairing rotator cuff injuries with multi-tissue regenerative approaches

Background

In the musculoskeletal system, bone, tendon, and muscle form highly integrated multi-tissue units such as the rotator cuff complex, which facilitates functional and dynamic movement of the shoulder joint. Understanding the intricate interplay among these tissues within clinical, biological, and engineering contexts is vital for addressing challenging issues in treatment of musculoskeletal disorders and injuries.

Methods

A wide-ranging literature search was performed, and findings related to the socioeconomic impact of rotator cuff tears, the structure-function relationship of rotator cuff bone-tendon-muscle units, pathophysiology of injury, current clinical treatments, recent state-of-the-art advances (stem cells, growth factors, and exosomes) as well as their regulatory approval, and future strategies aimed at engineering bone-tendon-muscle musculoskeletal units are outlined.

Results

Rotator cuff injuries are a significant socioeconomic burden on numerous healthcare systems that may be addressed by treating the rotator cuff as a single complex, given its highly integrated structure-function relationship as well as degenerative pathophysiology and limited healing in bone-tendon-muscle musculoskeletal tissues. Current clinical practices for treating rotator cuff injuries, including the use of commercially available devices and evolving trends in surgical management have benefited patients while advances in application of stem/progenitor cells, growth factors, and exosomes hold clinical potential. However, such efforts do not emphasize targeted regeneration of bone-tendon-muscle units. Strategies aimed at regenerating bone-tendon-muscle units are thus expected to address challenging issues in rotator cuff repair.

Conclusions

The rotator cuff is a highly integrated complex of bone-tendon-muscle units that when injured, has severe consequences for patients and healthcare systems. State-of-the-art clinical treatment as well as recent advances have resulted in improved patient outcome and may be further enhanced by engineering bone-tendon-muscle multi-tissue grafts as a potential strategy for rotator cuff injuries.

Translational Potential of this Article

This review aims to bridge clinical, tissue engineering, and biological aspects of rotator cuff repair and propose a novel therapeutic strategy by targeted regeneration of multi-tissue units. The presentation of these wide-ranging and multi-disciplinary concepts are broadly applicable to regenerative medicine applications for musculoskeletal and non-musculoskeletal tissues.

Injection of Leukocyte-Poor Platelet-Rich Plasma for Moderate-to-Large Rotator Cuff Tears Does Not Improve Clinical Outcomes but Reduces Retear Rates and Fatty Infiltration: A Prospective, Single-Blinded Randomized Study

OBJECTIVES

To determine whether leukocyte-poor platelet-rich plasma (Lp-PRP) reduced retear rates, reduced fatty infiltration, and improved functional outcomes in patients with degenerative moderate-to-large rotator cuff tears.

METHODS

This was a randomized controlled study at a single center. A consecutive series of 104 patients with moderate-to-large rotator cuff tears was enrolled and randomly allocated to a control group (double-row suture-bridge arthroscopic rotator cuff repair alone, n = 52) and a study group (double-row suture-bridge repair followed by 3 Lp-PRP injections at the tendon repair site during surgery, at days 7 and 14 after surgery, n = 52). All patients were followed up for 27.2 months (range 24-36 months), with University of California at Los Angeles (UCLA) shoulder rating scale, the Constant score, and a visual analog scale (VAS) evaluated respectively. The integrity and fatty infiltration of repaired tissue were assessed by magnetic resonance imaging using the Sugaya classification and Goutallier grade classification at 24 months after surgery. Statistical analysis was performed based on the t test, χ² test, and the Kendall tau-b correlation coefficient.

RESULTS

Four patients refused follow-up, and 11 patients had incomplete data. Eventually, a total of 89 patients were available for 24 months follow-up. The mean UCLA score increased from 14.80 ± 2.53 to 29.37 ± 2.06 in control group and from 13.74 ± 3.30 to 30.14 ± 2.32 in study group (P = .103). The mean Constant score increased from 46.56 ± 5.90 to 86.83 ± 4.94 in control group and from 44.37 ± 7.92 to 88.80 ± 4.92 in study group (P = .063). The VAS score decreased from 3.22 ± 1.24 to 0.97 ± 1.12 in control group and in 3.49 ± 1.52 to 1.16 ± 0.99 in study group (P = .41). All differences in UCLA score, Constant score, and VAS between pre- and postoperation achieved minimal clinically important differences proposed for arthroscopic rotator cuff repair. Of the 89 patients, 76 had magnetic resonance imaging performed at 24 months after surgery. The retear rate was 17.6% in study group, which was lower than that in control group (38.1%, P = .049). In addition, the Goutallier grade was found to be significant difference between groups postoperatively (Kendall tau-b -0.24, P = .03) but no significant difference preoperatively (Kendall tau-b -0.18, P = .11). There were no complications in the patients.

CONCLUSIONS

Our procedures involving repeated injections of Lp-PRP during surgery and at days 7 and 14, as described in this study, have positive effects on reducing retear rate and promoting Goutallier grade in patients following arthroscopic rotator cuff repair and could also provide substantial clinical outcomes that reach the minimal clinically important difference for surgical treatment. However, given the numbers available for analysis, it did not promote better clinical results when compared with the control group.

LEVEL OF EVIDENCE

II, randomized controlled study.

Limited evidence for biological treatment measures for cartilage and tendon injuries of the shoulder

PURPOSE

To critically review the available literature on the usage of biologics to treat cartilage and tendon injuries of the shoulder.

METHODS

Four different databases were searched in January 2020 for studies reporting data on bone marrow stimulation, autologous chondrocyte implantation, platelet-rich plasma, autologous concentrated serum, and bone marrow aspirate concentrate for the treatment of cartilage and/or tendon injuries of the shoulder. Prospective, retrospective, cohort and case-control studies as well as case series, systematic reviews and laboratory studies (involving human tissue) were included. Cadaveric or animal studies were excluded. Findings were summarized and an expert opinion on trends was provided.

RESULTS

Although there is limited literature available on biologics in cartilage lesions of the shoulder, the advancement from micro- to nanofracture, that is well established for the treatment of cartilage lesions in the knee, may be the next step in the treatment of shoulder lesions as well. The high rate of failure and therefore the complexity of tendon healing following rotator cuff repair has led to a rising interest in biologic augmentation such as platelet-rich plasma and stem cells to enhance tendon-bone-healing and to decrease the prevalence of failure. Despite the increase in publications, there exists a huge heterogeneity of content, quality, and quantity of among studies and their processing methods reporting the use of platelet-rich plasma in rotator cuff repair.

CONCLUSION

Conclusions from individual studies cannot be generalized. Currently, no evidence supports that platelet-rich plasma provides clinical benefits in rotator cuff repair. Similar is reported for microfracture in rotator cuff repair, however, despite no clinical benefits, microfracture has shown to reduce the appearance of structural failures. Although some evidence exists for the use of stem cells form bone marrow aspirate concentrate, results from large case series are still lacking.

LEVEL OF EVIDENCE

Level V.

Leukocyte-Rich and Leukocyte-Poor Platelet-Rich Plasma in Rotator Cuff Repair: A Meta-analysis

To systematically review of randomized controlled trials(RCTs) to compared the effects of leukocyte-rich and leukocyte-poor platelet-rich plasma in arthroscopic rotator cuff repair. Two independent reviewers comprehensively searched PubMed, Embase, and Cochrane library databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparison of leukocyte-rich platelet-rich plasma or leukocyte-poor platelet-rich plasma in rotator cuff repair in a level I RCTs. Methodological quality assessment was carried out using Cochrane Review Manager 5.3 software. P<0.05 was considered statistically significant. Nine RCTs with 540 patients were included in this review. Meta-analysis showed that leukocyte-poor platelet-rich plasma in significantly reduced retear rate in rotator cuff repair [RR=0.56 95%CI (0.42,0.75); P＜0.05), and in clinical results, the constant score [MD=3.67, 95%CI (1.62,5.73); P=0.0005], UCLA score [MD=1.60, 95%CI (0.79,2.42); P=0.0001], ASES score [MD=2.16, 95%CI(0.12,4.20);P=0.04] were significantly improved. There was a significant result in favor of PRP for the Constant score [MD=-1.24, 95%CI(-1.50,-0.99); P＜0.00001], while SST scores were not significantly different among all groups [MD=0.21, 95%CI(-0.21,0.64); P=0.32]. In conclusion, leukocyte-poor platelet-rich plasma can improved the clinical function and reduced retear rate in arthroscopic rotator cuff repair. In contrast, the efficacy of leukocyte-rich platelet-rich plasma was not significantly improved with the exception of VAS score.

Better Short-Term Outcomes After Rotator Cuff Repair in Studies With Poorer Mean Shoulder Scores and Predominantly Small to Medium-Sized Tears at Baseline: A Systematic Review and Meta-analysis

PURPOSE

To perform a meta-analysis to explore factors associated with clinical and structural short-term outcomes in randomized and nonrandomized prospective studies of rotator cuff repair.

METHODS

Medline, clinicaltrials.gov, and Mendeley were searched for literature published from January 2000 to December 2020 to identify randomized controlled trials (RCT) and nonrandomized prospective cohort studies (PCS) describing the outcome of surgical repair of full-thickness rotator cuff tears. Study quality was assessed by two independent reviewers. We calculated standardized mean difference (SMD) from baseline to follow-up in each trial arm, preferably at 12 months follow-up. Between-study heterogeneity of outcomes, small-study effects and rates of retear were assessed. Meta-regression was performed to estimate associations between prespecified variables and clinical and structural outcomes.

RESULTS

Outcomes in 64 RCT and 19 PCS trial arms were analyzed. Median age was 59 years. There was substantial between-study heterogeneity in clinical outcomes (SMD range: .42 to 6.44; I² = 93% in RCT, 88% in PCS) and summary estimates were not calculated. On the basis of multivariate analysis, better clinical outcome was associated with lower (worse) mean outcome value at baseline, smaller tear size, and lower proportion of large-massive tears (R² = 56 and 44%, respectively). Overall retear rate at median 13-month follow-up was 19.9% (interquartile range: 10-30). Higher mean age together with larger tear size and higher proportion of large-massive tears were associated with increased retear rates (R² = 33% and 58%, respectively). Clinical outcome was not significantly related to rate of retear.

CONCLUSIONS

Studies with lower mean outcome values at baseline and predominantly small- to medium-sized tears reported better clinical outcomes. Studies with higher mean age and a predominance of large-massive tears had significantly increased retear rates, but retear rates were not associated with clinical outcome.

LEVEL OF EVIDENCE

Level II, meta-analysis of level I and II studies.

Platelet-Rich Plasma Has Better Results for Retear Rate, Pain, and Outcome Than Platelet-Rich Fibrin After Rotator Cuff Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE

To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) in the literature to ascertain the extent to which platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) improved patient outcomes in arthroscopic rotator cuff repair.

METHODS

Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with a third author resolving any discrepancies. RCTs comparing PRP or PRF to a control in rotator cuff repair were included. Quality of evidence was assessed using the Cochrane Collaboration risk of bias tool. Clinical outcomes were compared using the risk ratio for dichotomous variables and the mean difference for continuous variables. A P value <.05 was deemed statistically significant.

RESULTS

Included in this review are 23 RCTs with 1440 patients. PRP resulted in significantly decreased rates of retear (15.9% versus 29.0%, respectively; P < .0001). Significant results were noted in favor of PRP compared with control based on the Constant score (83.9 versus 81.2, respectively; P = .0006); the University of California, Los Angeles score (31.1 versus 30.2; P < .00001); the American Shoulder and Elbow Surgeons score (87.3 versus 84.5; P = .04); and the visual analog scale score (1.3 versus 1.6; P = .01). PRF resulted in an improved Constant score (80.1 versus 80.0, respectively; P = .04) compared with control.

CONCLUSIONS

The current evidence shows that using PRP in arthroscopic rotator cuff repair can improve pain levels and functional outcome scores while reducing the retear rate after surgery. PRF injection, on the other hand, improves only the Constant score.

LEVEL OF EVIDENCE

II; systematic review and meta-analysis of level I and II evidence.

Autograft Long Head Biceps Tendon Can Be Used as a Scaffold for Biologically Augmenting Rotator Cuff Repairs

PURPOSE

We create a viable, mechanically expanded autograft long head biceps tendon (LHBT) scaffold for biologically augmenting the repair of torn rotator cuffs.

METHODS

The proximal aspect of the tenotomized LHBTs was harvested from patients during rotator cuff repair surgery and was mechanically formed into porous scaffolds using a surgical graft expander. LHBT scaffolds were evaluated for change in area, tensile properties, and tenocyte viability before and after expansion. The ability of endogenous tenocytes derived from the LHBT scaffold to promote tenogenic differentiation of human adipose-derived mesenchymal stromal cells (ADMSCs) was also determined.

RESULTS

Autograft LHBTs were successfully expanded using a modified surgical graft expander to create a porous scaffold containing viable resident tenoctyes from patients undergoing rotator cuff repair. LHBT scaffolds had significantly increased area (length: 24.91 mm [13.91, 35.90] × width: 22.69 mm [1.87, 34.50]; P = .011) compared with the native LHBT tendon (length: 27.16 mm [2.70, 33.62] × width: 6.68 mm [5.62, 7.74]). The structural properties of the autograft were altered, including the ultimate tensile strength (LHBT scaffold: .56 MPa [.06, 1.06] vs. native LHBT: 2.35 MPa [1.36, 3.33]; P = .002) and tensile modulus (LHBT scaffold: 4.72 MPa [-.80, 1.24] versus native LHBT: 37.17 MPa [24.56, 49.78]; P = .001). There was also a reduction in resident tenocyte percent viability (LHBT scaffold: 38.52% [17.94, 59.09] vs. native LHBT: 68.87% [63.67, 74.37]; P =.004). Tenocytes derived from the LHBT scaffold produced soluble signals that initiated ADMSC differentiation into an immature tenocyte-like phenotype, as indicated by an 8.7× increase in scleraxis (P = .040) and a 3.6× increase in collagen type III mRNA expression (P = .050) compared with undifferentiated ADMSC controls.

CONCLUSIONS

The ability to produce a viable autologous scaffold from the proximal biceps tendon having dimensions, porosity, mechanical characteristics, native ECM components, and viable tenocytes that produce bioactive signals conducive to supporting the biologic augmentation of rotator cuff repair surgery has been demonstrated.

CLINICAL RELEVANCE

This biologically active construct may help to improve the quality of healing and regeneration at the repair site of rotator cuff tears, especially those at high risk for retear.

Systematic Review of Platelet-Rich Plasma for Rotator Cuff Repair: Are We Adhering to the Minimum Information for Studies Evaluating Biologics in Orthopaedics?

Background

The therapeutic efficacy of orthobiologic therapies for rotator cuff repair is difficult to evaluate owing to reporting inconsistences. In response, the Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) guidelines were developed to ensure standard reporting on orthobiologic therapies.

Purpose

To systematically review clinical studies evaluating platelet-rich plasma (PRP) for full-thickness rotator cuff repair and adherence to MIBO guidelines.

Study Design

Scoping review; Level of evidence, 4.

Methods

A search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, EMBASE, and the Cochrane Library databases. Inclusion criteria were clinical studies reporting on rotator cuff tears (≥1 cm) surgically repaired with PRP. Patient demographics, biologic intervention, and adherence to the MIBO guidelines were systematically reviewed.

Results

A total of 19 studies (1005 patients) were included in this review. Across all studies, 58.5% of the MIBO checklist items for PRP were reported. Out of 47 checklist items, 19 were reported in over 85% of studies, whereas 22 were reported in less than half of studies. Details of whole-blood processing and characteristics, as well as PRP processing and characteristics, were reported inconsistently, and no study provided adequate information to enable the precise replication of preparation protocols for PRP.

Conclusion

This systematic review highlights the current reporting deficiencies within the scientific literature of important variables for evaluating PRP for full-thickness rotator cuff repair. There was widespread variability among published studies that evaluate PRP for this application and, more specifically, studies were limited by inconsistent universal reporting of whole-blood and PRP processing and postprocessing characteristics. To improve our understanding of biologic efficacy and to promote repeatability, stricter adherence to the MIBO guidelines is necessary. We propose that the checklist limitations be addressed and that modification of the MIBO guidelines be considered to improve the reporting of individual components within certain categories.

Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis

BACKGROUND

There is no consensus about the best choice between all the options available for large and massive rotator cuff tear (mRCTs) management.

OBJECTIVE

To determine the comparative effectiveness of current treatment options for management of large and mRCTs.

DESIGN

Network meta-analysis.

SETTING

We searched the Cochrane systematic reviews, MEDLINE and EMBASE databases for all trials of adults with large and mRCTs that report preoperative and postoperative functional scores after an intervention option.

PATIENTS

The network meta-analysis included 20 trials with 1233 patients with 37.24 months follow-up.

INTERVENTIONS

Eight treatment options for management of large and mRCTs were compared.

MAIN OUTCOME MEASURES

The primary effectiveness outcome was the functional score.

RESULTS

This meta-analysis did not show statistically significant differences between conservative, partial repair, patch or platelet rich plasma (PRP) augmentation, reverse total shoulder arthroplasty, and complete repair. Latissimus dorsi (LD) transfer was ranked first for effectiveness [standardized mean difference (SMD): 2.17, 0.28-4.07] and debridement ranked last (SMD: -2.15, -3.13 to -1.17).

CONCLUSIONS

Latissimus dorsi transfer seems to be most effective for management of large and mRCTs, although some heterogeneity was observed in this network meta-analysis of full text reports. The choice of the operating technique depends on the patient's general health status and his expectations. When a decision has been reached to perform surgery, a repair, even if partial, should be attempted. Procedures involving biologic augmentation (eg, PRP) seem to convey no additional benefit while introducing more risk. Debridement alone should be avoided.

The Statistical Fragility of Platelet-Rich Plasma in Rotator Cuff Surgery: A Systematic Review and Meta-analysis

BACKGROUND

The practice of evidence-based medicine relies on objective data to guide clinical decision-making with specific statistical thresholds conveying study significance.

PURPOSE

To determine the utility of applying the fragility index (FI) and the fragility quotient (FQ) analysis to randomized controlled trials (RCTs) evaluating the utilization of platelet-rich plasma (PRP) in rotator cuff repairs (RCRs).

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

RCTs pertaining to the utilization of PRP in surgical RCRs published in 13 peer-reviewed journals from 2000 to 2020 were evaluated. The FI was determined by manipulating each reported outcome event until a reversal of significance was appreciated. The associated FQ was determined by dividing the FI by the sample size.

RESULTS

Of the 9746 studies screened, 19 RCTs were ultimately included for analysis. The overall FI incorporating all 19 RCTs was only 4, suggesting that the reversal of only 4 events is required to change study significance. The associated FQ was determined as 0.092. Of the 43 outcome events reporting lost to follow-up data, 13 (30.2%) represented lost to follow-up >4.

CONCLUSION

Our analysis suggests that RCTs evaluating PRP for surgical RCRs may lack statistical stability with only a few outcome events required to alter trial significance. Therefore, we recommend the reporting of an FI and an FQ in conjunction with P value analysis to carefully interpret the integrity of statistical stability in future comparative trials.

CLINICAL RELEVANCE

Clinical decisions are often informed by statistically significant results. Thus, a true understanding of the robustness of the statistical findings informing clinical decision-making is of critical importance.

Peri-operative platelet-rich plasma in arthroscopic femoroacetabular impingement surgery: a randomized controlled trial

This study aimed to determine whether the addition of platelet-rich plasma (PRP) during hip arthroscopy improves functional outcomes in femoroacetabular impingement (FAI) surgery. This was a prospective randomized single-blinded trial of arthroscopic hip patients aged between 16 and 50 years with a diagnosis of FAI conducted at a single centre. Patients with any previous hip surgery and significant osteoarthritic changes (Tonnis grade > 2) were excluded. Before surgery, patients were randomly assigned to receive either a PRP injection or a saline placebo. Efficacy was evaluated at 6 months, 1 year and 2 years post-surgery using patient-reported outcomes. The short version International Hip Outcome Tool (iHOT12) was the primary outcome. Recruited patients (n = 113) were aged 36.0 ± 10.5 (mean ± standard deviation) years and 56% male. At baseline, iHOT12 scores of the PRP (mean 43.8 ± 22.4) and placebo groups (mean 45.2 ± 21.5) were similar. At a minimum follow-up of 2 years, both groups had improved iHOT12 scores (PRP: mean 83.6 ± 13.4, control: mean 77.1 ± 23.3), with no significant difference in change between the two groups (P = 0.19). There were no significant group differences for the change in Non-Arthritic Hip and Hip Disability and Osteoarthritis Outcome Score—Shortform scores between the two groups (P = 0.22 and 0.46, respectively). The present study does not support the peri-operative use of PRP in arthroscopic surgery for FAI for mid-term improvement. There were no significant differences in outcome between PRP and placebo groups at 2-year minimum follow-up after surgery.

Retear rates after rotator cuff surgery: a systematic review and meta-analysis

Background

Rotator cuff retear (RCR) is one of the main postoperative drawbacks. RCR can be considered a multifactorial issue, which causes are related either to biological than biomechanical factors. The aim of this study was to define the incidence of RCR after surgical treatment at different time points and to identify the main factors influencing the postoperative rotator cuff (RC) healing.

Methods

A systematic review and meta-analysis were performed following the PRISMA guidelines. A comprehensive search of the literature was carried out in July 2020, using PubMed and Cochrane Library databases. Only level 1 and 2 clinical evidence studies were included. Studies were included if patients with preoperative repairable full-thickness RC tears were treated surgically, and if studies reported postoperative RCR confirmed by imaging diagnostic. The association between timing of retear and follow-up time points were investigated using an inverse-variance method of pooling data. A subgroup meta-analysis was performed using the DerSimonian and Laird method for the estimation of the between-study variance, i.e., τ². The association between retear rate after surgery and patients’ age, preoperative tear size, fatty infiltration, postoperative rehabilitation protocol, surgical techniques, and RC repairs was determined by expressing the effect measure in terms of odds ratio (OR) with 95% confidence interval (CI). The Mantel-Haenszel method with 95% CIs was used.

Results

Thirty-one articles were included in this study. The percentage of RCR after surgery was 15% at 3 months follow-up, 21% at 3–6 months follow-up, 16% at 6–12 months follow-up, 21% at 12–24 months follow-up, 16% at follow-up longer than 24 months. The main factors influencing RC healing are both patient-related (i.e., age, larger tear size, fatty infiltration) and not patient-related (i.e., postoperative rehabilitation protocol, surgical techniques, and procedures).

Conclusions

Postoperative RC healing is influenced by patient-related and non-patient-related factors. Further high-level clinical studies are needed to provide highly relevant clinical results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04634-6.

Platelet-Rich Product Supplementation in Rotator Cuff Repair Reduces Retear Rates and Improves Clinical Outcomes: A Meta-analysis of Randomized Controlled Trials

PURPOSE

The purpose of this study was to conduct a comprehensive systematic review and meta-analysis to investigate the clinical and imaging outcomes of all 4 types of platelet-rich therapies (pure platelet-rich plasma [P-PRP], leukocyte and platelet-rich plasma, pure platelet-rich fibrin, and leukocyte and platelet-rich fibrin) in rotator cuff repairs.

METHODS

A systematic literature search was performed to identify rotator cuff tears comparing any of the 4 types of platelet-rich products (PRP) to a control in rotator cuff repair. Data extracted from the studies included retear rates diagnosed with imaging studies, as well as outcome scores such as Constant, American Shoulder and Elbow Surgeons (ASES), University of California Los Angeles (UCLA), Simple Shoulder Test (SST), and visual analog scale (VAS). Meta-analyses compared postoperative outcome scores and retear rates between the control and study groups.

RESULTS

Seventeen studies were included in the meta-analysis. When pooling data from all studies, retear rate for the treatment group was 19.3%, compared to 25.4% for the control group (odds ratio [OR] 0.59, P = .0037). When stratified based on PRP type, only P-PRP resulted in a significant reduction in retear rate (OR 0.26, P = .0005). Overall, treatment with PRP significantly improved Constant scores when compared to controls (mean difference [MD] 2.41, P =.0027), as well as VAS scores (MD -0.12, P = .0014), and SST scores (MD 0.41, P = .0126). There was no significant difference in ASES scores (MD 0.37, P = .7762) or UCLA scores (MD 0.76, P =0.2447) between treatment and controls when pooling data from all studies.

CONCLUSIONS

This analysis demonstrates significant reductions in retear rates when rotator cuff repair is augmented with PRP. P-PRP appears to be the most effective formulation, resulting in significantly improved retear rates and clinical outcome scores when compared with controls.

Application of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

Background:

It is unclear how and which factors affect the clinical efficacy of platelet-rich plasma (PRP) applied during arthroscopic rotator cuff repair.

Purpose:

To evaluate the clinical efficacy of PRP for arthroscopic repair of full-thickness rotator cuff tear and investigate the factors that affect its clinical efficacy.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

We searched Cochrane Library, EMBASE, MEDLINE, and OVID to identify randomized controlled trials (RCTs) of patients who received PRP treatment and arthroscopic rotator cuff repair (PRP group) versus controls (no-PRP group). The primary outcomes included retear rate, Constant-Murley score, University of California Los Angeles (UCLA) score, short-term American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, and adverse events.

Results:

A total of 14 RCTs were included in this systematic review. Significant improvement in Constant-Murley, UCLA, and VAS pain scores were found in the PRP group during short-term, midterm, and long-term follow-up. The PRP group had a significantly decreased retear rate (risk ratio [RR], 0.57 [95% CI, 0.42 to 0.78]; P = .0003), especially for long-term follow-up (RR, 0.38 [95% CI, 0.17 to 0.83]; P = .02), large to massive tears (RR, 0.58 [95% CI, 0.42 to 0.80]; P = .0008), use of leukocyte-poor PRP (RR, 0.50 [95% CI, 0.33 to 0.76]; P = .001), and intraoperative application of PRP (RR, 0.57 [95% CI, 0.42 to 0.79]; P = .0007). No significant difference between the 2 groups was found in the incidence of adverse events (RR, 1.34 [95% CI, 0.83 to 2.15]; P = .23) or in ASES scores at short-term follow-up (weighted mean difference, 1.04 [95% CI, –3.10 to 5.19]; P = .62).

Conclusion:

The results of this review indicated that arthroscopic rotator cuff repair with PRP significantly reduced the long-term retear rate and shoulder pain and provided improved long-term shoulder function in patients. Intraoperative application of PRP, use of leukocyte-poor plasma, and large to massive tear size contributed to a significantly decreased retear rate for rotator cuff repair combined with PRP.

Current Options in Tendon Transfers for Irreparable Posterosuperior Rotator Cuff Tears

Massive irreparable posterosuperior rotator-cuff tears are debilitating lesions that usually require surgical treatment. Even though there is no consensus regarding the best surgical technique, tendinous transfers around the shoulder are the most commonly performed procedures. The latissimus dorsi tendon remains the most commonly used, but different modifications to the original technique have been shown to minimize complications and to improve functional results and satisfaction. Other techniques, such as the transfer of the lower trapezius tendon, are promising and should be considered, especially for patients with isolated loss of external rotation. The present paper is a literary review regarding tendon transfers for irreparable posterosuperior rotator-cuff tears.

Allogenic Pure Platelet-Rich Plasma Therapy for Adhesive Capsulitis: A Bed-to-Bench Study With Propensity Score Matching Using a Corticosteroid Control Group

BACKGROUND

While platelet-rich plasma (PRP) has been widely studied for musculoskeletal disorders, few studies to date have reported its use for adhesive capsulitis (AC). Fully characterized and standardized allogenic PRP may provide clues to solve the underlying mechanism of PRP with respect to synovial inflammation and thus may clarify its clinical indications.

PURPOSE

To clinically evaluate the safety and efficacy of a fully characterized pure PRP injection in patients with AC and to assess the effects of pure PRP on synoviocytes with or without inflammation in vitro.

STUDY DESIGN

Controlled laboratory study and cohort study; Level of evidence, 3.

METHODS

For the clinical analysis, a total of 15 patients with AC received an ultrasonography-guided intra-articular PRP injection and were observed for 6 months. Pain, range of motion (ROM), muscle strength, shoulder function, and overall satisfaction in the patients were evaluated using questionnaires at 1 week as well as at 1, 3, and 6 months after the PRP injection and results were compared with the results of a propensity score-matched control group that received a corticosteroid injection (40 mg triamcinolone acetonide). For the in vitro analysis, synoviocytes were cultured with or without interleukin-1β (IL-1β) and PRP. The gene expression of proinflammatory and anti-inflammatory cytokines as well as matrix enzymes and their inhibitors was evaluated.

RESULTS

At 6-month follow-up, pure PRP significantly decreased pain and improved ROM, muscle strength, and shoulder function to levels comparable with those after a corticosteroid injection. All pain values, strength measurements, and functional scores significantly improved up to 6 months in the PRP group, but these measures improved up to 3 months and then were decreased at 6 months in the corticosteroid group. ROM was significantly improved in the 2 groups at 6 months compared with baseline. Allogenic PRP did not cause adverse events. For the in vitro findings, PRP induced inflammation but significantly improved the IL 1β-induced synovial inflammatory condition by decreasing proinflammatory cytokines such as IL-1β, tumor necrosis factor-α, IL-6, cyclooxygenase-2, and microsomal prostaglandin E synthase-1 and decreased matrix enzymes (matrix metalloproteinase-1, -3, and -13 as well as a disintegrin and metalloproteinase with thrombospondin motifs-4 and -5) and further increasing anti-inflammatory cytokines such as vasoactive intestinal peptide.

CONCLUSION

This study showed that PRP decreased pain and improved shoulder ROM and function to an extent comparable with that of a corticosteroid in patients with AC. Allogenic pure PRP acted in a pleiotropic manner and decreased proinflammatory cytokines only in the inflammatory condition.

CLINICAL RELEVANCE

Allogenic PRP could be a treatment option for the inflammatory stage of AC.

The Effect of Platelet-Rich Plasma Leukocyte Concentration on Arthroscopic Rotator Cuff Repair: A Network Meta-analysis of Randomized Controlled Trials

BACKGROUND

It is unclear whether leukocyte-poor (LP) or leukocyte-rich (LR) varieties of platelet-rich plasma (PRP) as an adjuvant to arthroscopic rotator cuff repair (ARCR) result in improved tendon healing rates.

PURPOSE

To perform a network meta-analysis of the randomized controlled trials in the literature to ascertain whether there is evidence to support the use of LP- or LR-PRP as an adjunct to ARCR.

METHODS

The literature search was based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Randomized controlled trials comparing LP- or LR-PRP with a control alongside ARCR were included. Clinical outcomes, including retears and functional outcomes, were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-score.

RESULTS

There were 13 studies (868 patients) included, with 9 studies comparing LP-PRP with a control and 4 studies comparing LR-PRP with a control. LP-PRP was found to significantly reduce the rate of retear and/or incomplete tendon healing after fixation, even among medium-large tears; it also improved outcomes on the visual analog scale for pain, Constant score, and University of California Los Angeles score. LP-PRP had the highest P-score for all treatment groups. LR-PRP did not result in any significant improvements over the control group, except for visual analog scale score for pain. However, post hoc analysis revealed that LP-PRP did not lead to significant improvements over LR-PRP in any category.

CONCLUSION

The current study demonstrates that LP-PRP reduces the rate of retear and/or incomplete tendon healing after ARCR and improves patient-reported outcomes as compared with a control. However, it is still unclear whether LP-PRP improves the tendon healing rate when compared with LR-PRP.

Double-Row Rotator Cuff Repair Enhanced With Platelet-Rich Therapy Reduces Retear Rate: A Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE

To assess retear rates in arthroscopic double-row rotator cuff repair (double-row RCR) with and without platelet-rich therapy (PRT).

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, Embase, and Scopus databases were searched for RCTs involving use of PRT exclusively in arthroscopic double-row RCR. A random-effects model and the generic inverse variance method were used for quantitative data synthesis. Heterogeneity was tested with the I² statistic index.

RESULTS

The 9 RCTs included in the meta-analysis demonstrated a risk reduction of 49% for retears in patients receiving PRT (risk ratio [RR] 0.51; 95% confidence interval [CI] 0.35 to 0.76; P = .0008; I² = 0%). Divided by tear sizes, retear risk reduction of 47% (RR 0.53; 95% CI 0.30 to 0.95; P = .03; I² = 0%) was found in small to medium tears and 51% (RR 0.49; 95% CI 0.29 to 0.84; P = .009; I² = 0%) in large to massive tears. Linked double-row RCR resulted in risk reduction of 51% for retears in comparison with nonlinked repairs.

CONCLUSION

Double-row RCR plus PRT significantly reduced retear rates in all sizes of rotator cuff tears. Linked double-row RCR and applying the PRT during the surgical procedure and in the tendon-bone interface reproduced the best outcomes. Clinically, all patients improved, and no statistically significant difference was seen in clinical and functional scores between the intervention groups. All patients achieved optimal values for patient-reported outcomes measures.

LEVEL OF EVIDENCE

I, systematic review and meta-analysis of level I studies.

The clinical efficacy of leukocyte-poor platelet-rich plasma in arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of platelet-rich plasma (PRP) in the arthroscopic treatment of rotator cuff injury has been reported in the literature. However, conclusions have been inconsistent and more often related to differences in the types of PRP used. Therefore, to minimize these differences, we performed a meta-analysis of only studies investigating leukocyte-poor PRP to evaluate whether PRP promotes and improves the effects of arthroscopic rotator cuff repair.

METHODS

A comprehensive search of the PubMed, Embase, and Cochrane Library databases was conducted to evaluate the efficacy of leukocyte-poor PRP in arthroscopic rotator cuff repair. The available data were extracted, and the methodologic quality of the included studies was evaluated by the Cochrane risk-of-bias assessment tool.

RESULTS

In total, 10 randomized controlled trials involving 742 patients were included. The results of the meta-analysis showed that treatment with leukocyte-poor PRP performed better than the control treatment in relieving postoperative pain in the short-term (mean difference [MD], -0.57; 95% confidence interval [CI], -0.79 to -0.35; P < .0001) and medium- and long-term (MD, -0.18; 95% CI, -0.34 to -0.03; P = .02) follow-up groups. However, the changes in the MD in the visual analog scale score were below the minimal clinically important difference. Regarding the Constant shoulder (MD, 3.35; 95% CI, 1.68-5.02; P < .0001) and University of California, Los Angeles (MD, 1.73; 95% CI, 0.94-2.52; P < .0001) scores, statistically significant differences were found in favor of leukocyte-poor PRP over the control treatment. However, the changes in the MD in both the Constant and University of California, Los Angeles scores were below the minimal clinically important difference. Moreover, during medium- and long-term follow-up, the retear rate in the leukocyte-poor PRP group was lower than that in the control group regardless of the rotator cuff tear size (small and medium [<3 cm] [risk ratio (RR), 0.64; 95% CI, 0.43-0.97; P = .03] vs. medium and large [>3 cm] [RR, 0.51; 95% CI, 0.34-0.77; P = .001]) and surgical repair method (single-row repair [RR, 0.61; 95% CI, 0.43-0.87; P = .007] vs. double-row suture bridge repair [RR, 0.57; 95% CI, 0.38-0.84; P = .005]).

CONCLUSION

According to our study, leukocyte-poor PRP can significantly reduce the postoperative retear rate in the medium and long term regardless of the tear size and the method used for rotator cuff repair. However, the use of leukocyte-poor PRP failed to show clinically meaningful effects in terms of postoperative pain and patient-reported outcomes.

Platelet-rich plasma: a narrative review

The aim of this article was to synopsize platelet-rich plasma (PRP) use in musculoskeletal pathologies through evidence-based assessment of the preparation, classification, mechanism of action and applications of PRP, thereby answering which PRP type is best for each clinical indication.

The literature search was performed using Medline, EMBASE and Cochrane Reviews databases for papers containing the key terms “platelet-rich plasma” AND “orthopaedics” AND (“classification” OR “mechanism of action” OR “preparation” OR “clinical application”). Generated papers were evaluated for pertinence in following areas: preparation, classification, mechanism of action, clinical application within orthopaedics. Non-English papers were excluded. Included studies were evaluated for quality.

Sixty studies were included in our review. There are many commercial PRP preparation kits with differing component concentrations. There is no consensus on optimal component concentrations. Multiple PRP classifications exist but none have been validated. Platelet-rich plasma acts via growth factors (GFs) released from α-granules within platelets. Growth factors have been shown to be beneficial in healing. Grossly elevated concentrations of GFs may have inhibitory effects on healing. Multiple systematic reviews show efficacy of PRP in tendinopathies, early osteoarthritis, acute muscle injuries and in combination with rotator cuff repair and anterior cruciate ligament reconstruction.

The literature suggests leukocyte-rich PRP (L-PRP) is more beneficial in tendinopathies and pure PRP (P-PRP) is more beneficial in cartilage pathology. However, different PRP preparations have not been directly compared in any pathology. Classification of PRP type is frequently not stated in research. Standardization of PRP research parameters is needed to streamline findings and generate clear indications for PRP types to yield maximum clinical benefit.

Cite this article: EFORT Open Rev 2021;6:225-235. DOI: 10.1302/2058-5241.6.200017

A narrative review of platelet-rich plasma (PRP) in reproductive medicine

PURPOSE

Platelet-rich plasma (PRP) has become a novel treatment in various aspects of medicine including orthopedics, cardiothoracic surgery, plastic surgery, dermatology, dentistry, and diabetic wound healing. PRP is now starting to become an area of interest in reproductive medicine more specifically focusing on infertility. Poor ovarian reserve, menopause, premature ovarian failure, and thin endometrium have been the main areas of research. The aim of this article is to review the existing literature on the effects of autologous PRP in reproductive medicine providing a summation of the current studies and assessing the need for additional research.

METHODS

A literature search is performed using PubMed, MEDLINE, and CINAHL Plus to identify studies focusing on the use of PRP therapy in reproductive medicine. Articles were divided into 3 categories: PRP in thin lining, PRP in poor ovarian reserve, and PRP in recurrent implantation failure.

RESULTS

In women with thin endometrium, the literature shows an increase in endometrial thickness and increase in chemical and clinical pregnancy rates following autologous PRP therapy. In women with poor ovarian reserve, autologous intraovarian PRP therapy increased anti-Mullerian hormone (AMH) levels and decreased follicle-stimulating hormone (FSH), with a trend toward increasing clinical and live birth rates. This trend was also noted in women with recurrent implantation failure.

CONCLUSIONS

Limited literature shows promise in increasing endometrial thickness, increasing AMH, and decreasing FSH levels, as well as increasing chemical and clinical pregnancy rates. The lack of standardization of PRP preparation along with the lack of large randomized controlled trials needs to be addressed in future studies. Until definitive large RCTs are available, PRP use should be considered experimental.

Modified L'Episcopo tendon transfer for isolated loss of active external rotation

BACKGROUND

Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation.

METHODS

A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up.

RESULTS

Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%).

CONCLUSION

In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.

Biologics to Improve Healing in Large and Massive Rotator Cuff Tears: A Critical Review

Large and massive rotator cuff tears have the highest risk of retear. Common biologic modalities that can potentially reduce the retear rate and improve healing include platelet-rich plasma (PRP), scaffolds, and mesenchymal stem cells (MSCs). PRP has been studied for its role in improving rotator cuff healing and results of randomized controlled trials and meta-analyses show mixed results. Most studies in large and massivge tears show that PRP decreases the retear rate, but the connection between structural integrity and clinical outcomes is still unknown. Extracellular matrix (ECM) and synthetic scaffolds can increase healing in augmentation and bridging repair. Acellular dermal allografts have shown better healing rates and outcomes than xenografts in meta-analyses. Synthetic scaffolds augmented with bone marrow-derived stem cells have only been studied in vitro but are promising for the combination of mechanical stability and induction of a biological response. Superior capsule reconstruction is an exciting type of interposition graft reconstruction that has shown favorable early clinical outcomes for large and massive tears. Bone marrow-derived stem cells and adipose-derived stem cells improve the biomechanical characteristics of tendon repair and enhance the histological findings of the healing process in animal studies. However, evidence from human studies is lacking, especially in patients with large and massive tears. In summary, there are many biological options to augment rotator cuff repair in patients with large and massive tears. Due to mixed results and a lack of standardization in high-quality studies, we cannot recommend PRP at this time as an adjunct to rotator cuff repair. Both ECM and synthetic scaffolds, as well as SCR, can be used, especially in situations where native tendon is compromised, and additional mechanical augmentation is needed. Stem cells have been the least studied to date, so it is difficult to give recommendations for or against their use at this time.

Effects of applying platelet-rich plasma during arthroscopic rotator cuff repair: a systematic review and meta-analysis of randomised controlled trials

Because of its healing properties, platelet-rich plasma (PRP) has been applied to the bone-tendon interface during arthroscopic rotator cuff repair to improve surgical outcomes. However, its effects remain ambiguous. Therefore, we conducted this systematic review and meta-analysis to assess the effects of PRP on retear rate and functional outcomes. Randomised control trials were identified and extracted. Data collection was completed on 15 February 2020. The results are expressed as the risk ratio (RR) for the categorical variables and weighted mean difference for the continuous variables, with 95% confidence intervals (CIs). Analyses were performed using RevMan 5.3 software. Seven randomised controlled trials published from 2013 to 2018, with 541 patients in total, were included. The results revealed a significant decrease in retear rate [RR 0.38, 95% CI (0.22, 0.68), P = 0.0009). Furthermore, a significant improvement was observed regarding short-term Constant score [mean difference = 3.28, 95% CI (1.46, 5.11), P = 0.0004), short-term University of California at Los Angeles activity score [mean difference = 1.60, 95% CI (0.79, 2.42), P = 0.0001], and short-term visual analogue scale score [mean difference =  - 0.14, 95% CI (- 0.23, - 0.05), P = 0.002]. This systematic review indicates the efficacy of PRP when applied to the bone-tendon interface during arthroscopic rotator cuff repair.

Treatment of lateral ankle sprain with platelet-rich plasma: A randomized clinical study

BACKGROUND

We aimed to clinically evaluate the effect of platelet-rich plasma (PRP) therapy in patients with acute lateral ankle sprain treated with rigid immobilization.

METHODS

Patients with first-time grade II lateral ankle sprain clinically diagnosed were evaluated (n=21). A rigid immobilization was placed in all patients for ten days; previously, an application of PRP over the anterior talofibular ligament was performed in patients from the experimental group. The Visual Analogue Scale, the American Orthopedic Foot and Ankle Score, and the Foot and Ankle Disability Index were applied at 3, 5, 8 and 24 weeks of follow-up period.

RESULTS

The experimental group presented the highest reduction in pain and better functional scores than the control group at 8 weeks. At the end of follow-up period the results of both groups were similar.

CONCLUSIONS

A similar evolution was observed in patients treated with rigid immobilization with or without PRP after 24 weeks.

TRIAL REGISTRATION

Clinical Trials.gov with ID NCT02609308.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Use of Platelet-Rich Plasma for the Improvement of Pain and Function in Rotator Cuff Tears: A Systematic Review and Meta-analysis With Bias Assessment

BACKGROUND

Many clinical trials have investigated the use of platelet-rich plasma (PRP) to treat rotator cuff-related abnormalities. Several meta-analyses have been published, but none have focused exclusively on level 1 randomized controlled trials.

PURPOSE

To assess the efficacy of PRP for rotator cuff-related abnormalities and evaluate how specific tendon involvement, the inclusion of leukocytes, and the use of gel/nongel formulations affect pain and functional outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The literature was screened following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Baseline, short-term, and long-term data were extracted for the Constant score, University of California, Los Angeles (UCLA) score, visual analog scale (VAS) for pain, retear rate, Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) score. The 100-point modified Coleman Methodology Score (CMS) was used to assess methodological quality. Funnel plots and the Egger test were used to screen for publication bias, and sensitivity analysis was performed to evaluate the effect of potential outliers.

RESULTS

A total of 18 level 1 studies were included in this review, 17 (1116 patients) of which could be included in quantitative analysis. The mean modified CMS was 79.4 ± 10.39. The Constant scores of patients who received PRP were significantly better short term (weighted mean difference [WMD], 2.89 [95% CI, 0.89-4.90]; P < .01) and long term (WMD, 2.66 [95% CI, 1.13-4.19]; P < .01). The VAS scores were significantly improved short term (WMD, -0.45 [95% CI, -0.75 to -0.15]; P < .01). Sugaya grade IV and V retears in PRP-treated patients were significantly reduced long term (odds ratio [OR], 0.34 [95% CI, 0.20-0.57]; P < .01). In PRP-treated patients with multiple tendons torn, there were reduced odds of retears (OR, 0.28 [95% CI, 0.13-0.60]; P < .01). Patients who received leukocyte-rich PRP had significantly better Constant scores compared with the leukocyte-poor PRP group, but there was no difference in VAS scores. Patients receiving PRP gel reported higher Constant scores compared with the controls, whereas those receiving nongel PRP treatments did not, although there was no difference in VAS scores. Long-term odds of retears were decreased, regardless of leukocyte content (leukocyte-poor PRP: OR, 0.36 [95% CI, 0.16-0.82]; leukocyte-rich PRP: OR, 0.32 [95% CI, 0.16-0.65]; all P < .05) or usage of gel (nongel: OR, 0.42 [95% CI, 0.23-0.76]; gel: OR, 0.17 [95% CI, 0.05-0.51]; all P < .01).

CONCLUSION

Long-term retear rates were significantly decreased in patients with rotator cuff-related abnormalities who received PRP. Significant improvements in PRP-treated patients were noted for multiple functional outcomes, but none reached their respective minimal clinically important differences. Overall, our results suggest that PRP may positively affect clinical outcomes, but limited data, study heterogeneity, and poor methodological quality hinder firm conclusions.

The effect of perioperative platelet-rich plasma injections on postoperative failure rates following rotator cuff repair: a systematic review with meta-analysis

BACKGROUND

Platelet-rich plasma (PRP) has gained significant interest in recent years to potentially add biological augmentation of healing to surgical repairs of soft-tissue injuries. We sought to determine whether perioperative PRP injection influences the risk of failure following rotator cuff repair.

METHODS

A systematic search was performed in the Embase and PubMed databases and identified 16 randomized controlled trials or prospective cohort studies (1045 participants) reporting rates of failure, defined as a subsequent tear on postoperative imaging, after rotator cuff repair with or without perioperative PRP administration. A random-effects meta-analysis of the included studies was performed to determine the pooled effect of PRP administration on the postoperative failure risk.

RESULTS

Among the 16 studies investigating rotator cuff repairs, PRP augmentation resulted in a 25% reduction in the risk of repair failure, with low heterogeneity among the included studies. A significant protective effect was seen for studies of only small to medium tears (7 studies) (P = .007) and studies including large or massive tears (9 studies) (P < .001).

CONCLUSIONS

Intraoperative PRP reduces the failure risk following rotator cuff repair and has a consistent effect regardless of tear size. However, because of the variability in PRP preparations, a specific recommendation cannot be made.