Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up

Platelet-Poor versus Platelet-Rich Plasma for the Treatment of Muscle Injuries

ABSTRACT

Muscle injury in sport results in significant lost time and potential for reinjury for athletes. Autologous blood product, namely, platelet-rich plasma (PRP), has been investigated for possible augmentation of the treatment timeline with prevention of reinjury; however, conflicting results have been identified. A growing body of basic science and clinical literature is forming that supports the use of platelet-poor plasma (PPP) for muscle injury. The purpose of this study was to provide a background of the basic science of PRP versus PPP for muscle injury and to identify and review the clinical evidence for both autologous blood products, including the author's clinical experience utilizing the blood products. At the tissue level, PRP causes myoblast proliferation while PPP has led to myoblast induction, potentially identifying improved native muscle healing. Conflicting studies have been identified for the use of PRP for muscle injury. A growing body of positive results for PPP was identified, but high-quality comparative studies are needed.

Surgical Treatment and Outcomes for Gluteal Tendon Tears

PURPOSE OF REVIEW

Gluteus medius and minimus tears, or hip abductor tendon tears, are increasingly identified as a source of lateral hip pain. Once underappreciated and undertreated, they are now recognized as a cause of greater trochanteric pain syndrome and a pathology amenable to both nonoperative and operative modalities. This review summarizes relevant anatomy, clinical presentation, and treatment options for gluteus medius tears, focusing on surgical options.

RECENT FINDINGS

When surgical intervention is indicated, repair, reconstruction, or tendon transfer may be considered. Open and endoscopic repair techniques demonstrate similar outcomes with improvements in patient-reported outcomes and low complication and retear rates for both partial and full thickness tears. Variations in fixation construct and graft augmentations have been described, though clinical evidence remains limited to support specific techniques. Gluteus maximus transfer via open approach is a salvage option for the severely atrophied, retracted, or revision gluteus tendon; however, persistent limitations in abduction strength and gait abnormalities are common. Emerging evidence continues to evolve our understanding of surgical decision-making for gluteus tendon tears. The current literature supports either open or endoscopic repair techniques and open tendon transfer as a salvAage option. Further study is needed to determine the optimal fixation construct, the role of graft augmentation, and patient-related factors that influence postoperative outcomes.

Ultrasound-Guided Subfascial Platelet-Rich Plasma Injections Versus Enthesis Needling for Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial

Background

Greater trochanteric pain syndrome (GTPS) is characterized by gluteal enthesopathy involving the peritrochanteric space and associated with chronic pain and functional impairment. A corticosteroid injection in the trochanteric bursa is the usual palliative treatment for pain. However, it is important to investigate treatment options that will relieve pain in the peritrochanteric space.

Purpose

To compare the clinical efficacy of subfascial platelet-rich plasma (PRP) injection and enthesis needling for GTPS.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A total of 92 patients (90% women; mean age, 55 years old; mean body mass index, 25.3 kg/m2) were randomly divided into a subfascial PRP injection group and an enthesis needling group. Descriptive data and radiographic measurements of the pelvis-including leg-length difference, pelvic width difference, and pelvic trochanteric index-were recorded. The primary outcome measures were the Hip Outcome Score (HOS) activities of daily living (HOS-ADL) and sports-specific (HOS-SS) subscales and the visual analog scale for pain at 3, 6, and 12 months posttreatment. In addition, we evaluated the presence or absence of ultrasound characteristics (fascia nodules, trochanteric bursa distension, and calcium deposits) over time in response to treatment.

Results

Baseline demographic and radiological characteristics were similar between the groups. The PRP group saw significantly greater improvement from baseline to 12 months posttreatment on the HOS-SS subscore compared with the needling group (32.09 [95% CI, 28.99-40.20] vs 20.52 [95% CI, 11.99-29.05]; P = .048). At 3 months, 60% of patients in the PRP group versus 33.3% in the needling group had a reduction in pain compared with a baseline of >20% (P = .040). After subfascial PRP injection, fewer patients had a fascia nodule over the trochanter and/or bursa distension (P = .006 and P = .004, respectively). The pelvic trochanteric index was predictive of HOS-ADL and HOS-SS outcomes (P = .011 and P = .022, respectively). The interaction between treatment modality and fascia nodule influenced HOS-ADL and HOS-SS outcomes (P = .021 and P = .023) as well as the interactions of treatment modality, fascia nodules, and calcifications (P = .027).

Conclusion

Both subfascial PRP injection and enthesis needling resulted in clinical improvements, but the improvement in the HOS-SS was greater in the PRP group.

Registration

NCT04231357 (ClinicalTrials.gov identifier).

Is there structural change on MRI in gluteal tendinopathy after treatment? Single outcome measure extension of an RCT

BACKGROUND

The etiology of tendinopathy remains controversial and it is unknown whether degenerative structural changes in tendinopathies are reversible.

HYPOTHESIS

There will be no structural change on magnetic resonance imaging (MRI) taken > 2-years after treatment for gluteal tendinopathy.

STUDY DESIGN

Extension of a single site, double-blind, prospective randomized-controlled trial to analyze the additional outcome measure; MRI changes.

METHODS

University of Melbourne ethics approval number: 1852900, trial registration: ACTRN12613000677707. Participants with gluteal tendinopathy who had previously received a leukocyte-rich platelet-rich plasma injection (LR-PRP) or a corticosteroid injection (CSI) had a post treatment MRI between at least 2-years and up to 7 years following trial completion. A blinded, senior musculoskeletal radiologist graded all de-identified MRI scans using the Melbourne Hip Score (MHIP). The primary outcome measure was the change in overall pre- and post-treatment score.

RESULTS

Participants (n = 20) underwent MRI at mean time of 4.15 (SD 1.11; range 2-7) years after their initial treatment. There was no change in the overall mean MHIP score for the CSI group (Pre 4.3 (SD 2.3) Post 4.3 (SD 1.1), p = 1.00). Although there was an improvement in the LR-PRP group mean MHIP score (Pre 5.3 (SD 3.0) Post 4.77 (SD 2.5), p = 0.56) it was not statistically significant. However, in the LR-PRP intervention group, five out of nine of participants' MHIP score improved, with four of these improving by 2-4 points.

CONCLUSION

The hypothesis that there would be no improvement in MHIP scores following treatment of gluteal tendinopathy was supported. Findings of improvement in the LR-PRP group at 4 years would support further studies powered to look for structural improvement. These findings suggest that structural change following treatment for tendinopathy may be possible supporting the inclusion of MRI as a core outcome for future studies.

CLINICAL RELEVANCE

The study suggests that degenerative structural changes in tendons may be reversible.

Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level.» The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics.» Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments.» In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

Public Interest in Shoulder Platelet-Rich Plasma Injections Is Increasing: A 10-Year Google Trends Analysis

Purpose

To quantify and analyze public interest trends in platelet-rich plasma (PRP) therapy for shoulder pathology between 2011 and 2020 using Google Trends data.

Methods

Google Trends data were queried for online search data ranging from January 2011 to December 2020. Various combinations of terms related to PRP and shoulder pathology were queried. Terms related to corticosteroid therapy in association with shoulder pathology were also generated for comparative analysis. Analyses were performed regarding trends in online search volumes.

Results

Linear models were generated to evaluated trends in the volume of online searches for PRP and corticosteroid therapy for shoulder pathology. For both the PRP and steroid groups, linear models showed a statistically significant increase in search volume for the period studied (P < .001). The PRP group showed a significantly greater growth rate than the steroid group (P < .001). There were no statistically significant differences in online search volume when compared between different geographic and socioeconomic locations.

Conclusions

This study indicates consistently increasing public interest in PRP injections in the shoulder. The rate of online search volume growth of PRP is significantly greater than that of corticosteroid injections for the period studied.

Clinical Relevance

Awareness of patient perceptions has value in informing shared decision making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research.

Lower extremity ultrasound-guided interventions: tendon, ligament, and plantar fascia

Lower extremity tendinopathy and soft tissue injury are common clinical problems that can cause significant disability. Ultrasound-guided minimally invasive treatments using orthobiologics and image-guided percutaneous treatments continue to gain relevance with an ever-growing body of literature. We review the indications, technique, risks, and benefits according to the literature of common ultrasound-guided interventions utilized in the lower extremities.

Global research trends on platelet-rich plasma for tendon and ligament injuries from the past two decades: A bibliometric and visualized study

Background

In sports medicine, tendon and ligament injuries are the most prevalent conditions, and with the booming of sports competition, the incidence of sports injuries is gradually increasing, investigating more potent therapeutic options is therefore becoming increasingly crucial. Platelet-rich plasma therapy has gained popularity as an effective and secure treatment in recent years. Currently, a faceted systematic and clear visual analysis is lacking in this research area.

Methods

The literature related to using platelet-rich plasma to treat ligament and tendon injuries from 2003 to 2022 in the core dataset of the Web of Science database was collected and analyzed visually using Citespace 6.1 software. Research hotspots and development trends were analyzed in terms of high-impact countries or regions, authors, research institutions, keywords, and cited literature.

Results

The literature comprised a total of 1,827 articles. The annual publication volume of relevant literature has demonstrated a significant development tendency as the field of platelet-rich plasma research for tendon and ligament injuries has heated up in recent years. With 678 papers, the United States came in top place, followed by China with 187 papers. Hosp Special Surg ranked first with 56 papers. The hot research topics analyzed by keywords were tennis elbow, anterior cruciate ligament, rotator cuff repair, achilles tendon, mesenchymal stem cells, guided tissue regeneration, network meta analysis, chronic patellar tendinopathy, and follow up.

Conclusion

Analysis of the research literature over the past 20 years shows that the United States and China will continue to dominate in terms of volume of publications based on annual volume and trends, with some collaboration among high-impact authors and further collaboration still needed in different countries and institutions. Platelet-rich plasma is widely used in the treatment of tendon ligament injuries. Its clinical efficacy is influenced by a number of factors, the main ones being the inconsistency in the preparation and composition of platelet-rich plasma and its related preparations, and the differences in efficacy due to different activation methods of platelet-rich plasma, as well as factors such as injection time, injection site, administration method, number of administrations, acidity and evaluation methods, In addition, the applicability to different injury diseases remains controversial. In recent years, the molecular biology of platelet-rich plasma for tendon ligament therapy has received increasing attention.

Advances in the Clinical Application of Platelet-Rich Plasma in the Foot and Ankle: A Review

Autologous and recombinant biologic substances have been generated as a result of the research into the cellular features of the healing process. Orthobiologics are increasingly being used in sports medicine and musculoskeletal surgery. Nevertheless, clinical data are limited; consequently, further studies are required, particularly in foot and ankle pathologies. This review aims to provide evidence of the most recent literature results and ignite the interest of orthopedic specialists eager for an update about the most current discussion on platelet-rich plasma (PRP) clinical applications in the foot and ankle fields. Previous studies have shown that platelet-rich plasma can be beneficial in treating various conditions, such as chronic foot ulcers, osteoarthritis, Achilles tendinopathy, etc. Despite the positive effects of PRP on various musculoskeletal conditions, more prospective studies are needed to confirm its effectiveness at treating ankle and foot pathologies. In addition to clinical trials, other factors, such as the quality of the research and the procedures involved, must be considered before they can be used in patients. More long-term evaluations are needed to support or oppose its application in treating foot and ankle disorders. We present the most extensive review of PRP's clinical applications in the foot and ankle field.

Ilizaliturri Jr. V, Kohlrieser D, Laskovski J, Lifshitz L, P. McGovern R, Monnington K, O’Donnell J, Takla A, Tyler T, Voight M, Wuerz T, Martin RL. The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

Endoscopic treatment of gluteus medius tendon tear

Tears in the gluteus medius and minimus tendons are a common cause of greater trochanter pain syndrome (GTPS). Given the non-specific clinical signs and imaging findings, they are often misdiagnosed, with delayed treatment. The lesions can show several aspects: trochanteric bursitis, simple tendinopathy, partial or full-thickness tear, tendon retraction, or fatty degeneration. Non-surgical treatment associates physical rehabilitation and activity modification, oral analgesics, anti-inflammatories and peri-trochanteric injections (corticosteroids, PRP). In the event of symptoms recalcitrant to medical treatment, surgery may be indicated. A 5-stage classification according to intraoperative observations and elements provided by MRI is used to guide technique: isolated bursectomy with microperforation, single or double row tendon repair, or palliative surgery such as muscle transfer (gluteus maximus with or without fascia lata). The development of conservative hip surgery now makes it possible to perform all of these surgical techniques endoscopically, with significant improvement in functional scores and pain in the short and medium term and a lower rate of complications than with an open technique. However, tendon retraction and fatty degeneration have been reported to be factors of poor prognosis for functional results and tendon healing and palliative tendon transfer gives mixed results for recovery of tendon strength. It is therefore preferable not to wait for the onset of Trendelenburg gait to propose endoscopic repair of the gluteus medius tendon in case of pain with a tear visible on MRI and failure of more than 6 months' medical treatment. Based on expert opinion, this article provides an update on the diagnosis of gluteus medius lesions, treatment, and in particular the place of endoscopy, indications and current results. LEVEL OF EVIDENCE: V.

A Review of Abductor Tendon Tears: The Hidden Lesion of the Hip

»

Greater trochanteric pain syndrome consists of a group of associated conditions involving the lateral hip that can be debilitating to patients, mostly women between ages 40 and 60 years.

»

Abductor tendon tears are becoming a more recognized cause of lateral hip pain in patients without hip osteoarthritis.

»

Diagnosis of this condition is critical to patient care because misdiagnosis often leads to unnecessary prolonged pain and even unnecessary procedures that address different pathologies.

»

Treatment strategies consists of nonoperative modalities such as nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy, but for refractory cases, surgical techniques including repair, augmentation, and reconstruction have been well-described in the literature providing patients with acceptable outcomes.

The effect of corticosteroid injection in the treatment of greater trochanter pain syndrome: a systematic review and meta-analysis of randomized controlled trials

Background

corticosteroid injection (CSI) has been used to treat greater trochanter pain syndrome (GTPS) for many years. However, so far, the efficacy of CSI in the treatment of GTPS is still controversial. Therefore, the aim of this review is to evaluate the effectiveness of CSI in comparison with sham intervention, nature history, usual care, platelet-rich plasma (PRP), physiotherapy/exercise therapy, dry needling, or other nonsurgical treatment for improvements in pain and function in GTPS.

Methods

PubMed (Medline), Embase, Cochrane Library were searched from their inception until April 2021. Randomized controlled trails (RCTs) comparing CSI to nonsurgical treatment were included. Data on the effect of CSI on pain and function were extracted and checked by two review authors independently. The treatment effect was analyzed in the short term, medium term, and long term.

Results

Eight RCTs (764 patients) were included. This review suggests CSI may be superior to usual care and ‘wait and see,’ ESWT, but may not be superior to exercise, PRP, dry needling, and sham intervention in short-term pain or function improvement. In terms of medium-term pain or function improvement, CSI may be superior to usual care and ‘wait and see,’ but may not be superior to PRP. In terms of long-term pain or function improvement, CSI may be inferior to PRP and ESWT, but it may be superior to usual care and ‘wait and see’ at 12 months.

Conclusions

Due to the small sample size and lack of sufficient clinical studies, current evidence is equivocal regarding the efficacy of CSI in the treatment of GTPS. Considering the limitations, more large-sample and high-quality RCTs are needed to prove the therapeutic effect of CSI on GTPS.

Trial registration

PROSPERO registration number: CRD42021247991. Registered 09 May 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03175-5.

Leukocyte-Rich Platelet-Rich Plasma Has Better Stimulating Effects on Tenocyte Proliferation Compared With Leukocyte-Poor Platelet-Rich Plasma

Background:

Rotator cuff (RC) tendinopathy is one of the most common causes of shoulder pain. Platelet-rich plasma (PRP) has been frequently used in clinical scenarios, but its efficacy remains inconsistent.

Purpose:

To investigate the different responses of human tenocytes from torn RCs to leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) in a 2-chamber coculture device.

Study Design:

Controlled laboratory study.

Methods:

PRP was prepared using different platelet and leukocyte concentrations according to 5 groups: (1) LR-PRP with 5000 platelets/µL, (2) LR-PRP with 10,000 platelets/µL, (3) LP-PRP with 5000 platelets/µL, (4) LP-PRP with 10,000 platelets/µL, and (5) control with only culture medium supplementation and without PRP stimulation. Platelet-derived growth factor–AB (PDGF-AB) and transforming growth factor–β1 (TGF-β1) were measured in LR-PRP and LP-PRP via enzyme-linked immunosorbent assay. Microscopy, water-soluble tetrazolium salt assay, and quantitative real-time polymerase chain reaction were used to investigate the morphology, proliferation, and gene expression of RC tenocytes exposed to different PRP formulations. Data were collected from at least 3 independent measurements. The results were analyzed via 1-way analysis of variance, followed by the post hoc Bonferroni test.

Results:

The ratio of leukocytes to 5000 platelets/µL was 29.5 times higher in LR-PRP than in LP-PRP (P < .05). In the 5000 platelets/µL groups, the levels of TGF-β1 and PDGF-AB were both significantly higher in LR-PRP versus LP-PRP (TGF-β1: 367.0 ± 16.5 vs 308.6 ± 30.3 pg/mL, respectively [P = .043]; PDGF-AB: 172.1 ± 1.8 vs 94.1 ± 4.2 pg/mL, respectively [P < .001]). Compared with the control group, RC tenocyte proliferation was 1.42 ± 0.01 and 1.41 ± 0.03 times higher in the LR-PRP groups with 5000 platelets/µL and 10,000 platelets/µL, respectively (P < .05). The expression of tenocyte-related genes was higher in tenocytes cultured in LR-PRP.

Conclusion:

Both the LR-PRP groups with 5000 platelets/µL and 10,000 platelets/µL induced more growth factor release and increased RC tenocyte proliferation than did the LP-PRP groups.

Clinical Relevance:

In RC repair, LR-PRP may be better than LP-PRP for increasing the proliferation of tenocytes.

Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice

Tendinopathy is labeled by many authors as a troublesome, common pathology, present in up to 30% medical care consultations involving musculoskeletal conditions. Despite the lasting interest for addressing tendon pathology, current researchers agree that even the exact definition of the term tendinopathy is unclear. Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context. One of the main goals of current clinical management is to personalize treatment approaches to adapt them to the many different needs of the population. Tendons are complex structures that unite muscles and bones with two main objectives: to transmit forces and storage and release energy. Regarding the tensile properties of the tendons, several authors argued that tendons have higher tensile strength compared with muscles, however, are considered less flexible. Tendinopathy is an accepted term which is used to indicated a variety of tissue conditions that appear in injured tendons and describes a non-rupture damage in the tendon or paratendon, which is intensified with mechanical loading Even when the pathoetiology of tendinopathy is unclear, there is a wide array of treatments available to treat and manage tendinopathy. Although tendinitis usually debuts with an inflammatory response, the majority of chronic tendinopathies do not present inflammation and so the choosing of treatment should vary depending on severity, compliance, pain and duration of symptoms. The purpose of this article is to review and provide an overview about the currently research of the tendon diagnosis, management and etiology.

The use of biologics to improve patient-reported outcomes in hip preservation

Despite lack of clear understanding, the use of biologic treatment methods has increased in the United States. Therapeutic methods, including platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) and hyaluronic acid (HA) among other biologics, are commonly associated with relief of pain in a number of different orthopedic conditions. Within the past two decades, hip preservationists have investigated the roles of these biologic treatments in both non-operative and surgical management of common hip conditions. The purpose is to review the published literature surrounding the application and efficacy of biologics, most notably PRP, BMAC and HA, in the clinical management of hip conditions. The hip conditions examined in this review include hip osteoarthritis, femoroacetabular impingement syndrome and associated labral tear pathology, avascular necrosis of the femoral head and gluteal/hamstring tendinopathy. While our review of the literature suggests that there is support for the implementation of biologics to relieve pain and improve function for hip conditions. Through further research efforts, it is important to stay updated with the clinical efficacy of biologics in hip preservation.

Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation

Background:

Gluteal tendinopathy is the most common lower limb tendinopathy. It presents with varying severity but may cause debilitating lateral hip pain.

Purpose:

To review the therapeutic options for different stages of gluteal tendinopathy, to highlight gaps within the existing evidence, and to provide guidelines for a stage-adjusted therapy for gluteal tendinopathy.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We screened Scopus, Embase, Web of Science, PubMed, PubMed Central, Ovid MEDLINE, CINAHL, UpToDate, and Google Scholar databases and databases for grey literature. Patient selection, diagnostic criteria, type and effect of a therapeutic intervention, details regarding aftercare, outcome assessments, complications of the treatment, follow-up, and conclusion of the authors were recorded. An assessment of study methodological quality (type of study, level of evidence) was also performed. Statistical analysis was descriptive. Data from multiple studies were combined if they were obtained from a single patient population. Weighted mean and range calculations were performed.

Results:

A total of 27 studies (6 randomized controlled trials) with 1103 patients (1106 hips) were included. The mean age was 53.7 years (range, 17-88 years), and the mean body mass index was 28.3. The ratio of female to male patients was 7:1. Radiological confirmation of the diagnosis was most commonly obtained using magnetic resonance imaging. Reported treatment methods were physical therapy/exercise; injections (corticosteroids, platelet-rich plasma, autologous tenocytes) with or without needle tenotomy/tendon fenestration; shockwave therapy; therapeutic ultrasound; and surgical procedures such as bursectomy, iliotibial band release, and endoscopic or open tendon repair (with or without tendon augmentation).

Conclusion:

There was good evidence for using platelet-rich plasma in grades 1 and 2 tendinopathy. Shockwave therapy, exercise, and corticosteroids showed good outcomes, but the effect of corticosteroids was short term. Bursectomy with or without iliotibial band release was a valuable treatment option in grades 1 and 2 tendinopathy. Insufficient evidence was available to provide guidelines for the treatment of partial-thickness tears. There was low-level evidence to support surgical repair for grades 3 (partial-thickness tears) and 4 (full-thickness tears) tendinopathy. Fatty degeneration, atrophy, and retraction can impair surgical repair, while their effect on patient outcomes remains controversial.

Pertrochanteric Calcifications in Patients With Greater Trochanteric Pain Syndrome: Description, Prevalence, and Correlation With Intraoperatively Diagnosed Hip Abductor Tendon Injuries

BACKGROUND

Pertrochanteric calcifications can be found in patients with greater trochanteric pain syndrome (GTPS). A systematic description of the types and prevalence of these calcifications has not been undertaken. Furthermore, there is conflicting evidence regarding their association with abductor tendon injuries.

PURPOSE

(1) To describe the various types and prevalence of pertrochanteric calcifications in patients presenting for the surgical management of recalcitrant GTPS. (2) To evaluate the association of the various calcifications with intraoperatively diagnosed hip abductor tendon injuries, including tendinosis, partial-thickness tears, and full-thickness tears.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients undergoing surgical management for GTPS, in isolation or as an ancillary procedure during hip arthroscopy for femoroacetabular impingement, between April 2008 and February 2020 were included. Of these, 85 procedures were isolated treatment of GTPS and the remaining 628 were ancillary to hip arthroscopy. Radiographs were scrutinized for the presence of pertrochanteric calcifications. The hip abductor tendon status was intraoperatively classified as intact, partial-thickness tear, or full-thickness tear. The prevalence and correlation of the various radiographic findings in relation to the intraoperatively classified tendon condition were analyzed via the odds ratio (OR).

RESULTS

Surgery was performed on 713 hips with recalcitrant GTPS. No tear was found in 340 hips (47.7%), 289 hips (40.5%) had a partial-thickness tear, and 84 hips (11.8%) had a full-thickness tear. Radiographically, 102 hips (14.3%) demonstrated proximally directed enthesophytes, and 34 (4.8%) had distally directed enthesophytes. In addition, 75 hips (10.5%) had amorphous calcifications, 47 (6.6%) had isolated ossicles, and 110 (15.4%) had surface irregularities. The presence of any calcification was associated with partial-thickness tears (OR, 1.67 [95% CI, 1.21-2.21]; P = .002) and full-thickness tears (OR, 6.40 [95% CI, 3.91-10.47]; P < .001). Distally directed enthesophytes (OR, 10.18 [95% CI, 3.08-33.63]; P < .001) and proximally directed enthesophytes (OR, 8.69 [95% CI, 4.66-16.21]; P < .001) were the findings with the highest OR for the presence of any type of tear. Distally directed enthesophytes were the findings with the highest OR for a full-thickness tear (OR, 15.79 [95% CI, 7.55-33.06]; P < .001). Isolated ossicles were the findings with the highest OR for a partial-thickness tear (OR, 1.73 [95% CI, 0.96-3.13]; P = .070).

CONCLUSION

Pertrochanteric calcifications were common radiographic findings in patients with GTPS and can help guide management in these patients. Proximally and distally directed enthesophytes were strong predictors for the presence of a hip abductor tendon tear, and specifically a full-thickness tear, and increasing size of the findings was associated with more severe tendon injuries.

Orthobiologics in the treatment of hip disorders

Orthobiologics are biological materials that are intended for the regeneration or healing of bone, cartilage and soft tissues. In this review we discuss the use of orthobiologics for hip disorders providing an update. The orthobiologics included in this article are hyaluronic acid, platelet rich plasma, bone marrow, adipose tissue and expanded mesenchymal stem cells. We explain the concepts and definitions of each orthobiological product, and the literature regarding its use in the hip joint. The paucity of guidelines for the production and characterization of the biological products leads to uneven results across the literature. Each biologic therapy has indications and benefits; however, noteworthy are the characterization of the orthobiologics, the application method and outcome analysis for further improvement of each technique.

Reliability of a Novel Scoring System for MRI Assessment of Severity in Gluteal Tendinopathy: The Melbourne Hip MRI Score

Background

Gluteal tendinopathy is commonly reported in the literature, but there is a need for a validated magnetic resonance imaging (MRI)-based scoring system to grade the severity of the tendinopathy.

Purpose

To use intra- and interobserver reliability to validate a new scoring system, the Melbourne Hip MRI (MHIP) score, for assessing the severity of gluteal tendinopathy.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

The MHIP score assesses gluteal tendinopathy according to each 1 of 5 categories: (1) extent of tendon pathology (maximum 5 points); (2) muscle atrophy (maximum 4 points); (3) trochanteric bursitis (maximum 4 points); (4) cortical irregularity (maximum 3 points); and (5) bone marrow edema (maximum 1 point), with an overall range of 0 to 17 (most severe). A total of 41 deidentified MRI scans from 40 patients diagnosed with gluteal tendinopathy (mean baseline age, 57.44 ± 25.26 years; 4 male, 36 female) were read and graded according to MHIP criteria by 2 experienced musculoskeletal radiologists. The radiologists were blinded to previous reports, and the scans were read twice within a 2-month period. Statistical analysis using the intraclass correlation coefficient (ICC) was used to determine intra- and interobserver reliability and mean/range for the MHIP scores.

Results

Of a total of 123 readings, the mean MHIP score (±SD) was 3.93 ± 2.24 (range, 0-17 points). The MHIP score demonstrated excellent reliability for determining the severity of gluteal tendinopathy on MRI. The ICC for intra- and interobserver reliability was 0.81 (95% CI, 0.67-0.89) and 0.78 (95% CI, 0.62-0.87), respectively.

Conclusion

The MHIP score had excellent intra- and interobserver reliability in scoring gluteal tendinopathy. This score allows gluteal tendon pathology to be graded prior to treatment and to be used for standardized comparisons between results in future research undertaking radiological review of gluteal tendinopathy.

Effects of leukocyte- and platelet-rich plasma on tendon disorders based on in vitro and in vivo studies (Review)

Tendon-related disorders are common musculoskeletal system disorders in clinical practice, accounting for 30-50% of all sports-related injuries, and they are difficult to treat due to the hypovascular structure of the tendons. Platelet-rich plasma (PRP), including pure PRP and leukocyte- and platelet-rich plasma (L-PRP), has been attracting increasing attention, as it may stimulate tissue regeneration through the release of growth factors and cytokines. The aim of the present review was to provide a summary of the effects of L-PRP on tendon disorders and the underlying mechanisms through a comprehensive examination of the published literature, including in vitro, animal and clinical studies. It has been demonstrated that L-PRP results in comparatively greater pain relief and improved function in patients suffering from tendon disorders. Furthermore, L-PRP may exert its effects through a diverse range of mechanisms, such as neovascularization, cell proliferation and differentiation of tendon/progenitor stem cells into tenocytes, as well as extracellular matrix reorganization by transforming type III to type I collagen fibers. It has also been indicated that the effects of leukocytes in L-PRP depend on the biological state of the injured tissue and its surrounding microenvironment. L-PRP is beneficial and promotes tendon healing at the early stage, whereas it is likely detrimental to the repair of tendon at a later stage because of the risk of excessive catabolic and inflammatory responses. Overall, the application of L-PRP in tendon disorders appears to be a promising field that is worthy of further research.

The Use of Biologics for Hip Preservation

PURPOSE OF REVIEW

A wide array of nonoperative modalities to treat hip pain are aimed at restoring and maintaining the structural and physiologic characteristics of the joint. The purpose of this review is to describe the current understanding of biologics in hip pathology by providing an evidence-based overview of treatment modalities available for orthopedic surgeons.

RECENT FINDINGS

The use of biologics as a primary treatment or adjunct to traditional management has shown encouraging results for the treatment of hip pain. Studies have demonstrated safety with minimal complications when using platelet rich plasma, hyaluronic acid, or stem cells to treat hip pain caused by osteoarthritis, femoroacetabular impingement syndrome, tendinopathy, or osteonecrosis of the femoral head. Several studies have been able to demonstrate meaningful clinical results that can improve treatment standards for hip pain; however, more work must be performed to better delineate the appropriate protocols, indications, and limitations of each modality. Recent advances have inspired renewed interest in biologics for patients with hip pain. We present a concise review of platelet rich plasma, hyaluronic acid, stem cells, and matrix metalloprotease inhibitors and their applicability to hip preservation surgery.

Return to Activity After Gluteus Medius Repair in Active Patients Older Than 50 Years

Background:

Gluteus medius (GM) tears are a known cause of dysfunction and disability predominantly in older women.

Purpose

To report on return to activity, patient-reported outcomes (PROs), and a uniquely calculated minimal clinically important difference (MCID) at a minimum 2-year follow-up for active patients who had undergone either an endoscopic or an open GM repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients were considered eligible if they (1) underwent a GM repair with or without concomitant central and peripheral compartment procedures; (2) had baseline preoperative and minimum 2-year scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain; and (3) participated in a physical activity or sport within 1 year before their surgery. Return to activity was defined as the patient being able to participate in his or her activity at a minimum of 2 years postoperatively.

Results:

Of 87 eligible patients, 84 (96.6%) met all inclusion criteria. The mean follow-up was at 44.5 months. Six patients (7.1%) underwent an open GM repair, while the remaining 78 (92.9%) underwent an endoscopic GM repair. Concomitant central and peripheral compartment arthroscopic procedures were performed in 69 patients (82.1%). All PROs significantly (P < .001) improved as follows: mHHS, from 59.0 to 85.8; NAHS, from 57.9 to 84.0; HOS-SSS, from 32.6 to 63.7; and VAS pain, from 5.4 to 1.9. A total of 57 patients (67.9%) returned to their preoperative activity at the 2-year follow-up. The MCID was calculated for the mHHS, NAHS, and HOS-SSS to be 7.5, 7.4, and 10.9, respectively, with 79.3%, 86.4%, and 70.2% of patients achieving the MCID for each respective PROs.

Conclusion:

Active patients over the age of 50 years may benefit from endoscopic or open repair of GM tears, as the majority of patients in our cohort were able to return to their activity of choice. All measured PROs had significantly improved at a minimum 2-year follow-up, with high survivorship, satisfaction, and clinical effectiveness. Patients with partial-thickness tears compared with full-thickness tears and those who underwent isolated GM repair compared with GM repair with concomitant procedures had similar return to activity rates and PROs at the latest follow-up.

Platelet-Rich Plasma Applications for Achilles Tendon Repair: A Bridge between Biology and Surgery

Achilles tendon ruptures are very common tendon ruptures and their incidence is increasing in modern society, resulting in work incapacity and months off sport, which generate a need for accelerated and successful therapeutic repair strategy. Platelet-rich plasma (PRP) is emerging as adjuvant human blood-derived constructs to assist Achilles tendon rupture treatment. However, myriad PRP preparation methods in conjunction with poor standardization in the modalities of their applications impinge on the consistent effectiveness of clinical and structural outcomes regarding their therapeutic efficacy. The purpose of this review is to provide some light on the application of PRP for Achilles tendon ruptures. PRP has many characteristics that make it an attractive treatment. Elements such as the inclusion of leukocytes and erythrocytes within PRP, the absence of activation and activation ex vivo or in vivo, the modality of application, and the adjustment of PRP pH can influence the biology of the applied product and result in misleading therapeutic conclusions. The weakest points in demonstrating their consistent effectiveness are primarily the result of myriad PRP preparation methods and the poor standardization of modalities for their application. Selecting the right biological scaffold and applying it correctly to restitutio ad integrum of ruptured Achilles tendons remains a daunting and complex task.

Differences in Clinical Presentations and Surgical Outcomes of Gluteus Medius Tears Between Men and Women

BACKGROUND

Gluteus medius (GM) tears often occur in women aged >50 years. There is a paucity of literature comparing sex-based differences in those undergoing GM repair.

PURPOSE

To report differences between women and men in clinical presentations and patient-reported outcome (PRO) scores at a minimum 2-year follow-up after undergoing GM repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed. All included patients had postoperative scores for the following PROs: modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12. Men were propensity score matched 1:3 to women according to concomitant arthroscopic procedures and follow-up time. Clinical effectiveness was determined through a uniquely calculated minimal clinically important difference (MCID) for the mHHS and NAHS specific to this study population.

RESULTS

Thirteen men were successfully propensity score matched to 39 women. Women and men were 55.87 ± 11.0 and 62.38 ± 11.63 years old (mean ± SD), respectively (P = .02). Men were at increased risk for associated lumbar pathology as compared with women (relative risk, 3.32; P = .02). Women showed significant improvement from preoperative to minimum 2-year follow-up for the mHHS (59.32 ± 15.36 to 83.81 ± 16.82; P < .01), NAHS (56.23 ± 15.61 to 83.78 ± 17.66; P < .01), HOS-SSS (33.35 ± 20.28 to 67.88 ± 32.35; P < .01), and visual analog scale (5.48 ± 2.00 to 1.93 ± 2.29; P < .01). Similarly, men showed significant improvement for the mHHS (63.50 ± 16.41 to 84.77 ± 13.91; P < .01), NAHS (61.52 ± 9.87 to 84.42 ± 14.87; P < .01), HOS-SSS (33.97 ± 21.20 to 63.62 ± 26.20; P < .01), and visual analog scale (4.93 ± 2.69 to 1.86 ± 2.10; P < .01). The MCIDs for the mHHS and NAHS were calculated to be 7.89 and 7.24. Of the women, 28 (72%) and 34 (87%) met the MCID for the mHHS and NAHS. Eleven (85%) men met the MCID for the mHHS and NAHS.

CONCLUSION

These results suggest that women and men can both benefit after GM repair. Men were older and had increased risk for associated lumbar pathology than women at the time of surgery. Men and women both experienced significant improvements in PROs and compared favorably in terms of clinical effectiveness at a minimum 2-year follow-up.

Platelet-rich plasma versus corticosteroid injection for treatment of trigger finger: study protocol for a prospective randomized triple-blind placebo-controlled trial

Background

Trigger finger is a common hand disorder that limits finger range of motion and causes pain and snapping of the affected finger. Trigger finger is caused by an imbalance of the tendon sheath and the flexor tendon. The initial treatment is generally a local corticosteroid injection around the first annular (A1) pulley. However, it is not unusual that surgical release of the A1 pulley is required. Moreover, adverse events after local corticosteroid injection or operative treatment may occur. Platelet-rich plasma (PRP) has been shown to be safe and to reduce symptoms in different tendon pathologies, such as DeQuervain’s disease. However, the effects of PRP on trigger finger have not been studied. The aim of this single-center triple-blind randomized controlled trial is to study whether PRP is non-inferior to corticosteroid injection in treating trigger finger. The secondary outcome is to assess the safety and efficacy of PRP in comparison to placebo.

Methods

The trial is designed as a randomized, controlled, patient-, investigator-, and outcome assessor-blinded, single-center, three-armed 1:1:1 non-inferiority trial. The patients with clinical symptoms of trigger finger will be randomly assigned to treatment with PRP, corticosteroid, or normal saline injection. The primary outcome is Patient-Rated Wrist Evaluation and symptom resolution. Secondary outcomes include Quick-Disabilities of the Arm, Shoulder and Hand; pain; grip strength; finger active range of motion; and complications. Appropriate statistical methods will be applied.

Discussion

We present a novel RCT study design on the use of PRP for the treatment of trigger finger compared to corticosteroid and normal saline injection. The results of the trial will indicate if PRP is appropriate for the treatment of trigger finger.

Trial registration

ClinicalTrials.gov NCT04167098. Registered on November 18, 2019.

Proteomic analysis of platelet-rich and platelet-poor plasma

Background

Autologous blood products, such as platelet-rich plasma (PRP) are commercial products broadly used to accelerate healing of tissues after injuries. However, their content is not standardized and significantly varies in composition, which may lead to differences in clinical efficacy. Also, the underlying molecular mechanisms for therapeutic effects are not well understood.

Purpose

A proteomic study was performed to compare the composition of low leukocyte PRP, platelet poor plasma (PPP), and blood plasma. Pathway analysis of the proteomic data was performed to evaluate differences between plasma formulations at the molecular level. Low abundance regulatory proteins in plasma were identified and quantified as well as cellular pathways regulated by those proteins.

Methods

Quantitative proteomic analysis, using multiplexed isotopically labeled tags (TMT labeling) and label-free tandem mass spectrometry, was performed on plasma, low leukocyte PRP, and PPP. Plasma formulations were derived from two blood donors (one donor per experiment). Pathway analysis of the proteomic data identified the major differences between formulations.

Results

Nearly 600 proteins were detected in three types of blood plasma formulations in two experiments. Identified proteins showed more than 50% overlap between plasma formulations. Detected proteins represented more than 100 canonical pathways, as was identified by pathway analysis. The major pathways and regulatory molecules were linked to inflammation.

Conclusion

Three types of plasma formulations were compared in two proteomic experiments. The most represented pathways, such as Acute Phase Response, Coagulation, or System of the Complement, had many proteins in common in both experiments. In both experiments plasma sample sets had the same direction of biochemical pathway changes: up- or down-regulation. The most represented biochemical pathways are linked to inflammation.

Biologics

Biologics are a growing field that has shown immense promise for the treatment of musculoskeletal conditions both in orthopedic sports medicine and interventional pain management. These procedures utilize injection of supraphysiologic levels of platelets and growth factors to invoke the body's own inflammatory cascade to augment the healing of many bony and soft tissue conditions. While many patients improve with conservative care, there is a need to address the gap between those that improve with rehabilitation alone and those who ultimately require operative management. Orthobiologic procedures have the potential to fill this void. The purpose of this review is to summarize the basic science, evidence for use, and post-injection rehabilitation concepts of platelet-rich plasma (PRP) and mesenchymal stromal cells (MSCs) as they pertain to joints, tendons, ligaments, and the spine.

Common Musculoskeletal Disorders in the Elderly: The Star Triad

Musculoskeletal disorders are debilitating conditions that significantly impair the state of health, especially in elderly subjects. A pathological triad of inter-related disorders that are highly prevalent in the elderly consists of the following main “components”: sarcopenia, tendinopathies, and arthritis. The aim of this review is to critically appraise the literature relative to the different disorders of this triad, in order to highlight the pathophysiological common denominator and propose strategies for personalized clinical management of patients presenting with this combination of musculoskeletal disorders. Their pathophysiological common denominator is represented by progressive loss of (focal or generalized) neuromuscular performance with a risk of adverse outcomes such as pain, mobility disorders, increased risk of falls and fractures, and impaired ability or disability to perform activities of daily living. The precise management of these disorders requires not only the use of available tools and recently proposed operational definitions, but also the development of new tools and approaches for prediction, diagnosis, monitoring, and prognosis of the three disorders and their combination.

Post-Procedure Protocols Following Platelet-Rich Plasma Injections for Tendinopathy: A Systematic Review

OBJECTIVE

Platelet-rich plasma (PRP) has been increasingly studied as a treatment for tendinopathy. Many factors may influence outcomes after PRP, including different protocols following administration. It was hypothesized that there would be heterogeneity in post-PRP protocols.

LITERATURE SURVEY

A systematized review of the literature on post-PRP protocols for tendinopathy was conducted using an electronic search of MEDLINE and Embase databases through September 2018.

METHODOLOGY

After duplicates were removed, English language articles involving adult patients who received PRP for tendinopathy were reviewed. Exclusion criteria included studies with fewer than 10 patients, PRP used to treat pathology other than tendinopathy, multiple protocols in one study, and surgical settings. Protocol specifics were extracted including nonsteroidal anti-inflammatory drugs (NSAID) restrictions before and after injection, postinjection restrictions on movement and weight bearing, use of orthoses, activity modifications, and postinjection rehabilitation protocols. Given limitations in the data, a meta-analysis was not performed.

SYNTHESIS

Eighty-four studies met inclusion criteria. Following PRP injection, weight-bearing restrictions were mentioned rarely (12% of protocols). Orthosis use was uncommon overall (18%) but more common in Achilles tendinopathy protocols (53%). The majority of protocols instituted a period of stretching (51%) and strengthening (54%). Stretching programs generally began 2-7 days following injection, and strengthening programs began within 2-3 weeks. Preinjection NSAID restriction was reported rarely (20%), whereas postinjection NSAID restriction was more common (56%), with a typical restriction of greater than 2 weeks (38%). Return to play or full activity was reported in 42% of protocols, most commonly at 4-6 weeks following injection.

CONCLUSION

Although the clinical effectiveness of PRP remains controversial, even less is known about the effect of post-PRP protocols, which may affect the outcomes attributed to PRP itself. No studies directly compare post-PRP protocols, and the protocols studied demonstrate substantial heterogeneity. Some consensus regarding post-PRP protocols exists, although the rationale for these recommendations is limited.

Platelet-Rich Plasma Is an Equal Alternative to Surgery in the Treatment of Type 1 Medial Epicondylitis

Background:

Medial epicondylitis (ME) is characterized as an overuse injury resulting in pathological alterations of the common flexor tendon at the elbow. Platelet-rich plasma (PRP) has recently become of interest in the treatment of musculoskeletal conditions as an alternative to operative management.

Purpose:

To compare the outcomes of recalcitrant type 1 ME after treatment with either PRP or surgery.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

To compare the 2 methods of treatment, we performed a retrospective review of 33 patients diagnosed with type 1 ME from 2006 to 2016 with a minimum clinical follow-up of 1 year who had failed an initial nonoperative treatment program of injections, medication, topical creams, and/or physical therapy. Overall, 15 patients were treated with a series of 2 leukocyte-rich PRP injections, and 18 patients were treated with surgery. Outcome measures included time to pain-free status, time to full range of motion (ROM), the Mayo Elbow Performance Score (MEPS), and the Oxford Elbow Score (OES). Each patient had at least 1-year follow-up. They were then contacted by telephone to determine final scores at a minimum 2-year follow-up. Unsuccessful outcomes were determined by the Nirschl grading system and failure to reach pain-free status, achieve baseline ROM, or return to previous activity.

Results:

The mean final follow-up was 3.9 years. A statistically significant improvement was noted in both time to full ROM (42.3 days for PRP vs 96.1 days for surgery; P < .01) and time to pain-free status (56.2 days for PRP vs 108.0 days for surgery; P < .01). Successful outcomes were observed in 80% of patients treated with PRP and 94% of those treated operatively (P = .37). No significant difference was found in return-to-activity rates, overall successful outcomes, MEPS scores, or OES scores.

Conclusion:

In this case series, the use of PRP showed clinically similar outcomes to those of surgery in recalcitrant type 1 ME. PRP can be considered as an alternative to surgery in the treatment of recurrent ME, with an earlier time to full ROM and time to pain-free status compared with surgery.

Ultrasound-Guided Percutaneous Tenotomy for Gluteal Tendinopathy

Background:

Gluteal tendinopathy is a common cause of lateral hip pain. Percutaneous ultrasonic tenotomy (PUT) has been used successfully for the treatment of tendinopathy of the elbow, knee, and ankle, but its use in the hip has not been described.

Purpose:

To evaluate the efficacy of PUT in patients who did not respond to nonsurgical management of gluteal tendinopathy.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 29 patients with gluteal tendinopathy (mean age, 62 years) who did not respond to nonsurgical treatment were enrolled in this prospective study and underwent ultrasound-guided PUT in an outpatient setting. Patients with a history of ipsilateral hip surgery were excluded. All patients initially underwent magnetic resonance imaging or a computed tomography arthrogram demonstrating tendinopathy and/or partial tearing of the gluteus minimus or medius tendon or both tendons. Outcomes were assessed with a visual analog scale (VAS) for pain, the Harris Hip Score evaluation, and the 12-Item Short Form Health Survey (SF-12) before the procedure and at subsequent follow-up visits or by telephone interviews at 3 weeks, 3 months, 6 months, and final follow-up (range, 18-30 months).

Results:

The mean final follow-up was at 22 months postoperatively. At final follow-up, VAS scores had improved from a preprocedural mean ± SD of 5.86 ± 1.73 to 2.82 ± 2.22 (P < .01). Harris Hip Scores improved from a preprocedural mean of 60.03 ± 10.86 to 77.47 ± 14.34 (P < .01). Total SF-12 scores improved from a mean of 29.93 ± 5.39 (51% optimal) to 34.41 ± 4.88 (64% optimal) (P < .01). No complications were reported. At final follow-up, when asked whether they would have the procedure again, 15 patients replied “yes definitely,” 3 replied “yes probably,” 3 replied “maybe,” 1 replied “likely not,” and 2 replied “definitely not.” There were 3 patients who eventually had hip abductor tendon repair, and their PUT procedures were considered failures.

Conclusion:

PUT is an effective treatment, with good results for patients with gluteal tendinopathy.

Platelet-Rich Plasma Versus Surgery for the Management of Recalcitrant Greater Trochanteric Pain Syndrome: A Systematic Review

PURPOSE

To perform a systematic review of the outcomes of platelet-rich plasma (PRP) injections as an in-office procedure versus surgical treatment for recalcitrant greater trochanteric pain syndrome (GTPS).

METHODS

The MEDLINE and Embase databases were searched in June 2019 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Clinical studies on patients with recalcitrant GTPS treated with PRP or surgery were included. Demographic characteristics, patient-reported outcomes (PROs), and complications were compared. A qualitative analysis using the Methodological Index for Non-randomized Studies and Cochrane Risk of Bias Tool scores was performed.

RESULTS

A total of 5 PRP and 5 surgery studies met the inclusion criteria, contributing 94 and 185 patients, respectively. The mean follow-up time was shorter for the PRP studies (range, 2-26 months) than with surgery (range, 12-70 months). The mean Methodological Index for Non-randomized Studies scores for the PRP and surgery groups were 11.25 and 11.4, respectively, and the only randomized trial had a low risk of bias. Two studies in the PRP group (n = 56) reported improvements in the modified Harris Hip Score at final follow-up (from 53.8 to 82.6 and from 56.7 to 74.2). The other PRP studies reported improvements using other measures. In the surgery group, 2 studies reported improvements in the Harris Hip Score (from 53.0 to 80 and from 53.3 to 88) whereas 3 used unique PROs (Oxford score, from 20.4 to 37.3; modified Harris Hip Score, from 54.9 to 76.2; and Merle d'Aubigné and Postel score, from 10.9 to 16.7). Although significant improvement was reported in all studies included, PRP showed a large effect size whereas surgery showed a moderate to large effect size. No major complications were associated with PRP treatment; however, the surgery group reported a higher rate of complications including recurrent external snapping hip, retears resulting from falls, trochanteric fracture, venous thrombosis, and wound-related problems.

CONCLUSIONS

Both PRP and surgical intervention for the treatment of recalcitrant GTPS showed statistically and clinically significant improvements based on PROs. Although not covered by most medical insurance companies, PRP injections for recalcitrant GTPS provides an effective and safe alternative after failed physical therapy. If surgery is indicated, endoscopy is safer than the open technique.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Orthobiologics for the Hip Region: A Narrative Review

Management of hip region disorders is challenging. Orthobiologic treatments including platelet rich plasma (PRP), mesenchymal stem cells, and amniotic injectables have gained popularity as promising treatments despite a lack of robust evidence for their effectiveness. We review rationale and current evidence for orthobiologics for three common hip region conditions: hip osteoarthritis, gluteal tendinopathy, and proximal hamstring tendinopathy. Overall, the current state of evidence is extremely limited for orthobiologic treatments and is predominantly relevant to PRP injections. There is currently a lack of data to support the use of mesenchymal stem cells or amniotic injectables in these conditions of the hip.

Radiofrequency Microdebridement as an Adjunct to Arthroscopic Surgical Treatment for Recalcitrant Gluteal Tendinopathy: A Double-Blind, Randomized Controlled Trial

Background:

Recalcitrant greater trochanteric pain is increasingly recognized as an indication for surgical intervention. The arthroscopic approach has become rapidly more common than the open alternative.

Hypothesis:

Patients undergoing radiofrequency microdebridement (RFMD) as an adjunct to arthroscopic gluteal bursectomy (AGB) and iliotibial band release (ITBR) will experience better functional improvement than AGB and ITBR alone at 1 year.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

A total of 33 patients with failed nonoperative treatment of gluteal tendinopathy were randomly allocated to undergo AGB/ITBR or AGB/ITBR + RFMD. Full-thickness tears were excluded. The primary outcome measure was the modified Harris Hip Score (mHHS) at 52 weeks. Secondary outcome measures included the mHHS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and 12-item Short Form Health Survey (SF-12), which were evaluated at 0, 6, 12, 24, and 52 weeks. Statistical significance was defined as P < .05.

Results:

A total of 33 participants (33 hips; 30 female and 3 male; mean age, 58 years) were randomized; 16 patients underwent AGB/ITBR + RFMD, and 17 underwent AGB/ITBR. Participants’ functionality improved in both groups at all time intervals. The mean mHHS score improved from 57.49 ± 10.61 to 77.76 ± 18.40 (P = .004) and from 58.98 ± 12.33 to 79.96 ± 18.86 (P = .001) at 52 weeks in the AGB/ITBR and AGB/ITBR + RFMD groups, respectively, although there was no statistically significant difference between groups. There were no device-related adverse events.

Conclusion:

AGB/ITBR led to significant improvements in patients with recalcitrant gluteal tendinopathy. In this small RCT, the addition of RFMD showed no additional benefit to AGB/ITBR but provided a safe adjunct for the surgical management of recalcitrant gluteal tendinopathy.

Registration:

NCT01562366 (ClinicalTrials.gov identifier).

The Behavior of Tendon Progenitor Cells from Tendinopathic Tendons: Implications for Treatment

Tendinopathy remains a significant clinical challenge. Although there is some evidence that leukocyte-rich platelet-rich plasma can improve the symptoms of tendinopathy, more efficacious treatments will be required in the future to improve probability of successfully resolving this condition in athletes. Because optimal treatments are not currently available, there is a need to better understand the pathology of tendinopathy from the perspective of tendon progenitor cells (TPCs). TPCs isolated from normal and tendinopathy donors were characterized by their stem cell properties and proliferation capacities, along with their ability to become tenocytes under mechanical loading. The results showed a significant 2.6-fold increase in the viable cell population in tendinopathy versus normal donors. Although the percentage of self-renewing cells was similar, the total number of TPCs in tendinopathy was significantly higher (1.6-fold) than normal TPCs based on the colony formation assays. In contrast, TPCs from tendinopathy tissue showed significantly lower cellular proliferation rate by cumulative population doublings. Next, the expanded TPCs from both tissues successfully demonstrated the trilineage differentiation capabilities with specific gene markers, staining, and biochemical assays. To induce tenogenic differentiation, stretchable silicone wells were designed and fabricated, plus the creation of an adaptor platform used on a syringe pump for mechanical stretch. This economic design provided the adequate cyclic loading to drive tenogenic differentiation. With these devices, the stretch duration was optimized and showed the significant increase in scleraxis (SCX) and tenomodulin (TNMD) expression at 2.60 (fold change) and 3.86 (fold change in logarithm), respectively, by reverse transcription-quantitative polymerase chain reaction in normal TPCs after stretch. This assay also demonstrated the widespread cell reorientation following stretch in normal TPCs. In contrast, the mechanical loading did not increase the SCX gene expression; TNMD expression remained undetectable, and cell realignment was significantly less in tendinopathy TPCs. In addition, western blot analysis confirmed the elevated TNMD protein expression in normal TPCs following stretch and the lack of expression in tendinopathy TPCs. In summary, tendinopathy TPCs were unable to differentiate into tenocytes following mechanical stretch. Future studies may aim to reprogram tendinopathy TPCs to allow tenogenic induction. Impact Statement This article presents a model to distinguish between normal and tendinopathy progenitor cell behavior, which reveals insight into the pathophysiology of tendinopathy. With the design of a platform adaptor, mechanical stretch was applied to tendon progenitor cells (TPCs) that promoted tenogenic differentiation. This design provided programmable features for more flexible application with low cost. These devices successfully stimulated tenogenic differentiation of TPCs from normal, but not tendinopathic tendons under cyclic stretch. The scientific method provided in this article will allow testing of biologics, exosomes, and other treatment strategies to derive new, more efficient treatment of tendinopathy in the future.