Shoulder & Elbow

Platelet-rich plasma therapy improved both the pain scores and elbow tenderness for almost three-quarters of patients suffering from tennis elbow during a 6-month randomized, double-blind controlled trial.

This study is the third to show a treatment response with no significant complications in patients with lateral epicondylar tendinopathy, commonly known as tennis elbow, from platelet-rich plasma (PRP) injections.

Dr. Allan Mishra, of Stanford (Calif.) University Medical Center,* and his coinvestigators from eight other institutions presented their findings from the trial at the annual meeting of the American Academy of Orthopaedic Surgeons in Chicago.

The 230 study participants had symptoms for at least 3 months and reported tenderness at the lateral epicondyle and pain scored at a minimum of 50 out of 100 on a visual analog scale during a resisted wrist extension. All participants failed to respond to conventional therapy, including a combination of physical therapy, nonsteroidal anti-inflammatory medications, and/or steroid injections, the investigators reported.

Dr. Mishra and his colleagues used a Biomet GPS centrifuge and canister system to prepare a formulation of 2-3 mL of PRP for 116 patients who received the intervention. The PRP contained concentrated platelets and concentrated white blood cells at a concentration five to six times greater than in plasma at baseline.

Both the patients who received PRP and the 114 active controls were given a local anesthesia block of 0.25% bupivacaine with epinephrine before investigators needled the origin of their extensor tendons, delivering the PRP only to the intervention group.

At 12 weeks’ follow-up, patients receiving the PRP injections reported 55.1% improvement in their pain scores, compared with their baseline pain before the procedure, whereas controls reported 47.4% improvement in pain compared with baseline. The findings were not statistically significant (P = .094). The 12-week secondary outcome measurement was statistically significant, with 37.4% of the intervention group reporting significant elbow tenderness, compared with 48.4% of controls reporting significant tenderness (P = .036).

At 24 weeks, the difference in pain scores between the two groups was statistically significant: PRP patients reported 71.5% improvement, whereas controls reported 56.1% improvement (P = .027). Similarly, significant elbow tenderness remained in 29.1% of PRP patients and 54% of the controls (P less than .001).

The two previous trials, one led by Dr. Mishra with a mean 25.6-month follow-up, and another 2-year study, used the same methodology and PRP system as this one and showed similar improvements, said Dr. Mishra. "Together these studies have treated 350 patients in a prospective, controlled fashion with all of the studies showing superiority when patients are treated with PRP," he said.

However, PRP treatment should not be used as a first-line therapy, he said. "Most patients will respond to conservative treatment such as exercise and rest," Dr. Mishra said. "PRP should, however, be used instead of cortisone for patients who have failed initial treatment."

The investigators noted that there are several potential mechanisms by which the PRP helps improve the pain in tennis elbow. Preclinical studies have shown that PRP can improve cell proliferation and others have shown it improves local blood flow, Dr. Mishra said. "Finally, it may be possible that PRP modifies neurogenic pain receptors and thereby improves clinical outcomes," he said. "More research is clearly needed in this area."

As with the other two studies, no significant complications were reported among the participants in this study, the investigators found. "Importantly, these studies were conducted over the course of a decade with an excellent safety profile for PRP," Dr. Mishra said. "Clinicians and patients can now be confident when using this specific form of PRP to treat chronic tennis elbow."

The study was funded by Biomet Biologics. All authors have received funding from a range of industry sources, including Biomet.

* Correction, 3/28/13: Dr. Mishra's affiliation has been corrected and not all of the investigators were from the same institution.

[email protected]

Platelet-rich plasma therapy improved both the pain scores and elbow tenderness for almost three-quarters of patients suffering from tennis elbow during a 6-month randomized, double-blind controlled trial.

This study is the third to show a treatment response with no significant complications in patients with lateral epicondylar tendinopathy, commonly known as tennis elbow, from platelet-rich plasma (PRP) injections.

Dr. Allan Mishra, of Stanford (Calif.) University Medical Center,* and his coinvestigators from eight other institutions presented their findings from the trial at the annual meeting of the American Academy of Orthopaedic Surgeons in Chicago.

The 230 study participants had symptoms for at least 3 months and reported tenderness at the lateral epicondyle and pain scored at a minimum of 50 out of 100 on a visual analog scale during a resisted wrist extension. All participants failed to respond to conventional therapy, including a combination of physical therapy, nonsteroidal anti-inflammatory medications, and/or steroid injections, the investigators reported.

Dr. Mishra and his colleagues used a Biomet GPS centrifuge and canister system to prepare a formulation of 2-3 mL of PRP for 116 patients who received the intervention. The PRP contained concentrated platelets and concentrated white blood cells at a concentration five to six times greater than in plasma at baseline.

Both the patients who received PRP and the 114 active controls were given a local anesthesia block of 0.25% bupivacaine with epinephrine before investigators needled the origin of their extensor tendons, delivering the PRP only to the intervention group.

At 12 weeks’ follow-up, patients receiving the PRP injections reported 55.1% improvement in their pain scores, compared with their baseline pain before the procedure, whereas controls reported 47.4% improvement in pain compared with baseline. The findings were not statistically significant (P = .094). The 12-week secondary outcome measurement was statistically significant, with 37.4% of the intervention group reporting significant elbow tenderness, compared with 48.4% of controls reporting significant tenderness (P = .036).

At 24 weeks, the difference in pain scores between the two groups was statistically significant: PRP patients reported 71.5% improvement, whereas controls reported 56.1% improvement (P = .027). Similarly, significant elbow tenderness remained in 29.1% of PRP patients and 54% of the controls (P less than .001).

The two previous trials, one led by Dr. Mishra with a mean 25.6-month follow-up, and another 2-year study, used the same methodology and PRP system as this one and showed similar improvements, said Dr. Mishra. "Together these studies have treated 350 patients in a prospective, controlled fashion with all of the studies showing superiority when patients are treated with PRP," he said.

However, PRP treatment should not be used as a first-line therapy, he said. "Most patients will respond to conservative treatment such as exercise and rest," Dr. Mishra said. "PRP should, however, be used instead of cortisone for patients who have failed initial treatment."

The investigators noted that there are several potential mechanisms by which the PRP helps improve the pain in tennis elbow. Preclinical studies have shown that PRP can improve cell proliferation and others have shown it improves local blood flow, Dr. Mishra said. "Finally, it may be possible that PRP modifies neurogenic pain receptors and thereby improves clinical outcomes," he said. "More research is clearly needed in this area."

As with the other two studies, no significant complications were reported among the participants in this study, the investigators found. "Importantly, these studies were conducted over the course of a decade with an excellent safety profile for PRP," Dr. Mishra said. "Clinicians and patients can now be confident when using this specific form of PRP to treat chronic tennis elbow."

The study was funded by Biomet Biologics. All authors have received funding from a range of industry sources, including Biomet.

* Correction, 3/28/13: Dr. Mishra's affiliation has been corrected and not all of the investigators were from the same institution.

[email protected]

Platelet-rich plasma therapy improved both the pain scores and elbow tenderness for almost three-quarters of patients suffering from tennis elbow during a 6-month randomized, double-blind controlled trial.

This study is the third to show a treatment response with no significant complications in patients with lateral epicondylar tendinopathy, commonly known as tennis elbow, from platelet-rich plasma (PRP) injections.

Dr. Allan Mishra, of Stanford (Calif.) University Medical Center,* and his coinvestigators from eight other institutions presented their findings from the trial at the annual meeting of the American Academy of Orthopaedic Surgeons in Chicago.

The 230 study participants had symptoms for at least 3 months and reported tenderness at the lateral epicondyle and pain scored at a minimum of 50 out of 100 on a visual analog scale during a resisted wrist extension. All participants failed to respond to conventional therapy, including a combination of physical therapy, nonsteroidal anti-inflammatory medications, and/or steroid injections, the investigators reported.

Dr. Mishra and his colleagues used a Biomet GPS centrifuge and canister system to prepare a formulation of 2-3 mL of PRP for 116 patients who received the intervention. The PRP contained concentrated platelets and concentrated white blood cells at a concentration five to six times greater than in plasma at baseline.

Both the patients who received PRP and the 114 active controls were given a local anesthesia block of 0.25% bupivacaine with epinephrine before investigators needled the origin of their extensor tendons, delivering the PRP only to the intervention group.

At 12 weeks’ follow-up, patients receiving the PRP injections reported 55.1% improvement in their pain scores, compared with their baseline pain before the procedure, whereas controls reported 47.4% improvement in pain compared with baseline. The findings were not statistically significant (P = .094). The 12-week secondary outcome measurement was statistically significant, with 37.4% of the intervention group reporting significant elbow tenderness, compared with 48.4% of controls reporting significant tenderness (P = .036).

At 24 weeks, the difference in pain scores between the two groups was statistically significant: PRP patients reported 71.5% improvement, whereas controls reported 56.1% improvement (P = .027). Similarly, significant elbow tenderness remained in 29.1% of PRP patients and 54% of the controls (P less than .001).

The two previous trials, one led by Dr. Mishra with a mean 25.6-month follow-up, and another 2-year study, used the same methodology and PRP system as this one and showed similar improvements, said Dr. Mishra. "Together these studies have treated 350 patients in a prospective, controlled fashion with all of the studies showing superiority when patients are treated with PRP," he said.

However, PRP treatment should not be used as a first-line therapy, he said. "Most patients will respond to conservative treatment such as exercise and rest," Dr. Mishra said. "PRP should, however, be used instead of cortisone for patients who have failed initial treatment."

The investigators noted that there are several potential mechanisms by which the PRP helps improve the pain in tennis elbow. Preclinical studies have shown that PRP can improve cell proliferation and others have shown it improves local blood flow, Dr. Mishra said. "Finally, it may be possible that PRP modifies neurogenic pain receptors and thereby improves clinical outcomes," he said. "More research is clearly needed in this area."

As with the other two studies, no significant complications were reported among the participants in this study, the investigators found. "Importantly, these studies were conducted over the course of a decade with an excellent safety profile for PRP," Dr. Mishra said. "Clinicians and patients can now be confident when using this specific form of PRP to treat chronic tennis elbow."

The study was funded by Biomet Biologics. All authors have received funding from a range of industry sources, including Biomet.

* Correction, 3/28/13: Dr. Mishra's affiliation has been corrected and not all of the investigators were from the same institution.

[email protected]

WASHINGTON – The risk of infection following orthopedic surgery is increased in patients with inflammatory rheumatic disease, compared with those with degenerative disease or traumatic injury, according to findings from a review of more than 50,000 surgical procedures.

The risk is greatest in those inflammatory rheumatic disease patients treated with conventional disease-modifying anti-rheumatic drugs (cDMARDs) or tumor necrosis factor (TNF) inhibitors, especially those receiving more than one cDMARD or TNF inhibitor with a long administration interval, and when surgery takes place without discontinuation of treatment, Catrina B. Scherrer reported at the annual meeting of the American College of Rheumatology.

Of 50,359 surgical procedures performed in 37,137 patients from a hospital surgery registry, 422 resulted in surgery-related infections. Of these infections, 49 occurred in 2,472 patients with an inflammatory rheumatic disease (IRD; 2%), and 373 occurred in 47,887 patients with degenerative disease/posttraumatic injury (0.8%). The difference was statistically significant, even after adjustment for other risk factors, including age, gender, diabetes, being overweight, cardiovascular disease, smoking, and type of surgery, said Ms. Scherrer of the Schulthess Clinic, Zürich.

The lowest rates of infection occurred with hand and shoulder surgery; the highest rates occurred with elbow surgery, she noted.

In 1,329 patients in the IRD group for whom complete information about medication was available, 171 (13%) had documented use of TNF inhibitors, and 49 of these (29%) discontinued treatment more than three administration intervals before surgery. Of the remaining 122 TNF inhibitor users, the time lag was three or fewer administration intervals.

An increased infection rate was seen in those who used more than one cDMARD (odds ratio, 2.425) and more than one TNF inhibitor (OR, 2.627) prior to surgery, and the risk of infection was increased tenfold when surgery was performed within one administration interval (OR, 10.047).

Patients who had their last treatment within one administration interval before surgery included 81% of infliximab users, compared with only 33% of adalimumab users and 24% of etanercept users, Ms. Scherrer noted.

Surgery patients in this study were followed over 8 years as part of a single-center surgery registry. The findings, which are limited by the study’s retrospective design and thus require confirmation in prospective studies, are nonetheless important because patients with aggressive disease such as IRDs frequently require orthopedic surgery.

The study findings suggest that IRD patients are, in general, at high risk of postoperative infection, that special attention should be paid to patients using more than one cDMARD or TNF inhibitor with long administration intervals, and that the last intake of TNF inhibitors – particularly infliximab – should be at least more than one administration interval before planned surgery, as the risk of postoperative infection is significantly increased if surgery occurs within this period, she concluded.

Ms. Scherrer reported having no disclosures.

WASHINGTON – The risk of infection following orthopedic surgery is increased in patients with inflammatory rheumatic disease, compared with those with degenerative disease or traumatic injury, according to findings from a review of more than 50,000 surgical procedures.

The risk is greatest in those inflammatory rheumatic disease patients treated with conventional disease-modifying anti-rheumatic drugs (cDMARDs) or tumor necrosis factor (TNF) inhibitors, especially those receiving more than one cDMARD or TNF inhibitor with a long administration interval, and when surgery takes place without discontinuation of treatment, Catrina B. Scherrer reported at the annual meeting of the American College of Rheumatology.

Of 50,359 surgical procedures performed in 37,137 patients from a hospital surgery registry, 422 resulted in surgery-related infections. Of these infections, 49 occurred in 2,472 patients with an inflammatory rheumatic disease (IRD; 2%), and 373 occurred in 47,887 patients with degenerative disease/posttraumatic injury (0.8%). The difference was statistically significant, even after adjustment for other risk factors, including age, gender, diabetes, being overweight, cardiovascular disease, smoking, and type of surgery, said Ms. Scherrer of the Schulthess Clinic, Zürich.

The lowest rates of infection occurred with hand and shoulder surgery; the highest rates occurred with elbow surgery, she noted.

In 1,329 patients in the IRD group for whom complete information about medication was available, 171 (13%) had documented use of TNF inhibitors, and 49 of these (29%) discontinued treatment more than three administration intervals before surgery. Of the remaining 122 TNF inhibitor users, the time lag was three or fewer administration intervals.

An increased infection rate was seen in those who used more than one cDMARD (odds ratio, 2.425) and more than one TNF inhibitor (OR, 2.627) prior to surgery, and the risk of infection was increased tenfold when surgery was performed within one administration interval (OR, 10.047).

Patients who had their last treatment within one administration interval before surgery included 81% of infliximab users, compared with only 33% of adalimumab users and 24% of etanercept users, Ms. Scherrer noted.

Surgery patients in this study were followed over 8 years as part of a single-center surgery registry. The findings, which are limited by the study’s retrospective design and thus require confirmation in prospective studies, are nonetheless important because patients with aggressive disease such as IRDs frequently require orthopedic surgery.

The study findings suggest that IRD patients are, in general, at high risk of postoperative infection, that special attention should be paid to patients using more than one cDMARD or TNF inhibitor with long administration intervals, and that the last intake of TNF inhibitors – particularly infliximab – should be at least more than one administration interval before planned surgery, as the risk of postoperative infection is significantly increased if surgery occurs within this period, she concluded.

Ms. Scherrer reported having no disclosures.

WASHINGTON – The risk of infection following orthopedic surgery is increased in patients with inflammatory rheumatic disease, compared with those with degenerative disease or traumatic injury, according to findings from a review of more than 50,000 surgical procedures.

The risk is greatest in those inflammatory rheumatic disease patients treated with conventional disease-modifying anti-rheumatic drugs (cDMARDs) or tumor necrosis factor (TNF) inhibitors, especially those receiving more than one cDMARD or TNF inhibitor with a long administration interval, and when surgery takes place without discontinuation of treatment, Catrina B. Scherrer reported at the annual meeting of the American College of Rheumatology.

Of 50,359 surgical procedures performed in 37,137 patients from a hospital surgery registry, 422 resulted in surgery-related infections. Of these infections, 49 occurred in 2,472 patients with an inflammatory rheumatic disease (IRD; 2%), and 373 occurred in 47,887 patients with degenerative disease/posttraumatic injury (0.8%). The difference was statistically significant, even after adjustment for other risk factors, including age, gender, diabetes, being overweight, cardiovascular disease, smoking, and type of surgery, said Ms. Scherrer of the Schulthess Clinic, Zürich.

The lowest rates of infection occurred with hand and shoulder surgery; the highest rates occurred with elbow surgery, she noted.

In 1,329 patients in the IRD group for whom complete information about medication was available, 171 (13%) had documented use of TNF inhibitors, and 49 of these (29%) discontinued treatment more than three administration intervals before surgery. Of the remaining 122 TNF inhibitor users, the time lag was three or fewer administration intervals.

An increased infection rate was seen in those who used more than one cDMARD (odds ratio, 2.425) and more than one TNF inhibitor (OR, 2.627) prior to surgery, and the risk of infection was increased tenfold when surgery was performed within one administration interval (OR, 10.047).

Patients who had their last treatment within one administration interval before surgery included 81% of infliximab users, compared with only 33% of adalimumab users and 24% of etanercept users, Ms. Scherrer noted.

Surgery patients in this study were followed over 8 years as part of a single-center surgery registry. The findings, which are limited by the study’s retrospective design and thus require confirmation in prospective studies, are nonetheless important because patients with aggressive disease such as IRDs frequently require orthopedic surgery.

The study findings suggest that IRD patients are, in general, at high risk of postoperative infection, that special attention should be paid to patients using more than one cDMARD or TNF inhibitor with long administration intervals, and that the last intake of TNF inhibitors – particularly infliximab – should be at least more than one administration interval before planned surgery, as the risk of postoperative infection is significantly increased if surgery occurs within this period, she concluded.

Ms. Scherrer reported having no disclosures.