Efficacy of Ultrasound-Guided Glenohumeral Joint Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Hyaluronic Acid in the Treatment of Glenohumeral Osteoarthritis: A Randomized, Double-Blind Controlled Trial.

OBJECTIVE: To compare the efficacy of ultrasound-guided hyaluronic acid (HA) versus leukocyte-poor platelet-rich plasma (LP-PRP) injection in the treatment of glenohumeral osteoarthritis. DESIGN: Double-blind randomized controlled trial. SETTING: Academic institution. PATIENTS: Seventy patients with chronic glenohumeral osteoarthritis were randomly assigned to receive a single injection of HA (n = 36) or LP-PRP (n = 34). INTERVENTIONS: Leukocyte-poor platelet-rich plasma was processed using Harvest/TerumoBCT Clear PRP kits. Ultrasound-guided injections of 6 mL HA or 6 mL LP-PRP into the glenohumeral joint were performed. Patients, the injecting physician, and outcomes assessor were blinded to treatment assignments. MAIN OUTCOME MEASURES: Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) score, current/average numerical rating scale (NRS) pain scores, satisfaction, and side effects were assessed at the 5 follow-up time points over 12 months. RESULTS: Baseline characteristics were similar between groups. There were no significant between-group differences regarding SPADI, ASES, and current/average NRS pain scores at any time point up to 12 months postinjection ( P > 0.05). However, significant improvements in SPADI, ASES, and current/average NRS pain scores were observed in both groups starting at 1 or 2 months ( P < 0.01, P < 0.01, P < 0.001, and P < 0.01, respectively). These improvements were observed regardless of osteoarthritis severity. For patients who received LP-PRP, there was no effect of platelet yield on outcomes. Side effect and satisfaction rates were similar between groups. CONCLUSIONS: There were no differences in pain and functional outcomes after a single injection of LP-PRP versus HA. However, significant improvements in pain and function were observed after both treatments in patients with glenohumeral osteoarthritis.

Rehabilitation and Prevention of Proximal Hamstring Tendinopathy.

Proximal hamstring tendinopathy (PHT) comprises a small but significant portion of hamstring injuries in athletes, especially runners. PHT is a chronic condition that is clinically diagnosed but can be supported with imaging. The main presenting complaint is pain in the lower gluteal or ischial region that may or may not radiate along the hamstrings in the posterior thigh. There is little scientific evidence on which to base the rehabilitation management of PHT. Treatment is almost always conservative, with a focus on activity modification, addressing contributing biomechanical deficiencies, effective tendon loading including eccentric training, and ultrasound-guided interventional procedures which may facilitate rehabilitation. Surgery is limited to recalcitrant cases or those involving concomitant high-grade musculotendinous pathology. The keys to PHT management include early and accurate diagnosis, optimal rehabilitation to allow for a safe return to preinjury activity level, and preventative strategies to reduce risk of reinjury.

Longitudinal, prospective study of head impacts in male high school football players.

INTRODUCTION: Repetitive, subconcussive events may adversely affect the brain and cognition during sensitive periods of development. Prevention of neurocognitive consequences of concussion in high school football is therefore an important public health priority. We aimed to identify the player positions and demographic, behavioral, cognitive, and impact characteristics that predict the frequency and acceleration of head impacts in high school football players. METHODS: In this prospective study, three cohorts of adolescent male athletes (N = 53, 28.3% Hispanic) were recruited over three successive seasons in a high school American football program. Demographic and cognitive functioning were assessed at baseline prior to participating in football. Helmet sensors recorded impact frequency and acceleration. Each head impact was captured on film from five different angles. Research staff verified and characterized on-field impacts. Player-level Poisson regressions and year-level and impact-level linear mixed-effect models were used to determine demographic, behavioral, cognitive, and impact characteristics as predictors of impact frequency and acceleration. RESULTS: 4,678 valid impacts were recorded. Impact frequency positively associated with baseline symptoms of hyperactivity-impulsivity [ß(SE) = 1.05 impacts per year per unit of symptom severity (1.00), p = 0.01] and inattentiveness [ß(SE) = 1.003 impacts per year per T-score unit (1.001), p = 0.01]. Compared to quarterbacks, the highest acceleration impacts were sustained by kickers/punters [ß(SE) = 21.5 g's higher (7.1), p = 0.002], kick/punt returners [ß(SE) = 9.3 g's higher (4.4), p = 0.03], and defensive backs [ß(SE) = 4.9 g's higher (2.5), p = 0.05]. Impacts were more frequent in the second [ß(SE) = 33.4 impacts (14.2), p = 0.02)] and third [ß(SE) = 50.9 impacts (20.1), p = 0.01] year of play. Acceleration was highest in top-of-the-head impacts [ß(SE) = 4.4 g's higher (0.8), p<0.001]. CONCLUSION: Including screening questions for Attention-Deficit/Hyperactivity Disorder in pre-participation evaluations can help identify a subset of prospective football players who may be at risk for increased head impacts. Position-specific strategies to modify kickoffs and correct tackling and blocking may also reduce impact burden.

Cellular and Clinical Analyses of Autologous Bone Marrow Aspirate Injectate for Knee Osteoarthritis: A Pilot Study.

INTRODUCTION: Knee osteoarthritis (OA) is characterized by pain and functional deficits. Common conservative strategies include medications, physical therapy, and intra-articular injections. Recently, treatment using autologous cell injections has increased. OBJECTIVE: To characterize the cellular content of bone marrow aspirate (BMA) and to evaluate the effect of intra-articular autologous BMA injections in patients with mild knee OA. DESIGN: Prospective pilot observational study. SETTING: Academic institution. PATIENTS: Eleven patients with unilateral or bilateral mild knee OA (15 knees) were included in the cellular analysis. Ten patients (13 knees) were included in the overall (cellular and clinical) analysis. INTERVENTIONS: BMA was aspirated from patients' iliac crests and then injected intra-articularly under fluoroscopic and/or ultrasound guidance. BMA samples were analyzed using flow cytometry, colony forming unit (CFU) assays, and enzyme-linked immunosorbent assays. Questionnaires assessing pain and function were administered preinjection and at 1, 3, 6, and 12 months postinjection. Side effects and satisfaction were assessed. MAIN OUTCOME MEASURES: Total nucleated cell (TNC) concentration, mesenchymal stem cell (MSC) concentration, CFU count, and interleukin-1 receptor antagonist (IL-1Ra) concentration. RESULTS: BMA sample analyses revealed wide ranges in TNC concentration (173300-4 491 050 cells/mL), MSC concentration (0-500 cells/mL), CFUs (0-19), and IL-1Ra concentration (2806-29 394 pg/mL). Improvements in Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement were observed throughout the 12-month follow-up period (F[4,12] = 12.29, P < .001). Additionally, current, usual, best, and worst numerical rating scale pain scores significantly decreased over time (P < .001). Patient satisfaction was high (range: 8.1 ± 2.1-8.8 ± 1.9), and side effects were uncommon. CONCLUSIONS: The cellular content of BMA samples varied widely between patients and was lower than the anticipated yield reported by the device's manufacturer. However, intra-articular BMA injections for knee OA in a small pilot cohort appeared to be safe with potential therapeutic value. Larger, prospective, double-blinded studies are warranted.

Ultrasound-guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: A randomized controlled trial.

BACKGROUND: Tendinosis is a chronic degenerative condition. Current research suggests both percutaneous needle tenotomy (PNT) and leukocyte-rich platelet-rich plasma (LR-PRP) may be effective treatments for chronic tendinosis, but no studies have assessed the effectiveness of PNT alone versus PNT with intratendinous LR-PRP for multiple tendon types in a single study. OBJECTIVE: To assess the efficacy of PNT versus PNT + LR-PRP to treat chronic tendinosis. STUDY DESIGN: Double-blind, randomized, controlled comparative treatment study. SETTING: Primary academic institution. PARTICIPANTS: A convenience sample of 40 participants who had chronic tendinosis (rotator cuff, wrist extensor, wrist flexor, hip abductor, proximal hamstring, patellar, or Achilles) confirmed via ultrasound, failed conservative treatment, and did not have tendon tears, known coagulopathy, or systemic illnesses. INTERVENTIONS: Participants were randomly assigned to PNT (n = 19) or PNT + LR-PRP (n = 21). Participants and outcomes assessors were blinded to treatment assignments. PNT was performed with 20-30 passes of a 22-gauge needle under ultrasound guidance, with 1% lidocaine given outside the tendon. LR-PRP was processed from whole blood (30-60 mL) and injected into the affected tendon using the same PNT technique. MAIN OUTCOME MEASURES: Primary outcome was current numerical rating scale pain at 6 weeks. Secondary outcomes were average pain, function, general well-being, and sleep quality at 6, 52, and 104 weeks. RESULTS: Baseline characteristics were similar between groups. Overall, there were no significant differences between groups over time for any of the outcomes (P > .05). Between-group analyses showed significantly lower current and average pain after PNT compared to PNT + LR-PRP at 6 weeks (estimated-mean [SE]: 3.1[0.4] vs. 4.6[0.6], P = .04; 3.4[0.4] vs. 4.9[0.5], P = .03) only. Adverse event rates were low (PNT-3.9%; PNT + LR-PRP-5.0%) and related primarily to postprocedural pain and inflammation. CONCLUSIONS: Although pain scores were lower after PNT compared to PNT + LR-PRP at 6 weeks, there were no between-group differences in outcomes at 52 or 104 weeks.

Spondylodiscitis due to Cutibacterium acnes following lumbosacral intradiscal biologic therapy: a case report.

A 40-year-old woman with a history of chronic low back pain underwent a fluoroscopically guided intradiscal platelet-rich plasma injection (PRP) at the L5-S1 level. She subsequently developed progressive low back pain, night sweats and decreased ability to ambulate. Laboratory work-up revealed elevated acute phase reactants and imaging revealed L5-S1 intervertebral disc and vertebral end-plate abnormalities highly suggestive of spondylodiscitis. Computed tomography-guided aspiration and biopsy cultures grew Cutibacterium acnes and the patient was subsequently treated with intravenous antibiotics without surgical management. To the best of our knowledge, this is the first published case of lumbar spondylodiscitis following an intradiscal PRP injection, and brings to the forefront several clinically relevant issues including the antimicrobial effects of PRP, the role of C. acnes in spine infections and the ideal treatment protocol for intradiscal biologics in order to minimize morbidity and optimize functional outcomes.