A Greater Platelet Dose May Yield Better Clinical Outcomes for Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Systematic Review.

PURPOSE: To determine whether the platelet dose administered during a platelet-rich plasma (PRP) injection for knee osteoarthritis (OA) affects clinical outcomes. METHODS: A systematic review was performed by searching PubMed, Cochrane Library, and Embase for randomized controlled trials with at least 1 study arm using PRP for knee OA. Only studies that provided a platelet count, concentration, or dose with a minimum of 6-month outcome scores were included. Studies in which the PRP group had statistically significant positive outcomes were separated from those without statistical significance. The average platelet doses for studies with positive outcomes in the PRP group were compared with those without positive outcomes. RESULTS: After exclusion criteria were applied, 29 studies were analyzed. Of the 29, there were 31 arms that used PRP as a treatment method, of which 28 had statistically significant positive outcomes at 6 months compared with the control group. The mean platelet dose in the 28 with a positive outcome was 5,500 ± 474 × 106, whereas the 3 that had no positive difference had a mean platelet dose of 2,302 ± 437 × 106 (P < .01). There were 18 studies with 12-month outcomes, with 16 of 18 having positive outcomes. The positive studies had an average platelet dose of 5,464 ± 511, whereas the studies that had no statistical difference had an average platelet dose of 2,253 ± 753 × 106 (P < .05). CONCLUSIONS: Improved clinical outcomes from PRP injections for knee OA may be related to a greater platelet dose. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Diagnostic Imaging of A2 Pulley Injuries: A Review of the Literature.

Injury to the A2 pulley is caused by high eccentric forces on the flexor-tendon-pulley system. Accurate diagnosis is necessary to identify the most appropriate treatment options. This review summarizes the literature with respect to using ultrasound (US) to diagnose A2 pulley injuries, compares ultrasound to magnetic resonance imaging and computed tomography, and identifies current knowledge gaps. The results suggest that US should be used as the primary imaging modality given high accuracy, relatively low cost, ease of access, and dynamic imaging capabilities. Manual resistance is beneficial to accentuate bowstringing, but further research is needed to determine best positioning for evaluation.

Botulinum Toxin A for Chronic Exertional Compartment Syndrome Evaluated With Shear Wave Elastography: A Case Report.

ABSTRACT: This case presentation offers supportive evidence that shear wave elastography may provide an alternative method of diagnosis of chronic exertional compartment syndrome (CECS). A 39-year-old female runner presented with bilateral anterior shin pain on exertion. She initially underwent compartmental pressure testing confirming the diagnosis of CECS but declined fasciotomy. When her symptoms recurred, she was referred for botulinum toxin therapy. Shear wave muscle elastography was performed in the bilateral anterior and lateral compartments following symptom provocation treadmill testing and compared with 2 control subjects. At 6 weeks and 7 months after onabotulinumtoxinA injections, she was asymptomatic, and elastography measurements revealed a reduction in muscle stiffness from initial treadmill testing.

Calcific Tendinopathy of the Shoulder: A Retrospective Comparison of Traditional Barbotage Versus Percutaneous Ultrasonic Barbotage.

OBJECTIVE: The purpose of this study was to compare a traditional barbotage technique with percutaneous ultrasonic barbotage (PUB) for the treatment of rotator cuff (RC) calcific tendinopathy. DESIGN: Three-year retrospective review. SETTING: Participants aged 18 to 75 presenting at 2 highly specialized outpatient orthopedic referral centers with symptomatic RC calcific tendinopathy. PATIENTS: There were 75 patients included (23 patients in the traditional barbotage group; 52 patients in the PUB group) with an average age of 55.3(6.5) and 55.9(9.8), respectively. There was no significant difference in demographics between groups. INTERVENTIONS: Traditional barbotage or PUB. MAIN OUTCOME MEASURES: Primary outcome measure was pain rated on the Numeric Pain Rating Scale (NPRS) with secondary outcomes investigating patient satisfaction. RESULTS: The barbotage and PUB group demonstrated a significant improvement in pain (barbotage 2.4, P = 0.01; PUB = 2.6, P < 0.001) with no statistically significant difference between the 2 treatment modalities (95% CI: -1.8 to 2.2; P = 0.83, P = 0.83). Median follow-up for NPRS recordings was 17-weeks in the barbotage group and 8-weeks in the PUB group ( P = 0.004). Both groups demonstrated similar patient-reported satisfaction, without major complications. CONCLUSION: The traditional barbotage and PUB procedures improved pain with a high patient satisfaction rate. LEVEL OF EVIDENCE: Level III.

The Effect of Platelet Dose on Outcomes after Platelet Rich Plasma Injections for Musculoskeletal Conditions: A Systematic Review and Meta-Analysis.

PURPOSE OF REVIEW: This study aims to systematically review platelet dosage in platelet rich plasma (PRP) injections for common musculoskeletal conditions. RECENT FINDINGS: Notable heterogeneity exists in the literature regarding platelet dosage. Clinical studies indicate that a higher dosage may lead to improved outcomes concerning pain relief, functional improvement, and chondroprotection in knee osteoarthritis (OA). However, the impact of dosing on other musculoskeletal pathologies remains uncertain. Our investigation identifies a potential dose-response relationship between platelet dose and PRP effectiveness for knee OA treatment, pinpointing an optimal threshold of greater than 10 billion platelets for favorable clinical outcomes. Notably, this effect appears more pronounced for functional outcomes than for pain relief. For other conditions, a lower dosage may suffice, although the existing literature lacks clarity on this matter. PRP dosage may significantly influence treatmentoutcomes, particularly in knee OA. Further research is warranted to elucidate optimal dosages for varying conditions.

Regulatory Considerations of Orthobiologic Procedures.

The injection of biologic products for musculoskeletal pathologies is an emerging and promising field; however, dubious and unsafe uses for these products are often marketed. The Food and Drug Administration (FDA) has determined the need for varying degrees of regulation for these products for safety and efficacy. These regulations are frequently updated and federally enforced. As the regulatory landscape changes, clinicians using biologic products must stay informed to remain within the purview of the FDA. This article describes the current regulations of the most common products: platelet-rich plasma, bone marrow aspirate concentrate, adipose-derived products, and birth tissue products.

Non-operative Management and Outcomes of Femoroacetabular Impingement Syndrome.

PURPOSE: To serve as a guide for non-operative physicians in the management of femoroacetabular impingement syndrome and provide an algorithm as to when to refer patients for potential surgical management. RECENT FINDINGS: Supervised physical therapy programs that focus on active strengthening and core strengthening are more effective than unsupervised, passive, and non-core-focused programs. There is promising evidence for the use of intra-articular hyaluronic acid and PRP as adjunct treatment options. Recent systematic reviews and meta-analyses have found that in young active patients, hip arthroscopy demonstrates improved short-term outcomes over physical therapy. The decision for the management of FAIS is complex and should be specific to each patient. Consideration of the patient's age, timing to return to sport, longevity of treatment, hip morphology, and degree of cartilage degeneration is required to make an informed decision in the treatment of these patients.

Amniotic dehydrated cell and protein concentrate versus corticosteroid in knee osteoarthritis: preliminary findings.

Objectives: The purpose is to report preliminary data on clinical response to dehydrated cell and protein concentrate (dCPC) versus corticosteroid (CSI). Design: A single-site prospective, randomized controlled single-blinded trial of patients with knee osteoarthritis. Methods: Pain and function were assessed using a visual analog scale (VAS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Emory Quality of Life (EQOL) measure at 1, 2, 3, 6, 9 and 12 months. Results: 51 patients were enrolled at the time of analysis (27 dCPC, 24 CSI). Both groups demonstrated improvement on the VAS, KOOS and EQOL. Largest differences were observed at 2 (p = 0.05), 3 (p = 0.012) and 6 months (p < 0.001) with a decrease of 1.66 in VAS at 6 months for dCPC (95% CI: -2.67 to -0.65) and 1.34 (95% CI: -2.37 to -0.3) for CSI. Time-averaged measures showed no difference between groups (p = 0.20). Limited data at 9 and 12 months trended toward improvement in the dCPC group. Conclusion: dCPC products may be used as a treatment for knee osteoarthritis. Larger trials are warranted. Clinical Trial Registration: NCT03710005 (ClinicalTrials.gov).

The purpose of this study was to discuss preliminary data from a clinical trial comparing a single injection of an amniotic-derived tissue product (dehydrated cell and protein concentrate [dCPC]) to corticosteroid for the treatment of knee osteoarthritis. The study took place at a single institution. 51 patients were enrolled at the time of analysis (27 dCPC, 24 corticosteroid). Both groups demonstrated improvement in pain and function 6 months after treatment. There was a larger improvement in the amniotic-derived tissue product group, but this did not reach a level of statistical significance. There were limited data beyond 6 months, but this trended toward a continued improvement in the amniotic-derived tissue product group. Findings suggest that these amniotic derived tissue products may be used as a treatment for knee osteoarthritis, but larger studies are needed.

Mesenchymal stem cells for subchondral bone marrow lesions: From bench to bedside.

Subchondral bone marrow lesions (BMLs) are areas of disease within subchondral bone that appear as T1 hypointense and T2 hyperintense ill-defined areas of bone marrow on magnetic resonance imaging. The most common bone marrow lesions include subchondral lesions related to osteoarthritis, osteochondral defects, and avascular necrosis. Emerging therapies include autologous biologic therapeutics, in particular mesenchymal stem cells (MSCs), to maintain and improve cartilage health; MSCs have become a potential treatment option for BMLs given the unmet need for disease modification. Active areas in the preclinical research of bone marrow lesions include the paracrine function of MSCs in pathways of angiogenesis and inflammation, and the use of bioactive scaffolds to optimize the environment for implanted MSCs by facilitating chondrogenesis and higher bone volumes. A review of the clinical data demonstrates improvements in pain and functional outcomes when patients with knee osteoarthritis were treated with MSCs, suggesting that BM-MSCs can be a safe and effective treatment for patients with painful knee osteoarthritis with or without bone marrow lesions. Preliminary data examining MSCs in osteochondral defects suggest they can be beneficial as a subchondral injection alone, or as a surgical augmentation. In patients with hip avascular necrosis, those with earlier stage disease have improved outcomes when core decompression is augmented with MSCs, whereas patients in later stages post-collapse have equivalent outcomes with or without MSC treatment. While the evidence for the use of MSCs in conditions with associated bone marrow lesions seems promising, there remains a need for continued investigation into this treatment as a viable treatment option.

A scoping review of methods used in musculoskeletal soft tissue and nerve shear wave elastography studies.

This scoping review of shear wave elastography (SWE) articles in musculoskeletal soft tissue and nerve research demonstrates methodological heterogeneity resulting from a lack of standardized data collection and reporting requirements. Seven literature databases were searched for original articles published in English from 2004-2020 that examine human skeletal muscles, tendons, and nerves in vivo. Although 5,868 records were initially identified, only 375 reports met inclusion criteria. Of the 375 articles, 260 examined 89 unique muscles, 94 examined 14 unique tendons, and 43 examined 8 unique nerves. Cohorts were often small (n = 11-20) and young (mean = 20-29 years), and participants were typically tested in the prone position. Regarding equipment, a variety of ultrasound systems (n = 11), ultrasound models (n = 18), and transducers (n = 19) were identified. Only 11% of articles contained information on the use of electromyography to confirm absence of muscle activity, and only 8% reported measurement depth. Since musculoskeletal soft tissue and nerve stiffness can vary significantly based on data collection methods, it is essential to standardize SWE collection and reporting procedures. This will allow SWE to serve as a valid and reproducible tool for assessing tissue pathology, disease progression, and response to intervention within a variety of musculoskeletal and nerve-related disorders.

Hip position influences shear wave elastography measurements of the hamstring muscles in healthy subjects.

Ultrasound shear wave elastography (SWE) has recently emerged as a non-invasive tool for assessing muscle stiffness. The majority of studies utilizing SWE have focused primarily on upper-extremity muscles, with little attention attributed to lower-extremity muscles. In addition, of the studies that have been published, various joint and muscle positions have been examined, rendering it difficult to compare results across studies. Thus, the purpose of this investigation was to examine lower extremity medial hamstring muscles (semitendinosus and semimembranosus) and to determine how hip position (0° versus 90°) and muscle position (knee flexed versus extended) impacted resulting shear modulus values. Ten subjects varying widely in age participated in this study, and their hamstring stiffness was assessed in four separate positions: seated with the knee flexed and extended, and lying prone with the knee flexed and extended. Higher shear modulus values were found at the group-level when participants were seated compared to prone (hip placed at 90° compared to 0°). In addition, higher values were also found when the knee was extended compared to flexed, but only when the hip was placed at 90° (not 0°). These results demonstrate that joint and muscle position, particularly when assessing the hamstrings, largely impact resulting shear modulus values. Therefore, joint and muscle position need to be systematically controlled for and reported when establishing normative ranges for shear modulus values across specific age groups. This will enable physicians to more precisely determine whether patients' shear modulus values indicate clinically meaningful differences in comparison to normative data.

Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis.

Chemodenervation of cervical musculature using botulinum neurotoxin (BoNT) is established as the gold standard or treatment of choice for management of Cervical Dystonia (CD). The success of BoNT procedures is measured by improved symptomology while minimizing side effects and is dependent upon many factors including: clinical pattern recognition, identifying contributory muscles, BoNT dosage, and locating and safely injecting target muscles. In patients with CD, treatment of anterocollis (forward flexion of the neck) and anterocaput (anterocapitis) (forward flexion of the head) are inarguably challenging. The longus Colli (LoCol) and longus capitis (LoCap) muscles, two deep cervical spine and head flexor muscles, frequently contribute to these patterns. Localizing and safely injecting these muscles is particularly challenging owing to their deep location and the complex regional anatomy which includes critical neurovascular and other structures. Ultrasound (US) guidance provides direct visualization of the LoCol, LoCap, other cervical muscles and adjacent structures reducing the risks and side effects while improving the clinical outcome of BoNT for these conditions. The addition of electromyography (EMG) provides confirmation of muscle activity within the target muscle. Within this manuscript, we present a technical description of a novel US guided approach (combined with EMG) for BoNT injection into the LoCol and LoCap muscles for the management of anterocollis and anterocaput in patients with CD.

Acute Spinal Epidural Hematoma as a Complication of Dry Needling: A Case Report.

Dry needling is a procedure commonly performed for the relief of myofascial pain disorders. The procedure is generally well tolerated. Adverse events often are mild, but severe complications have been reported. This case report describes an acute spinal epidural hematoma as a complication of dry needling. It is a reminder to the performing physician or therapist to take specific precautions when placing a needle near the spine. Sudden onset of neuropathic pain after needling therapy in and around the spine should prompt emergency assessment with possibly advanced spine imaging to evaluate the integrity of the spinal cord. LEVEL OF EVIDENCE: V.

A Case of Anterior Spinal Artery Syndrome Caused by Streptococcus mitis Endocarditis.

BACKGROUND: Infectious endocarditis (IE) typically occurs in the setting of intravenous drug use, prosthetic heart valves, or rheumatic heart disease. However, there are a few reports of IE occurring in the setting of immunosuppression secondary to cancer and/or chemotherapy. Here, we present a case of a cancer patient who developed anterior spinal artery (ASA) syndrome secondary to a septic embolus from IE. CASE PRESENTATION: A 78-year-old male with a history of gastroesophageal cancer treated with chemotherapy and radiation presented to the hospital after a fall at home. He reported experiencing dyspnea and orthopnea for two weeks prior to presentation. In the ED, his vital signs were stable, and his examination was significant for a flaccid paralysis of the right lower extremity. Diagnosis of septic emboli secondary to IE was made after the echocardiogram showed the presence of vegetations on the aortic valve, blood cultures were positive for Streptococcus mitis, and thoracic spine MRI was indicative of an infarction at T10. DISCUSSION: This case highlights the presence of IE in the setting of cancer and chemotherapy. Although cancer is a rare cause of IE, clinicians must maintain a high index of suspicion in order to minimize the sequelae of IE.