Retrospective Analysis of Responders and Impaired Patients with Knee Osteoarthritis Treated with Two Consecutive Injections of Very Pure Platelet-Rich Plasma (PRP).

OBJECTIVES: To assess the effectiveness of two consecutive intraarticular injections of PRP to treat knee osteoarthritis (KOA), discriminating between responders and impaired patients. METHODS: This retrospective study included 73 consecutive patients who were referred for two intra-articular PRP injections (one week apart) for treating symptomatic moderate/severe KOA. Biological characterization of the PRP, including platelets, leukocytes and erythrocytes, was evaluated. Patient's subjective symptoms were recorded before the treatment and 1 year after the second injection using pain VAS and WOMAC scores. Responders were defined by an improvement of 10 points on WOMAC. RESULTS: At a 1-year follow up, we found 36 (49.3%) patients who fulfilled the criteria of responders, and 21 (28.8%) patients were impaired. A statistically and clinically significant global improvement of -29.2 ± 14.3 (p < 0.001) points in WOMAC score was observed 1 year after treatment in the responder group, with a higher response rate in patients with KL 2 (57.7%) compared to KL IV (28.6%). The percentage of patients with KL IV was higher in the impaired group (48.0%) compared to the responders (16.6%). As expected, the evaluation of the functionality of the knee in the impaired group indicates that it significantly worsened after one year from treatment (p = 0.027). However, the average pain score remained stable with no significant differences after 1 year (p = 0.843). No clinical complications or severe adverse events after the PRP injections were reported. CONCLUSION: The present study suggests that two intra-articular injections of 10 mL of very pure PRP provide pain and functional improvement in symptomatic KOA.

Transforaminal versus interlaminar CT-guided lumbar epidural steroid injections: prospective study of 237 patients with unilateral radicular pain and up to 5 years of follow-up.

OBJECTIVE: To compare the efficacy of the transforaminal approach (TFA) versus the interlaminar approach (ILA) for CT-guided epidural steroid injection (CTESI) in the treatment of persistent lumbosacral radicular pain (LRP > 6 weeks) with long-term follow-up. METHODS: Patients were prospectively assessed for pain by visual analogue scale (VAS) and functional disability (Oswestry Disability Index, (ODI)) before treatment, then 6 weeks (6W), 6 months (6 M), and 5 years (5Y) after CTESI. RESULTS: Overall, n = 237 patients (TFA, n = 71 and ILA, n = 166) were included, and 96 patients had 5 years of follow-up. Both groups showed a statistically significant improvement in VAS and ODI values at 6W (TFA, n = 60 and ILA, n = 146, P < 0.001 for both), at 6 M (TFA, n = 34 and ILA, n = 96, P < 0.001 for both), and at 5Y (TFA, n = 32 and ILA, n = 64, P < 0.001 for both). No significant differences were observed between the two approaches in VAS or ODI decreases at 6W (P = 0.38 and P = 0.33 respectively), 6 M (P = 0.13 and P = 0.51 respectively), or 5Y (P = 0.15 and P = 0.57 respectively). No major complications were noted. CONCLUSION: Outcomes after CTESI by ILA approaches are similar to those by TFA for the treatment of persistent LRP.

Intra-articular Injection of Bone Marrow Concentrate for Treatment of Patellofemoral Osteoarthritis: Preliminary Results Utilizing an Ultrasound-Guided Marrow Harvesting Technique.

OBJECTIVE: To assess the effectiveness of intra-articular injection of bone marrow concentrate (BMC) under ultrasound (US) guidance in the treatment of patellofemoral osteoarthritis (OA), with clinical and volumetric magnetic resonance (MR) imaging follow-up. METHODS: This retrospective study included 96 consecutive patients referred for US-guided intra-articular injection of BMC for symptomatic patellofemoral OA for which conservative treatment had failed. A control group of 21 patients with symptomatic patellofemoral OA was included for comparison. Data on International Knee Documentation Committee (IKDC), Visual Analog Scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores as well as volumetric MR imaging (using T2 mapping sequence) were collected before and 12 months after injection, and the results were compared. RESULTS: No technical adverse events were noted during bone marrow aspiration, BMC preparation, or intra-articular injection of BMC. No clinical adverse events were reported during long-term follow-up. All mean scores improved between baseline and 12 months after intra-articular injection of BMC (VAS 5.5 to 3.6, P < .0001; WOMAC 36.8 to 22.2, P < .0001; and IKDC 41.8 to 58.2, P < .0001). MR imaging at 1 year of follow-up after BMC treatment showed no statistically significant difference in hyaline cartilage volume compared with that at the baseline (P = .690), suggesting stabilization of the cartilage degradation process. In contrast, the group of untreated patients showed a significant decrease in the cartilage volume (P = .001), corresponding to a cartilage loss of 6.9%. CONCLUSIONS: The results suggest that intra-articular injection of BMC under US guidance could be a promising option for the treatment of symptomatic patellofemoral OA and could promote the preservation of healthy residual cartilage volume.

Ultrasound feature variants of the adductor longus tendon in asymptomatic sportive subjects: Management implications.

OBJECTIVES: The potential contribution of ultrasound (US) to diagnose adductor longus (AL) tendinopathy in athletic pubalgia requires clarification. We investigate US findings from AL tendons of asymptomatic participants to identify the range and prevalence of common US features not associated with groin pain. METHODS: We consecutively enrolled 45 volunteers physically active participants with no history of groin pain. US features of bilateral AL tendons were investigated and recorded by two experienced musculoskeletal radiologists (MSKR) in accordance with a defined ultrasound protocol. Two other MSKRs retrospectively and independently analyzed all US images. RESULTS: Ninety AL tendons from 45 participants (4/45 women) were imaged (average age: 35 years ±14.6; dominant side: 37/45 (82.2%) right, 8/45 (17.8%) left). Abnormalities on US were found in all 45 (100%) AL tendons, including: abnormal echogenicity (98.9%/100% respectively according to reader), loss of fibrillar structure (92.2%/97.8%), irregularities of the superficial paratendon (23.3%/30%), calcifications (22.2%/25.5%), and cortical erosion (52%/55.5%), with excellent inter-observer assessment. No AL tears or hyperemia at color Doppler were detectable. CONCLUSIONS: AL tendon abnormalities were identified via US in 100% of our asymptomatic athletes. The significance of these US findings should be interpreted cautiously with respect to clinical presentation. On the other hand, there is a need for supplemental investigation into the clinical relevance of US AL tendon tears not present in the present asymptomatic athlete population.

Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain.

INTRODUCTION: The treatment of persistent lumbar radicular pain (LRP) by CT-guided epidural steroid injection (ESI) is extensively used and associated with rare but serious complications. Platelet-rich plasma (PRP), which has recently been shown to favor healing and the anti-inflammatory process by delivering growth factors and cytokines, might be an alternative and potentially safer option. We compared the efficacy of interlaminar CT-guided epidural PRP injections (EPRPI) and ESI in the treatment of persistent LRP (> 6 weeks). METHODS: In this non-randomized comparative study, patients were prospectively assessed for pain using the numerical rating scale (NRS) and for function with the Oswestry Disability Index (ODI) before and 6 weeks after treatment. Related paired and independent t tests were used for intra- and inter-group comparisons. RESULTS: A total of 60 patients were included in 2 groups (n = 30 EPRPI, n = 30 ESI). A statistically significant improvement was found in both groups at 6 weeks (mean NRS values 5.7 (± 2.36) at D0 and 3.7 (± 2.3) at 6 weeks (p < 0.01); mean ODI values 30 (± 11) at D0 and 21 (± 13) at 6 weeks (p < 0.01)). No significant difference was observed in the decrease in NRS and ODI scores between the 2 groups at 6 weeks (p = 0.848 and p = 0.314 for the NRS and ODI, respectively). No major complications were noted. CONCLUSION: The results of CT-guided interlaminar EPRPI are similar to ESI for the treatment of persistent LRP and could be a safer option. KEY POINTS: • Treatment of persistent lumbar radicular pain by CT-guided epidural steroid injections is associated with rare but serious complications. • By promoting an anti-inflammatory process, epidural platelet-rich plasma injections might be an alternative treatment of persistent radicular pain. • Platelet-rich plasma CT-guided epidural injections are similar to steroid for the treatment of lumbar radicular pain at 6 weeks post-procedure and could be a safer option.

Critical shoulder angle: what do radiologists need to know?

The critical shoulder angle (CSA) constitutes a straightforward and highly reproducible tool. Degenerative rotator cuff tears (RCT) are associated with a significantly larger CSA. In this review, the most relevant features of the CSA are summarized: (1) the relationship between the CSA and RCT pathophysiology, (2) accurate measurement of the CSA according to various imaging modalities, (3) the contribution of the CSA in predicting the occurrence of RCT, and (4) RCT recurrence after surgical repair.

Imaging of Wrist Injuries: A Standardized US Examination in Daily Practice.

The keys to successful ultrasonography (US) of the wrist include knowledge of the relevant anatomy and understanding the biomechanical aspects. A wide spectrum of pathological findings including bone fractures (scaphoid, triquetrum) and ligament lesions (dorsal intercarpal and radiocarpal ligaments, scapholunate ligament) can be caused by an identical traumatic mechanism determined on the basis of the position of wrist at the time of injury. In the setting of wrist trauma, an early diagnosis can minimize the potential for inappropriate or delayed treatment. We describe a practical radiological approach by using a standardized imaging protocol: standard radiographs (four views) associated with an US examination focused on seven landmarks. If there is discordance between clinical and radiological features or if the diagnosis of a disruption of the scapholunate ligament remains uncertain, additional cross-sectional imaging (MRI or CT arthrogaphy) should be performed.

The Median Nerve at the Carpal Tunnel and Elsewhere.

The median nerve (MN) may be affected by various peripheral neuropathies, each of which may be categorized according to its cause, as either an extrinsic (due to an entrapment or a nerve compression) or an intrinsic (including neurogenic tumors) neuropathy. Entrapment neuropathies are characterized by alterations of the nerve function that are caused by mechanical or dynamic compression. It occurs because of anatomic constraints at specific locations including sites where the nerve courses through fibro-osseous or fibromuscular tunnels or penetrates a muscle. For the diagnosis of peripheral neuropathies, physicians traditionally relied primarily on clinical findings and electrodiagnostic testing with electromyography. However, if further doubt exists, clinicians may ask for an additional imaging evaluation.

Comparison of three CT-guided epidural steroid injection approaches in 104 patients with cervical radicular pain: transforaminal anterolateral, posterolateral, and transfacet indirect.

INTRODUCTION: The treatment of persistent cervical radicular pain (CRP) by CT-guided epidural steroid injections (CTESI) by a transforaminal anterolateral (TFA) approach is associated with rare but serious complications. Two recently described transforaminal posterolateral (TFP) and transfacet indirect (TFT) approaches may be safer options, but have not been extensively evaluated. We compared the efficacy of three CTESI approaches (TFA, TFP, and TFT) in the treatment of persistent CRP (>6 weeks). METHODS: Patients were prospectively assessed for pain using the visual analog scale (VAS) and for functional disability by the Neck Disability Index (NDI) before treatment, then 6 weeks and 6 months after CTESI. RESULTS: A total of 104 patients were included (n = 30 TFA, n = 36 TFP, and n = 38 TFT approaches). Each group was found to have a statistically significant improvement at 6 weeks (median VAS values: 7 (2-9) at D0 and 2 (3-6) at 6 weeks p < 0.01; median NDI values: 38 (24-50) at D0 and 29 (18-42) at 6 weeks (p < 0.01)), and at 6 months (median VAS values: 7 (2-9) at D0 and 4 (2-6) at 6 months (p < 0.01); median NDI values: 38 (24-50) at D0 and 28 (13-40) at 6 months (p < 0.01)). No significant difference was observed in the decrease in VAS and NDI scores among the three approaches at 6 weeks (p = 0.635 and p = 0.54 for VAS and NDI respectively) or 6 months (p = 0.704 and p = 0.315 for VAS and NDI respectively). No major complications were noted. CONCLUSION: The results of CTESI using the TFP or TFT approach are similar to those for TFA in the treatment of persistent CRP and could be a safer option.

The capsular line reference, a new arthroscopic reference for posterior/anterior femoral tunnel positioning in anterior cruciate ligament reconstruction.

BACKGROUND: Femoral malposition is the first cause for graft rupture during ACL reconstruction. Arthroscopic landmarks can be difficult to identify. So, landmark has to be found for reliable tunnel placement. A proximal-distal reference was described as "Apex reference" reported by Hart et al. but no posterior/anterior reference exists in the literature. The purpose of this study was to do a 3D CT-scan assessment of the femoral tunnel positioning using the Capsular Line Reference (CLR) as a landmark for posterior/anterior placement in ACL reconstruction. We hypothesized the CLR could provide a precise and reliable antero/posterior femoral tunnel positioning less than 2 mm from the Bernard & Hertel posterior quarter. METHODS: Seven cadaveric knee specimens with a mean age of 79.2 ± 11 years were used. Using standard approaches, the CLR was identified corresponding to a white line (the capsule) appearing at the posterior border of the femoral condyle after bony debridement of the medial and posterior part of the lateral femoral condyle. The center of the tunnel was marked. An inside-out technique with anteromedial drilling technique was performed using an 8-mm diameter reamer. The distal femurs were sawed and a CT-scan was done for each specimen to obtain 3-dimensional image reconstructions. These 3D reconstructions were analyzed to measure the position tunnel center on the posterior/anterior axis and the distance from the posterior/anterior quadrant according to the Bernard & Hertel method. RESULTS: The mean position for the posterior/anterior axis was 27.0 ± 1.8% (25-28.9) with a median of 26.9%. The position from the first quarter of the Bernard & Hertel method was 0.9 ± 0.8 mm (0-1.8) with a median of 0.8 mm. CONCLUSION: The CLR is a reliable and reproducible arthroscopic landmark to place the femoral tunnel for ACL reconstruction in the anterior/posterior axis. Proximal/distal position depends on the choice of the surgeon to reproduce anteromedial or posterolateral fibers.

Intra-articular Injection of Mesenchymal Stem Cells and Platelet-Rich Plasma to Treat Patellofemoral Osteoarthritis: Preliminary Results of a Long-Term Pilot Study.

PURPOSE: To assess the feasibility and safety of concomitant intra-articular (IA) knee injection of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) under fluoroscopic guidance to treat patellofemoral osteoarthritis (OA). MATERIALS AND METHODS: This prospective study included 19 consecutive patients referred for fluoroscopically guided IA MSC and PRP injection for symptomatic patellofemoral chondropathy in which conservative treatment had failed. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and magnetic resonance (MR) data, including T2 mapping sequence, were prospectively collected before and 6 months after treatment. Clinical data without MR imaging were collected until 12 months after the procedure. RESULTS: WOMAC scores were significantly lower after IA injection of MSCs and PRP at 6 months and during 12-months follow-up compared with baseline (mean score decreased from 34.3 to 14.2; P < .0018). Patients reported no complications. Concerning MR imaging follow-up, there were no significant differences in grade, surface, or T2 value of the chondral lesions (P > .375). CONCLUSIONS: IA injection of MSCs and PRP in early patellofemoral OA appears to allow functional improvement.

Combined use of platelet rich plasma & micro-fat in sport and race horses with degenerative joint disease: preliminary clinical study in eight horses.

BACKGROUND: To assess the safety and potential efficacy of a standardized technique consisting of intra-articular injection of 10 cc of a homogeneous mixed product using autologous micro-fat and platelet rich plasma (PRP) (ratio 1:1) in the carpus or the fetlock joint of sport horses presenting degenerative joint disease (DJD). METHODS: Eight sport horses with DJD confirmed by radiography and ultrasonography and causing lameness and the impossibility to compete were treated. PRP was prepared after a double centrifugation whereas micro-fat was harvested and purified using a closed system. The two products were connected and mixed by gentle back and forth shaking of the syringes to finally obtain 10 ml of an homogeneous mixed product. Follow up was performed from 5 to 10 months with assessment of AAEP lameness score and return to training and competition. RESULTS: Nine joints were treated with significant improvement of the AAEP lameness score three months after the procedure (p = 0.021). Four horses returned to official competition between 5 to 10 months after the procedure (7.0±2.5) and three of them resumed intensive training between 5 to 9 months (6.3±2.3). No adverse event occurred. CONCLUSION: This study is a first step in the development of innovative therapy for DJD which combines the potential chondrogenic differentiation of MSCs inside equine adipose tissue with the proliferative effect of growth factors present in PRP.

Unknown Tendons, Muscles and Nerves of the Shoulder: Proposal for a Standardized Ultrasound-guided Examination, a "mini GEL" Experience.

Thanks to its excellent spatial resolution and dynamic aspect, ultrasound of the shoulder allows an optimal evaluation of tendon, muscle and nerve' structures in shoulder pain. Through this article and owing to inter-observer reproducibility, we will describe an ultrasound standardized protocol (posterior, anterior, global plane) in basic first ultrasounds (ie without tendon abnormality of the supra/infra spinatus, the biceps and subscapularis).

Combined intra-tendinous injection of Platelet Rich Plasma and bevacizumab accelerates and improves healing compared to Platelet Rich Plasma in tendinosis: comprehensive assessment on a rat model.

PURPOSE: the aim of our study was to assess the potential of combined intratendinous injection of an anti-angiogenic drug: bevacizumab (AA) and Platelet Rich Plasma (PRP) to treat tendinopathy in a murine model of patellar and Achilles tendinopathy, and to evaluate its local toxicity. MATERIAL AND METHOD: twenty rats (80 patellar and Achilles tendons) were used for the study. We induced tendinosis (T+) in 80 tendons (patellar=40 and Achilles=40) by injecting under ultrasonography (US) guidance Collagenase 1® (day 0 = D0). Clinical examination was performed at D3, immediately followed by either PRP and AA (AAPRPT+, n=40) or PRP (PRPT+ n=40, control) US-guided intratendinous injection. Follow-up at D6, D18 and D25 using clinical, US and histology, and comparison between the 2 groups were performed. To study AA+PRP toxicity, we looked for necrosis or rupture on the 40 AAPRPT+. RESULTS: all AAPRPT+ showed better joint mobilization compared to PRPT+ at D6 (p=0.03), D18 (p=0.04) and D25 (p=0.02). Similar results were found regarding US and histology, with smaller collagen fiber diameters (D6, p≤0.017, D25, p≤0.015), less disorganization and fewer neovessels (D25, p=0.004) in AAPRPT+ compared to PRPT+. No AA+PRP local toxicity was discovered in histology assessment. CONCLUSION: our study suggests that combined injection of AA and PRP in tendinosis accelerates and improves tendon's healing compared PRP used alone, with no local toxicity.

Intratendinous injection of platelet-rich plasma under US guidance to treat tendinopathy: a long-term pilot study.

PURPOSE: To assess the potential therapeutic effect of intratendinous injection of platelet-rich plasma (PRP) under ultrasound (US) guidance to treat tendon tears and tendinosis in a pilot study with long-term follow-up. MATERIALS AND METHODS: The study included 408 consecutive patients referred for treatment by PRP injection of tendinopathy in the upper (medial and lateral epicondylar tendons) and the lower (patellar, Achilles, hamstring and adductor longus, and peroneal tendons) limb who received a single intratendinous injection of PRP under US guidance. Clinical and US data were retrospectively collected for each anatomic compartment for upper and lower limbs before treatment (baseline) and 6 weeks after treatment. Late clinical data without US were collected until 32 months after the procedure (mean, 20.2 months). The McNemar test and regression model were used to compare clinical and US data. RESULTS: QuickDASH score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and residual US size of lesions were significantly lower after intratendinous injection of PRP under US guidance at 6 weeks and during long-term follow-up compared with baseline (P < .001 in upper and lower limb) independent of age, gender, and type of tendinopathy (P > .29). No clinical complication was reported during follow-up. CONCLUSIONS: Intratendinous injection of PRP under US guidance appears to allow rapid tendon healing and is well tolerated.

Efficacy of intra-tendinous injection of platelet-rich plasma in treating tendinosis: comprehensive assessment of a rat model.

OBJECTIVES: To assess the potential of intra-tendinous injection of platelet rich plasma (PRP) to treat tendinosis (T+) in a rat model of patellar and Achilles T+, and evaluate its local toxicity. METHODS: Thirty rats (120 patellar and Achilles tendons) were used. We induced T+ into 80 tendons (patellar = 40, Achilles = 40) by injecting collagenase at day 0 under ultrasound (US) guidance. Clinical examination and US at day 3, followed by US-guided intra-tendinous injection of either PRP (PRPT+, n = 40) or physiological serum (ST+, n = 40, control). Follow-up was at days 6, 13, 18 and 25 using clinical, US and histological evaluation. To study PRP toxicity, we injected PRP into 40 normal tendons (PRPT-) and compared with 40 untreated normal tendons (T-). RESULTS: All PRPT+ showed better joint mobilisation compared with ST+ at day 6 (P = 0.005), day 13 (P = 0.02), day 18 (P = 0.003) and day 25 (P = 0.01). Similar results were found regarding US and histology, with smaller collagen fibre diameters (day 6, P = 0.003, day 25, P ≤ 0.004), less disorganisation and fewer neovessels (day 6, P = 0.003, day 25, P = 0.0003) in PRPT+ compared with ST+. Comparison between PRPT- and T- showed no PRP toxicity (P = 0.18). CONCLUSIONS: Our study suggests that mono-injection of PRP in T+ improves tendon healing, with no local toxicity. KEY POINTS: • We assessed the potential of platelet rich plasma (PRP) to treat tendinosis. • We treated patellar and Achilles tendinosis in a rat model. • We evaluated clinical, imaging and histological data. • Intra-tendinous PRP injection could be useful in the treatment of tendinosis.