David Connell

Ultrasound-guided autologous blood injection for tennis elbow

ObjectiveTo assess the efficacy of autologous blood injection under sonographic guidance for the treatment of lateral epicondylitis.Design and PatientsThirty-five patients (23 men, 12 women, mean age 40.9) with refractory lateral epicondylitis (mean symptom duration 13.8 months) underwent sonographic evaluation prior to dry-needling the tendon and injection with autologous blood. Patients were reviewed, and measures of Nirschl and Visual Analogue Scores (VAS) were taken pre-procedure and post-procedure, at 4 weeks and 6 months.ResultsFollowing autologous blood injections, significant reductions were reported for Nirschl scores, which decreased from a median (inter-quartile range) pre-procedure score of 6 (6–7), to 4 (2–5) at 4 weeks (p<0.001), and to 0 (0–1) at 6 months (p<0.001). Similarly, significant reductions were reported for VAS scores from a median (inter-quartile range) pre-procedure score of 9 (8–10), to 6 (3–8) at 4 weeks (p<0.001), and to 0 (0–1) at 6 months (p<0.001). Sonography demonstrated a reduction in the total number of interstitial cleft formations and anechoic foci; a significant reduction in tendon thickness from a mean (SD) of 5.15xa0mm (0.79) at baseline to 4.82xa0mm (0.62) at 6 months post-procedure (p<0.001) was observed. Hypoechoic change significantly reduced from a median (inter-quartile range) of 7 (6–7) at baseline to 2 (1–3) at 6 months post-procedure (p<0.001). Neovascularity also significantly decreased from a median (inter-quartile range) of 6 (4–7) at baseline to 1 (0–3) at 6 months post-procedure (p<0.001), although sonographic abnormality remained in many asymptomatic patients.ConclusionsAutologous blood injection is a primary technique for the treatment of lateral epicondylitis. Sonography can be used to guide injections and monitor changes to the common extensor origin.

Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections

Background Growth factor technologies are increasingly used to enhance healing in musculoskeletal injuries, particularly in sports medicine. Two such products; platelet-rich plasma (PRP) and autologous blood, have a growing body of supporting evidence. No previous trial has directly compared the efficacy of these two methods. Hypothesis Growth factor administration improves tissue regeneration in patients who have failed to respond to conservative therapy. Study design A prospective, double-blind, randomised trial. Methods Elbow tendinopathy patients who had failed conservative physical therapy were divided into two patient groups: PRP injection (N=80) and autologous blood injection (ABI) (N=70). Each patient received two injections at 0 and 1 month. Patient-related tennis elbow evaluation (PRTEE) was recorded by a blinded investigator at 0, 1, 3 and 6 months. The main outcome measure was PRTEE, a validated composite outcome for pain, activities of daily living and physical function, utilising a 0–100 scale. Results At 6 months the authors observed a 66% success rate in the PRP group versus 72% in the ABI group, p=NS. There was a higher rate of conversion to surgery in the ABI group (20%) versus the PRP group (10%). Conclusion In patients who are resistant to first-line physical therapy such as eccentric loading, ABI or PRP injections are useful second-line therapies to improve clinical outcomes. In this study, up to seven out of 10 additional patients in this difficult to treat cohort benefit from a surgery-sparing intervention.

Magnetic Resonance Imaging Parameters for Assessing Risk of Recurrent Hamstring Injuries in Elite Athletes

Background Magnetic resonance (MR) imaging has established its usefulness in diagnosing hamstring muscle strain and identifying features correlating with the duration of rehabilitation in athletes; however, data are currently lacking that may predict which imaging parameters may be predictive of a repeat strain. Purpose This study was conducted to identify whether any MR imaging-identifiable parameters are predictive of athletes at risk of sustaining a recurrent hamstring strain in the same playing season. Study Design Cohort study; Level of evidence, 3. Methods Forty-one players of the Australian Football League who sustained a hamstring injury underwent MR examination within 3 days of injury between February and August 2002. The imaging parameters measured were the length of injury, cross-sectional area, the specific muscle involved, and the location of the injury within the muscle-tendon unit. Players who suffered a repeat injury during the same season were reimaged, and baseline and repeat injury measurements were compared. Comparison was also made between this group and those who sustained a single strain. Results Forty-one players sustained hamstring strains that were positive on MR imaging, with 31 injured once and 10 suffering a second injury. The mean length of hamstring muscle injury for the isolated group was 83.4 mm, compared with 98.7 mm for the reinjury group (P = .35). In the reinjury group, the second strain was also of greater length than the original (mean, 107.5 mm; P = .07). Ninety percent of players sustaining a repeat injury demonstrated an injury length greater than 60 mm, compared with only 58% in the single strain group (P = .01). Only 7% of players (1 of 14) with a strain <60 mm suffered a repeat injury. Of the 27 players sustaining a hamstring strain >60 mm, 33% (9 of 27) suffered a repeat injury. Of all the parameters assessed, only a history of anterior cruciate ligament sprain was a statistically significant predictor for suffering a second strain during the same season of competition. Conclusion A history of anterior cruciate ligament injury was the only statistically significant risk factor for a recurrent hamstring strain in our study. Of the imaging parameters, the MR length of a strain had the strongest correlation association with a repeat hamstring strain and therefore may assist in identifying which athletes are more likely to suffer further reinjury.

Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment?

Objective: To assess if ultrasound guided autologous blood injection is an effective treatment for medial epicondylitis. Methods: Twenty patients (13 men, 7 women) with refractory medial epicondylitis with symptom duration of 12 months underwent sonographic evaluation. Tendinosis was confirmed according to three sonographic criteria: echo texture, interstitial tears and neovascularity. The tendon was then dry needled and autologous blood was injected. Patients were reviewed at 4 weeks and at 10 months. VAS scores and modified Nirschl scores were assessed pre-procedure and post-procedure. Results: There was significant reduction in VAS pain score between pre-procedure and 10 months post-procedure when it had a median (IQR) of 1.00 (1–1.75), range 0–7. The median (IQR) Nirschl score, which at pre-procedure was 6.00 (5–7), range 4–7, had decreased at 4 weeks to 4.00 (2.25–5), range 2–7, and at 10 months to 1.00 (1–1.75), range 0–7, revealing a significant decrease (zu200a=u200a3.763, p<0.001). The hypo-echoic change in the flexor tendon significantly decreased between pre-procedure, when there was a mean (SD) of 6.45 (1.47), and at 10 months, when it was 3.85 (2.37) (p<0.001). Doppler ultrasound showed that neovascularity decreased between pre-procedure, when there was a mean (SD) of 6.10 (1.62), range 4–9, and at 10 months, when it was 3.60 (2.56), range 0–9 (p<0.001). Discussion: The combined action of dry needling and autologous blood injection under ultrasound guidance appears to be an effective treatment for refractory medial epicondylitis as demonstrated by a significant decrease in VAS pain and a fall in the modified Nirschl scores.

A Comparison Between Clinical Assessment and Magnetic Resonance Imaging of Acute Hamstring Injuries

Background Physicians evaluating hamstring strains in professional football players are increasingly turning to magnetic resonance imaging to support the clinical diagnosis and management of the injury. However, little information is available to assess how magnetic resonance imaging compares with the clinical evaluation in establishing the duration of rehabilitation required. Hypothesis Magnetic resonance imaging of hamstring strains can be useful in determining duration of rehabilitation. Study Design Cohort study (Diagnosis); Level of evidence, 1. Methods Fifty-eight professional football players with a diagnosis of hamstring injury made by the team physician were enrolled in the study. All players underwent magnetic resonance imaging and a clinical evaluation by an independent physical therapist within 3 days of the injury. Presence, type, and location of injury were recorded in each examination. The physical therapist estimated the time required until return to competition, and the radiologist used the length of the injury (coronal view) to establish rehabilitation duration. Both clinicians were blinded to the other modality. Results Clinical and magnetic resonance imaging assessments were in agreement in 38 of 58 cases (65.5%). In 18 cases (31.0%), a clinically positive diagnosis was made, but no abnormalities were evident on magnetic resonance imaging. In 2 cases (3.4%), magnetic resonance imaging detected an injury, whereas the clinical examination had negative or equivocal findings. Both clinical examination and magnetic resonance imaging findings were strongly correlated with the actual time required to return to competition (r = .69, P < .001 and r = .58, P < .001, respectively). The correlation coefficient between clinical predictions and magnetic resonance imaging findings was moderate (r = .36, P = .006). Conclusion This study shows that magnetic resonance imaging is not required for estimating the duration of rehabilitation of an acute minor or moderate hamstring injury in professional football players.

Treatment of lateral epicondylitis using skin-derived tenocyte-like cells

Objectives: To culture collagen-producing cells derived from skin fibroblasts and o evaluate prospectively the safety and potential use of this cell preparation for treatment of refractory lateral epicondylitis in a pilot study. Design: Prospective clinical pilot study. Setting: Institution-based clinical research. Patients: A total of 12 patients (5 men and 7 women; mean age 39.1 years) with clinical diagnosis of refractory lateral epicondylitis. Interventions: Laboratory-prepared collagen-producing cells derived from dermal fibroblasts were injected into the sites of intrasubstance tears and fibrillar discontinuity of the common extensor origin under ultrasonography guidance. Main outcome measures: The outcome assessment was performed over 6 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale was used to assess pain severity and functional disability. Tendon healing response was measured using four criteria on ultrasonography: tendon thickness, hypoechogenicity, intrasubstance tears and neovascularity. Results: Cell cultures rich in collagen-producing cells was successfully prepared. After injection, the median PRTEE score decreased from 78 before the procedure to 47 at 6 weeks, 35 at 3 months and 12 at 6 months after the procedure (p<0.05). The healing response on ultrasonography showed median decrease in: (1) number of tears, from 5 to 2; (2) number of new vessels, from 3 to 1; and (3) tendon thickness, from 4.35 to 4.2 (p<0.05). Of the 12 patients, 11 had a satisfactory outcome, and only one patient proceeded to surgery after failure of treatment at the end of 3 months. Conclusions: Skin-derived tenocyte-like cells can be cultured in the laboratory to yield a rich preparation of collagen-producing cells. Our pilot study suggests that these collagen-producing cells can be injected safely into patients and may have therapeutic value in patients with refractory lateral epicondylitis.

Skin-derived tenocyte-like cells for the treatment of patellar tendinopathy.

Background: Recent research of lateral elbow tendinopathy has led to the use of laboratory-amplified tenocyte-like cells. Hypothesis: Ultrasound-guided injection of autologous skin-derived tendon-like cells are effective compared with other injectable therapies for the treatment of refractory patellar tendinosis. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: From 60 patellar tendons in 46 patients with refractory patellar tendinopathy, a 4-mm skin biopsy was sampled to grow tenocyte-like collagen-producing cells. Patients were allocated into 2 groups: (1) injection with laboratory-prepared, amplified collagen-producing cells derived from dermal fibroblasts and suspended in autologous plasma from centrifuged autologous whole blood or (2) injection with autologous plasma alone. Injections were made into the sites of hypoechogenicity, intrasubstance tears, and fibrillar discontinuity within the patellar tendon. The Victorian Institute of Sport Assessment (VISA) score was used to assess pain, severity, and functional disability. Ultrasound was performed to assess structural and blood flow changes, evaluating 4 criteria: tendon thickness, hypoechogenicity, intrasubstance tears, and neovascularity. Results: In the cell group, mean VISA scores improved from 44 ± 15 before treatment to 75 ± 17 at 6 months; in the plasma group, from 50 ± 18 to 70 ± 14. Estimated average difference between groups was 8.1, a significantly higher score in the cell group. Patients treated with collagen-producing cells also had significantly faster improvement and a highly significant effect of treatment, with the difference between groups estimated as 2.5 per unit increase in 1 / time . One patient treated with cell therapy had a late rupture and progressed to surgery; histopathology showed normal tendon structure. Conclusion: Ultrasound-guided injection of autologous skin-derived tendon-like cells can be safely used in the short term to treat patellar tendinopathy, with faster response of treatment and significantly greater improvement in pain and function than with plasma alone.

Cerebellar and brainstem infarction as a complication of CT-guided transforaminal cervical nerve root block

A 60-year-old man with a 4-year history of intractable neck pain and radicular pain in the C5 nerve root distribution presented to our department for a CT-guided transforaminal left C5 nerve root block. He had had a similar procedure on the right 2xa0months previously, and had significant improvement of his symptoms with considerable pain relief. On this occasion he was again accepted for the procedure after the risks and potential complications had been explained. Under CT guidance, a 25G spinal needle was introduced and after confirmation of the position of the needle, steroid was injected. Immediately the patient became unresponsive, and later developed a MR-proven infarct affecting the left vertebral artery (VA) territory. This is the first report of a major complication of a cervical root injection under CT guidance reported in the literature. We present this case report and the literature review of the potential complications of this procedure.

Lateral Elbow Tendinopathy: Correlation of Ultrasound Findings With Pain and Functional Disability

Background: Lateral elbow tendinopathy is a common condition often diagnosed by ultrasound. Debate exists regarding which ultrasound findings correlate with disease severity and prognosis. Hypothesis: Sonographic predictors for tendon healing in patients with lateral elbow tendinopathy can be found by correlating initial ultrasound findings with subsequent changes in pain and functional disability scores after a period of nonoperative management. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Sixty-two elbows (34 right, 28 left) in 62 patients (30 male, 32 female) with a clinical diagnosis of lateral elbow tendinopathy underwent sonographic evaluation of the common extensor origin after assessment with a validated outcome measure, the Patient-Rated Tennis Elbow Evaluation (PRTEE). After 6 months of nonoperative standardized treatment (physiotherapy with eccentric loading), the PRTEE questionnaire was repeated. Results: The mean pretreatment PRTEE was 78 (range, 51-97) and posttreatment score was 29 (range, 0-91). This difference in means was found to be significant (P < .0001). A positive correlation was identified between the presence of a lateral collateral ligament tear (P < .0001) and the size of the largest intrasubstance tear (P < .0001) and poor outcome. A negative correlation was identified with amount of hypoechogenicity (P = .0009). No correlation was found with age, sex, side, duration of symptoms, thickness of tendon, or amount of neovascularity. Conclusion: The size of intrasubstance tears and presence of a lateral collateral ligament tear on ultrasound can be used to assess lateral elbow tendinopathy severity, indicate those who may not respond to nonoperative therapy, and potentially guide more invasive treatment. Those patients with a large intrasubstance tear or tears identified on ultrasound are less likely to respond to nonoperative treatment. Presence of neovascularity has little correlation with change in pain severity or functional disability and may be a poor predictor of prognosis.

Upright positional MRI of the lumbar spine.

Supine magnetic resonance imaging (MRI) is routinely used in the assessment of low back pain and radiculopathy. However, imaging findings often correlate poorly with clinical findings. This is partly related to the positional dependence of spinal stenosis, which reflects dynamic changes in soft-tissue structures (ligaments, disc, dural sac, epidural fat, and nerve roots). Upright MRI in the flexed, extended, rotated, standing, and bending positions, allows patients to reproduce the positions that bring about their symptoms and may uncover MRI findings that were not visible with routine supine imaging. Assessment of the degree of spinal stability in the degenerate and postoperative lumbar spine is also possible. The aim of this review was to present the current literature concerning both the normal and symptomatic spine as imaged using upright MRI and to illustrate the above findings using clinical examples.