Omer Mei-Dan

Platelet-Rich Plasma or Hyaluronate in the Management of Osteochondral Lesions of the Talus:

Background: Nonoperative options for osteochondral lesions (OCLs) of the talar dome are limited, and currently, there is a lack of scientific evidence to guide management. Purpose: To evaluate the short-term efficacy and safety of platelet-rich plasma (PRP) compared with hyaluronic acid (HA) in reducing pain and disability caused by OCLs of the ankle. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Thirty-two patients aged 18 to 60 years were allocated to a treatment by intra-articular injections of either HA (group 1) or PRP (plasma rich in growth factors [PRGF] technique, group 2) for OCLs of the talus. Thirty OCLs, 15 per arm, received 3 consecutive intra-articular therapeutic injections and were followed for 28 weeks. The efficacy of the injections in reducing pain and improving function was assessed at each visit using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHFS); a visual analog scale (VAS) for pain, stiffness, and function; and the subjective global function score. Results: The majority of patients were men (n = 23; 79%). The AHFS score improved from 66 and 68 to 78 and 92 in groups 1 and 2, respectively, from baseline to week 28 (P < .0001), favoring PRP (P < .05). Mean VAS scores (1 = asymptomatic, 10 = severe symptoms) decreased for pain (group 1: 5.6 to 3.1; group 2: 4.1 to 0.9), stiffness (group 1: 5.1 to 2.9; group 2: 5.0 to 0.8), and function (group 1: 5.8 to 3.5; group 2: 4.7 to 0.8) from baseline to week 28 (P < .0001), favoring PRP (P < .05 for stiffness, P < .01 for function, P > .05 for pain). Subjective global function scores, reported on a scale from 0 to 100 (with 100 representing healthy, preinjury function) improved from 56 and 58 at baseline to 73 and 91 by week 28 for groups 1 and 2, respectively (P < .01 in favor of PRP). Conclusion: Osteochondral lesions of the ankle treated with intra-articular injections of PRP and HA resulted in a decrease in pain scores and an increase in function for at least 6 months, with minimal adverse events. Platelet-rich plasma treatment led to a significantly better outcome than HA.

IOC consensus paper on the use of platelet-rich plasma in sports medicine

PRP and its variant forms were originally used in clinical practice as an adjunct to surgery to assist in the healing of various tissues. PRP has also been used in prosthetic surgery to promote tissue healing and implant integration, and to control blood loss. 4 5 Furthermore, the application of activated PRP has an effect on pain and pain medication use following open subacromial decompression surgery. 5

Autologous platelet-rich plasma: a revolution in soft tissue sports injury management?

Abstract Platelet-rich plasma (PRP) therapy is an emerging technology that aims to improve the process of tissue repair through local delivery of autologous bioactive agents to influence critical physiological mechanisms such as inflammation, angiogenesis, or extracellular matrix synthesis. These biological properties have prompted the therapeutic administration of PRP in orthopedics and sports medicine. Given its biocompatibility and healing properties, percutaneous injections of PRP are used in athletes to treat tendon and muscle injuries. Studies of varying levels of evidence have demonstrated the safety and beneficial effects of PRP in these applications, but standardization of the methods of plasma preparation and procedures for application is necessary for further advancements. Continued efforts to identify factors that influence the biological response to PRP treatment may yield new formulations tailored to each specific application. The growing emphasis on an evidence-based approach in the sports medicine setting demands additional research efforts before incorporating this technology in routine clinical care.

A Dynamic Ultrasound Examination for the Diagnosis of Ankle Syndesmotic Injury in Professional Athletes A Preliminary Study

Background Syndesmotic ankle injuries are not easy to recognize when an associated fracture or frank diastasis is not present. There is a need for a simple, fast, inexpensive, and easily reproducible diagnostic tool to assess the integrity of the distal tibiofibular synedesmosis. Hypothesis Dynamic ultrasound (US) examination can accurately diagnose anteroinferior tibiofibular ligament (AITFL) rupture. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods We evaluated 3 groups: 9 consecutive professional athletes with recent AITFL rupture, a control group of 18 subjects without a history of ankle injury, and 20 patients with lateral ankle sprain. The dynamic US examination was performed in neutral (N), forced internal rotation (IR), and external rotation (ER) of the foot for measuring the tibiofibular clear space on the anterior aspect of the ankle, at the level of the AITFL, 1 cm proximal to the joint line. Results The mean age of the study group was 27 years (range, 16-32). Magnetic resonance imaging (MRI) confirmed the diagnosis of AITFL rupture in all cases. Differences between the injured and control group were statistically significant for the N, IR, and ER positions (P < .001) and for the measured Δ between the AITFL in the ER and N positions (P < .01). The difference in the tibiofibular clear space between the 2 ankles of the injured athletes was significantly different compared with the control athletes for all 3 positions (P < .001). The measured difference between the ER and N positions for both sides of the study group showed a specificity and sensitivity of 100% (P < .001; cutoff point of 0.9 mm and 0.7 mm, respectively). The Δ (Δ = ER — N) of the injured side showed a specificity and sensitivity of only 89% (P < .001; cutoff point of 0.4 mm). Additionally, the third group with the history of lateral ankle sprain showed, as expected, that this type of injury does not correlate with AITFL injury on dynamic US examination. Conclusion We conclude that dynamic US examination can be used to accurately diagnose an AITFL rupture. This preliminary study has found the described method to be a simple, inexpensive, and easily reproducible examination.

Platelet-rich plasma: any substance into it?

Autologous platelet-rich plasma (PRP) is perceived to accelerate healing in muscu loskeletal injuries. PRP is increasingly used in situations that require rapid return-to play, which, in the professional sports arena, translates to fame and money. It is astonishing but understandable that the most influential stimulus for PRP therapy in the USA, years after the method had been popularised in Europe, was a February 2009 article in the lay press.1 Human blood platelet counts are approx imately 200 000/ml. PRP is an autologous concentration of human platelets above this in a small volume of plasma.2 Reports vary regarding the platelet concentration and different growth factors present in the PRP concentrate. Also, there are many preparation protocols, kits, centrifuges and methods to trigger platelet activation before use. The same is true for application methods, including using injectable activated PRP liquid concentrate versus implanting a fibrin scaffold, optimal timing of injection and the specific volume to use. Almost every major manufacturer in the orthopaedic and sports medicine world markets a different commercial kit. Some claim to produce a better quantity and quality of PRP than their competitors from the same amount of blood from the same patient. Costs vary tremendously: a commercial kit yields a PRP concentrate at the cost of several hundred dollars, but inhouse non-automatised techniques produce a PRP concentrate for approximately US

The Medial Longitudinal Arch as a Possible Risk Factor for Ankle Sprains: A Prospective Study in 83 Female Infantry Recruits

10. Each method to concentrate platelets leads to a different product with different biology and potential uses,3 with a high variation (3 to 27-fold) in growth factor concentration and in the kinetics of release.3,–,5 Most techniques yield a PRP concentrate of approximately 10% of the blood volume taken (eg, 20 ml of whole blood would result in approximately 2 ml of PRP). These differences might be of relevance to clinical management, …

Septic arthritis with Staphylococcus lugdunensis following arthroscopic ACL revision with BPTB allograft

Background: Ankle sprains are frequent, especially in athletes, soldiers, or others who perform high levels of physical activity. Although prevention is a primary goal, little is known about the risk factors. We evaluated the association of the structure of the medial arch of the foot to the occurrence of acute and recurrent ankle sprains in 83 female infantry recruits. We found no previous studies on ankle sprains in women in the English literature. Methods: Arch height was quantified using the Chippaux-Smirak index, and each arch was classified as high, normal, or low. Retrospective data were obtained from questionnaires in which the soldiers noted whether or not they had had ankle sprains in the past, the grade of the sprain, and recurrence. Prospective data were accumulated in the 4 months of basic training, during which time every ankle sprain was documented and classified according to its grade and cause. Results: The retrospective data showed more frequent ankle sprains in the low arch group than in the normal arch group, mainly in the right foot (RR of 2.9, p < 0.05). Recurrent sprains studied retrospectively also showed that more sprains occurred in the low arch group than in the normal arch and high arch groups (RR of 10.3, p < 0.05). The prospective data suggested a pattern toward the same outcome (50% in the low arch as opposed to 36% in the normal arch group, RR, 1.3), but with no statistical significance. Conclusions: We concluded that a low arch of the foot might be a risk factor for ankle sprains. However, our study consisted of a relatively small population, and further studies are needed.

Hip arthroscopy distraction without the use of a perineal post: prospective study.

Septic arthritis following anterior cruciate ligament reconstruction is an uncommon but a serious complication resulting in six times greater hospital costs than that of uncomplicated ACL surgery and an inferior postoperative activity level. Promptly initiating a specific antibiotic therapy is the most critical treatment, followed by open or arthroscopic joint decompression, debridement and lavage. Staphylococcus lugdunensis is a coagulase-negative staphylococcus predominantly infecting the skin and soft tissue. The few reported cases of bone and joint infections by S. lugdunensis indicate that the clinical manifestations were severe, the diagnosis elusive, and the treatment difficult. If the microbiology laboratory does not use the tube coagulase (long) test to confirm the slide coagulase test result, the organism might be misidentified as Staphylococcus aureus. S. lugdunensis is more virulent than other coagulase-negative staphylococcus; in many clinical situations it behaves like S. aureus, further increasing the confusion and worsening the expected outcome. S. lugdunensis is known to cause infective endocarditis with a worse outcome, septicemia, deep tissue infection, vascular and joint prosthesis infection, osteomyelitis, discitis, breast abscess, urine tract infections, toxic shock and osteitis pubis. We present the first case report in the literature of septic arthritis with S. lugdunensis following arthroscopic ACL revision with bone–patellar–tendon–bone allograft.

The role of platelet-rich plasma in rotator cuff repair.

Hip arthroscopy is being used with increasing frequency as the understanding of arthroscopic management of groin pain improves. To access the hip joint arthroscopically, traction must be placed on the leg. In most cases, countertraction is provided with a padded post in the groin. Complications of traction are often attributed to the post and include perineal or pudendal neuropraxias and skin complications. The purpose of this study was to investigate the safety of a traction technique that avoids a perineal post. A supine position is used with the foot in a standard traction boot. The patient is moved down the table such that his or her perineum is located 7 to 10 cm proximal to the traction post. The post is also located 5 to 10 cm lateral to midline. The operative table is placed in 15° to 20° of Trendelenburg. With this position, enough friction is generated between the patients upper body and bed to allow successful hip distraction without the post contacting with the perineum. One hundred seventy patients (111 men and 59 women) were followed prospectively and evaluated for possible side effects of this traction technique immediately postoperatively and 1 and 14 days and 3 and 6 months postoperatively. Patients were examined at each visit. No significant complications related to traction occurred during follow-up. The described technique has been used in more than 2000 hip arthroscopies without a documented groin or perineal complication. It allows easy positioning and access to the central compartment.

Normal anatomy and imaging of the hip: emphasis on impingement assessment.

The shoulder is a common source of disability resulting from traumatic and degenerate tears of the rotator cuff, subacromial impingement, and osteoarthritis. Nonoperative management has focused on treatment of the predisposing factors, the use of analgesics and anti-inflammatory medication usually in association with local anesthetic and steroid injections. Surgical intervention allows debridement of the degenerate cuff and partial thickness cuff tears, subacromial bursitis, impinging bone spurs and osteophytes together with rotator cuff repairs. Repairs of degenerate and torn tissue are often prone to failure due to many intrinsic and extrinsic factors. It is assumed that some biological therapies might improve clinical, mechanical, and histologic outcomes. Injections of platelet-rich plasma (PRP) have led to reduced pain and improved recovery in other degenerate pathologies areas together with the restoration of function. This study reviews the current literature on PRP and in particular discusses its relevance in the treatment of rotator cuff tears.