Title: A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma injections
1A systematic review of four injection therapies
for lateral epicondylosis prolotherapy,
polidocanol, whole blood and platelet rich plasma
injections
- 16th Nordic Congress
- Copenhagen Denmark
- David Rabago, University of Wisconsin, USA
- Rabago D, Best TM , Zgierska A , Zeisig E , Ryan
M and Crane D A systematic review of four
injection therapies for lateral epicondylosis
prolotherapy, polidocanol, whole blood and
platelet rich plasma BJSM doi10.1136/bjsm.2008.0
52761 2008
2Basics Tennis Elbow is Bad
- Tendon disease
- 7 of injury-related diagnoses
- Tennis Elbow 1-3 (16 auto-industry)
- 4-7 cases / 1000 / year
- Often refractory to conservative care
- High quality-of-life and work impact
- Expensive billions direct and indirect costs
- Conventional therapies do not treat the
underlying pathology
3Systematic Review
- 4 injection therapies with recent clinical trial
data - Reviewed every database, paper, trial registry
for all reports assessing these injections for
lat epi in humans
4Histology of Common Tendinopathies
- Common extensor tendon Tennis Elbow
- neovascularization, collagen disruption,
- ? fibroblasts, mucoid degeneration
- Achilles Tendon
- increased vascularity, lipoid degeneration,
collagen fibers degeneration derangement - Patellar Tendon
- increased vascularity, disorganized collagen
fibers, mucoid degeneration
5Histology of Tendinopathies
Normal Tendon
6Pathophysiology of overuse tendon injuries
Successful Healing Response
Acute Inflammation?
Tendinopathy Cycle
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8Tennis Elbow U/S
Extensor tendon origin
Distal humerus
Hypo-echoic
Radial head
Joint space
9Tennis Elbow U/Swith color doppler
104 Injection Therapies
- Polidocanol
- Platelet rich plasma and whole blood
- Prolotherapy with dextrose and sodium morrhuate
11Polidocanol?
- Sclerosant most widely used worldwide
- Disrupts venous cellular membrane,
- causing fibrosis - most commonly used in vein Tx
(varicosities, telangectasias) - Safe
- low incidence of allergic reactions
- low incidence of staining
- relatively forgiving if extravasated
12Platelet-rich Plasma/Autologous Whole Blood?
13Platelet Rich Plasma Biology
- PDGF
- Chemoattractive for Mesenchymal Stem Cells
- Differentiation of Fibroblasts and Osteoblasts
- TGF-B
- Promotes cell mitosis, Type I Collagen
- VEGF
- Stimulates angiogenesis
- Basic Fibroblast GF, Epidermal GF, Connective
Tissue GF - Many other Bioactive Factors
14- PRP Application Technique
- Withdraw peripheral blood
- Place blood in canister
- Centrifuge
15- PRP Application Technique
- Remove PPP
- Shake vigorously for 30 seconds
-
Platelet Poor Plasma (PPP)
Platelet Rich Plasma (PRP)
Packed Red Blood Cells
16- Platelet Rich Plasma Biology
- Growth Factors increase linearly with platelet
concentration
17Prolotherapy Hyperosmolar Dextrose?
- Traditionally defined as causing osmotic shock to
localized cells - Trauma of water exiting disrupts cell membrane
- Pro-inflammatory, anabolic reaction
18Prolotherapy Sodium Morrhuate?
- Traditionally identified as chemotactant causing
anabolic inflammatory response - Sclerosant direct disruption of neovascular
cellular membrane - Regulation of VEGF, TGFß, Substance P, apoptosis,
others?
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20Response of stretch-injured rat MCLs to Dextrose
PrT
21Systematic Review
- Reviewed all major databases, paper reference
sections and trial registries for all reports
assessing these injections for tennis elbow
22Systematic Review Methods Assessment
- Overall Methodological Quality
- Relative Effect Size Compared to Controls
- Cohens d Effect Size when appropriate
- Effect size of secondary outcomes
23Systematic Review Results
- 2003-2008, 9 papers, 201 subjects 3 autologous
whole blood, 2 polidocanol,2 prolo, 1 PRP - Methodological quality moderate to strong
- Pain from 3-25 months, often refractory
- Adverse events routine associated with inj.
- Follow up from 9-108 weeks
- Relative effect size from 51-94
- All but 1 used pre-post VAS scale
244 injection Txs for Lat Epi
254 injection Txs for Lat Epi
26Whats really going on?
Prolotherapy
Polidocanol
Platelet Rich Plasma/AWB
27Conclusions/Future Directions
- Consistent moderate-large effect sizes in these
pragmatic, pilot level studies - Each therapy is likely of clinical use for
refractory tennis elbow in primary care settings
confirmatory RCT and larger pragmatic studies are
warranted - Larger, randomized
- Direct comparison of injectants
28Citations
- Zeisig E, Fahlström M, Ohberg L, H. A. A 2-year
sonographic follow-up after intratendinous
injection therapy in patients with tennis elbow.
Br J Sports Med 2008ePub - Zeisig E, Fahlström M, Ohberg L, Alfredson H.
Pain relief after intratendinous injections in
patients with Tennis elbow - results of a
randomised study. Br J Sports Med 200842267-271 - Scarpone M, Rabago D, Zgierska A, Arbogest J,
Snell ED. The efficacy of prolotherapy for
lateral epicondylosis a pilot study. Clinical J
Sports Med 200818248-254 - Connell DA, Ali KE, Ahmad M, Lambert S, Corbett
S, Curtis M. Ultrasound-guided autologous blood
injection for tennis elbow. Skeletal Radiol
200635(6)371-377 - Mishra A, Pavelko T. Treatment of Chronic Elbow
Tendinosis With Buffered Platelet-Rich Plasma.
Am. J. Sports Med 2006341774 1778 - Zeisig E, Ohberg L, Alfredson H. Sclerosing
polidocanol injections in chronic painful
elbow-promising results in a pilot study. Knee
Surg Sports Traumatol Arthrosc 2006141218-1224 - Glick R et al. Prolotherapy for the treatment of
lateral epicondylitis A double-blind pilot
study. North American Research Conference on
Complementary and Integrative Medicine 2006
Edmonton, Canada. Focus Altern Complement Ther - Lyftogt J. Subcutaneous prolotherapy treatment of
refractory knee, shoulder and lateral elbow pain.
Australasian Musculoskeletal Medicine Journal
200712 - Gani NU, Butt MF, Dhar SA, Farooq M, Mir MR,
Kangu KA, et al. Autologous Blood Injection In
The Treatment Of Refractory Tennis Elbow . The
Internet Journal of Orthopedic Surgery 20075. - Edwards SG, Calandruccio JH. Autologous blood
injections for refractory lateral epicondylitis.
J Hand Surgery Am 200328272-278. - Zeisig E, Ohberg L, Alfredson H. Extensor origin
vascularity related to pain in patients with
tennis elbow. Knee Surg Sports Traumatol Arthrosc
200614659-663
29Thanks!Discussion