Journal of Orthopaedic Surgery 2015;23(1):6-10
Leukocyte-poor platelet-rich plasma versus bupivacaine for recalcitrant lateral epicondylar tendinopathy Prateek Behera, Mandeep Dhillon, Sameer Aggarwal, Neelam Marwaha, Mahesh Prakash
Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
ABSTRACT Purpose. To compare a single leukocyte-poor (type-4B) platelet-rich plasma (PRP) injection versus bupivacaine injection for recalcitrant lateral epicondylar tendinopathy (LET). Methods. 25 patients aged 27 to 50 years with painful and recalcitrant LET of the humerus were randomised to receive leukocyte-poor (type-4B) PRP (n=15) or bupivacaine (n=10) injection. Outcome measures included visual analogue scale (VAS) for pain, modified Mayo clinic performance index for elbow (MMCPIE) for elbow function, and Nirschl score for activity-related pain at 1, 3, 6, and 12 months by a single assessor. Results. At baseline, the PRP and bupivacaine groups were comparable in terms of age, sex, duration of symptoms, VAS for pain, MMCPIE score, and Nirschl score. After one month, the percentage of improvement was less in the PRP than bupivacaine group in terms of the VAS for pain (17.7% vs. 26.5%), MMCPIE score (24.0% vs. 27.6%), and Nirschl score (20.7% vs.
31.1%). Nonetheless, improvement in the respective scores was greater in the PRP than bupivacaine group after 3 months (42.5% vs. 30.9%, 34.1% vs. 27.2%, and 50.7% vs. 39.6%), 6 months (67.3% vs. 20.1%, 40.6% vs. 16.3%, and 71.4% vs. 31.1%), and one year (83.2% vs. 45.6%, 47.0% vs. 21.7%, and 76.6% vs. 56.3%). The differences in scores between groups were significant at 6 months and one year only (p60) and recalcitrant (failed conservative treatment for >3 months) LET of the humerus were randomised to receive type-4B PRP (n=15) or bupivacaine (n=10) injection. Bony pathology was ruled out.
7
Patients aged 60 years who had pain secondary to radial tunnel syndrome or cervical radiculopathy, or a history of carpal tunnel syndrome or systemic disorders (diabetes, rheumatoid arthritis, or hepatitis) were excluded, as were those who had thrombocytopenia, were taking anticoagulants, or were pregnant. Baseline platelet, red cell, and leukocyte counts were obtained before PRP preparation. 100 ml blood was collected into an anticoagulant blood bag and centrifuged at 1500 rpm for 15 minutes to separate the red cells from the rest of the components. The supernatant fluid was transferred into another blood bag. Leukocytes were filtered out using a filter (Imuguard III-PL, Terumo Penpol, Thiruvananthapuram, India) to obtain leukocytepoor PRP, with the platelet count between 6 and 8 ×105/µl, and the leukocyte count a 3-log reduction.8 Under ultrasonographic guidance, 3 ml of type-4B PRP and 0.5 ml of calcium chloride was injected into the maximum hypo-echoic area of the extensor carpi radialis brevis (ECRB) tendon using the peppering technique (Fig.).7 Overall, 5 to 6 passes were made into the tendon using a single skin portal. For bupivacaine injection, 10 ml of blood was collected but not used, and 3 ml of bupivacaine and 0.5 ml of normal saline was injected in a similar fashion. After injection, patients sat for 15 minutes with the arm supported in a sling. They were advised to rest the arm for 2 days. Taking oral paracetamol (650 mg) for pain was allowed. After 2 days, standard wrist extensor stretching was started at home for 4
Table 1 Types of platelet-rich plasma (PRP)8 Type
White blood cells
1A 1B 2A 2B 3A 3B 4A 4B
Increased Increased Increased Increased Minimal or absent Minimal or absent Minimal or absent Minimal or absent
Activation of Concentration PRP of platelets No No Yes Yes No No Yes Yes
≥5×
Leukocyte-poor platelet-rich plasma versus bupivacaine for recalcitrant lateral epicondylar tendinopathy Prateek Behera, Mandeep Dhillon, Sameer Aggarwal, Neelam Marwaha, Mahesh Prakash
Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
ABSTRACT Purpose. To compare a single leukocyte-poor (type-4B) platelet-rich plasma (PRP) injection versus bupivacaine injection for recalcitrant lateral epicondylar tendinopathy (LET). Methods. 25 patients aged 27 to 50 years with painful and recalcitrant LET of the humerus were randomised to receive leukocyte-poor (type-4B) PRP (n=15) or bupivacaine (n=10) injection. Outcome measures included visual analogue scale (VAS) for pain, modified Mayo clinic performance index for elbow (MMCPIE) for elbow function, and Nirschl score for activity-related pain at 1, 3, 6, and 12 months by a single assessor. Results. At baseline, the PRP and bupivacaine groups were comparable in terms of age, sex, duration of symptoms, VAS for pain, MMCPIE score, and Nirschl score. After one month, the percentage of improvement was less in the PRP than bupivacaine group in terms of the VAS for pain (17.7% vs. 26.5%), MMCPIE score (24.0% vs. 27.6%), and Nirschl score (20.7% vs.
31.1%). Nonetheless, improvement in the respective scores was greater in the PRP than bupivacaine group after 3 months (42.5% vs. 30.9%, 34.1% vs. 27.2%, and 50.7% vs. 39.6%), 6 months (67.3% vs. 20.1%, 40.6% vs. 16.3%, and 71.4% vs. 31.1%), and one year (83.2% vs. 45.6%, 47.0% vs. 21.7%, and 76.6% vs. 56.3%). The differences in scores between groups were significant at 6 months and one year only (p60) and recalcitrant (failed conservative treatment for >3 months) LET of the humerus were randomised to receive type-4B PRP (n=15) or bupivacaine (n=10) injection. Bony pathology was ruled out.
7
Patients aged 60 years who had pain secondary to radial tunnel syndrome or cervical radiculopathy, or a history of carpal tunnel syndrome or systemic disorders (diabetes, rheumatoid arthritis, or hepatitis) were excluded, as were those who had thrombocytopenia, were taking anticoagulants, or were pregnant. Baseline platelet, red cell, and leukocyte counts were obtained before PRP preparation. 100 ml blood was collected into an anticoagulant blood bag and centrifuged at 1500 rpm for 15 minutes to separate the red cells from the rest of the components. The supernatant fluid was transferred into another blood bag. Leukocytes were filtered out using a filter (Imuguard III-PL, Terumo Penpol, Thiruvananthapuram, India) to obtain leukocytepoor PRP, with the platelet count between 6 and 8 ×105/µl, and the leukocyte count a 3-log reduction.8 Under ultrasonographic guidance, 3 ml of type-4B PRP and 0.5 ml of calcium chloride was injected into the maximum hypo-echoic area of the extensor carpi radialis brevis (ECRB) tendon using the peppering technique (Fig.).7 Overall, 5 to 6 passes were made into the tendon using a single skin portal. For bupivacaine injection, 10 ml of blood was collected but not used, and 3 ml of bupivacaine and 0.5 ml of normal saline was injected in a similar fashion. After injection, patients sat for 15 minutes with the arm supported in a sling. They were advised to rest the arm for 2 days. Taking oral paracetamol (650 mg) for pain was allowed. After 2 days, standard wrist extensor stretching was started at home for 4
Table 1 Types of platelet-rich plasma (PRP)8 Type
White blood cells
1A 1B 2A 2B 3A 3B 4A 4B
Increased Increased Increased Increased Minimal or absent Minimal or absent Minimal or absent Minimal or absent
Activation of Concentration PRP of platelets No No Yes Yes No No Yes Yes
≥5×
