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(PRP) Injection in Treatment of Lateral Epicondylitis ⇑ Enass M

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(PRP) Injection in Treatment of Lateral Epicondylitis ⇑ Enass M The Egyptian Journal of Radiology and Nuclear Medicine xxx (2017) xxx–xxx Contents lists available at ScienceDirect The Egyptian Journal of Radiology and Nuclear Medicine journal homepage: www.sciencedirect.com/locate/ejrnm Original Article Role of Ultrasound Guided Platelet-Rich Plasma (PRP) Injection in Treatment of Lateral Epicondylitis ⇑ Enass M. Khattab , Mohamad H. Abowarda Department of Radiodiagnosis, Faculty of Medicine, Zagazig University, Egypt article info abstract Article history: Background: Lateral epicondylitis is referred to a degenerative disorder that affects the common extensor Received 15 November 2016 tendon (CET) where it attaches to the lateral epicondyle of the humerus. Nowadays, one of minimally Accepted 4 March 2017 invasive interventions is platelet-rich plasma (PRP) injection that had been explored in some controlled Available online xxxx clinical studies to show its effectiveness in treating lateral epicondylitis through inducing inflammation rather than suppressing it. Keywords: Objectives: The aim of our study was to investigate the effectiveness of ultrasound guided platelet-rich Ultrasound plasma (PRP) injection in treating chronic lateral epicondylitis in addition to identifying the potential Injection of PRP sonographic morphological changes in the common extensor tendon (CET) after PRP injection. Lateral epicondylitis Results: Statistical analysis showed high significant improvement in all ultrasound findings of common extensor tendon (CET) including echotexture, thickness, cross section, partial tear and calcification in majority of patients. Conclusion: We concluded that US-guided platelet-rich plasma (PRP) injection for treatment of lateral epicondylitis was a safe, minimally invasive and effective procedure in improving the sonographic and pathological changes of common extensor tendon (CET). Ó 2017 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/). 1. Introduction However, medications like non-steroidal anti-inflammatory drugs (NSAIDS), physical therapy, shock wave therapy, botulism Lateral epicondylitis is referred as a degenerative disorder that toxin injection and corticosteroids injection were used to treat lat- affects the common extensor tendon (CET) where it attaches to the eral epicondylitis many studies showed that they did not alter poor lateral epicondyle of the humerus [1]. healing of the CET and had long term course of treatment. In addi- Waseem et al. [2] explained that this condition is not an inflam- tion, adverse side effects of long-run use of NSAIDs like bleeding matory process with no inflammatory cells (e.g. macrophages, lym- ulcers and renal failure and those of corticosteroids like tendon phocytes or neutrophils) could be detected in the affected tissue. atrophy and permanent structural changes, make these types of But, it is a form of tendinosis that affects the common extensor ten- treatments controversial [4]. don with a fibroblastic and vascular response called angio- Nowadays, minimally invasive interventions that stimulate fibroblastic degeneration of CET. Moreover, tennis elbow (TE) is healing response and counteracting the degenerative structural considered a misnomer since tennis player account for only about changes in lateral epicondylitis have been investigated. One of these 5% of all patients suffering from this condition. That make ‘‘lateral emerging technologies is platelet-rich plasma (PRP) injection [5]. epicondylosis” or ‘‘lateral elbow tendinosis” is the most appropriate Platelet-rich plasma is a volume of the plasma fraction of autol- term that express that condition. Despite of this lateral epicondyli- ogous blood having a platelet concentration of 5 times more than tis is more recognized and widely used in the scientific community. base line (5 Â 200,000 platelets/ul). Platelets in PRP contain growth The annual prevalence of lateral epicondylitis is about 1–3% of factors and build up reparative processes. The action of PRP population that induces morbidity secondary to pain and function therapy in chronic tendinopathies is varied and hypothesized to disability that prevents an active life style [3]. include angiogenesis, increase in growth factor expression and cell proliferation, increase the effect of repair cells and tensile strength. Peer review under responsibility of The Egyptian Society of Radiology and Nuclear Lateral epicondylitis may be characterized by complex changes in Medicine. the tendon in addition to an inflammatory process. Therefore, ⇑ Corresponding author. E-mail address: [email protected] (E.M. Khattab). http://dx.doi.org/10.1016/j.ejrnm.2017.03.002 0378-603X/Ó 2017 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Khattab EM, Abowarda MH. Egypt J Radiol Nucl Med (2017), http://dx.doi.org/10.1016/j.ejrnm.2017.03.002 2 E.M. Khattab, M.H. Abowarda / The Egyptian Journal of Radiology and Nuclear Medicine xxx (2017) xxx–xxx PRP owing to its high content of various growth factors may be 38 years old).The mean time of symptoms was19.95 months more effective as a healing agent [5]. (range 3–36 months). Patients were diagnosed, treated and fol- Diagnostic ultrasound and MRI before PRP injection will help to lowed up in the ultrasound unit in the Radiology Department by confirm clinical diagnosis and establish baseline findings. sonographic assessments at baseline diagnosis, during injection Ultrasound guidance of the injection will ensure precise targeting of PRP, three and six months post procedure. of tissue needle placement and real-time visualization of needle during injection with documentation of changes in tendon mor- 2.1.2. Subjects included in the study phology & structure after PRP injection [6]. US is an excellent option for diagnostic imaging evaluation of Inclusion criteria: lateral epicondylitis, with a reported sensitivity of approximately 1. All patients were suspected to have chronic lateral epi- 80% and specificity of approximately 50%. Tendinosis appears as condylitis as determined on clinical examination (based on tendon enlargement and heterogeneity. Tendon tears are depicted symptoms, site of tenderness and pain elicited with resisted as hypoechoic regions with adjacent tendon discontinuity. Sur- active extension of the wrist in pronation and elbow in rounding fluid and calcification also may be seen [7]. extension) and confirmed with base line ultrasonographic The normal MR imaging appearance of the CET is that of a ver- examination and MRI examinations. tically oriented structure that originates from the lateral epi- 2. History of at least two periods of elbow pain lasting condyle. The tendon should show uniform low signal intensity, >10 days; symptoms lasting at least 3 months or longer. regardless of the imaging sequence used. Tendon morphology is Exclusion criteria: best assessed on coronal and axial images. The MR imaging find- 1. Patients with normal base line ultrasonographic imaging. ings of lateral epicondylitis on both T1- and T2-weighted images 2. Presence of full tendon tear. include intermediate signal intensity within the substance of the 3. Patients received local steroid injection within 3 months of tendon with or without tendon thickening. Partial thickness tears randomization; are seen as a region with the signal intensity of fluid extending 4. Patients received oral non-steroidal anti-inflammatory or partway across the tendon [8]. corticosteroids within 15 days before inclusion in the study. The aim of the present study is to investigate the effectiveness 5. Patients unable to comply with scheduled visits. of ultrasound guided (PRP) injection in treating chronic lateral epi- 6. History of trauma. condylitis in addition to identify the potential sonographic mor- 7. Medical history of rheumatic disorder. phological changes in the CET after PRP injection with respect to All patients were subjected to: the baseline sonographic findings. 1. Full history taking. 2. Clinical evaluation of all patients at baseline, they were asked to rate their levels of pain and function disability from 2. Patients and methods 0 to 10 according to a validated questionnaire called PRTEE Questionnaire (Patient Rated Tennis Elbow Evaluation). It 2.1. Technical design consists of two subscales, PAIN subscale (0 = no pain, 10 = worst imaginable) and FUNCTION subscale (0 = no diffi- 2.1.1. Site of the study, sample size and methods of collection of culty, 10 = unable to do). In addition to the individual sub- patients scale scores, a total score was computed on a scale of 100 Forty-two patients (31 females and 11 males), were included in (0 = no disability) where pain and functional problems are the study with age range from 30 to 50 years old (median of age weighted equally [9] Table 1 Symptoms before and 6 months after treatment. Symptoms Before treatment (N = 42) 6 months after treatment Test p-value (Sig.) (N = 42) No. % No. % Impaired grip No 0 0% 16 38.1% 19.765§ <0.001 (HS) Yes 42 100% 26 61.9% Restricted daily activities No 0 0% 9 21.4% 10.080§ <0.001 (HS) Yes 42 100% 33 78.6% Pain No 0 0% 16 38.1% 19.765§ <0.001 (HS) Yes 42 100% 26 61.9% PRTEE pain subscale Mean ± SD 29.97 ± 10.35 19.92 ± 11.61 À5.306a <0.001 (HS) Median (range) 29.50 (12–47) 18 (6–48) PRTEE function subscale Mean ± SD 30.38 ± 11.02 20.30 ± 11.31 À5.297a <0.001 (HS) Median (range) 30 (11–48) 19.50 (4–48) PRTEE total score Mean ± SD 60.35 ± 21.36 40.23 ± 22.79 À5.382a <0.001 (HS) Median (range) 59.50 (23–95) 37.50 (10–96) p < 0.05 is significant. Sig.: significance. a Wilcoxon signed ranks test. § McNemar test. Please cite this article in press as: Khattab EM, Abowarda MH. Egypt J Radiol Nucl Med (2017), http://dx.doi.org/10.1016/j.ejrnm.2017.03.002 E.M.
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