Aims and Objectives: The aim of this study is to evaluate the efficacy of platelet-rich plasma (PRP) injections in chronic/recalcitrant cases of lateral epicondylitis in comparison to steroid injections and their role in averting surgical procedures.
Methods: A prospective study was carried out in the Post Graduate Department of Orthopaedics, Government Medical College and Hospital, Jammu, from July 21 to June 22.
Results: The patients managed with PRP injections tend to have a better outcome in long-term follow-up than the steroid group and the results in our study have been found to be statistically significant (p&lt;0.05).
Conclusion: We consider PRP injection for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms as well as averting the need for surgical intervention in this difficult cohort of patients

CHOUDHARY, NITIN

GUPTA, AKHIL

GUPTA, SANJEEV

MAHAJAN, NEERAJ

English

Innovare Academic Sciences: E-Journals

Vol 15, Issue 11, 2022Online - 2455-3891 Print - 0974-2441ROLE OF PLATELET-RICH PLASMA INJECTIONS IN TENNIS ELBOW; A PROSPECTIVE STUDYNITIN CHOUDHARY, AKHIL GUPTA*, SANJEEV GUPTA, NEERAJ MAHAJANDepartment of Orthopaedics, Government Medical College, Jammu, Jammu and Kashmir, India. Email: nitchy700@gmail.comReceived: 16 June 2022, Revised and Accepted: 30 July 2022ABSTRACTMethods: A prospective study was carried out in the Post Graduate Department of Orthopaedics, Government Medical College and Hospital, Jammu, from July 21 to June 22.Results: The patients managed with PRP injections tend to have a better outcome in long-term follow-up than the steroid group and the results in our study have been found to be statistically significant (p<0.05).Conclusion: We consider PRP injection for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms as well as averting the need for surgical intervention in this difficult cohort of patients.Keywords: Tennis elbow, Lateral epicondylitis, platelet-rich plasma injection, Steroid injection, Visual analog score, Disabilities of arm, shoulder and hand score.INTRODUCTIONLateral epicondylitis (tennis elbow), a familiar term used to describe myriad symptoms around the lateral aspect of the elbow, occurs more frequently in non-athletes than athletes, with a peak incidence in the early fifth decade and has a nearly equal gender incidence. Lateral epicondylitis can occur during activities that require repetitive supination and pronation of the forearm with the elbow in near full extension. Runge first described the clinical entity in 1873, and since then almost 30 different conditions have been proposed as causes. Recent studies have suggested that some individuals may have a genetic predisposition to develop tennis elbow. Although originally described as an inflammatory process, the current consensus is that lateral epicondylitis is initiated as a microtear, most often within the origin of the extensor carpi radialis brevis. Microscopic findings show immature reparative tissue that resembles angiofibroblastic hyperplasia. The pathologic process mainly involves the origin of the extensor carpi radialis brevis but can involve the tendons of the extensor carpi radialis longus and the extensor digitorumcommunis.The introduction of platelet rich plasma (PRP) as a possible adjunct to conservative and operative treatment has motivated significant research into this topic [1]. PRP is promoted as an ideal autologous biological blood-derived product that can be exogenously applied to various tissues where it releases high concentrations of platelet-derived growth factors (PDGF) that enhance wound, bone, and tendon healing [2]. Platelets present in PRP function as a tissue sealant, initiating wound repair [3]. Whereas fibrin matrix acts as a drug delivery system slowly releasing various platelet-derived bioactive factors [4] such as vascular endothelial growth factor (VEGF), transforming growth factor -β1, insulin-like growth factor, and PDGF [5,6], PRP platelets are initially activated by thrombin and collagen, releasing growth factors that attract undifferentiated cells into the newly formed matrix and trigger cell division [7]. PRP can inhibit cytokine release from macrophages, improving tissue healing and regeneration by limiting the inflammation [8], can promote new capillary growth [9], and can accelerate epithelialization [4] in chronic wounds. PRP has found its application in various orthopedic conditions such as tendinopathies (i.e., lateral epicondylitis [2,8,10-12], patellar tendinopathy, Achilles tendinopathy, shoulder impingement syndrome, rotator cuff tear, osteoarthritis knee, and avascular necrosis of femoral head).METHODSThe study was a prospective study conducted from July 2021 to June 2022.Patients with signs and symptoms of chronic lateral epicondylitis not responding to conservative management such as oral medication, tennis elbow belt, physiotherapy, aged between 18 and 60 years were included in our study.Exclusion criteriaThe following criteria were excluded from the study:1. Patients with history of anemia (hemoglobin <7.0 g/dL)2. Thrombocytopenia (platelets <150×103 μL)3. Pregnancy4. Local malignancy5. Rheumatoid disease and previous surgery or elbow dislocation6. Diabetes mellitus.Thirty subjects were included in our study and were divided into two random groups with 15 subjects in each group.Written informed consent was taken from all the patients participating in the study. PRP was prepared using double spin centrifugation method. 20 ml of venous blood is drawn from cubital vein. The blood is immediately transferred into six 2.7 ml vacutainers prefilled with acid citrate dextrose. All the containers are filled till the markings on the vacutainers. The vacutainers are then placed in the slot available in the centrifugation machine in such a way that they are counter balanced. The initial centrifuge will be done at 1500 rotations/min for 3 min. This separates the blood into two layers. RBC rich at the bottom and plasma along with the platelets is at the top. The top layer is then transferred to fresh vacutainers using a long 18 G needle and syringe. The vacutainers are now again centrifuged at 2500 rotations/min for 3 min. This separates the column of plasma to platelet rich at the bottom and © 2022 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/) DOI: http://dx.doi.org/10.22159/ajpcr.2022v15i11.45565. Journal homepage: https://innovareacademics.in/journals/index.php/ajpcrResearch ArticleObjectives:  The  aim  of  this  study  is  to  evaluate  the  efficacy  of  platelet-rich  plasma  (PRP)  injections  in  chronic/recalcitrant  cases  of  lateral epicondylitis in comparison to steroid injections and their role in averting surgical procedures.79Asian J Pharm Clin Res, Vol 15, Issue 11, 2022, 78-80 Choudhary et al.platelet poor at the top. Using along 18 G the top half column which is platelet poor is discarded. The PRP at the bottom is now collected from the vacutainers and is now ready for use. The patients in the PRP group were given 2 mL of PRP prepared from autologous blood at the most tender point over the lateral epicondyle and were repeated after 4 weeks.The patients in the steroid group received a single dose of 2 mL of methylprednisolone (40 mg/mL, injection tricot). Patients were rested for 15 min after injection and advised not to massage.In both groups, patients were prescribed a combination of tramadol and paracetamol (37.5 mg+325 mg) tablets for pain for 3–5 days following injection. Patients were assessed using a 10-point visual analog score (VAS) for pain and disabilities of arm, shoulder, and hand scale (DASH) score before and after the treatment at 2, 6 weeks and 3, 6 months.RESULTSThere was no statistical difference in the age of these groups. Mean age group was 38.1±9.3 years in PRP group and 40.4±8.15 years in steroid group. The incidence of females was higher in both groups than males (Table 1).The values of VAS and DASH were taken at regular intervals of 2, 6 weeks and 3, 6 months as mentioned above for both groups.As seen in the results above (Tables 2 and 3), we can see that there are significant improvements in symptoms of patients of both groups till 6 weeks with steroid having better values than the other group, however, with time, the effect of steroid begins to deplete and PRP continues to show improvement in results continuously with values being statistically significant in both groups, that is, ≤0.05 for both VAS as well as DASH Scores. Figs. 1 and 2 also show that with both techniques’ patients fare good for up to 6 weeks; however, at and above 3 months, the lines crossover depicting that the effect of steroid wares off while PRP group shows continuous improvement over a long follow-up.DISCUSSIONLateral epicondylitis will continue to be a relatively common disorder with a significant health burden [13]. CS injection used to be the treatment of choice for LE. CS suppresses the immune system by suppressing the pro-inflammatory proteins. Its potential side effects include lipodystrophy, skin pigmentation changes, and tendon atrophy/ruptures. PRP is an increasingly popular treatment for LE.Our results are consistent with studies done by Peerbooms et al. [10] and Hastie et al. [14] showing the efficacy of PRP. PRP increases expression of the collagen gene and production of VEGF and hepatocyte growth factor in human tenocytes [14,15], and Type-I collagen [16]. PRP initially inhibits the inflammatory process and then stimulates proliferation and maturation of the healing process. It enhances stromal and mesenchymal stem cell proliferation [17] and prevents the fibrous scar tissue healing that occurs with macrophage-mediated tendon-to-bone healing [18]. PRP may also suppress macrophage proliferation and interleukin-1 production within the first 72 h [16-19]. PRP injection is superior to CS injection for chronic LE as proven in our results which have also been proved in the past in studies conducted by Hastie et al. [14], Krogh et al. [20], Hardy et al. [21]. Ultrasonography revealed a decrease in thickness of the tendon after CS injection and an increase in thickness after PRP injection [22]. The recurrence rate and need for repeated injection or surgery are higher in the CS than PRP group [21-23].CONCLUSIONWe conclude that PRP injections have better results than local steroid injections and help in averting surgical procedures in chronic/recalcitrant cases of lateral epicondylitis.DECLARATION OF PATIENT CONSENTWell informed consent was taken from all subjects included in our study.Table 2: VAS scores for both groupsTime Steroid group PRP group p‑valueAt presentation 4.85±1.09 4.60±0.94 -2 weeks 1.60±1.03 3.10±0.796 weeks 0.85±0.45  2.15±0.813 months 1.80±1.1 1.05±0.816 months 2.65±1.0 0.55±0.69 0.02PRP: Platelet-rich plasmaTable 1: Sociodemographic features of participants of  both groupsCharacteristics PRP group Steriod group p‑valueAge 38.1±9.3 40.4±8.15 0.38Duration of symptoms 6 (4–12) 6 (4–7) 0.37GenderMale 6 7 -Female 9 8 -PRP: Platelet-rich plasmaTime Steroid group PRP group p‑valueAt presentation 53.69±5.62 57.64±6.34 -2 weeks 30.82±3.01 47.30±6.456 weeks 25.90±1.79 38.26±4.943 months 31.79±1.67 29.95±2.656 months 34.06±1.55 23.26±1.48 0.03PRP: Platelet-rich plasma, DASH: Disabilities of arm, shoulder and hand scale Fig. 2: Dash score for both groups over timeFig. 1: VAS score for both groups over timeTable 3: DASH scores for both groups80Asian J Pharm Clin Res, Vol 15, Issue 11, 2022, 78-80 Choudhary et al.AUTHOR’S CONTRIBUTIONAll the authors have contributed to the study design. 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ROLE OF PLATELET-RICH PLASMA INJECTIONS IN TENNIS ELBOW; A PROSPECTIVE STUDY

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