13 July 2018
As Wimbledon 2018 plays out you might be thinking of getting back on a tennis court yourself. But is a shoulder injury preventing you from playing?
Consultant Orthopaedic Surgeon and Shoulder Specialist Mr Giuseppe Sforza discusses the artho-biological techniques possible as a treatment pathway at Spire Dunedin Hospital, Reading, in the following article.
If you would like to arrange an appointment with Mr Sforza regarding a shoulder issue, please phone Tania Sandham on 01189 521 317
The shoulder is the most flexible joint in the body, enabling a wide range of movements including forward flexion, abduction, adduction, external rotation, internal rotation, and 360-degree circumduction.
This ability to be multi-directional means the shoulder joint is considered the most insecure joint of the body. It is only as a result of the support of ligaments, muscles and tendons that the required stability of function is achieved. It is therefore not a surprise that it can be easily and repeatedly injured.
With respect to achieving success in addressing injury in this area, biologic factors can be used either as part of a conservative management pathway or as adjuvants to surgical therapy. It can be that an individual has tried other pathways, such as physical therapy, medication, activity modification, bracing or even steroid injections, which have not resulted in alleviation of chronic pain.
At Spire Dunedin Hospital we have introduced several artho-biological techniques to increase the options available in treating shoulder injury, including:
- PRP/ACP treatment for Tendinopathy of the upper limb caused by an articular cartilage defect. PRP/ACP can also be used in the treatment of osteoarthritis in upper limb joints.
- PRP/ACP + Collagen scaffold injection for severe Tendinopathy, lateral and medial Epicondilytis, or Rotator Cuff disease.
- Stem cell therapy with SVF/ACP injections for treatment of articular cartilage defect, Osteoarthritis of the upper limb joints and enhancement of healing in fractures.
Platelet-rich plasma (PRP) or Autologous Conditioned Plasma (ACP), has gained popularity for shoulder disorders over the last ten years, as a biological treatment that could potentially improve rotator cuff tendinopathy. PRP/ACP is a fraction of whole blood with a supra-physiological concentration of platelets that, once activated, releases various growth factors and activates inflammatory cells and proteins. This subsequently enhances stromal and mesenchymal stem cell proliferation and prevents fibrous scar tissue healing. The initial release of growth factors from alpha granules activates additional differentiation and secretion of growth factors after 7-10 days, which coincides with the inflammatory and repair phases of the tendon rebuild.
New techniques that add collagen scaffold prolong the activity of growth factors for up to 44 days increasing the biological effect on the tissue healing and thus reducing the number of treatments needed.
Injections of PRP/ACP have gained popularity in the treatment of tendinopathy in the shoulder because of their promoting effects on tendon cell proliferation, collagen synthesis, and vascularization. This has been shown to be the case in both animal and in vitro studies. Recently, two controlled randomized trials evaluated the use of PRP injections in rotator cuff tendinopathy which confirmed good clinical results.
PRP/ACP has also been extensively used for treating tendinopathy around the elbow with multiple studies conducted on that subject that showed better results of this technique in comparison to local anaesthetic or steroid injections. Similar outcomes were noted in pain improvement and the ability to return to work with respect to both PRP injection and surgery in chronic tennis elbow.
Therefore, PRP may avoid patients having surgical intervention. It is thus a useful way of managing patients who want to avoid surgery or are poor surgical candidates.
With respect to the Stem cell therapy with SVF/ACP injections mentioned, the use of mesenchymal stem cells (MSCs) or Stem Cells from adipose tissue, has also gained ground over the last decade. This is due to their potential to differentiate between different target cells and their anti-inflammatory and angiogenic characteristics. MSCs are progenitor cells that have the capacity to self-renew and differentiate into several forms of mesenchymal tissue including muscle, fat, bone, ligament, tendon, and cartilage. There is thus the possibility of recreating specific tissue for therapeutic use.
Cell-based therapies using MSCs/SVF appear to be ideally suited for therapeutic use in cartilage regeneration and to modulate the local environment through their anti-inflammatory, growth supporting, and immunomodulatory functions. As a result, MSCs/SVF has attracted the interest of researchers with their potential for regeneration of damaged cartilage tissue in patients with Osteoarthritis.
Most studies that report on the use of intra-articular stem cell injections in OA, to date, are cases with short-term follow-up. These studies concluded that intra-articular injection of culture-expanded autologous bone marrow MSCs/SVF is a safe method, with no major adverse events related to the injections observed during treatment and follow-up (12–18 months).
It can be concluded that stem cell therapy improves pain and functional outcomes in patients with OA in the short term, and aids in delaying the implant of joint arthroplasty in young patients, whilst providing an alternative therapy for patients who have tried other treatments.