Rabbit fire. OK. Hello, everybody. Everybody's awake after the pizza and beer, or they're going to sleep. I have a question. How many people in this room have done any orthobiologic procedure of any kind? OK. If you are going to think about orthobiologics as we move forward here and talk about the options. Is this in here? Here we go. Lateral epicondylitis. Am I pushing the right one? Here we go. Slide. Here we go. Sorry. There we go. So lateral epicondylitis is probably the one to consider doing if you're just getting started. And let's talk about a specific case discussion. 45-year-old with 18 months of lateral elbow pain failed three cortisone injections and physical therapy. Still has 8 out of 10 pain with resisted wrist extension, gripping, and direct palpation laterally. So there's a lot of controversies we're going to talk about today and tomorrow. And we're going to learn some techniques tomorrow. And I'll show you exactly how I've been doing this. But I think this one is no longer controversial. And that statement might have been controversial. But I have a question for you. Do you want to treat this patient well, or do you want to treat them optimally? OK. Who's going to treat them well? All right. Who's going to treat them? Try to treat them optimally. OK. So you have only two things to remember if you want to treat them optimally. Number one, you've got to get the diagnosis right. OK? Lateral epicondylitis is pretty obvious for the most part. So probably not going to get there. But the other thing is to follow elite published evidence. And so let's start with that first one. And it's important, because you can get fooled. You certainly have to take a good history in physical. And then you have to confirm that diagnosis, because not all lateral elbow pain is lateral epicondylar tendinopathy. Trust me on that. So I do get an X-ray on everybody who comes in with chronic tennis elbow. You can get arthritis. You can get loose bodies. And that's really important to rule that out. The next thing I do, and this is important because this is an ultrasound. Of course, I've been using ultrasound in my practice for about six or seven years. And I find it now absolutely invaluable. And this is that first patient we're talking about. This is the same day, five minutes after I've examined him and looked at his X-ray, I can look at the echo texture. I can see that there's a partial tear. And it's an excellent tool to evaluate tendinopathy. So I'm just going to have to help me a little bit. Can you play that video back there? I'm not quite sure how to use the mouse up here. Thank you. So you can also do a dynamic examination. So you can look at them. This is the patient doing resisted wrist extension. And then we'll go to the next one. The important part, you can play that video, is you can also look at pronation supination. So there are little synovial folds you can see in the radiocapitellar joint by ultrasound that may or may not click or pop or may be part of the symptoms. That's one of the reasons why somebody might fail PRP for lateral epicondylar tendinopathy is a synovial fold interarticularly that's causing them pain. MRI still can be very helpful. Now, why is that? MRI does things for you that ultrasound and X-ray don't. So yes, this patient has some lateral epicondylar tendinopathy by MRI. And this patient came in basically saying, I came here. You're going to give me the PRP today, right? OK, can I see at least look at your elbow first? And I said, this isn't adding up. Ended up getting an MRI of his elbow. And his X-ray did not show this cartilage damage. You can see there. And his radial head's lighting up like a Christmas tree. So yes, he has lateral epicondylar tendinopathy. But his pain is not just isolated to that. It can come from other causes. So back to our patient. Well or optimally? What are we going to do with this guy? All right. We're going to take a little poll. What would you do and why? So I've heard I've been presenting about tennis elbow for longer than I think I've been alive. But I've always heard that it always goes away. So should we continue to wait? Who wants to continue to wait? All right. Nobody. Who wants to operate on him? OK. Here we go. We've got a few operating. All right. So if we look at surgery, has anybody followed the really recent literature on surgical debridement versus sham? This came out of Australia. So when I was publishing that paper in 2014, I did a worldwide search on all the tennis elbow papers I could find. And this paper right here started out as a PhD dissertation out of a guy in Australia. So I called him up and I said, what's the story with this? So it turns out that if you make a skin incision versus making a skin incision going down to the tendon and doing a debridement, this is in a prospective randomized way with a single surgeon that there is no difference. OK. So debriding the tendon versus just making a skin incision, which by the way, when you make a skin incision, what happens? It bleeds. And then you've got a wound to heal, which is what I kind of tell people what PRP is. It's trying to mimic an injury to your elbow or an area you don't have a great blood supply. Another little thought to put in your head. Is all LRPRP the same? So now how many people want to treat them with LRPRP? Who's been paying attention to Brian and Jason, by the way? Who wants to treat them with LPRP or LPRP, leukocyte poor versus leukocyte rich? Leukocyte poor? Anybody? OK. Excellent. OK. Leukocyte rich? All right. So is all leukocyte rich the same? Maybe, maybe not. But I think you should follow the literature. So I had this question. Could PRP work to treat tennis elbow? I'm not even going to tell you exactly how many years ago, because it's been a long time, but it's been more than 15. And I actually had to inject my own left elbow prior to Stanford approving the IRB. You can imagine how crazy I was thought of back then. True story is it didn't hurt that much. There's been no long-term side effects. And I'm actually not pitching for the Giants or playing for the 49ers. I've got no anabolic effect on my left elbow. But it does appear to be safe. So that led to the first human investigation, which was published in 2006, showing a 93% improvement over the course of two years, suggesting it might be valuable. This then led to a prospective randomized trial in Europe in the Netherlands by Taco Ghosn and his colleagues. They did PRP versus cortisone. And they found that in the short term, it wasn't too much different. In the medium and the long term, PRP was much better than cortisone. So if there's one minor take-home message from this, don't give anybody any cortisone. You're better off doing something, which we tested it against in this prospective randomized trial. So needling of the elbow is a known treatment. So needling under anesthetic is a known treatment. That's better, in my opinion, than using cortisone. We tested that of needling of the elbow with or without PRP. And Lucas outreached PRP to be specific. Now, everybody stands up here and says, we need more prospective randomized trials. I'll tell you, this took me five years to do and another year to write it up. So if you're going to say you want to write a big trial, you've got to commit a half a decade or more if you're going to really do it. Recruitment designed through publication. This was 230 patients. Jason and Brian, thank you. You've already seen this slide. There was differences at 24 weeks. If you look at your patient population and you say, I want my patients to be at least 50% better, this is also in the paper, 82% of the people who had Lucas outreached PRP needling had that effect versus 60. So 60% of people will get better at least 50% with needling. So that's a reasonable thing to consider. But if you're going to treat them optimally, you would use Lucas outreached PRP. This has led to a series of people who have published their independent evaluation of whether PRP is reasonable for tennis elbow. PRP has been found to have an important and effective role. It's also supposedly of great clinical significance. And this article is published in the American Journal of Sports Medicine. And finally, I think this is what may come and tip this over. It definitely can reduce the need for surgical intervention. So if you look at the evidence, multiple controlled trials show that Lucas outreached PRP is a safe and effective profile. I do caution you, because I think it's very important to know that the results are specific to the techniques and the LPRP system used in the published studies. And I refer you to the published papers to learn more. So back to our patient. What did we do? Well, of course, I gave him the Lucas outreached PRP. And this is what it looks like. For those of you who haven't used ultrasound for tendinopathy, it's awesome. And these are un-Photoshopped pictures. But you can start to get an idea on the one on the bottom that there's improved echo texture. But if you can play both of those videos, one right after another, and then just leave it. So this is, like I said, I do a dynamic examination. And I'm not sure how that projects out there with the lights on. But then if you look at what happens, and when you look at the tendon on your left, it's thick and amorphous. And if you look at the tendon on the right, it's thinner. And if you look at it, we don't want to loop the videos. But you can see that there's more specificity to the architecture of the tendon. So that's a subjective thing. But it's also interesting to look at. So back to treating well or optimally, I think that LPRP should be considered prior to surgical intervention. Bruce Ryder from the American Journal of Sports Medicine let me slip that in in 2006, into that paper. OK, that was presumptuous at the time. But I think in 2018, that's a very reasonable way. So if you're getting started in biologics and you want to do something safe, effective, with multiple trials, that's the way to go. One bonus question here, because it wasn't on our agenda, but I'll use one and a half minutes to talk about gluteal tendinopathy. This is what I see a ton of in my office now because it's not being treated by the hip arthroscopists. They go in. They do their CAM or pincer decompression. They fix the labrum. But then they still come back with lateral hip pain. So this is one of those patients that one of my partners in California treated. Came back, still had a partial tear. We treated him with a leukocyte-rich PRP. Significant improvement by the tendon by ultrasound and clinically. And this is, again, published. Like I said, if you're going to treat people optimally, you need to follow the published peer-reviewed data. I thought this was just a crazy idea that I had because I've been doing this for five years in my office. This year in AJSM, prospective randomized trial using the same system, leukocyte-rich PRP versus cortisone, showing significant efficacy. And to finish, I would just say that if you're going to talk about doing one thing, you cannot be faulted for considering using leukocyte-rich PRP for tendinopathy. There's been three, at least for tennis elbow. There may be some debate, and I'm looking forward to the next talk about patellar tendinopathy. But three positive prospective randomized trials on three different continents showing efficacy. Thank you very much.

orthobiologic procedures

lateral epicondylitis

diagnosis

platelet-rich plasma

tendinopathy treatment