Skin-Derived Tenocyte-like Cells for the Treatment of Patellar Tendinopathy

1. Andrew W. Clarke, FRANZCR*†,
2. Faisal Alyas, FRCR†,
3. Tim Morris‡,
4. Claire J. Robertson, MSc, PGCE, MCSP§,
5. Jonathan Bell, FRCS(Orth)‖ and
6. David A. Connell, FRANZCR†

+ Author Affiliations

1. ^†Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom
2. ^‡MRC Clinical Trials Unit, London, United Kingdom
3. ^§University of London, London, United Kingdom
4. ^‖Kingston Hospital NHS Trust, Surrey, United Kingdom
5. Investigation performed at Royal National Orthopaedic Hospital, Stanmore, United Kingdom

1. *Andrew W. Clarke, Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, London HA7 4LP United Kingdom (e-mail: david.connell@googlemail.com).

Abstract

Background: Recent research of lateral elbow tendinopathy has led to the use of laboratory-amplified tenocyte-like cells.

Hypothesis: Ultrasound-guided injection of autologous skin-derived tendon-like cells are effective compared with other injectable therapies for the treatment of refractory patellar tendinosis.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: From 60 patellar tendons in 46 patients with refractory patellar tendinopathy, a 4-mm skin biopsy was sampled to grow tenocyte-like collagen-producing cells. Patients were allocated into 2 groups: (1) injection with laboratory-prepared, amplified collagen-producing cells derived from dermal fibroblasts and suspended in autologous plasma from centrifuged autologous whole blood or (2) injection with autologous plasma alone. Injections were made into the sites of hypoechogenicity, intrasubstance tears, and fibrillar discontinuity within the patellar tendon. The Victorian Institute of Sport Assessment (VISA) score was used to assess pain, severity, and functional disability. Ultrasound was performed to assess structural and blood flow changes, evaluating 4 criteria: tendon thickness, hypoechogenicity, intrasubstance tears, and neovascularity.

Results: In the cell group, mean VISA scores improved from 44 ± 15 before treatment to 75 ± 17 at 6 months; in the plasma group, from 50 ± 18 to 70 ± 14. Estimated average difference between groups was 8.1, a significantly higher score in the cell group. Patients treated with collagen-producing cells also had significantly faster improvement and a highly significant effect of treatment, with the difference between groups estimated as 2.5 per unit increase in . One patient treated with cell therapy had a late rupture and progressed to surgery; histopathology showed normal tendon structure.

Conclusion: Ultrasound-guided injection of autologous skin-derived tendon-like cells can be safely used in the short term to treat patellar tendinopathy, with faster response of treatment and significantly greater improvement in pain and function than with plasma alone.

Predictors of Outcome After Nonoperative and Operative Treatment of Adhesive Capsulitis

1. Brian K. Rill, MD*,
2. Cassie M. Fleckenstein, MS†,
3. Martin S. Levy, PhD‡,
4. Vinutha Nagesh, MS‡ and
5. Samer S. Hasan, MD, PhD†§

+ Author Affiliations

1. ^*Henry Ford Hospital, Sterling Heights, Michigan
2. ^†Cincinnati SportsMedicine Research and Education Foundation, Cincinnati, Ohio
3. ^‡University of Cincinnati, Cincinnati, Ohio
4. Investigation performed at Cincinnati Sports Medicine Research and Education Foundation, Cincinnati, Ohio

1. §Samer S. Hasan, MD, PhD, Cincinnati SportsMedicine Research and Education Foundation, 10663 Montgomery Road, First Floor, Cincinnati, OH 45242 (e-mail: cfleckenstein@csmref.org).

Abstract

Background: Few studies regarding adhesive capsulitis have concurrently evaluated nonoperative and operative treatment.

Purpose: The objectives were to evaluate the efficacy of operative and nonoperative treatment of adhesive capsulitis and to determine predictors of clinical outcome.

Study Design: Cohort study; Level of evidence, 3.

Methods: At minimum 24 months’ follow-up, 85 patients underwent self-assessment using the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) score, including 24 patients treated operatively.

Results: Mean number of yes responses on the SST improved from 4.0 ± 2.7 at initial presentation to 9.9 ± 2.8 at final follow-up (P < .0001). Patients who received nonoperative treatment and patients who underwent surgery demonstrated similar improvements on the SST. For the entire cohort, forward elevation and external rotation at the side improved from 119° ± 20° to 152° ± 15° and from 29° ± 18° to 46° ± 11° (P < .0001), respectively, between initial presentation and discharge from treatment. Internal rotation to the back improved from the gluteal area to the thoracolumbar junction (P < .0001). Improvements in forward elevation and external rotation were greater for patients undergoing surgery. After nonoperative treatment, patients with diabetes had a lower final SST than patients without diabetes (P < .05). For the entire cohort, initial SST predicted final SST (P < .05), and a shorter duration of symptoms predicted a higher final ASES score (P < .05). Younger patients (P < .001) and those with a lower initial SST (P < .05) were more likely to undergo surgery.

Conclusions: A multimodal nonoperative treatment program is effective for most patients with adhesive capsulitis. Patients who do not improve, including those with diabetes, respond well to manipulation and arthroscopic release. Residual motion deficits at discharge from treatment do not appear to affect longer-term clinical outcome.