SPORTS MEDICINE University of Colorado - ISAKOS.com

Darby A. Houck, BA
Matthew J. Kraeutler, MD
Loree B. Thronton, BA
Eric C. McCarty, MD
Jonathan T. Bravman, MD

Division of SPORTS           MEDICINE
            Sports Medicine and Shoulder Surgery
Department ofU  Orthopedics
                 niversity of Colorado
University of Colorado

          SPORTS MEDICINE
              University of Colorado

¡   Eric McCarty, MD
    §   American Orthopaedic Society for Sports Medicine: Board or committee member
    §   Biomet: IP royalties; Paid consultant; Research support
    §   elesevier: Publishing royalties, financial or material support
    §   International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine: Board
        or committee member
    §   Mitek: Research support
    §   Orthopedics Today: Editorial or governing board
    §   Orthopedics American Journal of Sports Medicine: Editorial or governing board
    §   Smith & Nephew: Research support
    §   Stryker Smith nephew: Research support

¡   Jonathan T. Bravman, MD
    §   DJ Orthopaedics: Paid consultant
    §   Mitek: Other financial or material support
    §   Shukla Medical: IP royalties; Unpaid consultant
    §   Smith & Nephew: Other financial or material support; Paid consultant
    §   Stryker: Other financial or material support; Research support
    §   Western Orthopedic Association: Board or committee member

¡   Previous meta-analyses have been conducted
    to compare outcomes of treatment injections
    for lateral epicondylitis (LE)
    § Corticosteroid injections (CSI) improve pain and
      elbow function in short-term
    § Autologous blood products (ABP), such as
      autologous blood (AB), and platelet-rich plasma
      (PRP) may provide the most functional
      improvement in the intermediate-term

¡   To conduct a systematic review of
    overlapping meta-analyses comparing
    different injection treatments (CSI, AB, PRP)
    for LE to determine which meta-analyses
    provide the best available evidence.

¡   Systematic review using PRISMA guidelines
¡   Included meta-analyses which compared clinical
    outcomes of CSI, AB, and PRP for the treatment of LE
¡   Results were reviewed by 2 independent reviewers to
    determine study eligibility
¡   Patient outcomes were extracted from these meta-
    analyses
¡   Meta-analysis quality was assessed using the Oxman-
    Guyatt and Quality of Reporting Meta-analyses
    (QUOROM) systems
¡   The Jadad decision algorithm was then used to
    determine which meta-analyses provided the best
    level of evidence

¡ 9 meta-analyses with 8,656 patients
¡ Seven meta-analyses found that ABP
  significantly improve pain and elbow function
  in the intermediate-term (12-26 weeks).
¡ Four studies demonstrated CSI would
  effectively relieve pain and improve function
  in the short-term (

Results

Arirachakarn et al in
2016 = highest
quality study and
best level of
evidence

¡ Arirachakarn et al found that both PRP and AB
  are superior to CSI both within and after 2
  months
¡ Lower quality meta-analyses indicate that
  dosage, injection number, and follow-up period
  may be essential factors in determining the
  appropriate LE treatment injection protocol.

¡   ABP (i.e. AB and PRP) were the most effective
    treatment à intermediate term (12-26 weeks)
    § Pain relief, elbow function
    § The lack of a significant short-term effect with
      injection of ABP could represent the time-period
      needed for proper tendon tissue regeneration
¡   CSI was an effective treatment à short-term
    (

¡   The current best-available evidence suggests that -
    § CSI improves functional outcomes and pain relief in the
      short-term
    § AB and PRP are the most effective treatment options in
      the intermediate-term
¡   Despite lacking significant support, the results of this
    review indicate that –
    § Dosage, number of injections, and combination of various
      treatment injections may be critical factors and dependent
      variables in determining the success of CSI, AB, and PRP
    § A more detailed evaluation and longer follow-up is needed
      to determine the appropriate LE injection protocol

¡   Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-
    rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-
    analysis. J Orthop Traumatol. 2016;17(2):101-112. PMID: 26362783
¡   Chou LC, Liou TH, KuanYC, Huang YH, Chen HC. Autologous blood injection for treatment of lateral epicondylosis: A
    meta-analysis of randomized controlled trials. Phys Ther Sport. 2016;18:68-73. PMID: 26616689
¡   Dong W, Goost H, Lin XB, et al. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network
    meta-analysis. Br J Sports Med. 2016;50(15):900-908. PMID: 26392595
¡   Jadad AR, Cook DJ, Browman GP. A guide to interpreting discordant systematic reviews. CMAJ. 1997;156(10):1411-1416.
    PMID: 9164400
¡   Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a
    systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013;41(6):1435-1446.
    PMID: 22972856
¡   Mi B, Liu G, Zhou W, et al. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical
    trials. Phys Sportsmed. 2017;45(2):97-104. PMID: 28276986
¡   Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of meta-analyses of randomised controlled trials:
    the QUOROM statement Quality of Reporting of Meta-analyses. Lancet. 1999;354(9193):1896-1900. PMID: 10584742
¡   Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin Epidemiol. 1991;44(11):1271-1278.
    PMID: 1834807
¡   Qian X, Lin Q, Wei K, Hu B, Jing P, Wang J. Efficacy and Safety of Autologous Blood Products Compared
    With Corticosteroid Injections in the Treatment of Lateral Epicondylitis: A Meta-Analysis of Randomized Controlled Trials.
    PM R. 2016;8(8):780-791. PMID: 26968611
¡   Sayegh ET, Strauch RJ. Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no
    treatment? A meta-analysis. Clin Orthop Relat Res. 2015;473(3):1093-1107. PMID: 25352261
¡   Sirico F, Ricca F, DI Meglio F, et al. Local corticosteroid versus autologous blood injections in lateral epicondylitis: meta-
    analysis of randomized controlled trials. Eur J Phys Rehabil Med. 2017;53(3):483-491. PMID: 27585054
¡   Tsikopoulos K, Tsikopoulos A, Natsis K. Autologous whole blood or corticosteroid injections for the treatment of
    epicondylopathy and plantar fasciopathy? A systematic review and meta-analysis of randomized controlled trials. Phys
    Ther Sport. 2016;22:114-122. PMID: 27085490

¡   Jonathan.Bravman@UCDenver.edu

    SPORTS MEDICINE
      University of Colorado

    SPORTS MEDICINE
      University of Colorado