Latest updates first

Recent evidence for PRP in small joint arthritis

• The bulk of the high-quality PRP literature is in the knee; small joint-specific evidence (thumb base, interphalangeal, ankle, wrist) is limited but growing.
  A systematic review and meta-analysis of small joint OA (hand and foot) found PRP significantly improved both pain and function, with superiority over other injectables increasing at longer follow-up intervals
• For thumb carpometacarpal (CMC1/trapeziometacarpal) OA, one RCT (Malahias et al.) showed PRP significantly outperformed corticosteroid at 12 months (VAS, Q-DASH, patient satisfaction, p<0.025), despite corticosteroid performing better in early weeks
• A 2025 JBJS double-blind RCT for thumb CMC OA is now available, strengthening the evidence base for this indication -BoneJointSurg(JBJS)
• A network meta-analysis of thumb base OA injections found PRP performed well at long-term follow-up; corticosteroid remains faster-acting short-term -PubMedCentral(PMC)
• Evidence for interphalangeal joint OA is very limited; most studies are case series or small prospective cohorts
• Evidence for ankle OA and talar osteochondral lesions shows promising results: PRP superior to HA for osteochondral lesions when combined with microfracture
• PRP formulation heterogeneity (leukocyte-poor vs. leukocyte-rich, platelet concentration, activation method, number of injections) remains the dominant confounder across all studies

Synopsis PRP Research to 2025

Platelet-Rich Plasma (PRP) represents an increasingly explored autologous orthobiologic in the therapeutic landscape for osteoarthritis (OA). Derived from a patient's own blood through a centrifugation process, PRP delivers a concentrated solution of platelets and an array of bioactive growth factors, including platelet-derived growth factor (PDGF), transforming growth factor (TGF), insulin-like growth factor (IGF), fibroblast growth factor (FGF), and vascular endothelial growth factor (VEGF).¹ These components are believed to stimulate an immunological and inflammatory response that supports physiological healing, modulates inflammation, promotes tissue repair, and stimulates anabolic processes within chondrocytes, synoviocytes, and mesenchymal stem cells, with the overarching aim of alleviating pain and potentially slowing disease progression.¹

Current evidence suggests that PRP injections, particularly leukocyte-poor PRP (LP-PRP), can offer superior pain relief and functional improvement when compared to traditional treatments such as hyaluronic acid (HA) and corticosteroids. This benefit is most notable in patients with mild to moderate knee OA (Kellgren–Lawrence grades I–III).² While some studies indicate sustained effects up to 12 months, it is important to note that the onset of pain relief with PRP may be slower than with corticosteroids.⁴ The effectiveness of PRP can also vary significantly depending on the specific joint affected.⁶

The safety profile of PRP is generally favorable, with reported adverse events typically mild and temporary, primarily consisting of post-injection pain.⁷ The autologous nature of PRP inherently minimizes the risk of immune reaction.¹⁰

Despite these promising outcomes, the exact clinical utility of PRP remains a subject of ongoing discussion and its specific applications in clinical practice are quite varied. A primary challenge lies in the substantial variability of preparation protocols, including differences in platelet concentration, leukocyte content, and activation status.¹ This heterogeneity complicates consistent conclusions and reproducibility across studies and therefore requires individual clinicians to monitor their own results (ours shown below). Consequently, major clinical guidelines from prominent organizations such as the American Academy of Orthopaedic Surgeons (AAOS), American College of Rheumatology (ACR), and Osteoarthritis Research Society International (OARSI) maintain cautious or inconclusive stances, citing insufficient evidence and concerns regarding study bias.² Furthermore, current imaging studies do not demonstrate that PRP promotes cartilage regeneration or halts the structural progression of OA.²

This blog / post below summarises some important studies and some of our own patient reported outcomes with PRP therapy, with the more recent appearing first.

Update Late 2021

The PRP literature expands constantly, which is good because we all need more precise data. An important paper published in Arthroscopy July 2021 did a network meta analysis. Zhao et al. from Guangzhou University of Chinese Medicine included 43 randomized controlled trials in patients with knee osteoarthritis (level II evidence -for more about evidence levels see here). They compared intra-articular hyaluronic acid (HA), leukocyte-poor platelet-rich plasma (LP-PRP), leukocyte-rich platelet-rich plasma (LR-PRP), bone marrow mesenchymal stem cells (BM-MSCs), adipose mesenchymal stem cells (AD-MSCs), and saline (placebo) during 6 and 12 months of follow-up. During the 12-month follow-up, both AD-MSCs and LP-PRP showed pain relief effects and functional improvement was achieved with LP-PRP. "BM-MSCs seem to have potentially beneficial effects, but the wide credibility interval makes it impossible to draw a well-supported conclusion". "HA viscosupplementation clinical efficacy was lower than that of biological agents during follow-up". The authors concluded "Considering the evaluation of treatment-related AEs , LP-PRP is the most advisable choice."

In the related editorial Dr. Hohmann notes that Platelet-Rich Plasma (PRP) is the safest option, with the greatest effect on function and a good effect on pain, confirming the results of another recent network meta analysis (Migliorini et al. July 2020) that concluded: "Intra-articular injections of PRP demonstrated the best overall outcome compared to steroids, hyaluronic acid and placebo for patients with knee osteoarthrosis at 3, 6 and 12-months follow-up. Among CCS, hyaluronic acid and placebo, no discrepancies were detected."

Migliorini et al. July 2020 also found that multiple RCTs (randomised clinical trials) found that multiple PRP injections resulted in significantly better outcomes than a single injection, something that is clear to me from administering PRP therapy.

Update Early 2021

The following data was collected from ~60 patients who undertook PRP therapy in the latter half of 2020, and is based on our updated PRP protocol and includes both tendons and joints (but 80% were joints). As you can see 86% achieved a >50% improvement in pain levels when measured at more than 6 weeks post therapy. This correlates closely with an 85% satisfaction rate. These results are better than our earlier data. There may be a number of reasons for this: may indicate the higher mix of joint versus tendon problems, we may be treating less severe cases, and/or we may have improved our technique and protocols (we have changed several factors as we gain experience and learn more from others around the globe).

Update 2020

To see lots more information about PRP therapy go here.

There are a number of recent PRP studies that challenge the accepted dogma that corticosteroid injections are the first choice when conservative management fails. One such from Jane Fitzpatrick and colleagues (an Australian study -see here) showed that patients with chronic gluteal tendinopathy for more than 4 months achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection.

Larry Miller and colleagues did a meta-analysis and found a total of 16 randomised controlled trials (18 groups) of PRP versus control for tendinopathy. They found that PRP was more efficacious than control in reducing tendinopathy pain, with an effect size of 0.47 (95% CI 0.22 to 0.72, p<0.001), signifying a moderate treatment effect. Heterogeneity among studies was moderate (I²=67%, p<0.001). In subgroup analysis and meta-regression, studies with a higher proportion of female patients were associated with greater treatment benefits with PRP.

They concluded that "injection of PRP is more efficacious than control injections in patients with symptomatic tendinopathy."

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Update September 2017

I have reviewed the data on 50 cases of PRP therapy (from 2015-2016) that fulfilled the above criteria. Thanks to those who responded to my emails. The data is shown below in graphical format. The responses are based on 4-6 month follow-up data. 55% had at least a moderate improvement with 27% an excellent response -remembering that virtually all these patients had failed all other therapies. Unfortunately 24% did not respond significantly. Most of these patients had plantar fascia, elbow tendon, or achilles tendon tears.

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Update October 2015

PRP (platelet-rich plasma) therapies have been used for over a decade for a whole number of clinical problems (see PRP wikipedia entry). PRP is blood plasma that has been enriched with platelets and contains (and releases through degranulation) several different growth factors and other cytokines that stimulate healing of bone and soft tissue. It is a great concept but how should it be used? The research on PRP has suffered a common problem seen in clinical medicine. Researchers and clinicians have a new treatment/test/technology and hope to find a use but don't know how to choose the right group of patients/problems/complaints/ or phenomena to test it with or which variables to manage/control. It is surprising that we make much headway as the constraints and variables are numerous.

In musculoskeletal medicine it has been used for many purposes but I will focus on its use in tendon injuries.

In the case of PRP therapy and tendon conditions there is little homogeneity between the studies. The evidence for PRP (platelet-rich plasma) therapy in tendinopathies is mixed and is summarized in the paper by Kaux et al in the JSRM^11. Overall the literature on PRP therapy is generally neutral or positive but the variables and study designs make it difficult to either refute or confidently endorse the use of PRP for a given clinical scenario.

If you look only at studies which were of level 1 evidence , had a followup period of at least 6 months and used ultrasound guidance (3 lateral epicondylitis studies, 2 rotator cuff (not including the study below), 3 patellar tendon) then there is substantial evidence that a subgroup of patients do very well with PRP.

In particular I have been impressed by the, as yet unpublished, study of Dr. Francesco Arrigoni at the University of L'Aquila, Italy, that was presented at RSNA Chicago in 2014, and later featured by auntminnie.com online. In a retrospective study of 240 patients they found that ultrasound-guided PRP injection of the supraspinatus tendon significantly outperformed the use of medical and physical therapy alone.

Arrigoni and colleagues evaluated the effectiveness of ultrasound-guided PRP injection (2 injections 21 days apart) of the supraspinatus tendon by comparing it with medical and physical therapy alone. Patients were included in the study if they had a diagnosis of tendinosis or small focal tear of the supraspinatus tendon (< 1 cm). They followed up all patients with MRI up to four years.

After 4 years the results are summarized in table 1:

	MRI Better	MRI same	MRI worse	Pain better	Function better
PRP Rx	32%	48%	20%	75%	56%
Physical Rx	3%	34%	63%	16%	9%

He acknowledged a number of limitations to the study. Patients were not divided by age, and the medical and physical therapy was not standardized. It should also be noted that they did not quantify the degree change of the tendinopathy on MRI and the medical therapy was not standardized.

Who are these PRP responders? It is not clear from the published studies as a whole, as the patient selection is highly variable and based on clinical features that almost certainly represent a variety of different pathologies. What is lateral epicondylitis or plantar fasciitis? The clinical syndromes are associated with a variety of imaging findings. The mechanisms of pain in any tendinopathy may be multiple it it seems likely that PRP is an appropriate treatment where the mechanism of pain is linked to a failure of healing associated with a tendon or (plantar) fascia tear*. Therefore if I can demonstrate this failure using ultrasound then it makes sense that this group of patients are potential responders. The first of my selection criteria involve persistent pain linked to an unhealed tear demonstrable on scanning (how one knows a tear is unhealed is the subject for another day and uses technology not yet available on standard ultrasound machines). From the literature and my own observations I have made the following conclusions to assist me in my own practice and so as to use PRP in a consistent and reproducible way (and hopefully deliver maximum benefit).

My criteria (2015) for selecting patients that may benefit from injection with PRP are as follows:

The patients should meet these clinical and scan criteria:

1. Small unhealed partial thickness or split tears of the tendon confirmed with ultrasound or MRI and supported by ultrasound elastography where possible
2. Symptomatic for > 6months
3. Functional limitation

The PRP injection:

1. Must have a platelet concentration 3-4 x blood
2. Have small numbers of white cells
3. Have no red cells
4. Must not be directly mixed with local anaesthetic or corticosteroids
5. Will be directed into the abnormal tendon with smallest gauge needle possible

The patients having PRP:

1. Should avoid anti-inflammatories and aspirin from one week prior until three weeks after the injection
2. Should rest the tendon for several days followed by an isometric strengthening program for the affected part

Ideally all patients treated should be followed up both with ultrasound and clinically as the evidence suggests the benefits are not immediate. The clinical trails often showed the biggest differences at 6-12 months and beyond post injection.

* For a complete review of treatment review of plantar fascia injection therapy evidence see here. Though not stated in the abstract the article states "PRP had the highest probability of being the best treatment in the medium term."

1. Platelet-Rich Plasma for Osteoarthritis in 2024 – More Hype, accessed on June 30, 2025, https://www.sportsmed.org/membership/sports-medicine-update/spring-2024/platelet-rich-plasma-for-osteoarthritis-in-2024
2. Platelet-Rich Plasma for Knee Osteoarthritis: A Comprehensive ..., accessed on June 30, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC12156035/
3. Comparison of hyaluronic acid and platelet-rich plasma in knee ..., accessed on June 30, 2025, https://pubmed.ncbi.nlm.nih.gov/40069655/
4. Platelet-Rich Plasma Injections Are Inferior to Corticosteroid ..., accessed on June 30, 2025, https://pubmed.ncbi.nlm.nih.gov/40081606/
5. Analyzing the performance of platelet-rich plasma and bone marrow aspirate concentrate injections for the treatment of knee osteoarthritis - Mayo Clinic, accessed on June 30, 2025, https://www.mayoclinic.org/medical-professionals/physical-medicine-rehabilitation/news/analyzing-the-performance-of-platelet-rich-plasma-and-bone-marrow-aspirate-concentrate-injections-for-the-treatment-of-knee-osteoarthritis/mqc-20578651
6. (PDF) Efficacy and safety of platelet-rich plasma injections for the treatment of osteoarthritis: a systematic review and meta-analysis of randomized controlled trials - ResearchGate, accessed on June 30, 2025, https://www.researchgate.net/publication/371930900_Efficacy_and_safety_of_platelet-rich_plasma_injections_for_the_treatment_of_osteoarthritis_a_systematic_review_and_meta-analysis_of_randomized_controlled_trials
7. Ultrasound-guided injection of platelet-rich plasma for ..., accessed on June 30, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10072988/
8. Platelet-rich plasma for rotator cuff tendinopathy: A systematic ..., accessed on June 30, 2025, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251111
9. Comparison of hyaluronic acid and platelet-rich plasma in knee osteoarthritis: a systematic review - PubMed, accessed on June 30, 2025, https://pubmed.ncbi.nlm.nih.gov/40069655
10. Effectiveness of Platelet-Rich Plasma in Treating Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis | Journal of Orthopaedic Case Reports, accessed on June 30, 2025, https://jocr.co.in/wp/2025/03/01/effectiveness-of-platelet-rich-plasma-in-treating
11. Kaux JF, Drion P, Croisier JL, Crielaard: Tendinopathies and platelet-rich plasma (PRP): from pre-clinical experiments to therapeutic use. JSRM 2015; 11: 7-17.

Dr Iain Duncan

April 2026

2026 has been both interesting and challenging. Something new will be happening at ultrasoundCBR soon, but you will need to wait a little longer. My website is pretty static except for an update on small joint PRP therapy -see here. Our usCBR team continues to work together and we all make each other better. Let us know how we could do better at hello@ultrasoundCBR.com.au.

November 2025

This has been a year of continuous change for me. I have become increasingly involved in clinical assessments and adjusting to a narrower focus: either musculoskeletal assessment (clinical plus ultrasound) or leading an amazing ultrasound team at ultrasoundCBR. I am enjoying every minute. Spending time with an enthusiastic, dedicated, and experienced team has been a joy. The team brings years of experience with a dedication to ongoing improvement and proving the best possible assessment and experience. The office team enables a great patient experience and will do their best to help wherever they can. Also I have enjoyed a new collaboration with Sam at Junee Ultrasound (see photo), which has been both rewarding and fun.
In terms of injection therapy recent evidence suggest Platelet rich plasma is the choice for Carpal Tunnel Syndrome, with 5% dextrose as 2nd preference, and corticosteroid only better than placebo for 3 months (see https://doi.org/10.1371/journal.pone.0303537, https://doi.org/10.1016/j.apmr.2022.11.009, and https://doi.org/10.1002/term.2950)

June 2025

On my departure from GMI I have stepped back from molecular imaging and nuclear medicine to lead the team at ultrasoundCBR and provide this next level ultrasound service. The first six months of ULTRASOUNDCBR have been fulfilling and amazing. The whole team has come together in quite an extraordinary way. There were very few "glitches" and we have pioneered new IT and care delivery systems. Nick Ingold was instrumental in setting up all our systems and employing our amazing staff. He also managed to participate in the "Shitbox rally" to raise funds for the Cancer Council of Australia (see photo), which of course we were delighted to sponsor.

I have now focused fully on delivering the best possible ultrasound service across the whole spectrum of ultrasound scans. In addition the team and I will continue to provide state of the art assessment and interventions for musculoskeletal problems.
I am pleased to see many old friends and patients have found us at Bruce and bring their friendly faces.

December 2024

After a significant break I am starting a new specialised ultrasound and clinical practice in Canberra named ULTRASOUNDCBR which we launched this month. This is an independent practice with specialised skill and experience in ultrasound dedicated to patient centred care. All the sonographers have decades long experience. We have every ultrasound specialty covered. Worth a visit!

June 2024

I am leaving Garran Medical Imaging with some sadness and I apologise to those that may be affected. At this stage I cannot give a date for a return but will post an update when the situation changes.

May 2024

The year marches on. I was pleased to see an article about my work on Tc-PSMA scanning in the North American Publication Medicine Innovates -see here. I attended the ANZSNM conference in Christchurch at the end of April which alerted me to what my colleagues are doing around the country. Nuclear medicine is such a diverse discipline and often we are unaware of progress in areas that we do not directly work. I note there is a massive shortage of nuclear medicine physicians in NZ.

Christchurch city is still full of "voids" post the 2011 earthquake, but gradually new builds are appearing. We also spent time in Lake Wanaka where we were privileged to see the first snow of winter falling (see photo below).

I also welcomed my first grandchild to the world on 19th April. A truly amazing feeling.

March 2024

The Maldives was a great place to spend a week at Christmas, but that was so long ago...
Another year launched and already Summer has nearly finished and the deep delve into fiction and non-medical books is giving way to brushing up on latest findings. Meta-analyses are popular forms of literature review but often lose some of the strengths of the underlying individual studies. By putting multiple studies together we are strengthening the findings about some general interventions, but often looking at the specific differences between studies is as useful as the similarities used to combine data. For example I have added some recent PRP (platelet rich plasma) meta-analyses to the list of PRP references. An interesting note on the meta-analysis of Barman et al was that they chose randomised clinical trials that compared autologous-PRP injections with placebo or another intervention for
persons with shoulder diseases. So any comparator and several shoulder diseases were all considered. Clearly this approach while providing some general information about the utility of PRP, is not the way a clinician would approach a shoulder problem in the real world. The overall effect of PRP therapy was compared to whatever comparator the individual studies used for whatever indication the study included. Of note there were very few placebo studies and in one of the studies which significantly reduced the pool effect of PRP, the comparator was PRP+HA!
As a clinician the details I look for in any given paper are I suspect quite different to a pure researcher. While I respect the importance of academic assessment of published papers, there are many (different) details which as a clinician I look at very closely, so I can understand the differences of approach to my own and therefore sometimes the importance (or not) of the findings. The standardized pain and function measures used in clinical trials are not the same as specific patient reported outcome measures I use as a clinician. Hopefully I will do a full review of our own patient reported outcomes measures (from my PRP patients) later this year.

July 2023

Where to go in 2023? I don't mean a geographical location but rather a strategic direction. There are so many possibilities for improvement and research in clinical medicine (see some of my recent publications). I collect a lot of data which might not sustain critical academic scrutiny in the conventional clinical trial paradigm as medicine has yet to embrace big data in any meaningful way. I first advocated the value of big data in the very earliest days of office and personal computers (1980's). I designed a rheumatology database system in DBASE and later Microsoft Access which had detailed diagnostic, treatment, and outcome measures for all my patients. This database profoundly influenced the basis of my early clinical practice (which was paperless before that was a thing). The data I collected allowed me to nuance and develop my treatment of rheumatic disease far more than the published clinical trials. I was sure this would be routine practice across medicine within a decade but here we are 3-4 decades later with still only the beginnings of widespread patient data collection and application. Australia in particular lags behind much of the first world in this respect. Value based healthcare (for more about this visit the Patient Experience Agency) is coming but the sacred cow of Medicare is a block to its implementation in medical practice. Funding remains fixed to episodes of interaction not to provision of (quality) care.
Measuring PROMS and PREMS (patient outcome measures) is easier in rheumatology than Medical Imaging as Diagnostic Imaging (DI) is a single component of multidisciplinary care and shares patient outcome with multiple participants.

Performance in DI is not systematically measured and yet it is a critical part of patient care. Many patients diagnosis and subsequent management are based on DI which has an estimated error rate of at least 5%. Communication between DI specialists and clinicians is often poor and a great deal could be done in this area. We at GMI would love to partner with others to improve this situation but there are so many blocks. Sharing the patient's clinical data across services would be a start....

April 2023

Returned from another walk in Tasmania, equally as invigorating. Also another episode of Covid (like so many others) despite just having a 5th vaccination. GMI keeps moving relentlessly forward and we try hard to keep at the cutting edge of so many things. Our work on Tc PSMA scans was published this month in The Prostate and I would like to thank all those who have contributed along the way. Well done.

Keep to the path

January 2023

Happy New Year. I have just returned from a wonderful walk in Tasmania. So good that we are already planning our next walk.

Bring on 2023! GMI has a new website and online booking facility for 2023? This should streamline bookings and avoid too much waiting on the phone. Nevertheless we are always happy to talk to you as the more customised we can make your booking the better your experience and outcome. In particular for myself I can provide a consultation service but only if you have a referral for such.

We will be introducing a few new services in 2023 where there is a significant quality gap in the ACT.

October 2022

2022 has been an interesting year at GMI. My co-founder Kevin Osborn has retired and of the original team there are only 4 remaining. We continue to evolve and have recently launched a new website. Our practice is close to functional capacity in the footprint we have at Garran. We have modified several spaces to try and improve both functionality and throughput, without compromising patient care. 2022 looks like the first year where some AI applications are ultrasound ready and I have already had some interesting discussions with developers. We have at this stage decided to go with smart software to improve workflow and efficiency rather than AI applications at this stage, but I suspect that may change in the next few years. Nevertheless at the core of our practice the human element is likely to be enhanced rather than replaced by near-future developments.
The ASUM conference (Australia's premiere ultrasound conference) in Adelaide in September was a great success and most of our ultrasound team were able to attend. ASUM premiered a new format involving a "deep dive" day which allowed the attendees to spend an entire day on a given topic. In my case I spent time learning a lot more about endometriosis and the team here at GMI have instituted several changes to our protocols to enhance our evaluation and detection of this under-diagnosed condition that affects a up to 10% of women of child bearing age. Endometriosis Australia is a great resource for this condition.
Nick Ingold (GMI practice Manager and nuclear medicine guru)and I also spent time in Vancouver at the The Society of Nuclear Medicine and Molecular Imaging (SNMMI) and briefly in Brisbane doing a theranostics course. The photo below shows it wasn't all study!
Continuing education never ends! This keeps us on the "edge" here at GMI where we can work together to pass on the latest techniques and understanding to our patients.

July 2022

A recent publication shows an Achilles fat pad steroid injection may help rehabilitation in some patients with mid-Achilles tendinopathy. While the study shows substantial differences between placebo and steroid, many injection candidates were excluded prior to the study which indicates that in the real world this intervention may have quite a restricted practical application.

June 2022

No updates since October so my regular reader will be disappointed. I remain manic at home and work as I really don't know how to get bored. I'm working on that too. When I'm not actually at GMI I'm working on data (PSMA scans and PRP injection therapy mainly) or reading (medical, fiction, and non-fiction). I do a bit of binge TV watching also (recent binges include anatomy of a scandal, Ozark, and the Lincoln Lawyer). A recent non-fiction that I enjoyed greatly was The Journey of Humanity by Oded Galor which really makes you think about the world differently. Galor looks at human diversity and progress over the entire history of homo sapiens and looks at the "big" influences and determinants of human economic and social development. What he finds is ultimately surprising. It seems that there may be an optimal level of population diversity and that this is linked to migratory distance from Africa. If this tweaks your curiosity I recommend the read.
Our PSMA experience /data up to August 2021 has now be collated and the first paper is in its final stages. Hopefully will be published before year's end. My PRP injection data is less sophisticated but I may be sharing this with a wider medical audience later this year also. Academic business may be normalizing post covid. Fortunately I suffered only a mild bout of the illness. I'm heading off to the The Society of Nuclear Medicine and Molecular Imaging (SNMMI) conference in Vancouver this month, my first trip post covid. Looking forward to it!
I'm pleased Australia has voted in a new Government, gives us hope for the future. Remember GEM is a universal key (Gratefulness, Empathy, Mindfulness).

October 2021

I have written a new PRP update which highlights the increasing evidence for LP-PRP (leucocyte poor platelet rich plasma) therapy as being the best intra-articular option for knee osteoarthritis in a network meta analysis which compared it with intra-articular hyaluronic acid, leukocyte-rich platelet-rich plasma (LR-PRP), bone marrow mesenchymal stem cells (BM-MSCs), adipose mesenchymal stem cells (AD-MSCs), and saline.

In the world of nuclear medicine and molecular imaging there was an exciting announcement by the Australian Government committing $30million to the design a new world leading manufacturing facility to be built at Lucas Heights in Sydney. This is overdue as the current facilities have been dogged by recurrent failures and breakdowns in recent years, despite the availability of the OPAL state-of-the-art reactor. As stated in the release " will save Australian lives, support thousands of jobs and further enhance our sovereign capability in this important area of medicine."

Radioisotopes save lives

September 2021

There is not a lot to talk about with business restricted to necessities only during our A.C.T. covid lockdown. I added this research to my shoulder list: https://doi.org/10.5414/CP203262 . This supports the use of PRP for shoulder capsulitis or frozen shoulder, and is something I undertook for the first time this month, and only as all other options had failed. This will be a tough clinical test for PRP in a severely frozen shoulder.
I continue to spend many hours every week making sure I am up to date in all of the areas in which I practice. While at times this can be onerous, it is also reaffirming and at times exciting. I discover some gem every few weeks which may improve the way we practice at GMI. Sometimes knowing that we are already ahead of the game is reaffirming but there is no "cruising" in the modern world. Change is a constant. I hope to be the best I can be on the day before I step away from my current role.

June 2021

We are proud to have (again) achieved full diagnostic imaging accreditation at Garran Medical Imaging for a further 4 years. The accreditation process takes a great deal of work and ensures you can expect all our scanning, professional, and diagnostic processes won't let you down. I have also personally achieved recertification of my Diploma in Diagnostic Ultrasound (DDU) for a further 4 years. While the latter is not a requirement of any regulatory body, it does ensure that I am personally up to date in all the ultrasound field in which I practice.

May 2021

I have been reading the recent reviews and literature on PRP therapy. The Biobridge Foundation has recently published an excellent 180 page summary of 20 years of research (laboratory and clinical) and reviews by leading clinicians in the use of PRP (platelet rich plasma) and HA (hyaluronic acid). This plus other data supports our use of leucocyte poor platelet rich plasma (LP-PRP) as the preferred injection therapy for many of the conditions we treat. I am still trying to finesse the clinical applications of LP-PRP, hyaluronic acid (HA), and combination therapies to try and predict the optimal choice for each patient and clinical problem. While there are a growing number of clinical trials demonstrating their value, the clinical setting for each patient has so many likely important variables, which cannot be adequately studied in clinical trials. Optimizing our protocols and recommendations is in constant evolution which requires ongoing feedback and follow-up. At least in 2021 we can get a lot of follow-up using email and online surveys. Thanks to those who have helped or will help me in this project.

March 2021

March saw Canberra day, the Balloon Festival, and Enlighten in Canberra. The practice was busy and aside from supply shortages everything is running well. A publication in Arthroscopy showed a better pain response to PRP for partial thickness rotator cuff tears up to 3 months post injection, but no difference at 12 months. Only a single injection of either was used whereas other trials have done more than one injection.

The latest PRP therapy result from Garran Medical Imaging can be found here. I am pleased to say 86% of our patients report a >50% improvement in pain after PRP therapy (for tendon and joint problems), when measured at between 2 and 6 months post therapy.

February 2021

I hope everyone had a "break " over the holiday season. Mine was belated but restful. I didn't get to travel being afraid of both rapidly changing Covid-19 restrictions and losing yet another deposit to the inflexible Airbnb. Also we didn't want to contribute further to the long term housing/rental shortage created fueled by the Airbnb craze.

On the medical front I note a couple of interesting knee osteoarthritis studies. For patients with osteoarthritis of the knee this study suggests a "winner" in the long debated issue of footwear and OA knee. A popular belief among many professionals is that flat flexible shoes improved knee pain but this study found that stable supportive shoes were significantly better, in a head to head comparison with regards to knee pain over a 6 month period. The supportive shoes also showed a trend towards improved function relative to the flat shoes.

Another study looked at comparing a stepped (and online supervised) exercise program with a standard education program. Patients in the stepped program get increased intervention depending on their response to each level of intervention: "The STEP-KOA intervention began with 3 months of an internet-based exercise program (step 1). Participants who did not meet response criteria for improvement in pain and function after step 1 progressed to step 2, which involved 3 months of biweekly physical activity coaching calls. Participants who did not meet response criteria after step 2 went on to in-person physical therapy visits (step 3). The AE group received educational materials via mail every 2 weeks". Only 35% progressed to step 3. The stepped group had a significantly better WOMAC score (this is a standard overall hip/knee arthritis score) compared with the "control" group.

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December 2020

I am now introducing combination PRP injections with hyaluronic acid for osteoarthritis in the knee. This is done using the cellular matrix device, which has only recently become available in Australia. Evidence for this combination comes from these previous studies which showed the superiority of the combination over solo therapy.

We are doing a lot of PSMA scans this month. For those interested in the underlying evidence, some of the original research is listed here.

November 2020

The holiday season awaits. Are we rushing to get there or hesitantly moving forward? I'm in two minds, having got into a comfortable routine and staying close to home all this year.

This month I was introduced to a new and exciting therapeutic program by Tina McIntosh at Brainchanger.io. This has been a gamechanger for many patients with chronic pain whose pain "systems" have become dysfunctional. It can run parallel with other interventions and utilises modern pain theory to "recalibrate" their pain experience.

I was also able to speak to our local rheumatology group about assessing rheumatoid arthritis with ultrasound and about PRP therapy for knee osteoarthritis.

Both these activities can help raise the bar on effective communication between healthcare professionals. This is as important as the interventions as healthcare can so often be fragmented and difficult for the patient to navigate effectively.

October 2020

Continuing on with the data theme of September (see below), I am overwhelmed by the amount of data that I collect in the course of my work. I have always been a keen data collector designing my first medical database in the 1980s and writing my own practice software for my rheumatology practice in 1990. Over several years I was able to instantly analyze which patients were on which treatments, how they responded, etc. I could view overall response rates and side effect profiles of different therapies across my patient groups. Even today this sort of ongoing analysis is not available in practice software.

I continued with data collection after my move to medical imaging, but while data collection is second nature, getting useful information from the data, clinical follow-up of interventions and scan results is much more difficult. I am currently making a more concerted effort to get better follow-up. So if you get an email, look kindly at it, and thanks in advance for your cooperation.

September 2020

The data space we live in gets larger exponentially every year, and paradoxically data mining becomes more of an art form. We hope that AI will help us make sense of this sea of data. No more is this more evident in Medicine where conventional medical journals are under assault on all fronts. This assault in many ways is both reasonable and predictable, but we need to ensure that the "baby is not thrown out with the bathwater". It will be interesting to see whether the conventional model and established journal monopolies will make the required adaptations going forward.

For those interested in some staggering Covid 19 data see this article in JAMA.

August 2020

August was our busiest month ever but...

July 2020

Life goes on (despite Covid-19). Fortunately, my work life is little affected, though like many my out-work-life is now quite "confined", but the upside is I'm saving $ not eating out, and when I do its a (very) special occasion.

PRP therapy continues to generate more and more interest, so I have started a collection of references that have influenced my thinking on the subject, see https://driainduncan.com.au/references-for-prp-therapy/.

There are quite a number of studies that really challenge the accepted dogma that corticosteroid injections are the first choice when conservative management fails. One such from Jane Fitzpatrick and colleagues (an Australian study -see here) showed that patients with chronic gluteal tendinopathy for more than 4 months achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection.

I have added new material to the sections Updates on PRP for Osteoarthritis and Updates on PRP for tendinopathies and tendon tears. I note that there is now more evidence supporting a longer-term benefit for PRP with one study showing an average patients' subjective symptomatic relief of 9 months for HA (viscosupplementation) and 12 months for PRP (platelet-rich plasma).

June 2020

I was supposed to be delivering a lecture this month on Quantitative SPECT: From Theory into Practice at the (North American) Society of Nuclear Medicine and Molecular Imaging in New Orleans, but unsurprisingly I am not. Instead, I am spending my time bike riding and walking the streets of Canberra and the tracks around Lake Burley-Griffin. There is still plenty of building activity in Canberra which has not been affected by Covid-19. Constitution Place (right) is starting to look spectacular.

May 2020

Work rebounded in May with plenty to do at GMI but the ANU and its Medical school remain closed. (Alas) I did not get to present my 3 abstracts on Tc-PSMA in prostate cancer at the ANZSNM conference in Sydney, but no doubt I can present the data at another forum or even publish it (time willing).

April 2020

It was pretty quiet at work as a result of the Covid-19 lockdown. Still a chance to focus on what matters most.

New to the site are some of the American Academy of Orthopaedic Surgeons' recommendations for the management of rotator cuff tears.

Meanwhile, in Canberra, I caught up with John Curtin and Ben Chifley who like many older statesmen were exempt from the social distancing rules.

March 2020

I have recently perused the 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee published in Arthritis and Rheumatology in January. While I agree with more than 90% of the recommendations there are a few I believe are conservative and ignore some pretty good evidence in favor of the status quo -most particularly those regarding intra-articular hyaluronic acid (HA) and Platelet-rich plasma (PRP) injections. The recommendations are based on a consensus from experts within the American College of Rheumatology and Arthritis Foundation after a review of the literature. In regard to specific recommendations, they do not provide a formal analysis or rarely list the pivotal literature. Though generally recommending against HA the guidelines state: "In clinical practice, the choice to use hyaluronic acid injections in the knee OA patient who has had an inadequate response to nonpharmacologic therapies, topical and oral NSAIDs, and intraarticular steroids may be viewed more favorably than offering no intervention, particularly given the impact of the contextual effects of intraarticular hyaluronic acid injections (38)." The guidelines also capitulate with the longstanding belief that IA steroid injections have a better evidence track record: "In OA generally, intraarticular glucocorticoid injection is conditionally recommended over other forms of intraarticular injection, including hyaluronic acid preparations. Head-to-head comparisons are few, but the evidence for the efficacy of glucocorticoid injections is of considerably higher quality than that for other agents." I believe this statement is incorrect and that evidence standards were simply lower 30-40 years ago, when the steroid lore was established. When you go back and carefully scrutinise the evidence, the study designs are no better than recent studies of HA and PRP. Indeed this study from Gormeli et al (2017) of HA and PRP into knees is as good as it gets (randomised, double blinded, and placebo controlled) -see my brief analysis here. Furthermore, this meta-analysis provides further evidence of the benefit of PRP and HA in osteoarthritis. The guidelines make no comment as to how they come to their recommendation regarding PRP, which I suspect remains in the too difficult category for analysis.

Most of the patients referred to me with osteoarthritis for intra-articular injection have failed almost all the standard recommended therapies and are either too old or too young for joint replacements. It would be hard to refuse therapies to these patients with significant pain and dysfunction on the basis of ACR guidelines, particularly where the risks are lower than with corticosteroid and the potential benefit probably higher.

January & February 2020

Summer has been a troubling time this year with ongoing bushfires, perpetual smokey haze, extraordinary temperatures, and later the spectre of a novel coronavirus. In some way, these have affected us all and make it hard to adopt the "business as usual" attitude. Even when I "escaped" to the south island of New Zealand (for a family wedding) the smoke from Australia was evident on several days. Still, the pack rafting was both hard work (carrying the raft upstream) and exhilarating (paddling it down again).

Like many, I have been filled with some existential angst about wanting to take some action to reduce mankind's impact on the planet but believing I can make little difference. I also tell myself that I can work best where my skills lie, by helping those patients who come through our practice. There is much to be done in achieving better health outcomes in a caring and sensitive way. I usually focus on the technical and clinical aspects of my practice, but I am aware of how much more (holistically) is needed to provide better care. For those who really want to learn more about patient-centered care I recommend reading Patients For Life by Shelley Thomson.

So every year there are new challenges, some expected and some not. I will endeavor to take most of them on (or ask others to help), which is a recipe for being busy, but will it be productive? Some of what we do at GMI is generally not available in many parts of the world or even Australia. I believe I should spread our experience and (perhaps) wisdom, but in practice, it is hard to do from a small, busy, single practice. This year I have submitted 3 abstracts on Tc-PSMA in prostate cancer to the ANZSNM conference in April and have agreed to give a lecture on Quantitative SPECT: From Theory into Practice at the Society of Nuclear Medicine and Molecular Imaging in New Orleans in June (SNNMI 2020). Hopefully, like my trek in NZ, if I cover the hard yards upstream then these activities will have a significant "downstream" effect, even if not for a few years.

December 2019

The holiday season is upon us again, but December often turns out to be frantic before Xmas. I recently spoke at an education evening about Tc-PSMA in prostate cancer, and I include a window into our experience here. I am hopeful that I will cobble at least some of the data together for either a publication or at least an abstract at the 2020 ANZSNM meeting in Sydney. However, it is likely this project will be competing with others for attention in the 2020 year. As the popular Mark Manson (Everything is F*cked) said (and I may be paraphrasing) "freedom is the ability to choose your pain."

November 2019

An update on liver elastography.

A publication in Radiology Online cautions us about significant complications following intraarticular corticosteroid injections for osteoarthritis, though the authors do concede these case studies do not necessarily imply causation. The phenomena of accelerated OA progression, subchondral insufficiency fracture, osteonecrosis, and rapid joint destruction can all be seen in patients with OA who have not had injections. Sometimes they are misdiagnosed as OA and have an injection before the recognition of the diagnosis.

October 2019

I am saddened that due to circumstances beyond my control I will no longer be traveling to Bega and the South Coast. This ends a long relationship with many people, staff, and doctors on the far South Coast. Recently South East Radiology was purchased by the Qscan group and new management has elected not to continue with the existing service arrangements with GMI (Garran Medical Imaging).

A big thanks go to all those who worked with me at Bega over the last decade -your support and kindness were greatly appreciated. I hope to keep in touch with many of you. Of course, any patients who would like to journey "up the hill" to Garran Medical Imaging are most welcome.

On another note, a recent meta-analysis shows there are only 4 factors that have been found to predict the progression of hip joint osteoarthritis. To some extent, these are not surprising and 3 of them correspond to the x-ray appearance of the hip (an x-ray is still a valuable tool). The fourth factor relates to co-morbidity, ie general health of the individual.

I will be talking at both the ANZSNM Capital Region Forum and the ASA SIG meetings this month. The former will be a lecture on xSPECT/CT bone and the latter on rheumatology ultrasound, both subjects I can get a little passionate about...

September 2019

Winter has been invigorating here in Canberra and it is always with some trepidation that I anticipate the Spring Allergy season.

For those interested in xSPECT/CT bone imaging my lecture at the World Molecular Imaging Summit is now online here.

For those with chronic pain, there is a great new system and management resource at Brain Changer.

We are now importing our Tc-PSMA from Hungary and have noticed a significant improvement in image clarity. It is very clear that these scans are having a significant impact on therapy for prostate cancer.

I was impressed by a recent paper on PRP and viscosupplementation injections for rotator cuff tears -see my comments here. I believe there is sufficient evidence to offer these injection options with some confidence about improving outcomes for patients with these smaller cuff tears, which (untreated) often progress over time. Check out the evidence for yourself here.

June 2019

I hope 2019 is going well for you all. As you can see from the lack of updates it has been pretty busy for me. Professionally my life is "full" and my personal life is fulfilling but mostly supports my busy professional life. Can't always separate the two -sometimes that's good and sometimes not. For those who are interested in mental health, anxiety, and the dysfunction spreading through western liberal democracies I suggest the following are excellent reading: Lost Connections by Johann Hari, and Australia Reimagined by Hugh Mackay. Though these are two very different books the reader will immediately see a common underlying thread in terms of the epidemic of anxiety/depression within our (lack of) communities.

I have been able to make time to attend the ANZSNM annual conference in Adelaide and travel to speak at The World Molecular Imaging Summit hosted by Siemens in Lausanne, Switzerland. The latter provided a great excuse for a (well deserved?) break in Northern Europe (Switzerland, Germany, Czech Republic, and Norway). The Norwegians do interesting modern apartments (see photo) and have lots of electric cars.

My talk on xSPECT/CT bone in Lausanne was very well received and reinforced to me that what we do at Garran Medical Imaging is really the cutting edge in bone scan technique. I will share the link to my talk if and when it is available online. While the science is complex and obscure for most (both patients and doctors) I have seen how it is really making a difference at the clinical level. It was a great pleasure to present the GMI experience (in Switzerland) to an appreciative audience.

I am hoping to spend some time in the latter part of 2019 reviewing our extensive data that we are continuing to accumulate in various research projects, but I'm not so good at looking through the data as accumulating it! I need some help there.

December 2018

I have been invited to participate in Siemens World Molecular Imaging Summit in Switzerland next year, a great honor for me and an accolade for the high-quality work we are doing at Garran Medical Imaging. I will be sharing my experience with xSPECT/CT bone scans in the arena of musculoskeletal medicine with our molecular imaging leaders from around the world.

2018 has been another in which I hope we have continued to serve our patients and referrers with world-class service and medical imaging. Particular medical communities we have made special efforts for in 2018 include long-term renal patients (dialysis patients and those on the transplant list), rheumatology patients, those suffering from prostate cancer, and those with chronic musculoskeletal disorders. If you think we can help, please email us at admin@garranmedicalimaging.com.au.

I have and will continue to travel to Bega to provide cardiac testing and medical imaging support to the region. I was delighted to talk and catch-up with many local practitioners about my experience in Prostate Cancer Imaging and Diagnosis. This took place in colourful Merimbula, in October this year. I hope it was a helpful update in a rapidly changing field.

November 2018

I can't believe Christmas is nearly here. The last few months have been busy enough to prevent me from doing any updates! Garran Medical Imaging and our work with xSPECT/CT bone has been noted at several "locations" around the globe, such as in Medical Imaging Life -see the online article here. Mostly the latter part of this year has been about consolidation and improvement rather than the new stuff. Collecting data and refining our systems so that we can be sure we are delivering the world's best care.

I have noted increasing referral for articular therapies for Osteoarthritis -mostly for PRP and viscosupplementation (eg. duralane, synvisc and monovisc). These therapies provide additional options for those suffering from significant pain related to their osteoarthritis. All of the options are safe but involve some cost to the patient with limited and variable health fund reimbursement. The clinical response are very mixed, but for some the result is quite amazing, with surprising improvement seen on scans in parallel with clinical changes.

Our Tc-PSMA scan data is also accumulating and some initial data is being looked at by the urology registrars at The Canberra Hospital. We have improved our scan parameters substantially over the last two years and I am proud of the technical results. I am sure local analysis of the clinical data will go a long way to improving the management of prostate cancer, and ultimately outcome for patients both locally and elsewhere. Hopefully some publications may result in 2019.

July 2018

New to the site: Osteoporosis screening tools and links to recent recommendations.

June 2018

June has been filled with chores and commitments and challenges that I'd rather not deal with, but alas are part of life's administrative burden. The winter in Canberra has made Cairns feel so long ago. I have been able to maintain great fitness with my HIIT (High intensity interval training) and hopefully this might delay my inevitable ageing according to a recent article in The Guardian.
On the professional front I'm seeing some commentaries spring up about xSPECT bone imaging which I hope means it will be more widely adopted around the globe. It is gratifying to see our research reaching afar. More about xSPECT bone can be found on Siemens website here. When combined with xSPECT quant this provides and much more reliable and detailed imaging landscape to assess our patients and referrers diagnostic and management problems. We continue to have great success solving cases which have proven elusive using more conventional nuclear medicine techniques (both for bone and parathyroid imaging). I am hopeful that as more and more medical imaging practices use the technology the data generated will bring new insights and clinical understanding.

May 2018

I have spent some time in Adelaide, Melbourne, and Cairns during April. A mixture of business and vacation. It has been refreshing and educational. Our poster from the WFNMB Melbourne conference was on quantitative bone imaging and how it can improve and standardise the quality of reporting in nuclear medicine. The poster can be viewed here.

The symposium in Cairns was on imaging and therapy for prostate carcinoma. This had some of the foremost experts in the World and I learnt a great deal, which I can put into practice immediately. Managed to fly over the reef in a small helicopter (see my photo right) which was one of the highlights.

My time in Adelaide was a nostalgia trip visiting some old haunts including Goolwa Beach (see photo) and McLaren Vale. Drove past The Queen Elizabeth Hospital where I did my rheumatology training so many years ago....

April 2018

The 12th World Congress of the Federation of Nuclear Medicine and Biology is taking place in Melbourne later this month and I am looking forward to it. I will have a Poster on xSPECT Quant (Siemens Healthineers) which will hopefully generate some interest. This technology is reshaping the way we do our scans and together with xSPECT makes nuclear medicine in general and bone scans specifically much more precise. Though this technology is not widely available I am hoping our experience will convince others of its substantial clinical benefits.

March 2018

Nicholas ingold and I celebrated publication of our study "The clinical value of xSPECT/CT Bone versus SPECT/CT. A prospective comparison of 200 scans" in the European Journal of Hybrid Imaging. This was the culmination of a lot of hard work and data collection and demonstrates how it is possible to undertake quality research in a private practice setting. It is been important for us to contribute in as many ways as we can to improving medical care. In addition it helps us confirm the validity of our practices. When we adopt new techniques we to look carefully at existing research and where it is not sufficient, we try and collect our own data, or undertake our own research, to support (or refute) our current practice. We have fun too.

February 2018

January was quiet in Canberra (as usual) which is a great way to start the year and collect your thoughts. I have used the available time to collect our research data, to analyse some interesting cases, and to add to this website an update on PRP therapy for osteoarthritis of the knee. For those with osteoarthritis there is also recent evidence that topical non-steroidal anti-inflammatory drugs (NSAIDS) can be effective for some, and are safer than oral equivalents.

The update shows convincing evidence of its benefit. I also read the The Checklist Manifesto: How to Get Things Right, by Atul Gawande. This is definitely recommended reading for health professionals and shows how far we have to go in placing the patient at the centre of healthcare.

December 2017

The end of another year. Some landmarks for myself and Garran Medical Imaging in 2017:

A 97% satisfaction rate from our patient feedback.
80% of patients benefitted from their tendon or joint PRP therapy.
Introduced routine quantification in nuclear medicine studies -presentation about this coming at the 12th World Congress of the World Federation of Nuclear Medicine and Biology in 2018.
Passed 1000 liver elastography assessments (and did not charge a separate fee for this service).
Presented our xSPECT/CT Bone data at the ANZSNM meeting in Hobart in April.

And some firsts...

The first 40 Technetium PSMA scans in Australia
The first full study on xSPECT/CT bone in the world (in press for publication early 2018)
The first Australian practice to be featured on the European Society of Hybrid Imaging Website

I am proud to be part of an amazing innovative and committed team who provide service to the best of their ability. Their dedication to ongoing learning, patient service, and helping me with anything I throw at the them inspires me. Our shared priorities at Garran Medical Imaging go something like this:

Our priorities are friendship, adding value to people's lives, having fun, solving problems, self-improvement, and only then making money.

We had a great year and we plan to do more of the same next year. I hope everyone has a great 2018. Seasons greetings.

November 2017

Our (myself and Nick Ingold, Garran Medical Imaging) research paper on xSPECT/CT bone scans has been accepted by the European Journal of Hybrid Imaging and hopefully will be in press soon. We have also submitted an abstract on Quantitative nuclear medicine for the 12th World Congress of the World Federation of Nuclear Medicine and Biology in 2018. I am proud that we can undertake research, try new techniques, and provide a great clinical services in a small private practice. This helps us stay at the cutting edge and provide the best possible care for those that chose to use our services. We will look after you!

On the website I have posted an abstract re corticosteroid injections for osteoarthritis of the knee. The study findings more or less mirrors my years of clinical experience with this intervention -the benefits are short term and generally more effective for milder degrees of OA. No one has yet directly compared corticosteroid, viscosupplementation, and platelet rich plasma injections all of which are used in similar clinical settings. Generally a pragmatic approach is taken for treating OA knee which includes mostly "try and see" for each of the available injection options, as well as other symptomatic options (analgesia, NSAIDs, acupuncture). Everyone should be encouraged to do regular quadriceps exercises.

October 2017

The last two months have been busy. Mostly finishing and upgrading our study on xSPECT bone -making it (we hope) of sufficient standard for publication. Also on PRP therapy (both undertaking injections and reviewing the literature). An update on therapy for lateral epicondylitis has been added to the website.

The latter shows that if any therapy is required for lateral epicondylitis (common extensor tendinopathy and tears) then PRP injections is the preferred option.
We also has some visitors from "over the ditch" (New Zealand) who came to learn about PSMA SPECT/CT which is an attractive option in NZ where PET scans are expensive and generally not covered by the healthcare system. We have now done about 50 scans and they are living up to our performance expectations.

August 2017

I was delighted to see that the first publication from the Australasian Radiopharmaceutical Trials Network has arrived and can be found online here. ARTnet supports multi-centre research in Australian Nuclear Medicine and is a joint initiative of two organisations that I am a (proud) member of, the Australasian Association of Nuclear Medicine Specialists and the Australian and New Zealand Society of Nuclear Medicine Ltd . It was established several years ago to address the need for a formal research network in Australia for a collaborative, multicentre clinical trials utilising radiopharmaceuticals for imaging or therapy.

The trial shows the clinical value of PSMA PET scanning in the management of prostate cancer. While PET PSMA remains difficult to access for many I am confident that our recently introduced xSPECT/CT PSMA scans at GMI can prove equally useful.

We have been working hard on these since we started earlier this year (see March 2017 below), and can now produce outstanding quality images. Based on experience in Germany and several early publication (eg from New York Presbyterian ) the Tc-PSMA is providing equivalent results with a very high sensitivity and specificity for prostate cancer. For those of you who wish to know more about PSMA I will, eventually, write some more about it from a patient's perspective. There is a brief introduction at Garran Medical Imaging.

I have also updated my post about PRP therapy for osteoarthritis after 2 years more of experience and journal monitoring.

July 2017

I didn't spend much time on nuclear medicine in July as I was best man at my brother's wedding in Scotland. It was an awesome, auspicious, and joyful event that I thoroughly enjoyed. The summer weather wasn't kind but the scenery spectacular.

June 2017

I have updated my article on back pain and bone scans following belatedly following the publication of an article showing the utility of SPECT/CT bone scans in the clinical workup for patient with lower back pain. The practice at Garran keeps me challenged but I am off to Europe for three weeks!

May 2017

A recent publication in Clinical Nuclear Medicine demonstrated that ^99mTc-MIBI SPECT/CT enhanced the performance of conventional imaging for renal tumours, improving the characterisation of benign v malignant lesions and lowering the possibility of misclassification. They demonstrated that sestamibi (a tracer usually used for myocardial and parathyroid scans) has an avidity for oncoytomas but not renal cell carcinomas and this correctly predicted benign lesions pre surgery. For more information see the original article here and they Auntminnie article here.

Also from Auntminnie this month a brief comment regarding an industry-supported study of more than 600 adults with knee osteoarthritis in five countries showed that compared with placebo with a daily dose of pharmaceutical-grade chondroitin. The latter improved pain and function as much as the anti-inflammatory celecoxib. At the 1-month mark, celecoxib improved symptoms the most, but by 6 months both were similarly effective. Chondroitin is widely available and is becoming a useful adjunct in the management of knee osteoarthritis. The mainstay of early to moderate OA (more about the stages of OA knee here) of the knee remains quadriceps tone/strengthening, simple analgesia, and sometimes viscosupplemenation or PRP -more information for patients here.

April 2017

I draw your attention to two recent publications that concern osteoarthritis of the knee. Published in the Journal of the American Medical Association the first study shows that frequent intra-articular steroid injections do accelerate cartilage deterioration. The second in Radiology confirms that those "who lost weight over 48 months showed significantly lower cartilage degeneration, as assessed with MR imaging; rates of progression were lower with greater weight loss."

I presented my data on the first 200 cases of xSPECT bone at the Australian and New Zealand Society of Nuclear Medicine meeting in Hobart this month (abstract O60). A summary this research can be found here.

March 2017

Diagnostic Imaging in Canberra took a leap this month when Garran Medical Imaging undertook Australia's first Tc-PSMA scan. This will be an invaluable adjunct to assessing and managing prostate cancer. Currently it is available only under the patient special access scheme but we can aim to get approval and import the tracer within 1-2 weeks following a request. We are able to use our direct quantification to assess lesions both for diagnosis and for response to therapy.

I read an amazing book PEAK -Secrets from the new science of expertise, by Anders Ericsson and Robert Pool. I don't generally recommend books to a wide audience but this is something everyone should read. It turns so many accepted dogmas on their heads and does it using years of research and some very careful observations. I wish I had read it when I was young, but of course it wasn't written then! Certainly teachers and anyone trying to push themselves should read this. It is quite uplifting and empowering.

February 2017

The year has moved into full-swing this month. Managed to get the years travel planning and data collection in order. I have found the memento database a great tool for data collection and/or creating reference databases. This allows you to create a database entry "app" on you android phone which you can synchronise with others and with google sheets. The latter allows you to collect data for later analysis and to update entries on a recurrent basis (for me that means subsequent treatments, visits, or scans).

February was also full of hot days and spectacular sunsets.

As a small operator in a field where large corporates and giant businesses are the norm I take some solace from the following equation (where did I read this?):

LONGEVITY + DOMINANCE = INNOVATION x GOVERNANCE

The dedicated small team at Garran use the excellent advantage we have on the right side of the above equation to compete effectively in a relatively crowded marketplace. We have clear advantages in innovation and customer/patient services and are still able to offer a better price than our larger competitors. On the innovation side we have several specific projects in 2017:

• Use of PRP therapy for unhealed split tendon tears and osteoarthritis
• xSPECT bone in musculoskeletal imaging
• Intrinsic elastography in the evaluation of tendon pain
• Shearwave elastography for liver disease
• Assessing response to denosumab (Antiresorptive) therapy in metastatic bone disease using quantitative bone imaging
• Evaluating Tc-PSMA in staging prostate carcinoma

January 2017

I really enjoyed a low key Christmas and New Year. I had a chance to reflect on the highs (and lows) of 2016. I think most of us take time out during the holiday season and as I write this I am feeling that gnawing feeling that I need to start doing 2017 things. My whiteboard has been cleaned and the multiple tracks I intend to follow for 2017 are in place. So now I need to start. That means designing a lot of new tools for data collection, considering what abstracts to write and what meetings to attend, and planning any overseas trips. Our modern professional lives are information rich and time poor. Over commitment is easy and though there are useful suggestions to follow we inevitably underestimate the time commitment each project or activity requires. Annie Gibbins has some useful tips but I'm still left with the problem that I enjoy and find rewarding a long list of activities.

Reflecting on 2016 I acknowledge that the amazing xSPECT bone technology I use remains in the "wings" and that its clear superiority over conventional SPECT remains underappreciated by the professionals and patients who might most benefit. Most medical breakthroughs and new technologies have slow uptake and of note my life partner Shelley is no stranger to my "impatience", particularly in traffic. The benefits are self evident -see images comparing SPECT and xSPECT of the same slice in a C2 vertebra. The pathology is clear in the xSPECT image and remains undetectable in the SPECT image. I have submitted an abstract on xSPECT bone scanning for the ANZSNM scientific meeting in April, which may keep the professional interest growing.

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An update April 2023

We have just scanned patient 847. The full results of our Tc-PSMA SPECT/CT research has now been published in The Prostate http://dx.doi.org/10.1136/ard.49.6.378

An update December 2019

Nicholas Ingold and I started doing Tc-PSMA SPECT/CT scans at GMI in 2016 and have now done about 300. Initially there was a steep learning curve as we worked on improving the technical parameters and image reconstruction, but over time I have become confident that we are producing a high quality and clinically important scan.

As part of my ongoing commitment to R&D I have recently reviewed our data and am pleased to note that the scan quality and more importantly the scan results are close to the benchmarks defined by the world literature on Ga-PSMA PET scans. The results below indicate the accuracy and value of the test.

Detection rates

Our detection rates are higher than the limited publications on Tc-PSMA. Our detection rate for recurrent disease post prostatectomy is shown in the table below.

PSA (ng/ml)	Number	+SCAN	-SCAN
<0.5	39	23 (59%)	16 (41%)
0.5-1.0	15	11 (73%)	4 (27%)
1.0-5.0	51	45 (88%)	6 (12%)
>5	133	130 (98%)	3 (2%)

Table 1: Detection rates for recurrent disease Tc-PSMA at GMI 2016-19.

Comparison with MRI

We also had 108 cases in which we had a comparative MRI at staging of the primary disease. As suggested in the literature for Gallium PSMA we found more disease in the prostate than the MRI in a substantial number of cases (table 2 below).

MRI v PSMA in prostate	Number	%
Discordant	3	3.5%
Concordant	36	46%
More disease on PSMA	37	47%
Less disease on PSMA	3	3.5%

Table 2: Comparison of mpMRI with Tc-PSMA for carcinoma of the prostate

Comparison with Conventional Staging

In 236 cases we had enough data to compare Tc-PSMA with conventional staging (CT scan +-Bone scan). In 145 cases (61%) there was no change. In the remaining 39% staging was altered: 15% upstaged; 13.6% different disease distribution; and 10% down-staged.

Relationship to Biopsy and PSA levels

We also had enough data to compare serum PSA, Gleason score at pathology, and SUVmax (PSMA uptake) of the principal prostate lesion in 146 cases (Figure 2). This shows a stronger correlation between SUVmax and Gleason score than between PSA and Gleason score (poor correlation).

1. Ridley, E. (2015). US-guided injections help ward off rotator cuff degeneration. AuntMinnie. http://www.auntminnie.com/index.aspx?sec=sup&sub=ult&pag=dis&ItemID=110012
2. Randelli, P., Randelli, F., Ragone, V., Menon, A., D’Ambrosi, R., Cucchi, D., Cabitza, P., & Banfi, G. (2014). Regenerative medicine in rotator cuff injuries. BioMed Research International, 2014. https://doi.org/10.1155/2014/129515
3. Kwong C et al. Platelet-Rich Plasma in Patients With Partial-Thickness Rotator Cuff Tears or Tendinopathy Leads to Significantly Improved Short-Term Pain Relief and Function Compared With Corticosteroid Injection: A Double-Blind Randomized Controlled Trial. Arthroscopy 2021, 37(2):510-517. DOI:https://doi.org/10.1016/j.arthro.2020.10.037
4. Lin,J. (2018). Platelet-rich plasma injection in the treatment of frozen shoulder: A randomized controlled trial with 6-month follow-up. International Journal of Clinical Pharmacology and Therapeutics, 56(8), 366–371. https://doi.org/10.5414/CP203262
5. Cai, Y., Sun, Z., Liao, B., Song, Z., Xiao, T., & Zhu, P. (2019). Sodium Hyaluronate and Platelet-Rich Plasma for Partial-Thickness Rotator Cuff Tears. Medicine and Science in Sports and Exercise, 51(2), 227–233. https://doi.org/10.1249/MSS.0000000000001781

The following are recognised sites and institutions with key clinical guidelines:

Guidelines American Academy of Orthopedic Surgeons

American College of Rheumatology Clinical Practice Guidelines

Thyroid Imaging Reporting & Data System (TI-RADS)

Musculoskeletal Outcome scores

Orthopaedic Score sheets

Below are a list of references I have read and used as a basis for reporting Tc-PSMA scans. The first list refers specifically to Tc-PSMA and the second list to GA-PSMA.

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Research on Tc-PSMA

1. Lawal, I. O., Ankrah, A. O., Mokgoro, N. P., Vorster, M., Maes, A., & Sathekge, M. M. (2017). Diagnostic sensitivity of Tc-99m HYNIC PSMA SPECT/CT in prostate carcinoma: A comparative analysis with Ga-68 PSMA PET/CT. Prostate, 77(11), 1205–1212. https://doi.org/10.1002/pros.23379
2. Su, H.-C., Xu, X.-P., Dai, B., Ling, G.-W., Zhu, Y., Hu, S.-L., & Ye, D.-W. (2016). Evaluation of 99m Tc-labeled PSMA-SPECT/CT imaging in prostate cancer patients who have undergone biochemical relapse. Asian Journal of Andrology, 19(3), 267. https://doi.org/10.4103/1008-682x.192638
3. Schmidkonz, C., Hollweg, C., Beck, M., Reinfelder, J., Goetz, T. I., Sanders, J. C., Schmidt, D., Prante, O., Bäuerle, T., Cavallaro, A., Uder, M., Wullich, B., Goebell, P., Kuwert, T., & Ritt, P. (2018). 99mTc-MIP-1404-SPECT/CT for the detection of PSMA-positive lesions in 225 patients with biochemical recurrence of prostate cancer. Prostate, 78(1), 54–63. https://doi.org/10.1002/pros.23444
4. Langbein, T., Chaussé, G., & Baum, R. P. (2018). Salivary Gland Toxicity of PSMA Radioligand Therapy: Relevance and Preventive Strategies. Journal of Nuclear Medicine, 59(8), 1172–1173. https://doi.org/10.2967/jnumed.118.214379
5. Vallabhajosula, S., Nikolopoulou, A., Babich, J. W., Osborne, J. R., Tagawa, S. T., Lipai, I., Solnes, L., Maresca, K. P., Armor, T., Joyal, J. L., Crummet, R., Stubbs, J. B., & Goldsmith, S. J. (2014). 99mTc-Labeled Small-Molecule Inhibitors of Prostate-Specific Membrane Antigen: Pharmacokinetics and Biodistribution Studies in Healthy Subjects and Patients with Metastatic Prostate Cancer. Journal of Nuclear Medicine : Official Publication, Society of Nuclear Medicine, 55(11), 1791–1798. https://doi.org/10.2967/jnumed.114.140426
6. Dér, J., Tenke, P., Joniau, S., Slawin, K., Ellis, W., Alekseev, B., Buzogány, I., Mishugin, S., Klein, E., Stolz, J., Student, V., Matveev, V., Köves, B., Babich, J., Youssoufian, H., Stambler, N., Armor, T., & Israel, R. (2014). C75: A phase 2 study of technetium Tc 99m trofolastat chloride (MIP-1404) SPECT/CT to identify local disease and lymph node metastases in high-risk patients undergoing radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) for prosta. European Urology Supplements, 13(6), e1263-e1263a. https://doi.org/10.1016/S1569-9056(14)61464-0
7. Hillier, S. M., Maresca, K. P., Lu, G. L., Merkin, R. D., Marquis, J. C., Zimmerman, C. N., Eckelman, W. C., Joyal, J. L., & Babich, J. W. (2013). Tc-99m-Labeled Small-Molecule Inhibitors of Prostate-Specific Membrane Antigen for Molecular Imaging of Prostate Cancer. Journal of Nuclear Medicine, 54(8), 1369–1376. https://doi.org/DOI 10.2967/jnumed.112.116624
8. Reinfelder, J., Kuwert, T., Prante, O., Wullich, B., Hennig, P., Beck, M., Sanders, J., Ritt, P., Schmidt, D., & Goebell, P. (2015). First experience with PSMA ­ SPECT / CT using a Tc ­ labeled PSMA inhibitor for patients with biochemical recurrence of prostate cancer. J Nucl Med, 56, Suppl 3 67.
9. Maurer, T., Weirich, G., Schottelius, M., Weineisen, M., Frisch, B., Okur, A., Kübler, H., Thalgott, M., Navab, N., Schwaiger, M., Wester, H. J., Gschwend, J. E., & Eiber, M. (2015). Prostate-specific Membrane Antigen-radioguided Surgery for Metastatic Lymph Nodes in Prostate Cancer. European Urology, 68(3). https://doi.org/10.1016/j.eururo.2015.04.034
10. Stanley, J., John, W., Cornell, W., College, M., & York, N. (n.d.). Prostate cancer using PSMA targeted molecular imaging probe , Tc-MIP-1404 : Phase I clinical study in patients undergoing radical prostatectomy SPECT in Patients Prior to Prostatectomy.

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Research on Ga-PSMA

1. Bahler, C. D., Green, M., Hutchins, G. D., Cheng, L., Magers, M. J., Fletcher, J., & Koch, M. O. (2020). Prostate Specific Membrane Antigen Targeted Positron Emission Tomography of Primary Prostate Cancer: Assessing Accuracy with Whole Mount Pathology. The Journal of Urology, 203(1), 92–99. https://doi.org/10.1097/JU.0000000000000501
2. Berger, I., Annabattula, C., Lewis, J., Shetty, D. V., Kam, J., MacLean, F., Arianayagam, M., Canagasingham, B., Ferguson, R., Khadra, M., Ko, R., Winter, M., Loh, H., & Varol, C. (2018). 68Ga-PSMA PET/CT vs. mpMRI for locoregional prostate cancer staging: Correlation with final histopathology. Prostate Cancer and Prostatic Diseases, 21(2), 204–211. https://doi.org/10.1038/s41391-018-0048-7
3. Bravaccini, S., Puccetti, M., Bocchini, M., Ravaioli, S., Celli, M., Scarpi, E., De Giorgi, U., Tumedei, M. M., Raulli, G., Cardinale, L., & Paganelli, G. (2018). PSMA expression: A potential ally for the pathologist in prostate cancer diagnosis. Scientific Reports, 8(1). https://doi.org/10.1038/s41598-018-22594-1
4. Chiu, L. W., Lawhn-Heath, C., Behr, S., Juarez, R., Perez, P. M., Lobach, I., Bucknor, M. D., Hope, T. A., & Flavell, R. R. (2020). Factors predicting metastatic disease in 68 Ga-PSMA-11 PET positive osseous lesions in prostate cancer. Journal of Nuclear Medicine, jnumed.119.241174. https://doi.org/10.2967/jnumed.119.241174
5. Donato, P., Roberts, M. J., Morton, A., Kyle, S., Coughlin, G., Esler, R., Dunglison, N., Gardiner, R. A., & Yaxley, J. (2019). Improved specificity with 68Ga PSMA PET/CT to detect clinically significant lesions “invisible” on multiparametric MRI of the prostate: a single institution comparative analysis with radical prostatectomy histology. European Journal of Nuclear Medicine and Molecular Imaging, 46(1). https://doi.org/10.1007/s00259-018-4160-7
6. Emmett, L., Tang, R., Nandurkar, R. H., Hruby, G., Roach, P. J., Watts, J. A., Cusick, T., Kneebone, A., Ho, B., Chan, L., Leeuwen, P. van, Scheltema, M., Nguyen, A., Yin, C., Scott, A., Tang, C., McCarthy, M., Fullard, K., Roberts, M., … Stricker, P. (2019). 3-year freedom from progression following 68GaPSMA PET CT triaged management in men with biochemical recurrence post radical prostatectomy. Results of a prospective multi-center trial. Journal of Nuclear Medicine, jnumed.119.235028. https://doi.org/10.2967/jnumed.119.235028
7. Haupt, F., Dijkstra, L., Alberts, I., Sachpekidis, C., Fech, V., Boxler, S., Gross, T., Holland-Letz, T., Zacho, H. D., Haberkorn, U., Rahbar, K., Rominger, A., & Afshar-Oromieh, A. (2020). 68Ga-PSMA-11 PET/CT in patients with recurrent prostate cancer—a modified protocol compared with the common protocol. European Journal of Nuclear Medicine and Molecular Imaging, 47(3), 624–631. https://doi.org/10.1007/s00259-019-04548-5
8. Hofman, M. S., Hicks, R. J., Maurer, T., & Eiber, M. (2018). Prostate-specific Membrane Antigen PET: Clinical Utility in Prostate Cancer, Normal Patterns, Pearls, and Pitfalls. Radiographics : A Review Publication of the Radiological Society of North America, Inc, 38(1). https://doi.org/10.1148/rg.2018170108
9. Hofman, M. S., Lawrentschuk, N., Francis, R. J., Tang, C., Vela, I., Thomas, P., Rutherford, N., Martin, J. M., Frydenberg, M., Shakher, R., Wong, L.-M., Taubman, K., Ting Lee, S., Hsiao, E., Roach, P., Nottage, M., Kirkwood, I., Hayne, D., Link, E., … Murphy, D. G. (2020). Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multi-centre study. The Lancet, 0(0). https://doi.org/10.1016/S0140-6736(20)30314-7
10. Koseoglu, E., Kordan, Y., Kilic, M., Sal, O., Seymen, H., Kiremit, M. C., Armutlu, A., Ertoy Baydar, D., Altinmakas, E., Vural, M., Falay, O., Canda, A. E., Balbay, D., Demirkol, M. O., & Esen, T. (2020). Diagnostic ability of Ga-68 PSMA PET to detect dominant and non-dominant tumors, upgrading and adverse pathology in patients with PIRADS 4–5 index lesions undergoing radical prostatectomy. Prostate Cancer and Prostatic Diseases, 1–8. https://doi.org/10.1038/s41391-020-00270-8
11. Kuten, J., Fahoum, I., Savin, Z., Shamni, O., Gitstein, G., Hershkovitz, D., Mabjeesh, N. J., Yossepowitch, O., Mishani, E., & Even-Sapir, E. (2020). Head-to-head comparison of 68Ga-PSMA-11 with 18F-PSMA-1007 PET/CT in staging prostate cancer using histopathology and immunohistochemical analysis as a reference standard. Journal of Nuclear Medicine, 61(4), 527–532. https://doi.org/10.2967/JNUMED.119.234187
12. Lawal, I. O., Ankrah, A. O., Mokgoro, N. P., Vorster, M., Maes, A., & Sathekge, M. M. (2017). Diagnostic sensitivity of Tc-99m HYNIC PSMA SPECT/CT in prostate carcinoma: A comparative analysis with Ga-68 PSMA PET/CT. Prostate, 77(11), 1205–1212. https://doi.org/10.1002/pros.23379
13. Öbek, C., Doğanca, T., Demirci, E., Ocak, M., Kural, A. R., Yıldırım, A., Yücetaş, U., Demirdağ, Ç., Erdoğan, S. M., & Kabasakal, L. (2017). The accuracy of 68Ga-PSMA PET/CT in primary lymph node staging in high-risk prostate cancer. European Journal of Nuclear Medicine and Molecular Imaging, 44(11), 1806–1812. https://doi.org/10.1007/s00259-017-3752-y
14. Ortega C, Schaefferkoetter J, Anconina R, Hawsawy A, Hussey D, Veit-Haibach P, and M. U. (2019). Evaluation of molecular imaging PSMA score (PROMISE) in the context of lesion size: do we need a correction factor? J Nucl Med, 60(supplement 1), 262. http://jnm.snmjournals.org/content/60/supplement_1/262.short?rss=1&related-urls=yes&legid=jnumed%3B60%2Fsupplement_1%2F262&utm_source=TrendMD&utm_medium=cpc&utm_campaign=J_Nucl_Med_TrendMD_0
15. Ortega, C., Schaefferkoetter, J., Veit-Haibach, P., Anconina, R., Berlin, A., Perlis, N., & Metser, U. (2020). 18F-DCFPyL PET/CT in Patients with Subclinical Recurrence of Prostate Cancer: Effect of Lesion Size, Smooth Filter and Partial Volume Correction on Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) criteria. Journal of Nuclear Medicine, jnumed.120.241737. https://doi.org/10.2967/jnumed.120.241737
16. Schmidkonz, C., Cordes, M., Goetz, T. I., Prante, O., Kuwert, T., Ritt, P., Uder, M., Wullich, B., Goebell, P., & Bäuerle, T. (2019). 68Ga-PSMA-11 PET/CT derived quantitative volumetric tumor parameters for classification and evaluation of therapeutic response of bone metastases in prostate cancer patients. Annals of Nuclear Medicine, 33(10), 766–775. https://doi.org/10.1007/s12149-019-01387-0
17. Sonni, I., Eiber, M., Fendler, W. P., Alano, R. M., Vangala, S. S., Kishan, A. U., Nickols, N., Rettig, M. B., Reiter, R., Czernin, J., & Calais, J. (2020). Impact of 68 Ga-PSMA-11 PET/CT on Staging and Management of Prostate Cancer Patients in Various Clinical Settings: A Prospective Single Center Study. Journal of Nuclear Medicine, 61(8), jnumed.119.237602. https://doi.org/10.2967/jnumed.119.237602
18. Su, H.-C., Xu, X.-P., Dai, B., Ling, G.-W., Zhu, Y., Hu, S.-L., & Ye, D.-W. (2016). Evaluation of 99m Tc-labeled PSMA-SPECT/CT imaging in prostate cancer patients who have undergone biochemical relapse. Asian Journal of Andrology, 19(3), 267. https://doi.org/10.4103/1008-682x.192638
19. van Leeuwen, P. J., Donswijk, M., Nandurkar, R., Stricker, P., Ho, B., Heijmink, S., Wit, E. M. K., Tillier, C., van Muilenkom, E., Nguyen, Q., van der Poel, H. G., & Emmett, L. (2019). Gallium-68-prostate-specific membrane antigen (68Ga-PSMA) positron emission tomography (PET)/computed tomography (CT) predicts complete biochemical response from radical prostatectomy and lymph node dissection in intermediate- and high-risk prostate cance. BJU International, 124(1), 62–68. https://doi.org/10.1111/bju.14506
20. Afaq, A., Alahmed, S., Chen, S., Lengana, T., Haroon, A., Payne, H., Ahmed, H., Punwani, S., Sathekge, M., & Bomanji, J. (2017). 68 Ga-PSMA PET/CT impact on prostate cancer management. Journal of Nuclear Medicine, jnumed.117.192625. https://doi.org/10.2967/jnumed.117.192625
21. Afshar-Oromieh, A., Avtzi, E., Giesel, F. L., Holland-Letz, T., Linhart, H. G., Eder, M., Eisenhut, M., Boxler, S., Hadaschik, B. A., Kratochwil, C., Weichert, W., Kopka, K., Debus, J., & Haberkorn, U. (2014). The diagnostic value of PET/CT imaging with the 68Ga-labelled PSMA ligand HBED-CC in the diagnosis of recurrent prostate cancer. European Journal of Nuclear Medicine and Molecular Imaging, 42(2), 197–209. https://doi.org/10.1007/s00259-014-2949-6
22. Afshar-Oromieh, A., Debus, N., Uhrig, M., Hope, T. A., Evans, M. J., Holland-Letz, T., Giesel, F. L., Kopka, K., Hadaschik, B., Kratochwil, C., & Haberkorn, U. (2018). Impact of long-term androgen deprivation therapy on PSMA ligand PET/CT in patients with castration-sensitive prostate cancer. European Journal of Nuclear Medicine and Molecular Imaging, 45(12). https://doi.org/10.1007/s00259-018-4079-z
23. Afshar-Oromieh, A., Holland-Letz, T., Giesel, F. L., Kratochwil, C., Mier, W., Haufe, S., Debus, N., Eder, M., Eisenhut, M., Schäfer, M., Neels, O., Hohenfellner, M., Kopka, K., Kauczor, H. U., Debus, J., & Haberkorn, U. (2017). Diagnostic performance of68Ga-PSMA-11 (HBED-CC) PET/CT in patients with recurrent prostate cancer: evaluation in 1007 patients. European Journal of Nuclear Medicine and Molecular Imaging, 44(8). https://doi.org/10.1007/s00259-017-3711-7
24. Ahmed, H. U., El-Shater Bosaily, A., Brown, L. C., Gabe, R., Kaplan, R., Parmar, M. K., Collaco-Moraes, Y., Ward, K., Hindley, R. G., Freeman, A., Kirkham, A. P., Oldroyd, R., Parker, C., & Emberton, M. (2017). Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. The Lancet, 389(10071), 815–822. https://doi.org/10.1016/S0140-6736(16)32401-1
25. Akdemir, E. N., Tuncel, M., Akyol, F., Bilen, C. Y., Baydar, D. E., Karabulut, E., Ozen, H., & Caglar, M. (2018). 68Ga-labelled PSMA ligand HBED-CC PET/CT imaging in patients with recurrent prostate cancer. World Journal of Urology, 0123456789. https://doi.org/10.1007/s00345-018-2460-y
26. Ballas, L. K., de Castro Abreu, A. L., & Quinn, D. I. (2016). What Medical, Urologic, and Radiation Oncologists Want from Molecular Imaging of Prostate Cancer. Journal of Nuclear Medicine, 57(Supplement_3). https://doi.org/10.2967/jnumed.115.170142
27. Barbosa, F. G., Queiroz, M. A., Nunes, R. F., Viana, P. C. C., Marin, J. F. G., Cerri, G. G., & Buchpiguel, C. A. (2019). Revisiting prostate cancer recurrence with PSMA PET: Atlas of typical and atypical patterns of spread. Radiographics, 39(1). https://doi.org/10.1148/rg.2019180079
28. Bashir, U., Tree, A., Mayer, E., Levine, D., Parker, C., Dearnaley, D., & Oyen, W. J. G. (2019). Impact of Ga-68-PSMA PET/CT on management in prostate cancer patients with very early biochemical recurrence after radical prostatectomy. European Journal of Nuclear Medicine and Molecular Imaging, 46(4), 901–907. https://doi.org/10.1007/s00259-018-4249-z
29. Beck, M., Reinfelder, J., Ritt, P., Sanders, J., & Torsten, K. (2016). Whole ­ Body Scintigraphy and Quantitative SPECT / CT Using the PSMA ­ Agent Tc ­ 99m ­ MIP ­ 1404 in the Preoperative Staging of Prostate Cancer ­ Preliminary Results. 57, 2016.
30. Beheshti, M., Manafi-Farid, R., Geinitz, H., Vali, R., Loidl, W., Mottaghy, F. M., & Langsteger, W. (2020). Multi-phasic 68Ga-PSMA PET/CT in detection of early recurrence in prostate cancer patients with PSA < 1 ng/ml: a prospective study of 135 cases. Journal of Nuclear Medicine, jnumed.119.238071. https://doi.org/10.2967/JNUMED.119.238071
31. Beheshti, M., Manafi-Farid, R., Geinitz, H., Vali, R., Loidl, W., Mottaghy, F. M., & Langsteger, W. (2020). Multi-phasic 68Ga-PSMA PET/CT in detection of early recurrence in prostate cancer patients with PSA < 1 ng/ml: a prospective study of 135 cases. Journal of Nuclear Medicine, jnumed.119.238071. https://doi.org/10.2967/jnumed.119.238071
32. Bieth, M., Krönke, M., Tauber, R., Dahlbender, M., Retz, M., Nekolla, S. G., Menze, B., Maurer, T., Eiber, M., & Schwaiger, M. (2017). Exploring New Multimodal Quantitative Imaging Indices for the Assessment of Osseous Tumor Burden in Prostate Cancer Using 68 Ga-PSMA PET/CT. Journal of Nuclear Medicine, 58(10). https://doi.org/10.2967/jnumed.116.189050
33. Bluemel, C., Linke, F., Herrmann, K., Simunovic, I., Eiber, M., Kestler, C., Buck, A. K., Schirbel, A., Bley, T. A., Wester, H. J., Vergho, D., & Becker, A. (2016). Impact of 68Ga-PSMA PET/CT on salvage radiotherapy planning in patients with prostate cancer and persisting PSA values or biochemical relapse after prostatectomy. EJNMMI Research, 6(1). https://doi.org/10.1186/s13550-016-0233-4
34. Bouchelouche, K., Turkbey, B., & Choyke, P. L. (2016). PSMA PET and Radionuclide Therapy in Prostate Cancer. In Seminars in Nuclear Medicine (Vol. 46, Issue 6). https://doi.org/10.1053/j.semnuclmed.2016.07.006
35. Calais, J., Ceci, F., Eiber, M., Hope, T. A., Hofman, M. S., Rischpler, C., Bach-Gansmo, T., Nanni, C., Savir-Baruch, B., Elashoff, D., Grogan, T., Dahlbom, M., Slavik, R., Gartmann, J., Nguyen, K., Lok, V., Jadvar, H., Kishan, A. U., Rettig, M. B., … Czernin, J. (2019). 18F-fluciclovine PET-CT and 68Ga-PSMA-11 PET-CT in patients with early biochemical recurrence after prostatectomy: a prospective, single-centre, single-arm, comparative imaging trial. The Lancet Oncology, July. https://doi.org/10.1016/s1470-2045(19)30415-2
36. Calais, J., Czernin, J., Cao, M., Kishan, A. U., Hegde, J. V, Shaverdian, N., Sandler, K. A., Chu, F.-I., King, C. R., Steinberg, M. L., Rausher, I., Schmidt-Hegemann, N.-S., Poeppel, T., Hetkamp, P., Ceci, F., Herrmann, K., Fendler, W. P., Eiber, M., & Nickols, N. G. (2017). (68)Ga-PSMA PET/CT mapping of prostate cancer biochemical recurrence following radical prostatectomy in 270 patients with PSA. Journal of Nuclear Medicine : Official Publication, Society of Nuclear Medicine, jnumed.117.201749. https://doi.org/10.2967/jnumed.117.201749
37. Calais, J., Kishan, A. U., Cao, M., Fendler, W. P., Eiber, M., Herrmann, K., Ceci, F., Reiter, R. E., Matthew, R. B., Hegde, J. V., Shaverdian, N., King, C. R., Steinberg, M. L., Czernin, J., & Nickols, N. G. (2018). Potential impact of 68 Ga-PSMA-11 PET/CT on prostate cancer definitive radiation therapy planning. Journal of Nuclear Medicine, jnumed.118.209387. https://doi.org/10.2967/jnumed.118.209387
38. Calais, J., Kishan, A. U., Cao, M., Fendler, W. P., Eiber, M., Herrmann, K., Ceci, F., Reiter, R. E., Rettig, M. B., Hegde, J. V, Shaverdian, N., King, C. R., Steinberg, M. L., Czernin, J., & Nickols, N. G. (2018). Potential impact of 68Ga-PSMA-11 PET/CT on prostate cancer definitive radiation therapy planning. Journal of Nuclear Medicine : Official Publication, Society of Nuclear Medicine, 59(11), 1714–1721. https://doi.org/10.2967/jnumed.118.209387
39. Ceci, F., Bianchi, L., Borghesi, M., Polverari, G., Farolfi, A., Briganti, A., Schiavina, R., Brunocilla, E., Castellucci, P., & Fanti, S. (2020). Prediction nomogram for 68Ga-PSMA-11 PET/CT in different clinical settings of PSA failure after radical treatment for prostate cancer. European Journal of Nuclear Medicine and Molecular Imaging, 47(1), 136–146. https://doi.org/10.1007/s00259-019-04505-2
40. Cho, S. Y. (2018). Proposed Criteria Positions PSMA PET for the Future. Journal of Nuclear Medicine, 1993, jnumed.117.204057. https://doi.org/10.2967/jnumed.117.204057
41. Corfield, J., Perera, M., Bolton, D., & Lawrentschuk, N. (2018). 68Ga-prostate specific membrane antigen (PSMA) positron emission tomography (PET) for primary staging of high-risk prostate cancer: a systematic review. World Journal of Urology, 36(4), 519–527. https://doi.org/10.1007/s00345-018-2182-1
42. Cremonesi, Marta; Ferrari, Mahila; Bodei, Lisa; Tosi, Giampiero; Paganelli, G. (2006). The Journal of Nuclear Medicine. The Journal of Nuclear Medicine, 47(9), 1467–1475. http://jnm.snmjournals.org/content/56/supplement_3/1279?cited-by=yes&legid=jnumed;56/supplement_3/1279
43. Dabasi, G., Barra, M., Tenke, P., Joniau, S., Goffin, K., Slawin, K., Ellie, W., Alekseev, B., Buzogany, I., Mishugin, S., Klein, E., Stolz, J., Student, V., Matveev, V., & Armor, T. (2014). Correlation of Technetium Tc99m trofolastat chloride (MIP-1404) uptake using SPECT/CT with histopathology: A phase 2 study of prostate cancer (PCa) patients undergoing radical prostatectomy (RP) with extended lymph node dissection (ePLND). Eur J Nucl Med Mol Imaging, 41(Suppl 2), S236–S237.
44. Demirci, E., Kabasakal, L., Şahin, O. E., Akgün, E., Gültekin, M. H., Doǧanca, T., Tuna, M. B., Öbek, C., Kiliç, M., Esen, T., & Kural, A. R. (2019). Can SUVmax values of Ga-68-PSMA PET/CT scan predict the clinically significant prostate cancer? Nuclear Medicine Communications, 40(1), 86–91. https://doi.org/10.1097/MNM.0000000000000942
45. Dér, J., Tenke, P., Joniau, S., Slawin, K., Ellis, W., Alekseev, B., Buzogány, I., Mishugin, S., Klein, E., Stolz, J., Student, V., Matveev, V., Köves, B., Babich, J., Youssoufian, H., Stambler, N., Armor, T., & Israel, R. (2014). C75: A phase 2 study of technetium Tc 99m trofolastat chloride (MIP-1404) SPECT/CT to identify local disease and lymph node metastases in high-risk patients undergoing radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) for prosta. European Urology Supplements, 13(6), e1263-e1263a. https://doi.org/10.1016/S1569-9056(14)61464-0
46. Eiber, M., Herrmann, K., Calais, J., Hadaschihk, B., Giesel, F. L., Hartenbach, M., Hope, T. A., Reiter, R., Maurer, T., Weber, W. A., & Fendler, W. P. (2017). PROstate cancer Molecular Imaging Standardized Evaluation (PROMISE): proposed miTNM classification for the interpretation of PSMA-ligand PET/CT. Journal of Nuclear Medicine, jnumed.117.198119. https://doi.org/10.2967/jnumed.117.198119
47. Eiber, M., Herrmann, K., Calais, J., Hadaschihk, B., Giesel, F. L., Hartenbach, M., Hope, T., Reiter, R., Maurer, T., Weber, W. A., & Fendler, W. P. (2017). PROstate cancer Molecular Imaging Standardized Evaluation (PROMISE): proposed miTNM classification for the interpretation of PSMA-ligand PET/CT. Journal of Nuclear Medicine : Official Publication, Society of Nuclear Medicine, jnumed.117.198119. https://doi.org/10.2967/jnumed.117.198119
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109. Vallabhajosula, S., Osborne, J., Nikolopoulou, A., Lipai, I., Tagawa, S., Scherr, D., Joyal, J., Armor, T., Goldsmith, S., & Babich, J. (2014). PSMA targeted SPECT imaging biomarker to detect local and metastatic prostate cancer ( PCa ): Phase I studies with Tc ­ MIP ­ 1404. 54(May 2013), 2014.
110. Van Leeuwen, P. J., Stricker, P., Hruby, G., Kneebone, A., Ting, F., Thompson, B., Nguyen, Q., Ho, B., & Emmett, L. (2016). 68Ga-PSMA has a high detection rate of prostate cancer recurrence outside the prostatic fossa in patients being considered for salvage radiation treatment. BJU International, 117(5), 732–739. https://doi.org/10.1111/bju.13397
111. Virgolini, I., Decristoforo, C., Haug, A., Fanti, S., & Uprimny, C. (2018). Current status of theranostics in prostate cancer. In European Journal of Nuclear Medicine and Molecular Imaging (Vol. 45, Issue 3). https://doi.org/10.1007/s00259-017-3882-2
112. Vogel, M. M. E., Kroeze, S. G. C., Henkenberens, C., Kirste, S., Becker, J., Burger, I. A., & Derlin, T. (2020). Prognostic risk classification for biochemical relapse-free survival in patients with oligorecurrent prostate cancer after PSMA-PET-guided metastasis-directed therapy. Eur J Nucl Med Mol Imaging. https://doi.org/10.1007/s00259-020-04760-8
113. von Eyben, F. E., Picchio, M., von Eyben, R., Rhee, H., & Bauman, G. (2016). 68Ga-Labeled Prostate-specific Membrane Antigen Ligand Positron Emission Tomography/Computed Tomography for Prostate Cancer: A Systematic Review and Meta-analysis. European Urology Focus. https://doi.org/10.1016/j.euf.2016.11.002
114. Wang, B. J., Gao, J., Zhang, Q., Fu, Y., Liu, G., Shi, J., Li, D., Wang, F., & Guo, H. (2020). Diagnostic Value of 68Ga-PSMA PET/CT for Detection of Phosphatase and Tensin Homolog Expression in Prostate Cancer: A Pilot Study. In Journal of nuclear medicine : official publication, Society of Nuclear Medicine (Vol. 61, Issue 6). https://doi.org/10.2967/jnumed.119.236059
115. Woythal, N., Arsenic, R., Kempkensteffen, C., Miller, K., Janssen, J.-C., Huang, K., Makowski, M. R., Brenner, W., & Prasad, V. (2017). Immunohistochemical validation of PSMA-expression measured by 68 Ga-PSMA PET/CT in primary prostate cancer. Journal of Nuclear Medicine, 59(2), jnumed.117.195172. https://doi.org/10.2967/jnumed.117.195172
116. Zacho, H. D., Nielsen, J. B., Haberkorn, U., Stenholt, L., & Petersen, L. J. (2018). 68Ga-PSMA PET/CT for the detection of bone metastases in prostate cancer: a systematic review of the published literature. In Clinical Physiology and Functional Imaging (Vol. 38, Issue 6). https://doi.org/10.1111/cpf.12480
117. Zamboglou, C., Schiller, F., Fechter, T., Wieser, G., Jilg, C. A., Chirindel, A., Salman, N., Drendel, V., Werner, M., Mix, M., Meyer, P. T., & Grosu, A. L. (2016). 68Ga-HBED-CC-PSMA PET/CT versus histopathology in primary localized prostate cancer: A voxel-wise comparison. Theranostics, 6(10), 1619–1628. https://doi.org/10.7150/thno.15344

Knee Osteoarthritis

Adam, P., Renevier, J. L., & Marc, J.-F. (2018). A novel treatment of knee degenerative disorders all-in-one intra-articular injection of platelet-rich plasma combined with hyaluronic acid. International Journal of Clinical Rheumatology, 13, 280–288. https://doi.org/10.4172/1758-4272.1000199

Barac, B., Damjanov, N., & Zekovic, A. (2018). The new treatment approach in knee osteoarthritis: Efficacy of cellular matrix combination of platelet rich plasma with hyaluronic acid versus two different types of hyaluronic acid (HA). International Journal of Clinical Rheumatology, 13, 289–295. https://doi.org/10.4172/1758-4272.1000200

Jacob, G., Shetty, V., & Shetty, S. (2017). A study assessing intra-articular PRP vs PRP with HMW HA vs PRP with LMW HA in early knee osteoarthritis. Journal of Arthroscopy and Joint Surgery, 4(2), 65–71. https://doi.org/10.1016/j.jajs.2017.08.008

Renevier J, Marc J, Adam P et al. Cellular matrix™ PRP-HA”: A new treatment option with platelet-rich plasma and hyaluronic acid for patients with osteoarthritis having had an unsatisfactory clinical response to hyaluronic acid alone: Results of a pilot, multicenter French study with long-term follow-up. International Journal of Clinical Rheumatology (2018) Volume 13, Issue 4. https://doi.org/10.4172/1758-4272.1000191

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Shoulder and rotator cuff

Cai, Y., Sun, Z., Liao, B., Song, Z., Xiao, T., & Zhu, P. (2019). Sodium Hyaluronate and Platelet-Rich Plasma for Partial-Thickness Rotator Cuff Tears. Medicine and Science in Sports and Exercise, 51(2), 227–233. https://doi.org/10.1249/MSS.0000000000001781

Order of updates is newest to oldest

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Iain Duncan Update July 2020

Based on a number of studies and our own experience there are benefits from doing repeated or cycling PRP injections for osteoarthritis of the knee. One such study showed PRP injections led to a significant reduction in pain and improvement in function after 12 months, which can be further improved at 18 months by annual repetition of the treatment. Although the beneficial effects are ill sustained at 2 years, the results are encouraging when compared to the pre-treatment function . Another study over 5yrs compared HA and PRP and concluded "both treatments were effective in improving knee functional status and symptoms over time". Of particular note:

"the median duration of patient subjective perception of symptomatic relief was 9 months for HA and 12 months for PRP"

A major metanalysis just published in Arthroscopy looked at level I randomised controlled trials comparing hyaluronic acid and PRP. They found 26 trials that met their criteria and concluded:

"For the nonsurgical treatment of KOA, compared with HA, intra-articular injection of PRP could significantly reduce patients' early pain and improve function. There was no significant difference in adverse events between the two groups. PRP was more effective than HA in the treatment of KOA, and the safety of these two treatment options was comparable."

See my extended list of PRP references here.

1. Gobbi, A., Lad, D. & Karnatzikos, G. The effects of repeated intra-articular PRP injections on clinical outcomes of early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 23, 2170–2177 (2015). https://doi.org/10.1007/s00167-014-2987-4
2. Di Martino A, Di Matteo B, Papio T, et al. Platelet-Rich Plasma Versus Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis: Results at 5 Years of a Double-Blind, Randomized Controlled Trial. Am J Sports Med. 2019;47(2):347-354. https://doi.org/10.1177%2F0363546518814532
3. Tan J, Chen H, Zhao L, Huang W. Platelet Rich Plasma Versus Hyaluronic Acid in the Treatment of Knee Osteoarthritis: a Meta-Analysis of 26 randomized controlled trials . Arthroscopy. 2020;S0749-8063(20)30604-6. doi:10.1016/j.arthro.2020.07.011

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Iain Duncan Update February 2018

This recent randomised double blind placebo controlled trail has shown eunequivocal benefit of PRP for OA knees².

Trial Design:

• A total of 162 patients with different stages of knee OA were randomly divided into four groups: each had 3 injections each: 3 IA doses of PRP, one dose of PRP, 3 inj of HA (hyaluronic acid) or a saline injection (control).
• Two subgroups: early OA (Kellgren–Lawrence grade 0 with cartilage degeneration or grade I–III) and advanced OA (Kellgren–Lawrence grade IV).
• The patients were evaluated before the injection and at the 6-month follow- ups using the EuroQol visual analogue scale (EQ-VAS) and International Knee Documentation Committee (IKDC) subjective scores.

Results:

• There was a statistically significant improvement in the IKDC and EQ-VAS scores in all the treatment groups compared with the control group.
• The knee scores of patients treated with three PRP injections were significantly better than those patients of the other groups. There was no significant difference in the scores of patients injected with one dose of PRP or HA.
• In the early OA subgroups, significantly better clinical results were achieved in the patients treated with three PRP injections, but there was no significant difference in the clinical results of patients with advanced OA among the treatment groups.

Conclusions:

1. The clinical results of this study suggest intra-articular PRP and HA treatment for all stages of knee OA.
2. For patients with early OA, multiple (3) PRP injections are useful in achieving better clinical results.
3. For patients with advanced OA, multiple injections do not significantly improve the results of patients in any group.

References

1. Sheth U; Dwyer T; Smith I; Wasserstein D; Theodoropoulos J; Takhar S; Chahal J. Does Platelet-Rich Plasma Lead to Earlier Return to Sport When Compared With Conservative Treatment in Acute Muscle Injuries? A Systematic Review and Meta-analysis. Arthroscopy. 2015; 31(11):2213-21
2. Görmeli et al (2017). Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy,25(3), 958–965. https://doi.org/10.1007/s00167-015-3705-6

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Iain Duncan Update August 2017

A recent trial and more experience with the use of PRP has prompted me to do this brief update on PRP therapy for knees.

I came across a further review in Arthroscopy¹ from that concluded PRP "is a viable treatment for knee OA and has the potential to lead to symptomatic relief for up to 12 months". Furthermore intra-articular PRP therapy "offers better symptomatic relief to patients with early knee degenerative changes, and its use should be considered in patients with knee OA".

We have now successfully undertaken a series of PRP injections in OA knee and most have had more advanced disease than is ideal (the best responders have the least radiological changes), but ~80% have had longer and better responses to PRP than earlier intra-articulator corticosteroid treatments. This is a similar response rate to tendon tears.

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Iain Duncan February 2016

I understand the rationale and use of platelet rich plasma (PRP) for tendon problems but I am continually asked about PRP injections for osteoarthritis. It is less intuitive than its use for tendon pathologies, where the PRP can be seen to simulate a normal healing response. PRP is not "normal" in joints and therefore its use is not entirely rational.

I have certainly done injections of PRP into both knees and hip for osteoarthritis(OA). Anecdotally in the few cases I have done there has been a universal improvement in symptoms, but it is too early to know whether there will be any longer term benefit. The results of studies using PRP for OA are comprehensively summarised in this paper by Filardo et al in this study from 2015: Platelet-rich plasma: why intra-articular? A systematic review of preclinical studies and clinical evidence on PRP for joint degeneration.

They conclude: "Besides the limits and sometimes controversial findings, the preclinical literature shows an overall support toward this PRP application. An intra-articular injection does not just target cartilage; instead, PRP might influence the entire joint environment, leading to a shortterm clinical improvement. Many biological variables might influence the clinical outcome and have to be studied to optimize PRP injective treatment of cartilage degeneration and osteoarthritis."

Any earlier assessment of PRP therapy in Osteoarthritis of the knee was done by the Health Policy Advisory Committee on Technology in August 2013 and the full document can be downloaded here. That review of the literature at that time concluded in its summary "All studies included in this assessment reported short-term improvements in function and a decrease in pain scores; however this effect did not appear to be sustained over a long period of time. The procedure appears to be safe, with the only adverse event reported being short-term pain following injection due to inflammation."

It is likely that over the next few years better data will be available and we will discover whether the benefit is only short-term, or whether it reduces or delays the need for surgical intervention. On the plus side no significant adverse effects have been documented and the cost is less than many other interventions. Even if its net effect is only to delay surgery many patients will consider this a worthwhile outcome.

Meta-analysis of PRP Studies

• Current Status and Advancements in Platelet-Rich Plasma Therapy - Published in Cureus in October 2023.
• Xiong, Y., Gong, C., Peng, et al (2023). Efficacy and safety of platelet-rich plasma injections for the treatment of osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. In Frontiers in Medicine (Vol. 10). Frontiers Media SA. https://doi.org/10.3389/fmed.2023.1204144
• Barman, A., Mishra, A., Maiti, R., et al (2022). Can platelet-rich plasma injections provide better pain relief and functional outcomes in persons with common shoulder diseases: a meta-analysis of randomized controlled trials. Clinics in Shoulder and Elbow, 25(1), 73–89. https://doi.org/10.5397/cise.2021.00353

List of references to 2021

1. Migliorini, F., Driessen, A., Quack, V., Sippel, N., Cooper, B., Yasser, ·, Mansy, E., Tingart, M., & Eschweiler, J. (2021). Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis: a Bayesian network meta-analysis. 141, 1473–1490. https://doi.org/10.1007/s00402-020-03551-y
2. D, Z., JK, P., WY, Y., YH, H., LF, Z., GH, L., & J, L. (2021). Intra-Articular Injections of Platelet-Rich Plasma, Adipose Mesenchymal Stem Cells, and Bone Marrow Mesenchymal Stem Cells Associated With Better Outcomes Than Hyaluronic Acid and Saline in Knee Osteoarthritis: A Systematic Review and Network Meta-analysis. Arthroscopy : The Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 37(7), 2298-2314.e10. https://doi.org/10.1016/J.ARTHRO.2021.02.045
3. Görmeli, G., Görmeli, C. A., Ataoglu, B., Çolak, C., Aslantürk, O., & Ertem, K. (2017). Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy, 25(3), 958–965. https://doi.org/10.1007/s00167-015-3705-6
4. Di Martino A, Di Matteo B, Papio T, et al. Platelet-Rich Plasma Versus Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis: Results at 5 Years of a Double-Blind, Randomized Controlled Trial. Am J Sports Med. 2019;47(2):347-354. https//doi:10.1177/0363546518814532
5. Muchedzi, T. A., & Roberts, S. B. (2017). A systematic review of the effects of platelet rich plasma on outcomes for patients with knee osteoarthritis and following total knee arthroplasty. Surgeon, 1–9. https://doi.org/10.1016/j.surge.2017.08.004
6. Tan J, Chen H, Zhao L, Huang W. Platelet Rich Plasma Versus Hyaluronic Acid in the Treatment of Knee Osteoarthritis: a Meta-Analysis of 26 randomized controlled trials . Arthroscopy. 2020;S0749-8063(20)30604-6. doi:10.1016/j.arthro.2020.07.011
7. Park, G. Y., Kwon, D. R., Cho, H. K., Park, J., & Park, J. H. (2017). Distribution of platelet-rich plasma after ultrasound-guided injection for chronic elbow tendinopathies. Journal of Sports Science and Medicine, 16(1), 1–5.
8. Mishra AK; Skrepnik NV; Edwards SG; Jones GL; Sampson S; Vermillion DA; Ramsey ML; Karli DC; Rettig AC. (2014). Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med, 42(2), 463–471. http://reference.medscape.com/medline/abstract/23825183
9. Lundquist, W., & Stanford, R. (2013). Targeting systemic inflammation in patients with obesity-related pain: One practice’s success with platelet-rich plasma therapy. The Journal of Family Practice. https://doi.org/jfp_6209o
10. Mi, B., Liu, G., Zhou, W., Lv, H., Liu, Y., Wu, Q., & Liu, J. (2017). Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. The Physician and Sportsmedicine, 0(0), 00913847.2017.1297670. https://doi.org/10.1080/00913847.2017.1297670
11. Gosens, T., Peerbooms, J. C., van Laar, W., & den Oudsten, B. L. (2011). Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis. The American Journal of Sports Medicine, 39(6), 1200–1208. https://doi.org/10.1177/0363546510397173
12. Sampson, S., Gerhardt, M., & Mandelbaum, B. (2008). Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr.Rev.Musculoskelet.Med., 1(1935-973X (Print)), 165–174.
13. Abate M Di Gregorio P, Pantalone A, Scuccimarra T, Vanni D, Andreoli E, Salini V, S. C. (2013). Comparison between hyaluronic acid and platelet rich plasma in the treatment of hip and knee osteoarthritis: Preliminary results. In Journal of orthopaedics and traumatology (Vol. 14, Issue 1 SUPPL. 1, p. S17). http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=cctr&NEWS=N&AN=CN-01024095
14. Shiple, B. J. (2013). How effective are injection treatments for lateral epicondylitis? Clinical Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine, 23(6), 502–503. https://doi.org/10.1097/JSM.0000000000000042
15. Mishra, A., & Pavelko, T. (2006). Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. The American Journal of Sports Medicine, 34(11), 1774–1778. https://doi.org/10.1177/0363546506288850
16. Zhang, J. Y., Fabricant, P. D., Ishmael, C. R., Wang, J. C., Petrigliano, F. A., & Jones, K. J. (2016). Utilization of Platelet-Rich Plasma for Musculoskeletal Injuries. Orthopaedic Journal of Sports Medicine, 4(12), 232596711667624. https://doi.org/10.1177/2325967116676241
17. Gobbi, A., Karnatzikos, G., Mahajan, V., & Malchira, S. (2012). Platelet-Rich Plasma Treatment in Symptomatic Patients With Knee Osteoarthritis. Sports Health: A Multidisciplinary Approach, 4(2), 162–172. https://doi.org/10.1177/1941738111431801
18. Yadav, R. (2015). Comparison of Local Injection of Platelet Rich Plasma and Corticosteroids in the Treatment of Lateral Epicondylitis of Humerus. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH, 2(6), 1412–1420. https://doi.org/10.7860/JCDR/2015/14087.6213
19. Zhang, J. Y., Fabricant, P. D., Ishmael, C. R., Wang, J. C., Petrigliano, F. A., & Jones, K. J. (2016). Utilization of Platelet-Rich Plasma for Musculoskeletal Injuries. Orthopaedic Journal of Sports Medicine, 4(12), 232596711667624. https://doi.org/10.1177/2325967116676241
    Brief, T. (2013). Health Policy Advisory Committee on Technology Technology Brief (Issue August). http://www.health.qld.gov.au/healthpact
20. Ridley, E. (2015). US-guided injections help ward off rotator cuff degeneration. AuntMinnie. http://www.auntminnie.com/index.aspx?sec=sup&sub=ult&pag=dis&ItemID=110012
21. Amable, P. R., Carias, R. B. V., Teixeira, M. V. T., da Cruz Pacheco, I., Corrêa do Amaral, R. J. F., Granjeiro, J. M., & Borojevic, R. (2013). Platelet-rich plasma preparation for regenerative medicine: optimization and quantification of cytokines and growth factors. Stem Cell Research & Therapy, 4(3), 67. https://doi.org/10.1186/scrt218
22. Peerbooms, J. C., Sluimer, J., Bruijn, D. J., & Gosens, T. (2010). Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: Platelet-rich plasma versus corticosteriod injection with a 1-year follow-up. Am J Sports Med, 38(2), 255–262. https://doi.org/10.1177/0363546509355445
23. Fader, R. R., Mitchell, J. J., Traub, S., Nichols, R., Roper, M., Dan, O. M., & McCarty, E. C. (2014). Platelet-rich plasma treatment improves outcomes for chronic proximal hamstring injuries in an athletic population. Muscles, Ligaments and Tendons Journal, 4(4), 461–466. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4327356&tool=pmcentrez&rendertype=abstract
24. Filardo, G., Kon, E., Roffi, A., Di Matteo, B., Merli, M. L., & Marcacci, M. (2015). Platelet-rich plasma: why intra-articular? A systematic review of preclinical studies and clinical evidence on PRP for joint degeneration. Knee Surgery, Sports Traumatology, Arthroscopy, 23(9), 2459–2474. https://doi.org/10.1007/s00167-013-2743-1
25. Tuakli-Wosornu, Y. A., Terry, A., Boachie-Adjei, K., Harrison, J. R., Gribbin, C. K., LaSalle, E. E., Nguyen, J. T., Solomon, J. L., & Lutz, G. E. (2016). Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study. PM & R : The Journal of Injury, Function, and Rehabilitation, 8(1), 1–10; quiz 10. https://doi.org/10.1016/j.pmrj.2015.08.010
26. Kececi, Y., Ozsu, S., & Bilgir, O. (2014). A cost-effective method for obtaining standard platelet-rich plasma. Wounds : A Compendium of Clinical Research and Practice, 26(8), 232–238. http://www.ncbi.nlm.nih.gov/pubmed/25860639
27. Tsikopoulos, K., Vasiliadis, H. S., & Mavridis, D. (2016). Injection therapies for plantar fasciopathy (‘plantar fasciitis’): a systematic review and network meta-analysis of 22 randomised controlled trials. British Journal of Sports Medicine, 1–10. https://doi.org/10.1136/bjsports-2015-095437
28. Gobbi, a., Karnatzikos, G., Mahajan, V., & Malchira, S. (2012). Platelet-Rich Plasma Treatment in Symptomatic Patients With Knee Osteoarthritis: Preliminary Results in a Group of Active Patients. Sports Health: A Multidisciplinary Approach, 4(2), 162–172. https://doi.org/10.1177/1941738111431801
29. Kaux, J. F., Drion, P., Croisier, J. L., & Crielaard, J. M. (2015). Tendinopathies and platelet-rich plasma (PRP): From pre-clinical experiments to therapeutic use. Journal of Stem Cells and Regenerative Medicine, 11(1), P7–P17.
30. Randelli, P., Randelli, F., Ragone, V., Menon, A., D’Ambrosi, R., Cucchi, D., Cabitza, P., & Banfi, G. (2014). Regenerative medicine in rotator cuff injuries. BioMed Research International, 2014. https://doi.org/10.1155/2014/129515
31. Schapiro, A., Health, P., Convention, A., Vista, L. B., & Prp, B. (2015). Imaging Detects Treatment Response in Epicondylosis. MEDSCAPE MEDICAL NEWS, 22–24.
32. Miller LE, Parrish WR, Roides B, et al (2017). Efficacy of platelet-rich plasma injections for symptomatic tendinopathy: systematic review and meta-analysis of randomised injection-controlled trials BMJ Open Sport & Exercise Medicine 2017;3. Open Access.
33. Napolitano, M., Matera, S., Bossio, M., Crescibene, A., Costabile, E., Almolla, J., Almolla, H., Togo, F., Giannuzzi, C., & Guido, G. (2012). Autologous platelet gel for tissue regeneration in degenerative disorders of the knee. Blood Transfusion, 10(1), 72–77. https://doi.org/10.2450/2011.0026-11
34. Jacob, G., Shetty, V., & Shetty, S. (2017). A study assessing intra-articular PRP vs PRP with HMW HA vs PRP with LMW HA in early knee osteoarthritis. Journal of Arthroscopy and Joint Surgery, 4(2), 65–71. https://doi.org/10.1016/j.jajs.2017.08.008
35. Fitzpatrick J, Bulsara MK, O’Donnell J, McCrory PR, Zheng MH. The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: A Randomized, Double-Blind Controlled Trial Comparing a Single Platelet-Rich Plasma Injection With a Single Corticosteroid Injection. Am J Sports Med. 2018 Mar;46(4):933-939. . Epub 2018 Jan 2.
    https://doi.org/10.1177%2F0363546517745525
36. Gobbi A, Lad D, Karnatzikos G. The effects of repeated intra-articular PRP injections on clinical outcomes of early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2014 Apr 20.
    https://doi.org/10.1007/s00167-014-2987-4

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For more references see also https://www.prpinjection.com.au/prp-research.html

For references re combination injection therapy see here

For references re rotator cuff and shoulder PRP see here

Yanhong Han, MD, Hetao Huang, PhD, Jianke Pan, PhD, Jiongtong Lin, MD, Lingfeng Zeng, PhD, Guihong Liang, MD, Weiyi Yang, PhD, Jun Liu, PhDAuthor Notes

Source document: Pain Medicine, Volume 20, Issue 7, July 2019, Pages 1418–1429, link: https://doi.org/10.1093/pm/pnz011

Purpose

The purpose of this meta-analysis was to compare platelet-rich plasma (PRP) and hyaluronic acid (HA) in patients with knee osteoarthritis (KOA).

Methods

Randomized controlled trials (RCTs) comparing the use of PRP and HA in KOA patients were retrieved from each database from the establishment date to April 2018. Outcome measurements were the Western Ontario and McMaster Universities Arthritis Index (WOMAC), visual analog scale (VAS), International Knee Documentation Committee, and Lequesne Index scores and adverse events. The pooled data were evaluated with Review Manager 5.3.5.

Results

Fifteen RCTs (N = 1,314) were included in our meta-analysis. The present meta-analysis indicated that PRP injections reduced pain more effectively than HA injections in patients with KOA at six and 12 months of follow-up, as evaluated by the WOMAC pain score; the VAS pain score showed a significant difference at 12 months. Moreover, better functional improvement was observed in the PRP group, as demonstrated by the WOMAC function score at three, six, and 12 months. Additionally, PRP injections did not display different adverse event rates compared with HA injections.

Conclusion

In terms of long-term pain relief and functional improvement, PRP injections might be more effective than HA injections as a treatment for KOA. The optimal dosage, the timing interval and frequency of injections, and the ideal treatment for different stages of KOA remain areas of concern for future investigations.

Fergie-Ross Montero-Cruz, DO, and Steve M. Aydin, DO.

Source: Interventional Pain Management 2018;183-188.

Link: https://www.ipmreportsjournal.com/current/pdf?article=MjE0&journal=11

BACKGROUND: Coccydynia is pain in the coccyx region. The most common cause of coccydynia is trauma, either from a direct axial force such as during a fall onto the coccyx or from cumulative trauma as a result of poor sitting mechanics. Risk factors include obesity, female gender and rapid weight loss. The anatomy of the region is not well vascularized, and consists of the coccyx bones, and supporting ligaments and tendons. For a majority of patients, conservative management may be successful but for the remainder of patients, pain relief may only be transient and pain can become debilitating. What has yet to be fully explored is the possible beneficial effect of local injection of platelet-rich plasma (PRP) for the treatment of refractory coccydynia. PRP injections have been successful in treating a variety of chronic tendon, ligament and bone injuries by inducing an inflammatory response to promote or re-initiate healing. In addition, local injections of PRP to the coccyx would be a less invasive option than surgery for patients who have exhausted all other treatment options and continue to struggle with the debilitating effects of coccydynia.

OBJECTIVES: To demonstrate the important role of PRP therapy in treating coccydynia refractory to traditional conservative management.

STUDY DESIGN: Retrospective case series.

METHODS: Three patients with coccygeal pain for greater than 6 months who presented to an outpatient pain management office in New York from 2014 until 2016, and failed conventional treatments. When the pain was deemed refractory for the patient, offering for PRP was done. This was presented with the option to repeat once again at the 6-8 week mark if needed. All patients underwent PRP with fluoroscopic injection, and the use of the same PRP commercially available system; Magellan-Arteriocyte. The patients were evaluated with a numerical rating scale, and percentage of pain relief at 6-8 week post-injection, 6 months post-injection, 12 months post-injection, and 24 months post-injection was recorded. Percentage of pain relief was then calculated.

RESULTS: Overall the patient series demonstrated significant improvement in numeric pain scale, as well as percentage of pain reduction. At the 6-8 week follow-up for all the post-PRP injections, there was an average of 75% improvement in overall pain. At 6 months, 1 patient had no change, while 2 patients maintained the same reduction in pain at the 12- and 24-month follow-ups.

LIMITATIONS: This retrospective case series is only a small sample size of patients with refractory coccydynia.

CONCLUSIONS: Here we discuss the first case series of PRP for coccydynia. The results of the 3 patients in this case series are encouraging.

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