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Comparative Effect between Infiltration of Platelet-rich Plasma and the Use of Corticosteroids in the Treatment of Knee Osteoarthritis: A Prospective and Randomized Clinical Trial

Marianna Ribeiro de Menezes Freire 1, Philippe Mota Coutinho da Silva 1, Arthur Rangel Azevedo 2, Denison Santos Silva 3, Ronald Bispo Barreto da Silva 3, Juliana Cordeiro Cardoso 3
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PMID: 33093718 PMCID: PMC7575359 DOI: 10.1016/j.rbo.2018.01.001
Abstract
Objectives This study aimed to analyze the efficacy of platelet-rich plasma obtained from the peripheral, autologous blood of the patients in pain complaints reduction and functional improvement of knee osteoarthritis compared with the standard treatment with injectable corticosteroid, such as triamcinolone. Methods The patients were followed-up clinically at the preinfiltrative visit, with quantitative evaluation using the Knee Society Score (KSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and the Kellgren and Lawrence scales. In addition, they were reevaluated with the same scales after 1 month and 6 months of intervention with 2.5 mL of triamcinolone acetate or 5 mL of platelet-rich plasma. The study was performed on 50 patients with knee osteoarthritis treated at the Medical Specialty Center and randomly divided into equivalent samples for each therapy. Results The present study verified the reduction of pain scores, such as the WOMAC score, and elevations of functional scales, such as the KSS, evidenced in 180 days when using platelet-rich plasma, a therapy that uses the autologous blood of the patient and has fewer side effects. Conclusion Although both platelet-rich plasma and corticosteroid therapies have been shown to be effective in the reduction pain complaints and functional recovery, there was a statistically significant difference between them at 180 days. According to the results obtained, platelet-rich plasma presented longer-lasting effects within 180 days in the treatment of knee osteoarthritis.

Keywords: corticosteroids; osteoarthritis; platelet-rich plasma.

The Author(s). This is an open access article published by Thieme


Arthroscopy
. 2020 Oct 19;S0749-8063(20)30843-4. doi: 10.1016/j.arthro.2020.10.013. Online ahead of print.

Intra-articular platelet-rich plasma combined with hyaluronic acid injection for knee osteoarthritis is superior to PRP or HA alone in inhibiting inflammation and improving pain and function

Zhe Xu 1, Zhixu He 2, Liping Shu 3, Xuanze Li 4, Minxian Ma 3, Chuan Ye 5
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PMID: 33091549 DOI: 10.1016/j.arthro.2020.10.013
Abstract
Purpose: The goal of this study was to evaluate the effectiveness and explore the therapeutic mechanisms of PRP combined with HA as a treatment for knee osteoarthritis (KOA).

Methods: In total, 122 knees were randomly divided into HA (34 knees), PRP (40 knees), and PRP+HA (48 knees) groups. Platelet densities in whole blood and PRP were examined using Wright-Giemsa staining. Visual Analogue Scale (VAS), Lequesne, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm scores and postoperative complications were evaluated. High-frequency color Doppler imaging was used to observe the synovium and cartilage. Enzyme-linked immunosorbent assays (ELISAs) were used to quantify interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), matrix metalloproteinase-3 (MMP-3), and tissue inhibitor of metalloproteinase-1 (TIMP-1) levels in synovial fluid.

Results: The platelet density in PRP was 5.13-times that in whole blood (P = .002). At 24 months, pain and function scores in the PRP+HA group were better than those in the HA and PRP alone groups (Ppain = .000; Pfunction = .000). At 6 and 12 months, synovial hyperplasia in the PRP and PRP+HA groups was improved (P < .05). After 6 and 12 months, the synovial peak systolic velocity (PSV), synovial end diastolic velocity (EDV), systolic/diastolic ratio (S/D) and resistance index (RI) were improved in the PRP+HA group (P < .05). Complications were highest in the PRP group (P = .008). After 6 and 12 months, IL-1β, TNF-α, MMP-3, and TIMP-1 in the PRP and PRP+HA groups decreased (P < .05), with more apparent inhibition in the PRP+HA group (P < .05).

Conclusions: PRP combined with HA is more effective than PRP or HA alone at inhibiting synovial inflammation and can effectively improve pain and function and reduce adverse reactions. Its mechanism involves changes in the synovium and cytokine content.

Copyright © 2020. Published by Elsevier Inc.
 
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Comparative Effect between Infiltration of Platelet-rich Plasma and the Use of Corticosteroids in the Treatment of Knee Osteoarthritis: A Prospective and Randomized Clinical Trial

Marianna Ribeiro de Menezes Freire 1, Philippe Mota Coutinho da Silva 1, Arthur Rangel Azevedo 2, Denison Santos Silva 3, Ronald Bispo Barreto da Silva 3, Juliana Cordeiro Cardoso 3
Affiliations expand
PMID: 33093718 PMCID: PMC7575359 DOI: 10.1016/j.rbo.2018.01.001
Abstract
Objectives This study aimed to analyze the efficacy of platelet-rich plasma obtained from the peripheral, autologous blood of the patients in pain complaints reduction and functional improvement of knee osteoarthritis compared with the standard treatment with injectable corticosteroid, such as triamcinolone. Methods The patients were followed-up clinically at the preinfiltrative visit, with quantitative evaluation using the Knee Society Score (KSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and the Kellgren and Lawrence scales. In addition, they were reevaluated with the same scales after 1 month and 6 months of intervention with 2.5 mL of triamcinolone acetate or 5 mL of platelet-rich plasma. The study was performed on 50 patients with knee osteoarthritis treated at the Medical Specialty Center and randomly divided into equivalent samples for each therapy. Results The present study verified the reduction of pain scores, such as the WOMAC score, and elevations of functional scales, such as the KSS, evidenced in 180 days when using platelet-rich plasma, a therapy that uses the autologous blood of the patient and has fewer side effects. Conclusion Although both platelet-rich plasma and corticosteroid therapies have been shown to be effective in the reduction pain complaints and functional recovery, there was a statistically significant difference between them at 180 days. According to the results obtained, platelet-rich plasma presented longer-lasting effects within 180 days in the treatment of knee osteoarthritis.

Keywords: corticosteroids; osteoarthritis; platelet-rich plasma.

The Author(s). This is an open access article published by Thieme


Arthroscopy
. 2020 Oct 19;S0749-8063(20)30843-4. doi: 10.1016/j.arthro.2020.10.013. Online ahead of print.

Intra-articular platelet-rich plasma combined with hyaluronic acid injection for knee osteoarthritis is superior to PRP or HA alone in inhibiting inflammation and improving pain and function

Zhe Xu 1, Zhixu He 2, Liping Shu 3, Xuanze Li 4, Minxian Ma 3, Chuan Ye 5
Affiliations expand
PMID: 33091549 DOI: 10.1016/j.arthro.2020.10.013
Abstract
Purpose: The goal of this study was to evaluate the effectiveness and explore the therapeutic mechanisms of PRP combined with HA as a treatment for knee osteoarthritis (KOA).

Methods: In total, 122 knees were randomly divided into HA (34 knees), PRP (40 knees), and PRP+HA (48 knees) groups. Platelet densities in whole blood and PRP were examined using Wright-Giemsa staining. Visual Analogue Scale (VAS), Lequesne, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm scores and postoperative complications were evaluated. High-frequency color Doppler imaging was used to observe the synovium and cartilage. Enzyme-linked immunosorbent assays (ELISAs) were used to quantify interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), matrix metalloproteinase-3 (MMP-3), and tissue inhibitor of metalloproteinase-1 (TIMP-1) levels in synovial fluid.

Results: The platelet density in PRP was 5.13-times that in whole blood (P = .002). At 24 months, pain and function scores in the PRP+HA group were better than those in the HA and PRP alone groups (Ppain = .000; Pfunction = .000). At 6 and 12 months, synovial hyperplasia in the PRP and PRP+HA groups was improved (P < .05). After 6 and 12 months, the synovial peak systolic velocity (PSV), synovial end diastolic velocity (EDV), systolic/diastolic ratio (S/D) and resistance index (RI) were improved in the PRP+HA group (P < .05). Complications were highest in the PRP group (P = .008). After 6 and 12 months, IL-1β, TNF-α, MMP-3, and TIMP-1 in the PRP and PRP+HA groups decreased (P < .05), with more apparent inhibition in the PRP+HA group (P < .05).

Conclusions: PRP combined with HA is more effective than PRP or HA alone at inhibiting synovial inflammation and can effectively improve pain and function and reduce adverse reactions. Its mechanism involves changes in the synovium and cytokine content.

Copyright © 2020. Published by Elsevier Inc.

Would have been nice if they had a sham arm considering we know corticosteroids cause long term harm.
 
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Platelet-rich plasma injections delay the need for knee arthroplasty: a retrospective study and survival analysis
Mikel Sánchez 1 2, Cristina Jorquera 2, Pello Sánchez 2, Maider Beitia 2, Beatriz García-Cano 1, Jorge Guadilla 1, Diego Delgado 3 4
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Abstract
Purpose: The biological action of platelet-rich plasma (PRP) could slow down the osteoarthritis progression, resulting in a delay of joint replacement. This work aims to evaluate the ability of PRP to postpone and even avoid knee replacement in patients with knee osteoarthritis (KOA) analyzing, on the one hand, the time of delay and on the other hand the percentage of patients without undergoing total knee arthroplasty (TKA).
Methods: A retrospective analysis and a survival analysis were conducted. KOA patients who underwent knee replacement between 2014 and 2019 and previously received PRP infiltrations were included in the retrospective analysis. Regarding survival analysis, KOA patients who received PRP treatment during 2014 and with follow-up until 2019 were included. The dates of PRP treatment and TKA, KOA severity, age of the patients, number of PRP cycles, and administration route were analyzed.
Results: This work included 1084 patients of which 667 met the inclusion criteria. 74.1% of the patients in the retrospective study achieved a delay in the TKA of more than 1.5 years, with a median delay of 5.3 years. The survival analysis showed that 85.7% of the patients did not undergo TKA during the five year follow-up. The severity degree, age, PRP cycles, and administration route had a statistically significant influence on the efficacy of PRP in delaying surgery.
Conclusion: These data suggest that the application of PRP in KOA patients is a treatment that could delay TKA, although further studies are needed to understand and improve this therapy.
Keywords:
Growth factors; Joint replacement; Knee osteoarthritis; Platelet-rich plasma; Total knee arthroplasty.

1603605854058.png
 
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Am J Sports Med

. 2021 Jan;49(1):249-260.
doi: 10.1177/0363546520909397. Epub 2020 Apr 17.

Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials​

John W Belk 1, Matthew J Kraeutler 2, Darby A Houck 1, Jesse A Goodrich 1, Jason L Dragoo 1, Eric C McCarty 1
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Abstract​

Background: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are 2 nonoperative treatment options for knee osteoarthritis (OA) that are supposed to provide symptomatic relief and help delay surgical intervention.
Purpose: To systematically review the literature to compare the efficacy and safety of PRP and HA injections for the treatment of knee OA.
Study design: Meta-analysis of level 1 studies.
Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 studies that compared the clinical efficacy of PRP and HA injections for knee OA. The search phrase used was platelet-rich plasma hyaluronic acid knee osteoarthritis randomized. Patients were assessed via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) scale. A subanalysis was also performed to isolate results from patients who received leukocyte-poor and leukocyte-rich PRP.
Results: A total of 18 studies (all level 1) met inclusion criteria, including 811 patients undergoing intra-articular injection with PRP (mean age, 57.6 years) and 797 patients with HA (mean age, 59.3 years). The mean follow-up was 11.1 months for both groups. Mean improvement was significantly higher in the PRP group (44.7%) than the HA group (12.6%) for WOMAC total scores (P < .01). Of 11 studies based on the VAS, 6 reported PRP patients to have significantly less pain at latest follow-up when compared with HA patients (P < .05). Of 6 studies based on the Subjective IKDC outcome score, 3 reported PRP patients to have significantly better scores at latest follow-up when compared with HA patients (P < .05). Finally, leukocyte-poor PRP was associated with significantly better Subjective IKDC scores versus leukocyte-rich PRP (P < .05).
Conclusion: Patients undergoing treatment for knee OA with PRP can be expected to experience improved clinical outcomes when compared with HA. Additionally, leukocyte-poor PRP may be a superior line of treatment for knee OA over leukocyte-rich PRP, although further studies are needed that directly compare leukocyte content in PRP injections for treatment of knee OA.
Keywords: hyaluronic acid; knee; osteoarthritis; platelet-rich plasma.


Cartilage
2021 Jan;12(1):51-61.
doi: 10.1177/1947603518805230. Epub 2018 Oct 20.

Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial​

Michael-Alexander Malahias 1 2, Leonidas Roumeliotis 1 3, Vasileios S Nikolaou 1, Efstathios Chronopoulos 1, Ioannis Sourlas 1, Georgios C Babis 1
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Abstract
Various systematic reviews have recently shown that intra-articular platelet-rich plasma (IA-PRP) can lead to symptomatic relief of knee osteoarthritis for up to 12 months. There exist limited data on its use in small joints, such as the trapeziometacarpal joint (TMJ) or carpometacarpal joint (CMCJ) of the thumb. A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the TMJ (grades: I-III according to the Eaton and Littler classification) was conducted. Group A patients (16 patients) received 2 ultrasound-guided IA-PRP injections, while group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval. Patients were evaluated prior to and at 3 and 12 months after the second injection using the visual analogue scale (VAS) 100/100, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH), and patient's subjective satisfaction. No significant differences between the baseline clinical and demographic characteristics of the 2 groups were identified. After 12 months' follow-up, the IA-PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of VAS score (P = 0.015), Q-DASH score (P = 0.025), and patients' satisfaction (P = 0.002). Corticosteroids offer short-term relief of symptoms, but IA-PRP might achieve a lasting effect of up to 12 months in the treatment of early to moderate symptomatic TMJ arthritis.

Keywords: corticosteroid injection; intra-articular injection; platelet-rich plasma; thumb carpometacarpal; trapeziometacarpal.

Clin Rheumatol
2021 Jan;40(1):263-277.
doi: 10.1007/s10067-020-05185-2. Epub 2020 Jun 12.

The effects of platelet-rich plasma injection in knee and hip osteoarthritis: a meta-analysis of randomized controlled trials​

Yujie Dong 1, Butian Zhang 2, Qi Yang 3, Jiajing Zhu 2, Xiaojie Sun 4
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Abstract​

Objective: We conducted this updated meta-analysis to evaluate the effects of PRP in patients with knee or hip OA.
Method: PubMed, Embase, and Web of Science were searched to identify randomized controlled trials (RCTs) that compared the efficacy of PRP with other intra-articular injections. The outcomes of interest included Western Ontario and McMaster (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Visual Analog Scale (VAS), Harris Hip Score (HHS), and International Knee Documentation Committee (IKDC).
Results: Twenty-four RCTs with 21 at knee OA and three at hip OA were included in this meta-analysis. The PRP injections significantly improved the WOMAC score, VAS score, IKDC score, and HHS score as compared with comparators. The WOMAC pain, stiffness, and physical function scores were also significantly better in the PRP group than in the control group. Most of the evaluated parameters that favored PRP were observed in knee OA but not in hip OA, at short-term (at 1, 2, 3, 6, 12 months) but not long-term follow-up (at 18 months), in RCTs with low risk of bias.
Conclusions: Intra-articular PRP injection provided better effects than other injections for OA patients, especially in knee OA patients, in terms of pain reduction and function improvement at short-term follow-up. Key Points • This updated meta-analysis, based on great sample size and high-quality studies, evaluates the effects of PRP in patients with knee or hip OA. • Intra-articular PRP injection provided better effects than other injections for OA patients. • Most of the evaluated parameters that favored PRP were observed in knee OA at short term (at 1, 2, 3, 6, 12 months).
Keywords: Hip osteoarthritis; Knee osteoarthritis; Platelet-rich plasma.
 
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Agast

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Are there cost-effective ways to offer PRP injections to patients? My understanding is that it is all out of pocket for them. What is the typical cash price for in office vs ASC procedures?
 
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Are there cost-effective ways to offer PRP injections to patients? My understanding is that it is all out of pocket for them. What is the typical cash price for in office vs ASC procedures?

No facility fee if done in office-based procedure room. That saves patients a ton of money. In my market a knee PRP injection is about 300% less expensive than an arthroscopy procedure and 800-1200% less expensive than a TKA. So, the economics pencil on the affordability side.

You can also offer care-credit type financing. Unfortunately, there's no group advocating for third-party insurance coverage.
 

painfree23

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Are there cost-effective ways to offer PRP injections to patients? My understanding is that it is all out of pocket for them. What is the typical cash price for in office vs ASC procedures?
Along these lines - what r typical charges?
 
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If the regen procedure (or any cash patients for that matter) needs to be done in ASC due to sedation/etc. You can usually negotiate a flat fee with the anesthesia and ASC owners. Usually not required though. When everything is cash, anything goes.
 

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$350-500 in my area. Must be 75 practices in 20 mile radius performing. Really no way to pencil it out if using a mfr kit and need to spin yourself.
 
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bedrock

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$350-500 in my area. Must be 75 practices in 20 mile radius performing. Really no way to pencil it out if using a mfr kit and need to spin yourself.
That is incredibly cheap. Likely due to competition. Many pain and ortho offering in LA, but much higher prices. Average was $1200. I was the one of the cheaper ones at $900
 

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Maybe I’m being a little cheap. 500-750 all over town. 350 for current patients in some aggressive practices. Can get MRIs for under 300 cash pay locally for reference.

there are several big names that charge more- regennex, steadman etc but they are pulling patients from out of state
 
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Maybe I’m being a little cheap. 500-750 all over town. 350 for current patients in some aggressive practices. Can get MRIs for under 300 cash pay locally for reference.

there are several big names that charge more- regennex, steadman etc but they are pulling patients from out of state
$300 for a MRI. That's a great price...
 

nvrsumr

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$300 for a MRI. That's a great price...
Competition in action. I have patients everyday that it’s cheaper to pay out of pocket then deductible for imaging.

maybe we should be careful what we wish for... sos makes me seem inexpensive option
 
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Competition in action. I have patients everyday that it’s cheaper to pay out of pocket then deductible for imaging.

maybe we should be careful what we wish for... sos makes me seem inexpensive option

How would hospitals afford to pay employed MD's without the Vig from SOS and "enterprise value" derived from downstream revenue sources?
 

nvrsumr

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Preaching to the choir.

if you charge more people think its worth more. I think there is a benefit from the sos created perceived high cost of our treatments to my biz success.
 

DOctorJay

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Network wants to charge patients $250 for PRP and give us 1.79 wRVUs
 
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Im employed, have to charge $1200 for PRP due to the blood draw placing me in the regulatory classification of a blood bank and the need for a Clia license, which I dont have in my office so I do it at the mothership’s radiology suite with lab staff. The one good thing is that that lab testing verifies that we get nearly a million platelets.

I hate that price though, and talk most people out of it. I dont think it should be more than $300-400. I had excellent results in a rectus abdominus tear that I likely did for free since by some miracle comp agreed to pay a lowball fee
 
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Im employed, have to charge $1200 for PRP due to the blood draw placing me in the regulatory classification of a blood bank and the need for a Clia license, which I dont have in my office so I do it at the mothership’s radiology suite with lab staff. The one good thing is that that lab testing verifies that we get nearly a million platelets.

I hate that price though, and talk most people out of it. I dont think it should be more than $300-400. I had excellent results in a rectus abdominus tear that I likely did for free since by some miracle comp agreed to pay a lowball fee

Wow. SOS for Regen. I think that kind of predatory pricing is going to ruin the field.
 

Doctodd

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I looked at the Regenex course for joint injections...$6,800 to get trained o_O

that sounds like everything......there are hundreds of little structures they teach you to hit. You dont need all that. The basics is pretty easy.....adipose, BMAC, and PRP. BMAC takes a few tries but it is not hard. Training your staff is probably the most difficult part.
 

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the little structures may not all need to be hit, but they need to be on the differential.

attributing all knee pain with degenerative changes to OA alone and flooding the joint space with injectate is a bit like calling all back pain DDD and performing an epidural.

your differential is only as good as your knowledge of the anatomy and pathophysiology... find a good anatomical atlas and you will realize how many structures there are you have NEVER heard about.


high quality MSK work makes doing the same B/B spine procedures look like a box of crayons in the rec room.
 
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the little structures may not all need to be hit, but they need to be on the differential.

attributing all knee pain with degenerative changes to OA alone and flooding the joint space with injectate is a bit like calling all back pain DDD and performing an epidural.

your differential is only as good as your knowledge of the anatomy and pathophysiology... find a good anatomical atlas and you will realize how many structures there are you have NEVER heard about.


high quality MSK work makes doing the same B/B spine procedures look like a box of crayons in the rec room.
On that note, does anyone have a good diagnostic ultrasound course/book/certification they can recommend?
 
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Doctodd

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the little structures may not all need to be hit, but they need to be on the differential.

attributing all knee pain with degenerative changes to OA alone and flooding the joint space with injectate is a bit like calling all back pain DDD and performing an epidural.

your differential is only as good as your knowledge of the anatomy and pathophysiology... find a good anatomical atlas and you will realize how many structures there are you have NEVER heard about.


high quality MSK work makes doing the same B/B spine procedures look like a box of crayons in the rec room.
true.....but he needs to walk before he runs. Then build on the foundation. I have some basic adipose and BMAC videos if you email me.
 
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oreosandsake

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On that note, does anyone have a good diagnostic ultrasound course/book/certification they can recommend?
Learning pattern recognition for Injections isn’t too tough. Diagnostic Msk US going to take those 10k hours... but you see a normal enough times pathology pokes you in the eye
 

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Learning pattern recognition for Injections isn’t too tough. Diagnostic Msk US going to take those 10k hours... but you see a normal enough times pathology pokes you in the eye
Bianchi and martinoli book is the Bible of diagnostic Msk US. About 600 pages. $500 too
consider buying Jacobson for $50
 
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Bianchi and martinoli book is the Bible of diagnostic Msk US. About 600 pages. $500 too
consider buying Jacobson for $50

Unless you get the trade paperback “international” version but that would be immoral and illegal and I would never suggest that you do that.
 
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Just practice on patients 😨

just kidding...sort of
 
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oreosandsake

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Unless you get the trade paperback “international” version but that would be immoral and illegal and I would never suggest that you do that.
I may have found a pdf of it once when I google searched it....
 
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If kits still cost about $200 I’m not interested. I’ve been “kit-less” for almost 10 years.

Are you able to produce the same quality “product” without a kit? Is the kit merely to make the process easier and quicker?
 
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