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Lucas J. Bader M.D. Orthopaedic Surgeon Fellowship Trained Foot & Ankle Surgeon.

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Presentation on theme: "Lucas J. Bader M.D. Orthopaedic Surgeon Fellowship Trained Foot & Ankle Surgeon."— Presentation transcript:

1 Lucas J. Bader M.D. Orthopaedic Surgeon Fellowship Trained Foot & Ankle Surgeon

2 Disclosure None

3 Goals Definition of PRP Review Basic Science Current Clinical Applications Review of the Literature Future

4 Introduction Emerging field of Biologics PRP utilized and studied since the 1970s Origins in fields of maxillofacial and general surgery

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8 Definition Platelet Rich Plasma Nonnucleated bodies in peripheral blood Autoglous blood with a concentration of platelets above a baseline value Fluid portion of blood

9 Bioactive Factors Potentially enhance healing by delivery of various growth factors and cytokines α granules Dense granules

10 α-Granules Cell proliferation Chemotaxis Cell differentiation Angiogenesis Conductive Scaffold

11 Platelet Derived Growth Factor Cell replication Angiogenesis Mitogen for fibroblasts

12 Vascular Endothelial Growth Factor Angiogenesis

13 Transforming Growth Factor-β1 Regulator in balance between fibrosis and myocyte regeneration

14 Fibroblast Growth Factor Proliferation of myoblasts, Angiogenesis

15 Epidermal Growth Factor Proliferation of mesenchymal and epithelial cells

16 Hepatocyte Growth Factor Angiogenesis, Mitogen for endothelial cells Antifibrotic

17 Insulin-like growth factor-1 Stimulates myoblasts/fibroblasts Mediates growth/repair skeletal muscle

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19 Adhesive Proteins Fibrinogen Fibronectin Vitronectin scaffold

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21 Dense Granules Non-Growth Bioactive Molecules Fundamental effect on the biologic aspects of inflammation Cell migration Conductive Matrix

22 Serotonin & Histamine Increase capillary permeability Inflammatory cell access Macrophage Activation

23 Adenosine Receptor Activation Modulates inflammation

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25 Advantage Normal biologic ratios vs Exogenous Factors

26 Formulation of PRP Can only be made from anticoagulated blood Cannot be made form clotted whole blood Cannot be made from serum

27 Preparation cc Drawn Add citrate to bind ionized calcium and prohibit clotting cascade

28 Centrifugation Step 1 Red blood cells Leukocytes Platelets Step 2 Platelet-Poor Portion Platelet-Rich Portion

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30 Activating Agents Calcium Chloride and/or Thrombin (OR) Collagen (Office) Initiates Platelet activation Clot formation Growth Factor Release

31 70 % within 10 minutes Nearly 100% within 1 hr

32 PRP Preparations Systems Several Available Qualitative and Quantitative Variability Volume of autologous blood Centrifuge rate/time Delivery Method Activating Agent Leukocyte concentration (?) Final PRP volume Final Platelet and Growth Factor Concentration

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34 Safety Concerns Autologous Blood Aseptic technique Relative Contraindications Hx of thrombocytopenia Anticoagulant therapy Active infection Tumor Metastatic Disease

35 Cost $150-$180 small kits $200 large Kits Centrifuge $1800 PRP is currently considered experimental and is not reimbursed by most third party payers

36 Effects of PRP on Soft Tissues & Bone- Basic Science 3 phases of healing Inflammation Proliferation Remodeling Basic Metabolic Processes Proliferation Chemotaxis Angiogenesis Differentiation EC Matrix Production

37 Effects PRP on Tendon Collagen gene expression Vascular endothelial growth factor Hepatocyte growth factor Matrix Metalloproteinase Tendon strength and callus formation Cell formation and angiogenesis

38 Effects PRP on Muscle IGF-1 & basic FGF improve healing and increase fast twitch and tetanus strength Accelerated satellite cell activation Increased diameter of regenerating myofibrils

39 Effects PRP on Bone Stimulate Osteoblasts Stmulate Fibroblasts Up regulate Osteoclacin Encourage differentiation of MSC into bone forming cells

40 Further Study Acute injury Chronic injury Timing of injection Effect of serial injections

41 Orthopaedic Applications for PRP Chronic Tendinopathies Bone healing Acute Ligamentous Injuries Muscle injuries Intraoperative Augmentation

42 Chronic Tendinopathy Lateral/medial Epicondylitis Achilles Tendinopathy Patellar Tendinopathy Posterior Tibial Tendinopathy Plantar Fasciitis

43 Bone Healing Fracture Healing Distraction Osteogenesis Osteoarthritis

44 Acute Ligamentous Injury Knee medial collateral ligament Ankle syndesmosis Ankle lateral ligament complex

45 Intraoperative Use Total Knee arthroplasty ACL reconstruction Achilles Tendon Repair Rotator Cuff Repair Acute Articular Cartilage Repair

46 Review of the literature Numerous basic science, animal studies, and small case reports Few controlled clinical studies Majority of studies are small, anecdotal, and underpowered Non-standardized techniques

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48 Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-Year Follow- Up. Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Gosens TPeerbooms JCvan Laar Wden Oudsten BL Randomized controlled trial; Level 1 of evidence PRP group (n = 51) or the corticosteroid group (n = 49) PRP group was more often successfully treated than the corticosteroid group (P <.0001). Success was defined as a reduction of 25% on VAS or DASH scores without a re-intervention after 2 years.

49 Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy A Randomized Controlled Trial Robert J. de Vos, MD; Adam Weir, MBBS; Hans T. M. van Schie, DVM, PhD; Sita M. A. Bierma-Zeinstra, PhD; Jan A. N. Verhaar, MD, PhD; Harrie Weinans, PhD; Johannes L. Tol, MD, PhD Robert J. de Vos, MD; Adam Weir, MBBS; Hans T. M. van Schie, DVM, PhD; Sita M. A. Bierma-Zeinstra, PhD; Jan A. N. Verhaar, MD, PhD; Harrie Weinans, PhD; Johannes L. Tol, MD, PhD Eccentric exercises (usual care) with either a PRP injection (PRP group) or saline injection (placebo group) PRP group (n = 27) or placebo group (n = 27) The mean VISA-A score improved significantly after 24 weeks in the PRP group and in the placebo group, but the increase was not significantly different between both groups

50 Platelet-rich Fibrin Matrix in Arthroscopic Rotator Cuff Repair: A Prospective, Randomized Study Stephen C Weber, MD Sacramento CA Jeffrey I Kauffman, MD Sacramento CA Sample size of 30 patients in each group Serial VAS scores were obtained, as well as SST scores at each interval. Final scores for each group included UCLA and ASES scores. Early follow-up does not show significant improvement in perioperative pain or clinical outcome.

51 Platelet Rich Plasma (PRP) Effectively Treats Chronic Achilles Tendonosis Raymond R Monto, MD Prospective study of thirty patients No controls AOFAS scores improved to 92 at 6 months. Resolution of Achilles abnormalities were seen in post treatment MRI/ultrasound studies and 28/30 were clinically satisfied with their clinical results.

52 Literature Summary Greatest support in treating tendinopathy Lateral Epicondylitis Patellar Tendinopathy Achilles Tendinopathy Plantar Fasciitis Caution with Acute Injuries Risk of Fibrosis Return to activity too early

53 Future PRP promising, but not proven Appropriately powered studies Sophisticated models of healing More precise formulations of PRP Narrower indications, but more definitive

54 My Protocol Treatment of last resort prior to surgery Indicated for chronic tendinopathies Performed under ultrasound guidance NSAIDS discontinuation 1 week prior and 2 weeks post procedure Activity modification for 7 days

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56 Thanks!


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