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
Safety Concerns Autologous Blood Aseptic technique Relative Contraindications Hx of thrombocytopenia Anticoagulant therapy Active infection Tumor Metastatic Disease
Cost $150-$180 small kits $200 large Kits Centrifuge $1800 PRP is currently considered experimental and is not reimbursed by most third party payers
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
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
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
Effects PRP on Bone Stimulate Osteoblasts Stmulate Fibroblasts Up regulate Osteoclacin Encourage differentiation of MSC into bone forming cells
Further Study Acute injury Chronic injury Timing of injection Effect of serial injections
Orthopaedic Applications for PRP Chronic Tendinopathies Bone healing Acute Ligamentous Injuries Muscle injuries Intraoperative Augmentation
Intraoperative Use Total Knee arthroplasty ACL reconstruction Achilles Tendon Repair Rotator Cuff Repair Acute Articular Cartilage Repair
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
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.
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
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.
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.
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
Future PRP promising, but not proven Appropriately powered studies Sophisticated models of healing More precise formulations of PRP Narrower indications, but more definitive
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