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Platelet Rich Plasma and ozone

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1 Platelet Rich Plasma and ozone
Adam Weglein,DO, DABMA,CAQ Founder: Regenerative Ortho Med Platelet Rich Plasma and ozone

2 Objectives Discuss the basic science of wound healing as it relates to PRP Review some current evidence based literature on PRP Ozone treatments with PRP

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4 Brazil Regenerative Orthopedic conference 2012
Ozone in orthopedics

5 Tissue healing Tissue heals through a immune cell mediated response that is regulated by tissue growth factors which are held in platelets PRP- is the idea of increasing the concentration of healing factors in tissue like tendons, ligaments and cartilage to help enhance healing.

6 Platelet Rich Plasma Definition: 200,000 Platelets/ micoliter( Red Cross

7 Why PRP The idea of promoting a natural healing response
Very good safety profile Simple and easy to set up Ability to implement in clinic setting Over 6,000 studies on Pubmed

8 My exposure to PRP I was introduced to prolo/ PRP during my sports medicine fellowship at South Pointe, Cleveland Clinic. Assistant Clinical Professor University of Texas Houston Medical School Certified Regenerative Injection Techniques, AAOM Founder: The Regenerative Ortho Med Institute( specializing in PRP, BMAC, prolo)

9 PRP background Started in 1980s H. Ward- stealers-
Knee MCLsuperbowl XLIII

10 PRP Ideal concentration?? Good question! Most 3-8 times baseline
Upper threshold of benefit Studies indicate that inhibition above 10ng/mL (Kevy Harvard) work indicates above 5 million seeing drop off in neovascular benefit Needs research for case and age of patient

11 PRP mechanism of action
PRP- provides growth factors->neovascularization PRP caused up regulation of local GFs TGF-Beta1 for 1st week post prp, increased IGF-1 for 4 weeks tenocytes post prp

12 Platelets Circulate for 7-10 days
Contain 800 proteins with 1,500 bio active factors Growth factors, peptide hormones, chemoattractants- macs, neutrophils, stem cells

13 Platelet Activation Collagen Serotonin PAF- platelet Activating factor
Calcium Mag In vitro- bone material- osteocondral scaffold Platelets release- + feedback loop Thromboxane A2 ADP Thrombin Decreased in PRP Caffine propofol

14 Platelet Activation Activated platelets
Cytoskeleton restructure- filopodia Degranulation Large initial burst of GF Anti- inflammatory cytokine hepatcyte GF( inhibit NF kappa B, and IL -1)

15 Factors affecting PRP platelet count
Centrifuge system used Starting whole blood Hematocrit- product. Hydration status Inflammatory status Lipemia-diet increased platelets Testosterone level

16 Pre PRP Ideal world a pre PRP CBC should be done along with PRP sample to ensure platelet concentration Very Important for research studies May consider if patient fails first PRP treatment MRI or ultrasound for diagnostic

17 PRP subtypes ?? Yes indeed.
WBC rich PRP WBC poor PRP Activated PRP Non activated PRP RBC rich PRP RBC poor PRP PRP- Prolo PRP-ozone PRP-BMAC

18 WBC poor PRP Presence of WBCs in prp can lead to catabolic breakdown of tissue and negative affect of matrix synthesis in tendons( Mcmarrel/ Foster et al.) Thought to be beneficial for muscle Still controversy More studies needed??

19 WBC rich PRP In high concentrations respiratory burst can cause tissue damage, mmp 2,9,13,15, IL-1, IL-6 chondro toxic Block GAGs in Hyaluronan Monocytes- TGF-B, VEGF, bFGF- suppress inflammation- necessary for healing tissue Macrophages are essential to in vivo healing Essential for ligamentous tissue debridement for ligament healing. Used for large dermal area with concern of infection

20 RBC- PRP Low concentration in general in prp Carry O2
Fe -> free radicals and tissue destruction apoptosis Best to use lower Hct level Ask your Centrifuge Rep HCT level?

21 Platelet derived growth factor (PDGF) Transforming growth factor (TGF)
Alpha Granules Platelet derived growth factor (PDGF) Transforming growth factor (TGF) Epidermal growth factor (EGF) Vascular endothelial growth factor (VEGF) Fibroblast growth factor (FGF) Connective tissue growth factor (CTGF) Dense Granules Serotonin ADP Histamine Calcium Mag Lamda granules Remove infection Plasminogen- fracture repair

22 Platelet Growth Factor Overview
PRP-GF Platelet Derived Growth Factor (PDGF) Powerful chemoattractant- stem cells Cell proliferation – osteoblasts ( Marko poulou et al.) Angiogenesis Transforming Growth Factor – Beta (TGF-B) Plays a major role in matrix formation and healing, chondrogenesis. Orthop Relat Res 2001;391(suppl):S171–81

23 PRP growth factors Epidermal Growth Factor (EGF) Linked to angiogenesis and collagen deposition at wound sites. Shown to stimulate wound repair in fibroblasts and epithelial cells.

24 PRP growth factor overview
Vascular Endothelial Growth Factor (VEGF) Stimulates endothelial growth and angiogenesis Fibroblast Growth Factor (FGF) Family of growth factors involved in angiogenesis, wound healing

25 Plasma growth factors PPP
IGF-1 stored in Plasma 679 proteins( albumin, Ig, complement, CF) Fibronectin, vitronectin- induce chemotaxis of stem cells, fibroblasts, osteoblasts. Calcium- activation of PRP and contractile myofibroblasts- in vitro Human growth hormone

26 PPP IGF-1 Improve healing in equine tendon
Improve healing in cartilage Being used in hydro dissection of nerves as filler to form bio scaffold, cosmetics and MMT Neurol Res Mar;26(2): The multifunctional role of IGF-1 in peripheral nerve regeneration.Rabinovsky ED.SourceMichael E. DeBakey

27 Phases of wound healing

28 Target tissue Ligament Tendon Inside the joint Nerve Muscle

29 PRP-Platelet Rich Plasma
Involves taking patients own blood about 20cc-180cc then spinning down to Platelet Rich portion Then identify target under MSK ultrasound 1% lido, sterile prep Then inject PRP Post injection physical therapy

30 Clinical indications Acute muscle, Tendon, ligament injury
Chronic tendonosis/ ligament injury Chronic Spine disorders ( facet, SIJ) Osteoarthritis Intra operative use as surgical adjunct to tissue healing

31 PRP- joints

32 Angel® Whole Blood Separation
Cytomedix™ Corporation PRP = Platelet Concentrate (1X-18X) PPP = Fibrin Sealant PRP + PPP = Platelet Enriched Fibrin Sealant Transfusable pRBCs Bone marrow aspirate processing

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36 Platelet Sensor System
The Angel System integrates LED lasers and detectors to specifically detect and distinguish oxyhemoglobin (red cells), platelets and leukocytes. Using this detection platform the Angel will produce a highly concentrated platelet sample that can range from 7X to greater than 18X of that found in the patients input sample. The concentration will vary dependent on the size of the sample processed as well as the distribution of platelet size and density in the individual patient.

37 PRP Sample Volume and Platelet Concentration
Patient Specific Application The table above is intended to guide appropriate dilution of the platelet concentrate to achieve a wide range of desired platelet concentrations.

38 PRP in muscle Sanchez M, et al; “Application of Autologous Growth Factors on Skeletal Muscle Healing”, World Congress on Regenerative Medicine Podium Presentation, May 18, 2005 Study: 20 patient prospective muscle injury pilot study with 6 month follow-up – Ultrasound guided injection of PRP within the injured muscle enhanced healing (echo-graphic images) and functional capacities 50% faster than the control group.

39 PRP Tendon Mishra A, Pafelko T, Coetzee; “Treatment of Chronic Severe Elbow Tendinosis with PRP”, American Journal of Sports Medicine, 34: , 2006 Study: 140 patients-> 15 months of rehab- conservative tx 20 patients were randomized to evaluate effectiveness of PRP –VS. bupiv 1,2, and 6 months all PRP patients had lower pain and greater ROM Conclusion: Treatment of chronic epicondylar pain with PRP should be considered prior to surgical intervention.

40 PRP Tendon 100 patients randomized steroid vs prp VAS/dash
Gosens, Peerbooms, et al. American Journal of Sports Medicine 2011 Randomized controlled trial; Level of evidence, 1 100 patients randomized steroid vs prp VAS/dash At 2 years cortisone dash went to baseline unlike prp

41 PRP-tendon Gosens two year follow up on tennis elblow Cortisone vs PRP
Results TREATMENT OF PATIENTS WITH CHRONIC LATERAL EPICONDYLITIS WITH PRP REDUCES PAIN AND INCREASES FUNCTION SIGNIFICANTLY, EXCEEDING THE EFFECT OF CORTICOSTEROID INJECTION EVEN AFTER A FOLLOW-UP OF 2 YEARS Gosens, Peerbooms, et al. American Journal of Sports Medicine 2011

42 Platelet-Rich Plasma or Hyaluronate in the Management of Osteochondral Lesions of the Talus, Omer Mei-Dan et al. OCL talus PRP vs HA Randomized ( level 2) 32 patients (18-60 age) 3 injections Follow at 28 weeks American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHFS); a visual analog scale (VAS) for pain OCL lesions of the ankle treated with intra-articular injections of PRP and HA resulted in a decrease in pain scores and an increase in function for at least 6 months. Platelet-rich plasma treatment led to a significantly better outcome than HA.

43 Osteoarthritis Have treated OA with PRP in most joints in the body Hip
Knee Ankle Finger Spine SI joint Shoulder

44 OA PRP Mild to moderate OA
Frequency of treatments is done on a case by case Mild OA often need only one PRP Moderate OA may take up to 3 PRP done at two week to monthly intervals Often combined with HA injections

45 Early OA PRP research Hunziker et al. TGF-B promotes chondrogenesis. Orthop Relat Res 2001;391(suppl):S171–81 Full Thickness cartilage defects in rabbits demonstrated better mechanical properties (Cugot 06).␣ Frisbie, et al. Clinical biochemical and histological effects of intra-articular administration of autologous conditioned serum in horses with experimentally induced osteoarthritis. Am J Vet Res. 2007;68(3):

46 PRP OA 2007 International cartilage repair society meeting Warsaw:
PR- amplification of chondrocyte proliferation with convincing clinical effects on degenerative knee OA. (Konet al)- PRP encouraged chondrogenesis with an injectable scaffold while seeded with chondrocytes in rabbit ears. (Wu et al 2007).

47 Observational, retrospective cohort study.␣
Sanchez, Anitua et al Clinical trial to evaluate intra-articular PRP vs hyaluron for knee OA Sanchez, Anitua et al Clinical trial to evaluate intra-articular PRP vs hyaluron for knee OA Observational, retrospective cohort study.␣ 60 patients, 3 weekly injections. (30 PRP 30 HA At week 5, 33% of PRP group improved vs 10% of hyaluronan group

48 PRP OA Kon, et al. 2009: PRP in 115 arthritic knees ›
Notable improvement in functional and pain scores which remained positive at 6 mos.› Mild degradation of the scores at 1 year› Better outcome in lower grades of arthritis and younger patients

49 Demonstrated consistent anti-inflammatory effects of PRP
Demonstrated consistent anti-inflammatory effects of PRP . Am J Sports Med November ; published online before print August 19, 2011, Gerben et al. Prior studies have demonstrated anabolic effect of PRP on chondrocyte cells inducing proliferation. ␣ Demonstrated consistent anti-inflammatory effects of PRP.␣ Counteracts the catabolic environment and inflammatory response by inhibiting IL-1 beta mediated effects on human osteoarthritic chondrocytes.␣ Inhibits Nuclear factor kappa B activation (Key in OA pathogenesis) Similar to NSAIDs, Glucocorticoids and proteasome

50 PRP-increased hyaluronic Acid
PRP increased hyaluronic acid concentration, stabilizing angiogenesis in ten patients with osteoarthritic knees Anitua E, Sanchez M, Nurden AT, et al: Platelet-released growth factors enhance the secretion of hyaluronic acid and induce hepatocyte growth factor production by synovial fibroblasts from arthritic patients. Rheumatology 2007;46:1769–72

51 IOC consensus paper on the use of platelet rich plasma in sports medicine
Br J Sports Med 2010:44: Slide courtesy of Joanne Borg-Stein, MD “….proceed with caution in the use of PRP in athletic sporting injuries. We believe more work on the basic science needs to be undertaken….” WADA: Intramuscular injections prohibited until 2011, when approved All other routes of administration, such as intra-articular, intra-or peritendinous are permitted and require a declaration of use. Isolated growth factors are prohibited: IGF-1, VEGF, PDGF

52 Ozone research growth factors
Therapeutic Effects of Topical Application of Ozone on Acute Cutaneous Wound Healing-J Korean Med Sci June; 24(3): 368–374 upregulation of platelet derived growth factor (PDGF), (TGF-β) and (VEGF) expressions, but not fibroblast growth factor expression in the ozone group on day 7

53 Ozone with PRP Bocci et al Ca chelated platelets in PRP insensitive to ozone IOA 13th ozone world congress 1997 pretreatment of PRP with ozone inhibited aggregation ROS- activate platelets

54 There is much that we don’t know
Frequency Combining HA with PRP at same time vs separate injections( pending publication in Singapore very positive) Interaction with other modalities? Case studies show better affect with combined tradition Prolo/ NPT and PRP/ stem cells. Exciting times ahead!!!

55 Putting it all together
I have used ozone in combination with a number of refractory PRP OA Pts in joints with outstanding results. I have found that the addition of PRP to ozone to be better than Ozone in patient reported outcomes at 6 weeks post injection

56 Thank you


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