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1 Platelet Rich Plasma copyrights:oibconsultantsinc 1

2 Circulation – Blood Vessel copyrights:oibconsultantsinc2

3 What is PRP? PRP stands for Platelet Rich Plasma Blood houses all cellular components – Red blood cells – White blood cells – Platelets – Plasma Platelets – Naturally make up only 10% of our blood’s cellular components In PRP – Platelet ratio is flipped to 90% platelets copyrights:oibconsultantsinc 3

4 PRP Tissue graft Autologous growth factors and/or autologous undifferentiated cells Cellular matrix Receptor site and tissue of regeneration copyrights:oibconsultantsinc 4

5 Platelet RBC/WBC copyrights:oibconsultantsinc 5

6 What is PRP Therapy? PRP is – Non-surgical healing treatment – Used in many fields Sports medicine Orthopedics Cosmetic – hair growth PRP is injected into affected region – Stimulate & enhance healing PRP is your own blood – Mega doses of body’s own healing “ingredients” Stored in platelets Growth Factors copyrights:oibconsultantsinc 6

7 What Conditions Are Treated With PRP? Most responsive to PRP – Soft tissue injuries Tendonitis Tendinosis Tendon tears Ligament sprains or tears Loose ligaments Muscle tears Also effective in treating – Cartilage degeneration Arthritis – Ligament tears in joints copyrights:oibconsultantsinc 7

8 What are the Benefits of PRP? Benefits of PRP – Thought to rely on Intrinsic platelet properties Concentrated growth factors copyrights:oibconsultantsinc 8 Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med 2009; 37: Wroblewski AP, Melia HJ, Wright VJ. Application of platelet-rich plasma to enhance tissue repair. Oper Tech Orthop 2010; 20: Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85: Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich fibrin (P-PRP) to leucocyte and plate- rich fibrin (L_PRF). Trends Biotechnol 2009; 27:

9 PRP Platelet Rich Plasma – First used in cardiac surgery by Ferrari et al in 1987 Autologous transfusion component after open heart surgery Used successfully in various specialties – Maxillofacial – Cosmetic + hair – Spine – Orthopedic – Podiatric – General wound healing – Sports injury copyrights:oibconsultantsinc 9 Ferrari M, Zia S, Valbonesi M, et al. A new technique for hemodilution, preparation of autologous platelet-rich plasma and intraoperative blood salvage in cardiac surgery. Int J Artif Org. 1987; 10: Gamradt Seth C, et al. Platelet Rich Plasma in Rotator Cuff Repair. Techniques in Orthopaedics. 22(1): Everts PAM, Knape JTA, Weibrich G, Schonberger JPAM, Hoffmann JJHL, Overdevest EP, Box HAM, and van Zundert A. Platelet- Rich Plasma and Platelet Gel: A Review. JECT. 2006; 38:

10 Professional Athletes Tiger Woods – Received PRP injections in left knee L.A. Dodger’s pitcher, Takashi Saito – Returned to mound for 2008 playoffs as result of PRP therapy Elite athletes – 35-40% have chronic tendonosis copyrights:oibconsultantsinc 10

11 Hines Ward copyrights:oibconsultantsinc 11

12 Troy Polamulu copyrights:oibconsultantsinc 12

13 Introduction PRP To Injury 1m 58s TV News copyrights:oibconsultantsinc13

14 Common Diagnoses Treated With PRP Shoulder – Rotator cuff tendinitis or tear – Rotator cuff impingement syndrome or bursitis – Bicipital tendinitis – Arthritis – Instability Elbow/Wrist/Hand – Tennis elbow – Golfer’s elbow – DeQuervaine’s Tenosynovitis – Trigger finger – Arthritis – Other wrist or finger tendonitis Hip – Iliotibial band tendinitis (ITB Syndrome) – Psoas tendinitis and bursitis – Greater trochanteric bursitis – Labrum tears – Arthritis – Sacroiliac joint dysfunction copyrights:oibconsultantsinc 14

15 Common Diagnoses Treated With PRP Knee – Patellar tendinitis – Partially torn or strained major ligaments of knee ACL LCL MCL – Meniscus tears – Chondromalacia – Arthritis – Instability Ankle – Achilles tendinitis – Peroneal tendinitis – Ankle sprain – Instability – Other foot or ankle tendinitis Spine – Whiplash injury – Ligament sprain – Instability – Rib problems – Arthritis Foot – Plantar Fasciitis – Heel pain – Metatarsalgia – Tendinitis – Joint pain – Sinus tarsi copyrights:oibconsultantsinc 15

16 PRP Used To Treat Platelet Rich Plasma grafting techniques – Musculoskeletal medicine Increasing effectiveness Soft tissue injuries treated with PRP include – Tendopathy – Tendonosis – Acute & chronic muscle strain – Muscle fibrosis – Ligamentous sprains – Joint capsular laxity – All sports injuries copyrights:oibconsultantsinc 16

17 Matrix copyrights:oibconsultantsinc 17

18 PRP Used to Treat Musculoskeletal injuries – Over 100 million office visits yearly Stronger bones Regenerate muscle & tendon Increase vascularity Distance runners – 52% suffer injury to Achilles tendon during lifetime copyrights:oibconsultantsinc 18 Mishra A, et al. Treatment of Chronic Elbow Tendinosis with Buffered Platelet-Rich Plasma: American Journal of Sports Medicine. 2006; 34: Zafar MS, et al. Basic science and clinical aspects of achilles tendenopathy. Sports Med. Arthro 2009: 17(3).

19 Effectiveness of PRP American Journal of Sports Medicine (2006) – Reviewed effectiveness of PRP 15 patients with chronic elbow pain – 60% improvement at 8 weeks – 81% improvement at 6 months – 93% improvement at final follow-up (12-38 months) – No side effects or complications reported copyrights:oibconsultantsinc 19

20 Everts On reviewing 21 human studies – Positive outcome – Found seven showed either no benefit or negative effects of PRP – Several had platelet portions that had been activated prior to use via differing means copyrights:oibconsultantsinc 20 Everts PAM, Knape JTA, Weibrich G, Schonberger JPAM, Hoffmann JJHL, Overdevest EP, Box HAM, and van Zundert A. Platelet-Rich Plasma and Platelet Gel: A Review. JECT. 2006; 38:

21 Standardizing the Nomenclature for PRP PRP synonyms – Platelet leukocyte gel – Platelet rich plasma gel – Platelet concentrate – Blood plasma therapy Therapeutic effectiveness factors for success – Concentrations of platelets – Nucleated cells – Growth factors – Fibrin – Platelet activation at the site Along with skillful percutaneous injection & surgical techniques result in – Effectiveness of therapy copyrights:oibconsultantsinc 21 Everts PA, Jakimowicz JJ, van Beek M, Schonberger JP, Devilee RJ, Overdevest EP, Knape JT, and van Zundert A. Reviewing the Structural Features of Autologous Platelet- Leukocyte Gel and Suggestions for Use in Surgery. Eur Surg Res. 2007; 39:

22 Delivery of PRP Delivery of PRP without exogenous activator – Commonly performed – Evidence demonstrating platelets can be slowly activated Exposure to tendon-derived collagen alone copyrights:oibconsultantsinc 22 Mishra A, Pavelko T: Treatment of chronic elbow tendinosis with buffered platelet rich plasma. Am J Sports Med 2006; 34: Fufa D, Shealy B, Jacobson M, Kevy S, Murray MM: Activation of platelet-rich plasma using soluble type I collage. J Oral Maxillofac Surg 2008; 66:

23 Surgical Applications For surgical applications – PRP commonly treated with Calcium chloride or Gluconate Thrombin – Allowing formation of putty or gel-like clot – Applied or sutured at surgical site copyrights:oibconsultantsinc 23 Gamradt SC, Rodeo SA, Warren RF: Platelet rich plasma in rotator cuff repair. Tech Orthop Surg 2007; 22: Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Mujika I: Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med 2007; 35:

24 How Does PRP Work To Heal? Growth Factors are released from large quantities of activated platelets at site of injury – Induced inflammatory reaction Initiates powerful effective healing cascade Growth Factors – Stimulate blood flow – Promote matrix formation “Groundwork” of all soft tissue – Restore tendon & ligamentous proteins – “Toughen up” cartilage More firm & resilient copyrights:oibconsultantsinc 24

25 Is PRP Painful? Patients tolerate procedure well – Post-injection soreness is expected PRP-induced inflammatory response – Up to 10 days copyrights:oibconsultantsinc 25

26 PRP Gel (Pre/Post) PRP that is activated with – Autologous thrombin Bovine thrombin – Thrombin alone – Calcium Chloride & Gluconate Depend on tissue treated (i.e., ulcer) – I use Autologous PRP gel – Use of autologous thrombin copyrights:oibconsultantsinc 26

27 Hesham El-Sharkawy et al… Measured – Platelet derived growth factor (PDGF)- AB – PDGF-BB – Transforming growth factor-b1 – Insulin-like growth factor-I – Fibroblast growth factor-basic (FGF-b) – Epidermal growth factor (EGF) – Vascular endothelial growth factor – Interleukin-12 (p40/70) Regulated on activation – Normal T-cell expressed & secreted (RANTES) levels By enzyme-linked immunosorbent assay Analyzed – Cytokine – Chemokine – LXA4 levels – Monocyte chemotactic migration PRP led to significantly increased levels of growth factors – Significantly suppressed inflammation By promoting secretion of LXA4 copyrights:oibconsultantsinc 27 Hesham El-Sharkawy et al. Platelet-Rich Plasma: Growth Factors and Pro- and Anti-Inflammatory Properties. J Periodontol. April 2007; 78:

28 Platelet Biology Hematology Slide copyrights:oibconsultantsinc 28

29 Platelets Platelets contain two unique types of granules 1.α -granules Contain variety of – Hemostatic proteins (coagulation) – Growth factors – Cytokines – Chemokines (pro-inflammation) – Adhesion proteins Three important adhesion molecules & seven growth factors 2.Dense granules Contain factors that promote platelet aggregation copyrights:oibconsultantsinc 29 Ibelgaufts, Horst. COPE: Cytokines & Cells Online Pathfinder Encyclopaedia Version 19.4 (April 2007). okines.de/. Last accessed 12/09/07. okines.de/

30 Platelet Granules copyrights:oibconsultantsinc 30

31 Growth Factors Interactions of growth & differentiation factors – Along with adhesive protein factors Fibronectin Vitronectin – Responsible for healing response – Promoting long regenerative process of » Chemotaxis » Cell proliferation » Removal of tissue debris » Angiogenesis » Extra-cellular matrix formation » Osteoid production » Collagen synthesis copyrights:oibconsultantsinc 31 Wroblewski AP, Melia HJ, Wright VJ. Application of platelet-rich plasma to enhance tissue repair. Oper Tech Orthop 2010; 20: Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85: Cieslik-Bielecka A, Bielecki T, Gazdzik TS, Arendt J, Krol W, Szczepanski T. Autologous platelets and leukocytes can improve healing of infected high- energy soft tissue injury. Transfus Apheresis Sci 2009; 41: Griffin XL, Smith CM, Costa ML. The clinical use of platelet-rich plasma in the promotiion of bone healing: a systematic review. Injury 2009; 40:

32 White Blood Cells in PRP White blood cells are a source of vascular endothelial growth factor (VEGF) VEGF is a potent stimulator of angiogenesis copyrights:oibconsultantsinc 32

33 Growth Factors Some important growth factors include – Platelet-derived endothelial growth factor – Transforming growth factor- β – Vascular endothelial growth factor – Fibroblast growth factor – Epidermal growth factor – Insulin-like growth factor-1 copyrights:oibconsultantsinc 33 Marx RE, Carlson ER, Eichstaedt R, et al: Platelet rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 85: 638, Kevy S, Jacobson M: Preparation of growth factors enriched autologous platelet gel. Proceedings of the 27 th Annual Meeting of Service Biomaterials, April 2001.

34 Various Growth Factors in PRP copyrights:oibconsultantsinc 34

35 Growth Factor Yields Per Device copyrights:oibconsultantsinc 35 *Clinaseal Sealed Technology Centrifuge; Salvin Dental Specialties Inc, Charlotte, NC. **ACE Surgical, Brockton, MA. ***AG Curasan, Kleinostheim, Germany. Slater M, Patava J, Kingham K, et al: Involvement of platelets in stimulating osteogenic activity. J Orthop Res 13: 655, Anitua E: The use of plasma rich growth factors (PRGF) in oral surgery. Pract Proced Aesthet Dent 13: 487, 2001.

36 Centrifuge Methods Different types of centrifuge methods – Gravitational platelet sequestration technique Requires only tabletop centrifuge system Centrifuge systems – May differ in ability to separate RBCs from platelets Affecting concentration – Separating leukocytes from platelets – Shearing platelets during centrifugation process Leading to premature platelet activation and degranulation copyrights:oibconsultantsinc 36 Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med 2009; 37: Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P-P’RP) to leucocyte and platelet-rich ribrin (L-PRF). Trends Biotechnol 2009; 27:

37 Centrifugation Separates whole blood into three layers – RBCs Bottom layer Specific gravity = 1.09 – Platelet-poor plasma Top layer Specific gravity = 1.03 – Platelet concentrate that contains WBCs Middle layer Specific gravity = 1.06 copyrights:oibconsultantsinc 37 Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P-P’RP) to leucocyte and platelet-rich ribrin (L- PRF). Trends Biotechnol 2009; 27:

38 Segmentation of Blood copyrights:oibconsultantsinc 38

39 Centrifugation Centrifugation process must be – Sterile – Precisely suited to platelet separation from red blood cells & their sequestration in high concentrations Without lysing the platelets or damaging them so that they can no longer actively secrete their growth factors Not all currently marketed PRP devices are equal copyrights:oibconsultantsinc 39

40 Predictability Technology – Revolutionary, self-calibrating, floating shelf technology automatically optimizes platelet recovery for every patient Flexibility – System can process as little as 20 cc of whole blood for smaller applications Larger volumes when needed copyrights:oibconsultantsinc 40

41 copyrights:oibconsultantsinc 41

42 Dr. Tai Laboratory PRP Separation 9m 49s PRP Video copyrights:oibconsultantsinc42

43 Blood Prep and Separation 3m 23s PRP Video copyrights:oibconsultantsinc43

44 Predictability Speed – Produces autologous platelet concentrate in a fraction of the time Less than 15 minutes Confidence – First & only system FDA cleared for preparation of APC May help – Improve handling characteristics of graft material – Facilitate fixation of graft material to surgical site – Help optimize conditions for healing copyrights:oibconsultantsinc 44

45 Reliability Automation – Unique automated dual-spin & decanting process coupled with self-calibrating disposables Significantly easier to use than any more complex, time consuming, operator dependent systems Consistency – Floating shelf technology ensures optimal results independent of Patient hematocrit Blood volume processed Operator copyrights:oibconsultantsinc 45

46 PRP Platelet Concentration Whole blood specimen PRP specimen copyrights:oibconsultantsinc 46

47 APC + ® Procedure Packs APC-20 – Provides 3 ml of APC + for small applications APC-60 – Provides ml of APC + for medium applications APC-120 – Provides ml of APC + for large applications copyrights:oibconsultantsinc 47

48 Smartjet® Applicator Systems FDA cleared for simultaneous pre-mixing & delivery of APC + & thrombin to the surgical site Applies fine bioactive coating or precision delivery of bioactive proteins to wound site Precisely controls mixing of APC + & thrombin (10:1 ratio) to ensure reproducible results Requires only single-handed operation Utilizes dual lumen design – Prevent clogging at delivery tip Comes packages sterile & assembles in seconds copyrights:oibconsultantsinc 48

49 Matrix Scaffold & Platelet copyrights:oibconsultantsinc49

50 PRP & Thrombus Assembly With Open Surgery 0m 27s PRP Video copyrights:oibconsultantsinc50

51 Research Growth factors derived from platelets – Affect mitogenic activity of osteoblasts & other undifferentiated cells At the wound site – Bioactive proteins act on undifferentiated cells With respect to – Cell recruitment (chemoattraction) – Cell division (mitosis) copyrights:oibconsultantsinc 51 Slater, Michael, et al, Involvement of Platelets in Stimulating Osteogenic Activity, Journal of Orthopaedics Research, 1995: 13: Haynesworth, Stephen, E, Bruder, Scott P., et al, Mitogenic Stimulation of Human Mesenchymal Stem Cells by Platelet Releasate, Poster Presentation, American Academy of Orthopedic Surgery, March 2001.

52 Platelets and Platelet Growth Factors Growth factors are proteins, stimulating wound healing cascades. copyrights:oibconsultantsinc 52

53 Research Concentration of platelets well above baseline levels – Not only increases attraction of undifferentiated cells to wound site – Increases proliferation of those cells Enhanced cellular proliferation resulting from high platelet concentrations – Can allow for reduction in autograft requirements – Can accelerate bone & soft tissue healing copyrights:oibconsultantsinc 53 Kirsner, R., Eaglstein, W.H., The Wound Healing Process, Wound Healing, 1993; 11: Patel, T. et al, The use of Platelet Concentrate in Posterolateral Fusion Biomechanical and Histological Analysis, Presented at the 28 th meeting of the International Society for the Study of Lumbar Spine, Edinburgh, Scotland, June Marx, R.E. et al, Platelet-Rich Growth Factor Enhancement for Bone Grafts, Oral Surg Oral Med, Oral Pathol, 1998; 85: Marx, R.E., et al, Healing Enhancement of Skin Donor Sites with Platelet-Rich Plasma, Oral Abstract Session, American Academy of Oral & Maxillofacial Surgery, September, 2000.

54 Quality Method used for concentrating platelets – Direct impact on bioactive proteins available to accelerate wound healing process copyrights:oibconsultantsinc 54 Slater, Michael, et al, Involvement of Platelets in Stimulating Osteogenic Activity, Journal of Orthopaedics Research, 1995: 13: Haynesworth, Stephen, E., Bruder, Scott P., et al, Mitogenic Stimulation of Human Mesenchymal Stem Cells by Platelet Releasate, Poster Presentation, American Academy of Orthopedic Surgery, March Patel, T. et al, The use of Platelet Concentrate in Posterolateral Fusion Biomechanical and Histological Analysis, Presented at the 28 th meeting of the International Society for the Study of Lumbar Spine, Edinburgh, Scotland, June Marx, R.E. et al, Platelet-Rich Growth Factor Enhancement for Bone Grafts, Oral Surg Oral Med, Oral Pathol, 1998; 85: Marx, R.E., et al, Healing Enhancement of Skin Donor Sites with Platelet-Rich Plasma, Oral Abstract Session, American Academy of Oral & Maxillofacial Surgery, September, 2000.

55 Platelet Rich Plasma Biology Growth factors increase linearly with platelet concentration copyrights:oibconsultantsinc 55

56 SmartPReP APC+® Platelets concentrated with the SmartPReP system – Have characteristics similar to requirements of American Association of Blood Banks for transfusable platelets – Release bioactive signal proteins & growth factors that remain active for up to 7 days – Were concentrated significantly higher than other so-called “PRP” systems – Met or exceeded the 4x to 5x increase above baseline levels needed to enhance wound healing copyrights:oibconsultantsinc 56 Marx, R.E. et al, Platelet-Rich Growth Factor Enhancement for Bone Grafts, Oral Surg Oral Med, Oral Pathol, 1998; 85: Marx, R.E., et al, Healing Enhancement of Skin Donor Sites with Platelet-Rich Plasma, Oral Abstract Session, American Academy of Oral & Maxillofacial Surgery, September, Kevy, S.V., Characterization of Growth Factor Levels in Platelet Concentrates, Presented at Engineering Tissues, 5 th Annual Meeting, February, Marx, R.E., University of Miami School of Medicine, Miami, FL, Kevy, S.V., Jacobson, M.S., Center for Blood Research Laboratories, Boston, MA, Platelet Concentrate Preparation in the Office Setting: A Comparison of Manual and Automated Devices, September, Kevy, S.V., Jacobson, M.S., Platelet Concentrate Preparation in the Office Setting: A Comparison of Manual and Automated Devices, March, 2001.

57 PRP Amount PRP amount is approximately 10% of volume of whole blood – 3 mL of PRP can be collected from 30 mL of whole blood After 15-minute spin at 3,200 revolutions per minute PRP is maintained in sterile environment – Immediately used during outpatient procedure or surgery copyrights:oibconsultantsinc 57 Alsousou J, Thompson M, Hulley P, Nobel A, Willet K. The biology of platelet-rich plasma and its application in trauma and orthopedic surgery: a review of the literature. J Bone Joint Surg Br 2009; 91:

58 Concentrated Platelet Portion When concentrated platelet portion is made – Buffy coat containing elevated levels of leukocytes Along with concentrated platelets – Suspended in small amount of plasma for subsequent grafting Platelets are not activated & remain suspended – Until grafting & contact with thrombin or collagen occurs copyrights:oibconsultantsinc 58

59 PRP & Proteins PRP is more than just platelet concentrate – Also contains 3 proteins in blood Fibrin Fibronectin Vitronectin – Known to act as Cell adhesion molecules for osteoconduction Matrix for – Bone – Connective tissue – Epithelial migration copyrights:oibconsultantsinc 59

60 Leukocytes – May result in secondary tissue damage in setting of muscle injuries Recent studies have suggested – Importance of keeping leukocytes in PRP concentrate copyrights:oibconsultantsinc 60 Smith C, Kruger MJ, Smith RM. Myburgh KH. The inflammatory response to skeletal muscle injury: illuminating complexities. Sports Med 2008; 38: Toumi H, Best TM. The inflammatory response: friend or enemy for muscle injury? Br J Sports Med 2003; 37: Lyras DN, Kazakos K, Verettas D, et al. The influence of platelet-rich plasma on angiogenesis during the early phase of tendon healing. Foot Ankle Int 2009; 30:

61 Leukocytes – May provide anti-infectious environment – Promote vascular endothelial growth factor – Regulate immunity – Shown to release oxygen-free radicals Leukocyte use in PRP – Decreased wound infection rates – Did not affect outcomes of PRP use in joint surgery – Able to promote regenerating & remodeling process in tendons copyrights:oibconsultantsinc 61 Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P- PRP) to leukocyte and platelet-rich fibrin (L- PRF). Trends Biotechnol 2009; 27: Dohan DM, Choukroun J, Diss A, et al. Platelet- rich fibrin (PRF): a second-generation platelet concentrate. Part III. Leucocyte activation: a new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101: e51-e55.

62 Platelet Activation If fibrin levels are too high – Or platelet activation occurs prior to collagen binding Graft is inhibited Other functions of platelet activation & subsequent cascade of events that occur include – Cytokine signaling – Chemokine release – Mitogenesis copyrights:oibconsultantsinc 62 Kumar V et al. Chapter 2 – Acute and chronic inflammation. In Robbins and Cotran Pathologic Basis of Disease, 7 th ed Saunders. Available at

63 Platelet Rich Plasma Biology: Platelets Resting State Activated copyrights:oibconsultantsinc 63

64 Relationship of Differing Platelet Concentrations & Human Mesenchymal Stem Cell Migration & Proliferation copyrights:oibconsultantsinc 64

65 PRP Grafts Evidence to suggest – PRP grafts in four- to six-fold range Have more anti-inflammatory mediators & effects Clinically relevant & useful for most situations – PRP grafts in eight- to thirteen-fold range Pro-inflammatory in nature copyrights:oibconsultantsinc 65 Hesham El-Sharkawy et al. Platelet-Rich Plasma: Growth Factors and Pro- and Anti-Inflammatory Properties. J Periodontol. April 2007; 78:

66 Foot Open Ulcer 0m 50s PRP Video copyrights:oibconsultantsinc66

67 Weibrich et al… Observed advantageous effect with – Platelet concentrations of approximately 106 µ/L (500% to 600%) Higher concentrations – Might have paradoxically inhibitory effects (> 800%) copyrights:oibconsultantsinc 67 Weibrich G, Hansen T, Kleis W, Buch R, and Hitzler WE. Effect of platelet concentration in platelet-rich plasma on peri- implant bone regeneration. Bone. 2004; 34:

68 Tissue Healing First step of healing process – Clot formation – Platelet activation Many growth & differentiation factors released from α - granules – Storage units found in platelets copyrights:oibconsultantsinc 68 Wroblewski AP, Melia HJ, Wright VJ. Application of platelet-rich plasma to enhance tissue repair. Oper Tech Orthop 2010; 20: Marx R. Platelet-function: assays and events – introduction. Suppl Thromb Haemost 1978; 63:

69 Wound Healing Cascade copyrights:oibconsultantsinc 69

70 Necessary Physiology Stages of Healing Normal platelet activation leads to three necessary stages of healing – Inflammation – Proliferation – Remodeling copyrights:oibconsultantsinc 70 Kumar V et al. Chapter 2 – Acute and chronic inflammation. In Robbins and Cotran Pathologic Basis of Disease, 7 th ed Saunders. Available at de la Torre J. The physicology of healing the chronic wound. the_chronic_wound. Last Updated: May 26, Last accessed 12/09/07. the_chronic_wound

71 Wound Healing Once tissue injury occurs – Hematoma forms at site of tissue damage – Platelets adhere to exposed collagen Create clot Inflammatory phase begins with activation of platelets – Resulting in release of » Growth factors » Bioactive factors » Hemostatic factors copyrights:oibconsultantsinc 71 Everts PA, Knape JT, Weibrich G, et al. Platelet-rich plasma and platelet gel: a review. J Extra Corpor Technol 2006; 38:

72 Necessary Stages of Healing If any stages are incomplete – Tissue homeostasis is lost – Pain & loss of function may result Most reviews focus on growth factors contained within alpha granule of platelet – Released upon platelet activation copyrights:oibconsultantsinc 72

73 Inflammatory Phase During inflammatory phase, functions of activated platelets include – Anti-microbial – Adhesion – Aggregation – Clot retraction – Pro-coagulation – Cytokine signaling – Chemokine release – Growth factor release copyrights:oibconsultantsinc 73

74 Proliferative Phase Within a few days of injury – Proliferative phase begins Characterized by – Angiogenesis – Collagen deposition – Granulation tissue formation – Epithelialization – Wound contraction copyrights:oibconsultantsinc 74

75 Proliferative Phase Following initial inflammatory phase – Typically lasts for two to three days – Fibroblasts enter site and begin proliferative phase Proliferative phase – Low pH & low oxygen levels Stimulate fibroblast proliferation in the injury site copyrights:oibconsultantsinc 75 Kumar V et al. Chapter 2 – Acute and chronic inflammation. In Robbins and Cotran Pathologic Basis of Disease, 7 th ed Saunders. Available at t.com. t.com Liu YBA et al. Fibroblast Proliferation due to Exposure to a Platelet Concentrate in Vitro is pH Dependent. Wound Rep Reg. 2002; 10:

76 Proliferative Phase Fibroblasts become most abundant cell – By seventh day Fibroblasts – Responsible for deposition of collagen & ground substance Proliferative phase – Lasts from two to four weeks – Mandatory for tissue repair copyrights:oibconsultantsinc 76

77 Proliferative Phase Proliferative phase – Peaking from day 5 to 15 – Can last for weeks Fibroblasts differentiate into myofibroblasts – Actin contracts to make wound smaller Low pH & hypoxemia – Stimulates neovascularization copyrights:oibconsultantsinc 77

78 Proliferative Phase Neovessels begin to form – Approximately days 5 – 7 – Process proceeds until neovessels disappear Near completion of remodeling phase copyrights:oibconsultantsinc 78

79 Remodeling Phase Tissue repair starts when production & break down of collagen equalizes Remodeling phase – Can last over one year – Type III collagen is replaced by type I collagen – Reorganization occurs – Blood neovessels disappear copyrights:oibconsultantsinc 79 Kumar V et al. Chapter 2 – Acute and chronic inflammation. In Robbins and Cotran Pathologic Basis of Disease, 7 th ed Saunders. Available at

80 Cell Proliferation Triangle PRP grafts function via triad of interactions – Cell proliferation triangle Each element of this triangle must be present for – Effective tissue repair – Pain relief copyrights:oibconsultantsinc 80 Barnett Jr MD and Pomeroy GC. Use of Platelet Rich Plasma and Bone marrow Derived Mesenchymal Stem Cells in Foot and Ankle Surgery. Techniques in Foot and Ankle Surgery (2): Last accessed 12/09/07.

81 Matrix Scaffold & Platelet copyrights:oibconsultantsinc81

82 How Many Treatments Needed? One to three treatments – Depending on Degree of injury How long injury has been there Treatments typically spaced 4-6 weeks apart copyrights:oibconsultantsinc 82

83 What Can You Expect After PRP? First 48 hours – Swelling & discomfort Typical in injected area – All patients provided with pain medication – Apply ice as needed By day 5 – Symptoms will begin to substantially resolve – Physical therapy is started Optimize PRP affects Follow-up with physician one month later copyrights:oibconsultantsinc 83

84 Carcinogenesis Growth factors act on cell surface receptors only – Do not enter cell – Do not cause DNA mutation – No plausible mechanism by which growth factors would result in neoplastic development No reports of this in the literature Scott & Pawson showed – Growth factors activate normal gene expression copyrights:oibconsultantsinc 84 Everts PAM, Knape JTA, Weibrich G, Schonberger JPAM, Hoffmann JJHL, Overdevest EP, Box HAM, and van Zundert A. Platelet-Rich Plasma and Platelet Gel: A Review. JECT. 2006; 38: Creaney L and Hamilton B. Growth Factor Delivery Methods in the Management of Sports Injuries: TheState of Play. Br J Sports Med : Published online: Nov 5, Scott JD and Pawson T. Cell communication: The inside story. Sci Am. Jun pp

85 Contraindications to Use of PRP Matrix Grafts Absolute contraindications include – Platelet dysfunction syndrome – Critical thromboctopenia – Hypofibrinogenemia – Hemodynamic instability – Septicemia – Sensitivity to bovine thrombin copyrights:oibconsultantsinc 85

86 Contraindications to Use of PRP Matrix Grafts Relative contraindications include – Consistent use of NSAID’s within 48 hours of procedure – Corticosteroid injection at treatment site or systemic use of corticosteroids within 2 week so f graft procedure – Recent fever or illness – Rash at graft donor site or at receptor site – Active cancer – especially hematopoietic or of bone – Active history or history of Pseudomonas Enterococcus Klebsiella infection – HGB < 10 g/dl – Platelet count less than 105/µL (low) copyrights:oibconsultantsinc 86 Bielecki TM et al. Antibacterial effect of autologous platelet gel enriched with growth factors and other active substances: an in vitro study. The Journal of Bone and Joint Surgery. March B(3):

87 Consent to Treat with PRP Average series of injections – Two to three at four- to six-week intervals – Different sites or areas of treatment May expand or contract with further treatment – Must functionally retrain kinetic chain once tissue has undergone some degree of healing copyrights:oibconsultantsinc 87

88 Risks Involved With PRP No reports of worsened pain or function – Following tissue maturation Pain at treatment site is common for short period following injections – Patients reported worsened pain for six months Treated lateral epicondyle Resolved and has been absent for over one year Remodeling of tissue – Necessary to see effects of therapy 1:50,000 chance of introducing infection with injection procedure copyrights:oibconsultantsinc 88

89 Risk of Infection or Allergic Reaction PRP is autologous preparation – Risk of introducing foreign material & risk of transmissible infection or allergic reaction Effectively eliminated – Procedure must be carried out in sterile conditions copyrights:oibconsultantsinc 89

90 PRP is Bacteriocidal During initial inflammatoyr phase – PRP is bacteriocidal Particularly against – Staphlococcus aureus – Escherichia coli » As shown by Bielecki et al Temporary formation of platelet & fibrin plugs at wound site – Noted to prevent entry of microorganisms PRP gel – Seems to induce in vitro growth of Ps. Aeruginosa May cause exacerbation of infections with this organism copyrights:oibconsultantsinc 90 Everts PAM, Knape JTA, Weibrich G, Schonberger JPAM, Hoffmann JJHL, Overdevest EP, Box HAM, and van Zundert A. Platelet-Rich Plasma and Platelet Gel: A Review. JECT. 2006; 38: Bielecki TM et al. Antibacterial effect of autologous platelet gel enriched with growth factors and other active substances: an in vitro study. The Hournal of Bone and Joint Surgery. March B(3):

91 Technique for Myotendinous or Teno-Osseous Sites Alcohol or Betadyne prep – Prefer Betadyne gel when using ultrasound probe for “live” injection guidance +/- Ethyl Chloride spray Inject PRP with approximately 1cc PRP per cm 3 of tissue/interface Important to touch bone and “pepper” area of teno- osseous junction – Stimulate greatest number of fibroblast colonies For myotendinous sites – Use ultrasound to ensure layered treatment through tendon Sterile band-aid applied post injection Kinesiotape to protect motion if needed copyrights:oibconsultantsinc 91

92 Technique for Intra-Osseous Sites Alcohol or Betadyne prep – Prefer Betadyne gel when using ultrasound probe for “life” injection guidance +/- Ethyl Chloride spray Local anesthetic – Mixed with PRP graft – To sites of tenderness to “road test” area prior to using graft Ensures PRP matrix graft is placed in proper areas Aspirate degenerative joint fluid prior to PRP matrix graft placement Gel to PRP – Or utilize other stabilizing matrix for intra-articular sites – Ligaments, tendons, and inherent matrix sites Do not require gel 8-10cc PRP matrix graft – Typical amount used for knee or shoulder “Treat regionally, not locally” copyrights:oibconsultantsinc 92

93 Intro Platelet Plasma and Joints and Cervical Locations 0m 29s PRP Video copyrights:oibconsultantsinc93

94 Arthro Knee With Hacket-Hemwall 2m 36s PRP Video copyrights:oibconsultantsinc94

95 Knee Medial Ligament Treatment 1m 06s PRP Video copyrights:oibconsultantsinc95

96 Dr. Sampson/Rausher Shoulder PRP 2m 00s TV News copyrights:oibconsultantsinc96

97 Elbow PRP 1m 03s PRP Video copyrights:oibconsultantsinc97

98 Hip Arthritis Bone and Joint 0m 41s PRP Video copyrights:oibconsultantsinc98

99 Dr. Sellar Ankle Sinus Tarsi/ Foot and Metatarsal Joint 2m 43s TV News copyrights:oibconsultantsinc99

100 How Long Does PRP Take To “Work”? Some element of improvement by 2-6 weeks after PRP – Pain intensity dropping along the way – Increased endurance & strentrh typically reported Clinical trials report – Ongoing improvement up to 6-9 months after PRP copyrights:oibconsultantsinc 100

101 Kevy & Jacobson Evaluated mixture of common local anesthetics with PRP – Found no significant platelet activation or diminution of graft growth factor functions copyrights:oibconsultantsinc 101 Kevy SV and Jacobson MS. Comparison of methods for point of care preparation of autologous platelet gel. J Extra Corpor Technol. 2004; 36: Personal communication of primary author and the Center for Blood Research, Cambridge, MA. February 2007.

102 Schnabel et al… Evaluated gene expression patterns, DNA & collagen content of equine flexor digitorum tendons – Cultured in media consisting of PRP & other blood products PRP at 100% concentration – Stimulated greatest number of » Collagen type I » Collagen type III » Cartilage oligometric protein (COMP) molecule genes Without increasing expression of pro-inflammatory matrix metalloproteinases ELISA detected higher levels of – PDGF – TGF-B » In PRP group copyrights:oibconsultantsinc 102 Schnabel L et al. Platelet Rich Plasma (PRP) Enhances Anabolic Gene Expression Patterns in Flexor Digitorum Superficialis Tendons. J of Orthopaedic Research. 2006; pp

103 du Toit et al… Culture studies performed for use in dermal regeneration – Confirmed potent mitogenic stimulation of Human fibroblasts Keratinocytes Chondrocytes Neural tissue Myoblasts copyrights:oibconsultantsinc 103 du Toit DF et al. Soft and Hard-tissue Augmentation with Platelet- Rich Plasma: Tissue Culture Dynamics. Regeneration and Molecular Biology Perspective. Int J Sohoulder Surg. April 2007; 1(2):

104 Anitua et al… In vitro studies of collagen & tendon – Autologous preparations rich in growth factors Promote proliferation Induce VEGF & HGF production – By human tendon cells in culture copyrights:oibconsultantsinc 104 Eduardo A et al. Autologous preparations rich in growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in culture. J of Orthopaedic Research. 2005; 23:

105 Tendinopathy Likely occurs from chronic repetitive stress in area of relative hypovascularity Unlike acute inflammatory phase – Majority of overuse chronic musculoskeletal conditions show no evidence of inflammatory cells Tennis elbow Achilles tendinopathy Plantar fasciitis copyrights:oibconsultantsinc 105 Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003; 93:

106 PRP For Acute Injuries PRP may be more effective for acute injuries – Muscle tears – Medial collateral ligament & ankle sprains – Acute hamstring injuries Common in sports Account for significant time lost & cost Slow to heal Prone to reinjury copyrights:oibconsultantsinc 106 Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med 2009; 37: Malliaropoulos N, Papacostas E, Kiritsi O, et al. Posterior thigh muscle injuries in elite track and field athletes. Am J Sports Med 2010; 38: Orchard J, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med 2002; 12: 3-5.

107 Healing Patellar Tendinopathy After PRP Treatment Long-axis Doppler ultrasound image shows thickening, hypoechogenicity, and hyperemia of proximal patellar tendon copyrights:oibconsultantsinc 107 Long-axis Doppler ultrasound image shows thickening, hypoechogenicity, and hyperemia of proximal patellar tendon

108 Tendon & Ligament Human Use of PRP Mishra evaluated 20 patients – Failed non-operative treatment for chronic epicondylar pain Randomized to – Single PRP injection – Injection with bupivicaine All PRP patients had – Lower pain – Greater ROM Than control Eight weeks after treatment – Platelet-rich plasma patients noted 60% improvement in visual analog pain scores Versus 16% improvement in control patients 60% of control subjects withdrew after 8-week period At six months – Patients treated with PRP noted 81% improvement At final follow-up PRP patients reported 93% reduction in pain – Compared with before treatment (P<.0001) No PRP-treated patient was worse after treatment – No complications reported copyrights:oibconsultantsinc 108 Mishra A et al. Treatment of Chronic Elbow Tendinosi s with Buffered Platelet- Rich Plasma: American Journal of Sports Medicine. 2006; 34:

109 Tendons Tendon rupture or partial rupture was noted Olena Virchenko & Per Aspenberg noted – Rat Achilles tendon transection model One postoperative injection resulted in increased strength after four weeks – Effect obliterated with use of Botox at site copyrights:oibconsultantsinc 109 Virchenko O and Aspenberg P. How can one platelet injection after tendon injury lead to a stronger tendon after 4 weeks? Interplay between early regeneration and mechanical stimulation. Acta Orthopaedica (5):

110 Scarpone et al… 14 patients with shoulder pain – Patients had rotator cuff tears with No significant AC joint thickness with impingement No other significant symptomatic pathology – Labral tears – Glenohumeral arthrosis – Gross instability 12 of 14 patients had significant improvements in pain scale & strength & endurance – At eight weeks 6 of 12 patients had radiographic evidence of healing of their tendinopathy on MRI – At eight weeks No complications noted copyrights:oibconsultantsinc 110 Scarpone MA, Davenport M, and Rauker N. PRP as a Treatment Alternative for Symptomatic Rotator Cuff Tendinopathy for Patients Failing Conservative Treatment tingpain.com/pa ges/int_pain/Sca rponeRotatorCur rstudy.pdf. Last accessed 1/2/08. tingpain.com/pa ges/int_pain/Sca rponeRotatorCur rstudy.pdf

111 Ventura et al… Evaluated PRP in ACL repair – Total of 20 patients with anterior cruciate ligament (ACL) injuries Treated by quadrupled hamstring tendon graft (QHTG) – With or without PRP gel growth factor (GF) application copyrights:oibconsultantsinc 111 Ventura A et al. Use of Growth Factors in ACL Surgery: Preliminary Study. Journal of Orthopaedic Traumatology. 2005; 6:

112 Clinical Evidence for Use for Platelet-Rich Plasma in Sports Medicine (Nonsurgical) copyrights:oibconsultantsinc 112

113 Clinical Evidence for Use for Platelet-Rich Plasma in Sports Medicine (Surgical) copyrights:oibconsultantsinc 113

114 Refernces copyrights:oibconsultantsinc 114 Mishra A, Pavelko T: Treatment of chronic elbow tendinitis with buffered platelet rich plasma. Am J Sports Med 2006; 34: Mishra A, Woodall J Jr, Vieira A: Treatment of tendon and muscle using platelet-rich plasma. Clin Sports Med 2009; 28: Kon E, Filardo G, Delcogliano M, et al: Platelet-rich plasma: New clinical application: A pilot study for treatment of jumper’s knee. Injury 2009; 40: Barrett S, Erredge S: Growth factors for chronic plantar fasciitis. Podiatry Today. 2004; 17: Sanchez M, Anitua E, Andia I: Poster presentation: Application of autologous growth factors on skeletal muscle healing. Regmed Available at: SanchezRegMed2005.pdf. Accessed September 4, SanchezRegMed2005.pdf Sanchez M, Anitua E, Azofra J, Aguirre JJ, Andia I: Intra-articular injection of an autologous preparation rich in growth factors for the treatment of knee OA: A retrospective cohort study. Clin Exp Rheumatol 2008; 26:

115 References copyrights:oibconsultantsinc 115 Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Mujika I: Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med 2007; 35: Randelli PS, Arrigoni P, Cabitza P, Volpi P, Maffulli N: Autologous platelet rich plasma for arthroscopic rotator cuff repair: A pilot study. Disabil Rehabil 2008; 30: Everts PA, Devilee RJ, Brown Mahoney C, et al: Exogenous application of platelet- leukocyte gel during open subacromial decompression contributes to improved patient outcome: A prospective randomized double-blind study. Eur Surg Res 2008; 40: Orrego M, Larrain C, Rosales J, et al: Effects of platelet concentrate and a bone plug on the healingof hamstring tendons in a bone tunnel. Arthroscopy 2008; 2004: Silva A, Sampaio R: Anatomic ACL reconstruction: Does the platelet-rich plasma accelerate tendon healing? Knee Surg Sports Traumatol Arthrosc 2009; 17: Sanchez M, Azofra J, Anitua E, et al: Plasma rich in growth factors to treat an articular cartilage avulsion: A case report. Med Sci Sports Exerc 2003; 35:

116 Sanchez et al… Reported on case-control study of 12 athletes with complete Achilles rupture – All 12 had open Achilles repair – 6 had PRGF Treatment group had no wound complications & experienced earlier functional restoration – ROM 7 vs. 11 weeks – Jogging 11 vs. 18 weeks – Training 14 vs. 21 weeks Measured – IGF-1 – TGF-B1 – PDGF-AB – EDF – VEGF – HGF Noted that number of platelets held direct correlation to level of growth factors copyrights:oibconsultantsinc 116 Sanchez M, Anitua E, Azofra J et al. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sp Med. 2007; 35(2):

117 Muscle Strain & Use of PRP Sanchez reported 20 prospective muscle injury – Pilot study with six-month follow-up Ultrasound guided injection of PRP within injured muscle – Enhanced healing & functional capacities 50% faster than control group copyrights:oibconsultantsinc 117 Sanchez M, et al. Application of Autologous Growth Factors on Skeletal Muscle Healing. 2 nd World Congress on Regenerative Medicine. Podium Presentation. May, 2005.

118 Ultrasound-Guided Needle Placement copyrights:oibconsultantsinc 118 Coronal proton density-weighted fat saturation MR image shows thickening of proximal MCL from an acute or chronic sprain injury Corresponding ultrasound image shows needle placement into proximal portion of MCL

119 Dr. Tai Wrist Joint 1m 23s PRP Video copyrights:oibconsultantsinc119

120 Sanchez et al… Utilized PRP after reattachment of large (2 cm) loose chondral body in crater in medial femoral condyle – Autologous plasma (PRP) injected into area between crater and fixed fragment Complete articular cartilage healing considerably accelerated Functional outcome was excellent – Allowing rapid resumption of symptom-free athletic activity copyrights:oibconsultantsinc 120 Sanchez M et al. Plasma Rich in Growth Factors to Treat Articular Cartilage Avulsion: A Case Report. Medicine & Science in Sports & Exercise pp

121 Knee X-Ray copyrights:oibconsultantsinc 121

122 PRP & Stem Cells Second phase of regenerative technique involves using – PRP in tandem with stem cells Expectation of inducing remission – Many patients with rheumatoid arthritis (RA) Effective treatment for osteoarthritis (OA) – Remains elusive RA only about 1/10 as common as OA copyrights:oibconsultantsinc 122

123 Dr. Lazar Fat Stem Cell Elbow Injury 2m 14s TV News copyrights:oibconsultantsinc123

124 In Vivo Study: Skin Healing Single-blind pilot study – 80 full-thickness skin punch wounds PRP applied topically – On day 17 Percentage of closure was – 81.1% for PRP treated sites – 57.2% for control sites – PRP wound closure velocities significantly faster Platelet count in gel more than six times baseline Epithelialization & granulation formation appeared three days earlier – In PRP treated group copyrights:oibconsultantsinc 124 The Healing Effects of Autologous Platelet Gel on Acute Human Skin Wounds. Arch Facial Plast Surg. May-Jun (3):

125 In Vivo Study: Diabetic Foot Ulcers Study examining PRP gel for diabetic foot ulcers – 13 of 19 patients in study group had complete healing Compared with only 9 of 21 of control group copyrights:oibconsultantsinc 125 Driver V et al. A Prospective, Randomized, Controlled Trial of Autologous Platelet-Rich Plasma Gel for the Treatment of Diabetic Foot Ulcers. Ostomyl Wound Management (6):

126 Pain Reduction With PRP Serotonin released from activated platelets may be responsible for decreased pain – Everts & Fanning Large amounts of serotonin – Contained within dense platelet granules Serotonin levels – Significantly increased at wound site Decrease in serotonin concentration in platelets – Increase in serotonin levels in plasma Suggesting normalization of plasma serotonin levels – Due to mobilization of platelet serotonin copyrights:oibconsultantsinc 126 Everts PAM, Devilee RJJ, Brown Mahoney C, et al. Exogenous application of platelet-leukocyte gel during open subacromial decompression contributes to improved patient outcome. A prospective randomized double-blinded study. Eur Surg Res. 2008; 40: Fanning J, Murrain L, Flora R, Hutchings, Johnson J, and Fenton B. Phase I/II prospective trial of autologous platelet tissue graft in gynaecologic surgery. J Min Invas Gyn. 2007; 14: Vanhoutte PM. Platelet-derived serotonin, the endothelium, and cardiovascular disease. J Cardiovasc Pharmacol. 1991; 17S: S6-S12.

127 Restoring Articular Cartilage Major goal of stem cell therapy – Restoration of diffuse diseased articular cartilage Use of techniques aimed at harvesting pluripotential power of – Embryonic stem cells (ESCs) – Adult mesenchymal stem cells (MSCs) » To differentiate into cartilage cells Variety of strategies copyrights:oibconsultantsinc 127

128 Joint copyrights:oibconsultantsinc 128

129 ESCs & MSCs ESCs (Embryonic) – Greater ability to multiply quickly – Potential for unchecked growth (neoplasia) MSCs (Mesenchymal) – Delivered via Direct intra-articular injection Use of cell-seeded scaffolds – Excellent concentration of stem cells (about 10 million to 50 million) – Obtained from bone marrow Harvested at the iliac crest copyrights:oibconsultantsinc 129

130 Synergy Between Stem Cells & PRP Stem cells – Tyrosine kinase receptors on cell surface Growth factors released from activated platelets – Bind to cell membranes to activate genes controlling mitosis Signal transduction occurs once growth factors bind to receptors copyrights:oibconsultantsinc 130 The Journal of Musculoskeletal Medicine, July 2009, pages

131 Introduction To Biofacial Skin Dr. Jo 2m 18s PRP on Face TV News copyrights:oibconsultantsinc131

132 Dr. Tai: Total Face PRP 17m 50s PRP Video copyrights:oibconsultantsinc132

133 Biofacial Skin Dr. Jo 2m 19s TV News copyrights:oibconsultantsinc133

134 Total Face Labial, Cheeks, Jaw, Eyes PRP 2m 29s PRP Video copyrights:oibconsultantsinc134

135 Hand Rejuvenation 0m 13s PRP Video copyrights:oibconsultantsinc135

136 Smart Skin Removes surface dead skin – Progressive Recommended for daily use – Non-invasive copyrights:oibconsultantsinc 136

137 Diamond Microdermabrasion Innovative natural skin care therapy Rejuvenate/renew/resurface skin Promotes growth of – Collage – Elastin copyrights:oibconsultantsinc 137

138 MTS Roller™ Mesotherapeutic, “non-ablative”, non-surgical tool – Facilitates procedure that reserves top layer of skin – Induces body to produce Collage Elastin Treatment involves roller with needles – Range from 0.2 mm to 2.0 mm Produces little downtime – Skin may be red & sensitive for about 2-3 hours after treatment copyrights:oibconsultantsinc 138

139 MTS Roller™ copyrights:oibconsultantsinc 139

140 Laser Re-Surfacing vs. Microneedle Therapy copyrights:oibconsultantsinc 140

141 MTS Roller™ Advantages – Not painful – Very short healing period – Can be used on thin skin – No permanent skin damage – Can be safely repeated for better results – Can be used on laser resurfaced skin – Helps skin to become thicker – Healing phase short (five days) – No anesthesia or post-operative pain – Skin is not sun sensitive copyrights:oibconsultantsinc 141

142 What is Microneedle? Ideal for non-surgical & non- ablative treatment of various skin conditions – Aging (wrinkles, stretching) – Scarring (acne, surgical) – Hyperpigmentation copyrights:oibconsultantsinc 142

143 How Effective? More effective than ablative treatments like – Laser resurfacing – Dermabrasion – Chemical peel Just as effective as non-ablative treatments like – IPL – CO2 laser – Fraxel in stimulating collagen & elastin production – Thicken skin – Erase wrinkles – Smooth scars copyrights:oibconsultantsinc 143

144 Absorbency 200 very fine needles – Injure skin sufficiently enough to stimulate collage/elastin production – Resulting micro-channels Aid in infusing therapeutic serums Serum absorption – Increased as much as 1,000 times copyrights:oibconsultantsinc 144

145 Absorbency copyrights:oibconsultantsinc 145

146 Advantages for Using MTS Roller™ Does same job as lasers & other ablative methods – Increasing production of collagen Minimal damage to protective layer of skin Just as effective as – Lasers – IPL – Thermage – Other “machine-based” treatments Fraction of the cost to practitioners & patients Non-surgical & non-ablative – Skin-friendly treatment – Patients experience little or no pain, downtime, & risk for complications copyrights:oibconsultantsinc 146

147 Models Personal MTS models – CR2 – CR3 Clinical MTS models – CR5 – CR10 – CR20 – CR30 Should be used with topical anesthetic copyrights:oibconsultantsinc 147

148 How Microneedle Therapy System Works copyrights:oibconsultantsinc 148

149 Technology Behind MTS Microneedles – Arranged in microfibricated arrays – Synthesized by reactive ion etching techniques on Silicon Other types of material – Create microscopic arrays of needles – Measuring µm in length, 10-15µm in tip diameter – Pierce stratum corneum Create microconduits – Transport across stratum corneum copyrights:oibconsultantsinc 149

150 MTS Roller™ Cylinder mechanically drives applied substance under skin – Through holes created by MTS Roller™ needles Miniscule holes of 0.7mm in diameter & 0.13mm to 2.5mm in depth copyrights:oibconsultantsinc 150

151 Frequently Asked Questions About MTS copyrights:oibconsultantsinc 151

152 Does MTS Roller™ Smooth Acne Marks? Within first treatment of CR5 (0.5mm) – Patients notice diminished superficial acne marks After third treatment – Deeper acne marks begin to fill in By 5 th or 6 th treatment – Patients experience results similar to deep chemical peel or laser resurfacing copyrights:oibconsultantsinc 152

153 Is the Personal MTS Roller™ As Effective As Clinical Versions? Personal MTS Rollers are shorter – 0.2mm or 0.3mm Collagen & elastin production not as significant – Designed to supplement clinical treatments copyrights:oibconsultantsinc 153

154 Who Can Buy MTS Roller? MTS Roller with 0.2mm of length – Anyone may purchase for personal skincare treatment MTS Roller™ up to CR5 (0.5mm) – Can be used by trained estheticians & other cosmological specialists with minimal theoretical & practical training Full range of MTS Roller™ models (CR2, CR3, CR5, CR10 & CR20) – Can be purchased by licensed dermatologists, skin surgeons, medical assistants, nurses, certified therapists copyrights:oibconsultantsinc 154

155 Can MTS Roller™ Make Hyperpigmentation Less Noticeable? Yes! Personal & clinical models can help to inhibit hyperpigmentation Several treatments required to even out skin tone – Get rid of hyperpigmentation copyrights:oibconsultantsinc 155

156 Skin Thickness (µm) copyrights:oibconsultantsinc 156

157 MTS Roller™ copyrights:oibconsultantsinc 157 IPL (VL-2, 10.5J, 1 pass) 0 week 2 weeks 4 weeks 8 weeks Dermaroller 0.5mm (5 pass = 15 strokes)      Skin thickness Western blot Bx. Histology ELISA

158 Collagen Quantitative Analysis (ELISA) copyrights:oibconsultantsinc 158

159 Skin Thickness copyrights:oibconsultantsinc 159

160 Collagen Quantitative Analysis (ELISA) copyrights:oibconsultantsinc 160

161 Penetration of Active Ingredients after MTS-Roller Prior to treatment Immediately after treatment Penetration of active ingredients copyrights:oibconsultantsinc 161

162 Total Face with Microneedle 4m 38s PRP Video copyrights:oibconsultantsinc162

163 Forehead Wrinkle Treatment Forehead prior to treatment 1 week after treatment 4 weeks after treatment copyrights:oibconsultantsinc 163

164 Forehead Wrinkle Treatment Light wrinkle fine lines prior to treatment Two months after treatment copyrights:oibconsultantsinc 164

165 Burn Scar Treatment Before 2 weeks after treatment One month after treatment copyrights:oibconsultantsinc 165

166 Alopecia Treatment Prior to treatment 6 weeks after treatment copyrights:oibconsultantsinc 166

167 Hair Restoration PRP Procedure Mix Thrombin Bovine origin 5000 IU with 5cc Calcium Chloride 10% 13.6 meq Ca/10ml Draw 5ml of mixture, apply to top of the hair to provide clotting before injections & apply after injections with 4x4 gauze copyrights:oibconsultantsinc 167

168 Hair Restoration PRP Procedure Inject 1/5 – 1/4 cc of PRP intradermal Use micro-roller over scalp after injection Massage mixture on site of treatment area with blood & PRP to stimulate hair growth Apply PRP after micro-roller to penetrate on site Leave the PRP on treatment site overnight Shampoo in the morning copyrights:oibconsultantsinc 168

169 Hair Restoration with Dr. Tai 7m 50s PRP Video copyrights:oibconsultantsinc169

170 MTS-Roller™ + PRP New age of alopecia solution – MTS Roller™ in combination with – PRP First & only product to – Directly stimulate Anagenic growth phase of hair cycle – Directly suppress Catagenic Rest & Telogenic Loss phases of hair cycle Delivers healthier scalp rejuvenation without – Surgery – Expense of other more invasive treatments copyrights:oibconsultantsinc 170

171 MTS + PRP When PRP is directly infiltrated through micro-pores to hair matrix – Acts immediately to develop best effects Up to 80% or more After treatment – Stratum corneum acts as long-term depot for PRP copyrights:oibconsultantsinc 171

172 Advantages of MTS-Roller™ + PRP At 8 weeks, 100% of men treated with MTS PRP experienced – Increase in hair growth – Average of 80% reduction in hair loss 12 weeks of study revealed – 62% reduction in sebum production Extremely high infiltration rate copyrights:oibconsultantsinc 172

173 Micro Needling & Injecting Platelet Rich Plasma Micro needling – Increase remolding of skin Creating thousands of microscopic channels in skin – Increase formation of new tissue by activating body’s healing cascade Micro needling platelet rich plasma (PRP) into dermis – Intensify natural wound cascade High concentration of patients own growth factors copyrights:oibconsultantsinc 173

174 New Collagen & Elastin Formation copyrights:oibconsultantsinc 174 Before After

175 Kim S.E., Ko D.S., and Lee A.Y., Moon H.S., Medical Conference Presentation, Dongguk University, Medical Science Lab of the Dept. of Dermatology at Eulji University School of Medicine and the Dept. of Dermatology, School of Medicine at Dongguk University Patients received three treatments at two week intervals – 18 control, 18 IPL, 18 MN Micro needling demonstrated – More skin thickness than IPL or control – Histology more collagen fiber than IPL or control – Higher collagen qualitative analysis than IPL or control copyrights:oibconsultantsinc 175

176 Fibroblasts & Collagen Among cells activated by TGF-beta When activated – Under goes cell division – Produces collagen Collagen is responsible for – Plumping the skin – Reversing visible signs of aging copyrights:oibconsultantsinc 176

177 TGF-beta & PDGF TGF-beta – Extremely important – Affects most aspects of tissue wound repair PDGF – Improves dermal regeneration – Acts locally to promote protein & collagen synthesis – Causes endothelial migration or angiogenesis – Induces expression of TGF-beta copyrights:oibconsultantsinc 177 Choi, Y., Fuchs, E., TGF-beta and retnoic acid regulation of growth and modifiers of differentiation human epidermal cells. Crell regal. 1, Ross, R., Platelet- derived growth factor. Am Rev. Med. 38, Pierce, G.F., Mustoe, T.A., Lingelbach, J., Masakowski, V.R., Gramates, P.P., Deuel, T.F., 1989a. Transforming grwoth factor B reverses the glucocorticoid-induced wound healing defect in rats: possible regulation in microphages by platelet- derived growth factor. Proc. Natl. Acad. Sci., 86,

178 PRP Gel Wounds treated with PRP gel – Exhibited enhanced wound repair Compared to controls – Possess more organized collagen than control tissues Without excessive disposition of connective tissue or scar formation copyrights:oibconsultantsinc 178 Carter, C.A., Jolly, D.G., Worden, C.E., Hendren, D.G., Kane, C.J.M., Plate- rich plasma gel promotes differentiation and regeneration during equine wound healing, Experimental and Molecular Pathology, 74, (2003),

179 Equine Study Demonstrated biopsy wounds treated with PRP gel to be – Densely organized, tightly packed fiber bundles parallel to overlying epidermis Suggesting dense collagen lattice had increased tensile strength in repaired wound copyrights:oibconsultantsinc 179

180 Method Freeze-dried collagen sheets moistened with PRP – Applied to area for 30 minutes copyrights:oibconsultantsinc 180

181 Collagen Synthesis Takes six weeks for new collagen synthesis Takes about six months for full effect of treatments Common response by patients after initial treatment – Skin has a “glow” copyrights:oibconsultantsinc 181

182 Before & After copyrights:oibconsultantsinc 182

183 SmartPReP Platelet Concentration System Performance copyrights:oibconsultantsinc 183


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