1. ANTOINE I. JABBOUR, MD www.drjabbour.com TULSA BONE & JOINT ASSOCIATES 918-392-1400 4/24/10ANTOINE I. JABBOUR, MD

2. PROFFESIONAL ATHLETES RECEIVING PRP 4/24/10ANTOINE I. JABBOUR, MD

3. TIGER WOODS AND PRP Tiger Admits to Platelet-Rich Plasma Therapy, What's That?Golfer Says Doctor Under Investigation Injected Blood, Not Human Growth 4/24/10ANTOINE I. JABBOUR, MD

4. PLATELET RICH PLASMA 4/24/10ANTOINE I. JABBOUR, MD

5. PLATELET RICH PLASMA APPLICATIONS 4/24/10ANTOINE I. JABBOUR, MD  CHRONIC TENDONITIS  WOUND HEALING  CARTILAGE REGENERATION  CARDIAC APPLICATIONS

6. HEALING CASCADE THREE PHASES INFLAMMATORY PROLIFERATIVE REMODELING TRULY OVERLAP IN REALITY 4/24/10ANTOINE I. JABBOUR, MD

7. INFLAMMATORY PHASE OBTAIN HEMOSTASIS RELEASE CHEMICAL MESSENGERS ATTRACT PHAGOCYTES 4/24/10ANTOINE I. JABBOUR, MD

8. INFLAMMATORY PHASE OF HEALING BLOOD CONTACTS COLLAGEN PLATELETS SECRETE COAGULATION FACTORS PLATELET ACTIVATING FACTORS CYTOKINES CHEMOKINES 4/24/10ANTOINE I. JABBOUR, MD

9. INFLAMMATORY PHASE THROMBOXANE/PROSTOGLANDINS LEAD TO VASOCONSTRICTION (PEAKS AT 5-10 MINUTES) HISTAMINE RELEASE LEADS TO VASODILATION (PEAKS AT 20 MINUTES) INCREASE IN BLOOD FLOW CELL MEMBRANE BECOMES POROUS PROTEINS/LEUKOCYTES LEAK INTO INJURED AREA SWELLING/INFLAMMATION 4/24/10ANTOINE I. JABBOUR, MD

10. INFLAMMATORY PHASE PMN FIRST WBC TO ARRIVE MOST ABUNDANT CELL DURING FIRST 48 TO 72 HOURS KILL BACTERIA, INGEST DEBRIS SECRETE FACTORS FOR ANGIOGENESIS, EPITHELIALIZATION,EXTRACELLULAR MATRIX (KEY IN INDUCING PROLIFERATIVE PHASE) 4/24/10ANTOINE I. JABBOUR, MD

11. INFLAMMATORY PHASE ANTIMICROBIAL LEADS TO PROLIFERATIVE PHASE VERY NECESSARY DON’T WANT IT TO LAST TOO LONG 4/24/10ANTOINE I. JABBOUR, MD

12. PROLIFERATIVE PHASE AFTER 48-72 HOURS FIBROBLASTS ENTER WOUND ENDOTHELIAL CELLS START NEOVASCULARIZATION SOME CLOT IS DISSOLVED FOR NEW VESSELS PEAKS AT 5-15 DAYS 4/24/10ANTOINE I. JABBOUR, MD

13. REMODELING PHASE CAN LAST ONE YEAR TYPE III COLLAGEN REPLACED BY TYPE I REORGANIZATION BLOOD VESSELS DISAPPEAR 4/24/10ANTOINE I. JABBOUR, MD

14. WE NEED INFLAMMATORY PHASE PLATELET SECRETION VERY IMPORTANT IN INFLAMMTORY PHASE TO INDUCE FIBROBLAST MIGRATION IN THE PROLIFERATIVE PHASE 4/24/10ANTOINE I. JABBOUR, MD

15. PLATELET BIOLOGY PERIPHERAL BLOOD HAS RBC WBC PLATELETS (0.4%) 4/24/10ANTOINE I. JABBOUR, MD

16. PLATELET CLOT FUNCTION STOPS BLEEDING SCAFFOLD FOR TISSUE REGENERATION GROWTH FACTORS CONCENTRATION STEM CELL BINDING 4/24/10ANTOINE I. JABBOUR, MD

17. PLATELET RICH PLASMA (PRP) 4/24/10ANTOINE I. JABBOUR, MD

18. PLATELET ACTIVATION RESTING STATE ACTIVATED PLATELET CELL FEET RELEASE OF GROWTH FACTORS 4/24/10ANTOINE I. JABBOUR, MD

19. PRP MORE PLATELETS, MORE GROWTH FACTORS MORE GROWTH FACTORS, MORE TISSUE REGENERATION 4/24/10ANTOINE I. JABBOUR, MD

20. GROWTH FACTORS FUNCTION CHEMOTAXIS DIRECTIONAL MOVEMENT OF CELLS IN RESPONSE TO A CHEMICAL STIMULUS STEM CELLS ATTRACTED TO GROWTH FACTORS AND MIGRATE INTO THE AREA PROLIFERATION CELL DIVISION IN RESPONSE TO A STIMULUS PLATELET SIGNALING GROWTH FACTORS BIND TO STEM CELL MEMBRANE GROWTH FACTORS STIMULATE CELL DIVISION 4/24/10ANTOINE I. JABBOUR, MD

21. GROWTH FACTORS GROWTH FACTORS ATTACH TO DIFFERENT CELLS RECEPTORS WHICH THEN SENDS MESSAGE INSIDE THE CELL TO CHANGE THE FUNCTION OF THE CELL 4/24/10ANTOINE I. JABBOUR, MD

22. GROWTH FACTORS IN PRP PDGF PLATELET DERIVED GROWTH FACTOR TGF-B TRANSFORMING GROWTH FACTOR-BETA VEGF VASCULAR ENDOTHELIAL GROWTH FACTOR IGF-1 INSULIN LIKE GROWTH FACTOR 4/24/10ANTOINE I. JABBOUR, MD

23. GROWTH FACTORS IN PRP PDGF ATTRACTS WBC, MESENCHYMAL STEM CELLS BONE, LIGAMENT,TENDON,CARTILAGE TGF-B INCREASE TYPE I COLLAGEN PRODUCTION IN TENDON SHEATH FIBROBLASTS (KLEIN, 2002) PROMOTE CELL DIVISION VEGF STIMULATES ANGIOGENESIS 4/24/10ANTOINE I. JABBOUR, MD

24. GROWTH FACTORS IN PRP 4/24/10ANTOINE I. JABBOUR, MD MORE CONCENTRATED PLATELETS THE MORE GROWTH FACTORS LINEAR RELATIONSHIP EPPLEY, 2004

25. GROWTH FACTORS IN PRP TENDON CELLS GROWN IN VITRO WITH PRP HAVE HIGHER CONCENTRATION OF COLLAGEN. PDGF AND TGF PROMOTE CELL GROWTH AND SYNTHESIS OF COLLAGEN I AND III 4/24/10ANTOINE I. JABBOUR, MD

26. GROWTH FACTORS IN PRP TENDON CELLS GROWN IN VITRO WTH VEGF PRP STIMULATES GROWTH OF BLOOD VESSELS. NEW BLOOD SUPPLY INCREASES CHANCE OF TENDON HEALING 4/24/10ANTOINE I. JABBOUR, MD

27. HOW TO GET PRP WITHDRAW 60 cc OF PERIPHERAL BLOOD 4/24/10ANTOINE I. JABBOUR, MD

28. HOW TO GET PRP SPIN IN CENTRIFUGE 4/24/10ANTOINE I. JABBOUR, MD

29. HOW TO GET PRP REMOVE PRODUCT 4/24/10ANTOINE I. JABBOUR, MD

30. PRP APPLICATIONS CHRONIC TENNIS ELBOW CHRONIC GOLFER’S ELBOW PARTIAL ROTATOR CUFF TEAR ACHILLES TENDONITIS PLANTAR FASCIITIS WOUND HEALING CARTILAGE RESTORATION ? SPINE DISC REGENERATION ? 4/24/10ANTOINE I. JABBOUR, MD

31. PRP CONCLUSION PRP PROVIDES HIGH CONCENTRATION OF PLATELETS HIGH CONCENTRATION OF GROWTH FACTORS, TRIGGERS AND ACCELERATES REGENERATION OF CHRONIC TISSUE PROBLEMS SUCH AS INFLAMMATION AND DEGENERATION 4/24/10ANTOINE I. JABBOUR, MD

32. PRP CAUTION HOW MANY TIMES NORMAL PLATELETS IS NEEDED TO PROVIDE ENOUGH GROWTH FACTORS (6X NORMAL) DO NOT ACTIVATE PLATELETS TOO EARLY MUST INJECT PRP INTO SPECIFIC AREA WITHIN 0.5 mm ACCURACY CAN ONLY BE ACHIEVED WITH ULTRASOUND GUIDED INJECTIONS 4/24/10ANTOINE I. JABBOUR, MD

33. MUSCULOSKELETAL ULTRASOUND (MSKUS) MUSCULOSKELETAL SONOGRAPHY RAPIDLY EVOLVING MODALITY WHICH IS GROWING IN POPULARITY IN THE MANAGEMENT OF SOFT TISSUE AND JOINT DISORDERS 4/24/10ANTOINE I. JABBOUR, MD

34. MSKUS ADVANTAGES OVER MRI READILY ACCESSIBLE PORTABLE QUICK SCAN TIME BETTER PATIENT TOLERABILITY LESS COST MRI STILL GIVES BETTER INTRAARTICULAR VIEWS. (LIGAMENTS,LABRUM, CARTILAGE) 4/24/10ANTOINE I. JABBOUR, MD

35. MSKUS TRANSDUCERS 12 L Mhz transducers Tennis elbow achilles shoulder knee 4 C Mhz transducers Hip spine 4/24/10ANTOINE I. JABBOUR, MD

36. MSKUS MODERN ULTRASOUND MACHINES WORK ON PULSE ECHO TECHNOLOGY TO PRODUCE HIGH RESOLUTION IMAGE COMPUTERS NOW ARE MUCH BETTER AT PRODUCING HIGH RESOLUTION IMAGES WITH CROSS BEAM TECHNOLOGY 4/24/10ANTOINE I. JABBOUR, MD

37. WHY DO WE NEED ULTRASOUND TO GUIDE OUR INJECTIONS? Accuracy of anterior intra-articular injection of the glenohumeral joint. Arthroscopy. 2005 Jan;21(1):77-80. Sethi PM, et at. Accuracy of needle placement into the intra-articular space of the knee. Journal of Bone & Joint Surgery. 2002 Sep; 84-A(9):1522-7.Jackson, Evans, Thomas 4/24/10ANTOINE I. JABBOUR, MD

38. WHY DO WE NEED ULTRASOUND TO GUIDE OUR INJECTIONS? Sacroiliac Joint Injections performed with sonographic guidance. J Ultrasound Med 22:553-559, 2003. Pekkafali, Kiralp, et al. AC JOINT: Accuracy of needle placement in ACJ injections. Knee Surg Sports Traumatol Arthrosc. 2006.14:762-765. Bisbinas, Belthur, Said, Green, Learmonth. 4/24/10ANTOINE I. JABBOUR, MD

39. WHY DO WE NEED ULTRASOUND TO GUIDE OUR INJECTIONS? THESE AND OTHER STUDIES HAVE SHOWN THAT EVEN EXPERIENCED PHYSICIANS AND SURGEONS ARE NOT INTRAARTICULAR >20% SOFT TISSUE INJECTIONS CAN BE DONE WITH 0.2 mm ACCURACY 4/24/10ANTOINE I. JABBOUR, MD

40. CLINICAL USES IN ORTHOPEDICS CURRENT CONCEPTS THE USE OF PLATELET RICH PLASMA IN ARTHROSCOPY AND SPORTS MEDICINE: OPTIMIZING THE HEALING ENVIRONMENT ARTHROSCOPY: VOL 26, No 2 February 2010 4/24/10ANTOINE I. JABBOUR, MD

41. CHRONIC ACHILLES TENDINOPATHY SANCHEZ IN AM J SPORTS MEDICINE 2007 SURGERY + PRGF DID BETTER AND RECOVERED SIGNIFICANTLY BETTER AND HAD A SMALLER AREA OF FIBROTIC TENDON AFTER 18 MONTHS AS COMPARED TO CONTROL GROUP 4/24/10ANTOINE I. JABBOUR, MD

42. CHRONIC TENNIS ELBOW ARNOCZKY, MISHRA ORTHOPEDICS TODAY 2009. THE ROLE OF PRP IN CONNECTIVE TISSUE. PRP COMPARED TO BUPIVICAINE. FASTER WITH PRP 4/24/10ANTOINE I. JABBOUR, MD

43. CHRONIC TENNIS ELBOW GOSEN FROM NETHERLANDS REPLICATED PROTOCOL WITH PRP VS STEROIDS. PORTUGAL 2008 4/24/10ANTOINE I. JABBOUR, MD

44. CHRONIC ROTATOR CUFF TENDINOPATHY ANDERSON & COLLEAGUES 2009 PLATELET RICH FIBRIN MATRIX USED LESS NARCOTICS AFTER SURGERY MANISCALO. ACTA BIOMED 2008 SHOWED GOOD RESULTS USING THE CASCADE MEMBRANE 4/24/10ANTOINE I. JABBOUR, MD

45. CHRONIC JUMPER’S KNEE MARCACCI AT THE RIZZOLI INSTITUTE INT ORTHOPEDICS JULY 2009 REFRACTORY PATELLAR TENDINOPATHY DID BETTER WITH PRP AS COMPARED TO PT ONLY 4/24/10ANTOINE I. JABBOUR, MD

46. MUSCLE INJURIES SANCHEZ, GERMANY MAY 2005 PRGF SYSTEM FROM BTI BIOTECHNOLOGY INSTITUTE EXTRACT HEMATOMA EARLY WITH ULTRASOUND AND THEN BACKFILL WITH PRGF 20 ATHLETES HEALED IN HALF THE EXPECTED TIME AND FIBROSIS NOT APPARENT AND NO RECURRENT PROBLEMS 4/24/10ANTOINE I. JABBOUR, MD

47. MENISCAL REPAIR ISHIDA: TISSUE ENG 2007 PRP ENHANCED RABBIT MENISCI HEALING IN VIVO AND IN VITRO SCAGLIONE, 2009 USED PRP AND MENISCAL REPAIR AND HAD 80% SUCCESS IN CLINICAL OUTCOMES 4/24/10ANTOINE I. JABBOUR, MD

48. SHOULDER SLAP REPAIRS HIRAHURA. CANADIAN ORTHOPEDIC ASSOCIATION JULY 2009 ENHANCED SLAP REPAIRS WITH FIBRIN-PRP CLOTS 4/24/10ANTOINE I. JABBOUR, MD

49. HIP LABRAL REPAIRS NO PUBLISHED REPORTS 4/24/10ANTOINE I. JABBOUR, MD

50. KNEE OSTEOCHONDRAL LOOSE BODY SANCHEZ; MED SCI SPORTS EXERCISE 2003. CASE REPORT 4/24/10ANTOINE I. JABBOUR, MD

51. KNEE ARTHRITIS SANCHEZ; CLIN EXP RHEUMATOLOGY, 2008 CUGAT; OSAKA JAPAN APRIL 2008 INTRAARTICULAR INJECTIONS OF PRGF TO TREAT OA 4/24/10ANTOINE I. JABBOUR, MD

52. KNEE ARTHRITIS ANITUA; RHEUMATOLOGY (OXFORD) 2007 PRP ENHANCE THE SECRETION OF HYALURONIC ACID AND INDUCE HEPATOCYTE GROWTH FACTOR PRODUCTION BY SYNOVIAL FIBROBLASTS FROM ARTHRITIC PATIENTS 4/24/10ANTOINE I. JABBOUR, MD

53. ACL FANELLI; ORTHOPEDICS TODAY 2009 PRP GRAFT WITH ALLOGRAFT ACL NO INFECTIONS, HEALED FASTER RADICE FROM CHILE. REV ARGENT. ARTOROSC 2008 PRP ACCELERATES GRAFT MATURATION BY HALF OF THE EXPECTED TIME SILVA; KNEE SURG SPORTS TRAUMATOLOGY ARTHROSCOPY 2009 PRP DID NOT CHANGE HEALING SMALL SAMPLE SIZE, NO ACTIVATION, NO SCAFFOLD) 4/24/10ANTOINE I. JABBOUR, MD

54. ACL AND PRP LIGAMENTIZATION OF TENDON GRAFTS TREATED WITH AN ENDOGENOUS PREPARATION RICH IN GROWTH FACTORS. SANCHEZ; ARTHROSCOPY VOL 26 No24, APRIL 2010 MORE REMODELING COMPARED WITH UNTREATED GRAFTS 4/24/10ANTOINE I. JABBOUR, MD

55. CONCLUSION NEED MORE DOUBLE BLIND RANDOMIZED STUDIES LONG TERM STUDIES HOW MANY PLATELETS ARE ENOUGH? WHICH GROWTH FACTORS NEEDED MORE? WHERE DOES IT WORK BEST? COST IS A MAJOR ISSUE HELP OUR PATIENTS AND NEVER CAUSING HARM 4/24/10ANTOINE I. JABBOUR, MD

56. PLATELET RICH PLASMA AND MUSCULOSKELETAL ULTRASOUND ANTOINE I. JABBOUR, MD TULSA BONE & JOINT ASSOCIATES 918 392 1400 www.drjabbour.com 4/24/10ANTOINE I. JABBOUR, MD

57. PLATELET RICH PLASMA AND MUSCULOSKELETAL ULTRASOUND 4/24/10ANTOINE I. JABBOUR, MD