\\HSUSA-MS\Documents\06-Jennifer\PRP September 23, 2011\REORGANIZED - Dr Tai PRP Workshop - 09-23-2011.pptx Platelet Rich Plasma copyrights:oibconsultantsinc

Circulation – Blood Vessel copyrights:oibconsultantsinc

What is PRP? PRP stands for Platelet Rich Plasma \\HSUSA-MS\Documents\06-Jennifer\PRP September 23, 2011\REORGANIZED - Dr Tai PRP Workshop - 09-23-2011.pptx What is PRP? PRP stands for Platelet Rich Plasma Blood houses all cellular components Red blood cells White blood cells Platelets Plasma Naturally make up only 10% of our blood’s cellular components In PRP Platelet ratio is flipped to 90% platelets copyrights:oibconsultantsinc

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

Platelet RBC/WBC copyrights:oibconsultantsinc

What is PRP Therapy? PRP is PRP is injected into affected region 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

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

What are the Benefits of PRP? Thought to rely on Intrinsic platelet properties Concentrated growth factors 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: 2259-2272. Wroblewski AP, Melia HJ, Wright VJ. Application of platelet-rich plasma to enhance tissue repair. Oper Tech Orthop 2010; 20: 98-105. 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: 638-646. 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: 158-167. copyrights:oibconsultantsinc

PRP Platelet Rich Plasma Used successfully in various specialties 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 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: 47-50. Gamradt Seth C, et al. Platelet Rich Plasma in Rotator Cuff Repair. Techniques in Orthopaedics. 22(1): 26-33. 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: 174-187. copyrights:oibconsultantsinc

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

Hines Ward copyrights:oibconsultantsinc

Troy Polamulu copyrights:oibconsultantsinc

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

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

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

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

Matrix copyrights:oibconsultantsinc

PRP Used to Treat Musculoskeletal injuries Distance runners Over 100 million office visits yearly Stronger bones Regenerate muscle & tendon Increase vascularity Distance runners 52% suffer injury to Achilles tendon during lifetime Mishra A, et al. Treatment of Chronic Elbow Tendinosis with Buffered Platelet-Rich Plasma: American Journal of Sports Medicine. 2006; 34: 1774-1778. Zafar MS, et al. Basic science and clinical aspects of achilles tendenopathy. Sports Med. Arthro 2009: 17(3). copyrights:oibconsultantsinc

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

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 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: 174-187. copyrights:oibconsultantsinc

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 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: 199-207. copyrights:oibconsultantsinc

Delivery of PRP Delivery of PRP without exogenous activator Commonly performed Evidence demonstrating platelets can be slowly activated Exposure to tendon-derived collagen alone Mishra A, Pavelko T: Treatment of chronic elbow tendinosis with buffered platelet rich plasma. Am J Sports Med 2006; 34: 1774-1778. 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: 684-690. copyrights:oibconsultantsinc

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 Gamradt SC, Rodeo SA, Warren RF: Platelet rich plasma in rotator cuff repair. Tech Orthop Surg 2007; 22: 26-33. 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: 245-251. copyrights:oibconsultantsinc

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

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

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

Hesham El-Sharkawy et al… Measured Normal T-cell expressed & secreted (RANTES) levels By enzyme-linked immunosorbent assay Platelet derived growth factor (PDGF)-AB Analyzed PDGF-BB Transforming growth factor-b1 Cytokine Insulin-like growth factor-I Chemokine Fibroblast growth factor-basic (FGF-b) LXA4 levels Epidermal growth factor (EGF) Monocyte chemotactic migration Vascular endothelial growth factor Interleukin-12 (p40/70) PRP led to significantly increased levels of growth factors Regulated on activation Significantly suppressed inflammation By promoting secretion of LXA4 Hesham El-Sharkawy et al. Platelet-Rich Plasma: Growth Factors and Pro- and Anti-Inflammatory Properties. J Periodontol. April 2007; 78: 661-669. copyrights:oibconsultantsinc

Platelet Biology Hematology Slide copyrights:oibconsultantsinc

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

Platelet Granules copyrights:oibconsultantsinc

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 Wroblewski AP, Melia HJ, Wright VJ. Application of platelet-rich plasma to enhance tissue repair. Oper Tech Orthop 2010; 20: 98-105. 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: 638-646. 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: 9-12. 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: 158-162. copyrights:oibconsultantsinc

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

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 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, 1998. Kevy S, Jacobson M: Preparation of growth factors enriched autologous platelet gel. Proceedings of the 27th Annual Meeting of Service Biomaterials, April 2001. copyrights:oibconsultantsinc

Various Growth Factors in PRP Source Function Transforming Growth Factor-beta, TGF-β Platelets, extracellular matrix of bone, cartilage matrix, activated TH1 cells and natural killer cells, macrophages/monocytes and neutrophils Stimulates undifferentiated mesenchymal cell proliferation; regulates endothelial, fibroblastic and osteoblastic mitogenesis; regulates collagen synthesis and collagenase secretion; regulates mitogenic effects of other growth factors; stimulates endothelial chemotaxis and angiogenesis; inhibits macrophage and lymphocyte proliferation Basic Fibroblast Growth Factor, bFGF Platelets, macrophages, mesenchymal cells, chondrocytes, osteoblasts Promotes growth and differentiation of chondrocytes and osteoblasts; mitogenic for mesenchymal cells, chondrocytes and osteoblasts Platelet Derived Growth Factor, PDGFa-b Platelets, osteoblasts, endothelial cells, macrophages, monocytes, smooth muscle cells Mitogenic for mesenchymal cells and osteoblasts; stimulates chemotaxis and mitogenesis in fibroblast/glial/smooth muscle cells; regulates collagenase secretion and collagen synthesis; stimulates macrophage and neutrophil chemotaxis Epidermal Growth Factor, EGF Platelets, macrophages, monocytes Stimulates endothelial chemotaxis/angiogenesis; regulates collagenase secretion; stimulates epithelial/mesenchymal mitogenesis Vascular endothelial growth factor, VEGF Platelets, endothelial cells Increases angiogenesis and vessel permeability, stimulates mitogenesis for endothelial cells Connective tissue growth factor, CTGF Platelets through endocytosis from extracellular environment in bone marrow Promotes angiogenesis, cartilage regeneration, fibrosis and platelet adhesion copyrights:oibconsultantsinc

Growth Factor Yields Per Device Mean PRP Volume (mL) PDGF-αβ (ng/mL) TGF-β (ng/mL) Laboratory Centrifuge (Anitua Protocol) 9.5 + 4.1 35 + 11.3 52 + 7.6 Laboratory Centrifuge (Landesberg Protocol) 10.6 + 2.4 26 + 13.7 50 + 10.8 Clinaseal Sealed Technology Centrifuge* 7.6 + 1.5 46 + 15.3 55 + 18.7 ACE Surgical ** 7.8 + 0.6 35 + 17.2 43 + 17.9 AG Curasan*** 39 + 11.4 39 + 16.4 3i PCCS 7.0 + 1.5 103 + 27 144 + 31.1 Harvest Technologies “SmartPReP” 7.4 + 0.5 133 + 29.2 170 + 42.3 *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, 1995. Anitua E: The use of plasma rich growth factors (PRGF) in oral surgery. Pract Proced Aesthet Dent 13: 487, 2001. copyrights:oibconsultantsinc

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 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: 2259-2272. 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: 158-167. copyrights:oibconsultantsinc

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 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: 158-167. copyrights:oibconsultantsinc

Segmentation of Blood copyrights:oibconsultantsinc

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

Predictability Technology Flexibility 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

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

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

Predictability Speed Confidence 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

Reliability Automation Consistency 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

PRP Platelet Concentration Whole blood specimen PRP specimen copyrights:oibconsultantsinc

APC+® Procedure Packs APC-20 APC-60 APC-120 Provides 3 ml of APC+ for small applications APC-60 Provides 5 - 10 ml of APC+ for medium applications APC-120 Provides 10 - 20 ml of APC+ for large applications copyrights:oibconsultantsinc

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

Matrix Scaffold & Platelet copyrights:oibconsultantsinc

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

Research Growth factors derived from platelets At the wound site 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) Slater, Michael, et al, Involvement of Platelets in Stimulating Osteogenic Activity, Journal of Orthopaedics Research, 1995: 13: 655-663. 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. copyrights:oibconsultantsinc

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

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 Kirsner, R., Eaglstein, W.H., The Wound Healing Process, Wound Healing, 1993; 11: 629-640. Patel, T. et al, The use of Platelet Concentrate in Posterolateral Fusion Biomechanical and Histological Analysis, Presented at the 28th meeting of the International Society for the Study of Lumbar Spine, Edinburgh, Scotland, June 2001. Marx, R.E. et al, Platelet-Rich Growth Factor Enhancement for Bone Grafts, Oral Surg Oral Med, Oral Pathol, 1998; 85: 638-646. 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. copyrights:oibconsultantsinc

Quality Method used for concentrating platelets Direct impact on bioactive proteins available to accelerate wound healing process Slater, Michael, et al, Involvement of Platelets in Stimulating Osteogenic Activity, Journal of Orthopaedics Research, 1995: 13: 655-663. 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. Patel, T. et al, The use of Platelet Concentrate in Posterolateral Fusion Biomechanical and Histological Analysis, Presented at the 28th meeting of the International Society for the Study of Lumbar Spine, Edinburgh, Scotland, June 2001. Marx, R.E. et al, Platelet-Rich Growth Factor Enhancement for Bone Grafts, Oral Surg Oral Med, Oral Pathol, 1998; 85: 638-646. 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. copyrights:oibconsultantsinc

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

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 Marx, R.E. et al, Platelet-Rich Growth Factor Enhancement for Bone Grafts, Oral Surg Oral Med, Oral Pathol, 1998; 85: 638-646. 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. Kevy, S.V., Characterization of Growth Factor Levels in Platelet Concentrates, Presented at Engineering Tissues, 5th Annual Meeting, February, 2001. 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, 2001. Kevy, S.V., Jacobson, M.S., Platelet Concentrate Preparation in the Office Setting: A Comparison of Manual and Automated Devices, March, 2001. copyrights:oibconsultantsinc

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 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: 987-996. copyrights:oibconsultantsinc

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

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

Leukocytes Leukocytes Recent studies have suggested May result in secondary tissue damage in setting of muscle injuries Recent studies have suggested Importance of keeping leukocytes in PRP concentrate Smith C, Kruger MJ, Smith RM. Myburgh KH. The inflammatory response to skeletal muscle injury: illuminating complexities. Sports Med 2008; 38: 947-969. Toumi H, Best TM. The inflammatory response: friend or enemy for muscle injury? Br J Sports Med 2003; 37: 284-286. 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: 1101-1106. copyrights:oibconsultantsinc

Leukocytes Leukocytes Leukocyte use in PRP \\HSUSA-MS\Documents\06-Jennifer\PRP September 23, 2011\REORGANIZED - Dr Tai PRP Workshop - 09-23-2011.pptx Leukocytes 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 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: 158-167. 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. copyrights:oibconsultantsinc

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 Kumar V et al. Chapter 2 – Acute and chronic inflammation. In Robbins and Cotran Pathologic Basis of Disease, 7th ed. 2005. Saunders. Available at www.mdconsult.com. copyrights:oibconsultantsinc

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

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

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 Hesham El-Sharkawy et al. Platelet-Rich Plasma: Growth Factors and Pro- and Anti-Inflammatory Properties. J Periodontol. April 2007; 78: 661-669. copyrights:oibconsultantsinc

copyrights:oibconsultantsinc PRP Video Foot Open Ulcer 0m 50s copyrights:oibconsultantsinc

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%) 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: 665-671. copyrights:oibconsultantsinc

Tissue Healing First step of healing process Clot formation Platelet activation Many growth & differentiation factors released from α-granules Storage units found in platelets Wroblewski AP, Melia HJ, Wright VJ. Application of platelet-rich plasma to enhance tissue repair. Oper Tech Orthop 2010; 20: 98-105. Marx R. Platelet-function: assays and events – introduction. Suppl Thromb Haemost 1978; 63: 65-80. copyrights:oibconsultantsinc

Wound Healing Cascade copyrights:oibconsultantsinc

Necessary Physiology Stages of Healing Normal platelet activation leads to three necessary stages of healing Inflammation Proliferation Remodeling Kumar V et al. Chapter 2 – Acute and chronic inflammation. In Robbins and Cotran Pathologic Basis of Disease, 7th ed. 2005. Saunders. Available at www.mdconsult.com. de la Torre J. The physicology of healing the chronic wound. http://www.emedicine.com/plastic/topic477.htm#section~the_physiology_of_healingof_the_chronic_wound. Last Updated: May 26, 2006. Last accessed 12/09/07. copyrights:oibconsultantsinc

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 Everts PA, Knape JT, Weibrich G, et al. Platelet-rich plasma and platelet gel: a review. J Extra Corpor Technol 2006; 38: 174-187. copyrights:oibconsultantsinc

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

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

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

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 Kumar V et al. Chapter 2 – Acute and chronic inflammation. In Robbins and Cotran Pathologic Basis of Disease, 7th ed. 2005. Saunders. Available at www.mdconsult.com. Liu YBA et al. Fibroblast Proliferation due to Exposure to a Platelet Concentrate in Vitro is pH Dependent. Wound Rep Reg. 2002; 10: 336-340. copyrights:oibconsultantsinc

Proliferative Phase Fibroblasts become most abundant cell Fibroblasts 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

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

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

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 Kumar V et al. Chapter 2 – Acute and chronic inflammation. In Robbins and Cotran Pathologic Basis of Disease, 7th ed. 2005. Saunders. Available at www.mdconsult.com. copyrights:oibconsultantsinc

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 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. 2007. 6(2): 89-94. www.Harvesttech.com. Last accessed 12/09/07. copyrights:oibconsultantsinc

Matrix Scaffold & Platelet copyrights:oibconsultantsinc

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

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

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 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: 174-187. Creaney L and Hamilton B. Growth Factor Delivery Methods in the Management of Sports Injuries: TheState of Play. Br J Sports Med. 2007 10.1136: 1-16. Published online: Nov 5, 2007. Scott JD and Pawson T. Cell communication: The inside story. Sci Am . Jun 2000. pp 54-61. copyrights:oibconsultantsinc

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

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) 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 2007. 89-B(3): 417-420. copyrights:oibconsultantsinc

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

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

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

PRP is Bacteriocidal During initial inflammatoyr phase 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 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: 174-187. 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 2007. 89-B(3): 417-420. copyrights:oibconsultantsinc

Technique for Myotendinous or Teno-Osseous Sites Alcohol or Betadyne prep Stimulate greatest number of fibroblast colonies Prefer Betadyne gel when using ultrasound probe for “live” injection guidance For myotendinous sites Use ultrasound to ensure layered treatment through tendon +/- Ethyl Chloride spray Sterile band-aid applied post injection Inject PRP with approximately 1cc PRP per cm3 of tissue/interface Kinesiotape to protect motion if needed Important to touch bone and “pepper” area of teno-osseous junction copyrights:oibconsultantsinc

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

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

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

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

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

copyrights:oibconsultantsinc PRP Video Elbow PRP 1m 03s copyrights:oibconsultantsinc

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

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

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

Kevy & Jacobson Evaluated mixture of common local anesthetics with PRP Found no significant platelet activation or diminution of graft growth factor functions Kevy SV and Jacobson MS. Comparison of methods for point of care preparation of autologous platelet gel. J Extra Corpor Technol. 2004; 36: 28-35. Personal communication of primary author and the Center for Blood Research, Cambridge, MA. February 2007. copyrights:oibconsultantsinc

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 Schnabel L et al. Platelet Rich Plasma (PRP) Enhances Anabolic Gene Expression Patterns in Flexor Digitorum Superficialis Tendons. J of Orthopaedic Research. 2006; pp. 230-240. copyrights:oibconsultantsinc

du Toit et al… Culture studies performed for use in dermal regeneration Confirmed potent mitogenic stimulation of Human fibroblasts Keratinocytes Chondrocytes Neural tissue Myoblasts 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): 64-73. copyrights:oibconsultantsinc

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 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: 281-286. copyrights:oibconsultantsinc

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 Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003; 93: 234-237. copyrights:oibconsultantsinc

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 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: 2259-2272. Malliaropoulos N, Papacostas E, Kiritsi O, et al. Posterior thigh muscle injuries in elite track and field athletes. Am J Sports Med 2010; 38: 1813-1819. 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. copyrights:oibconsultantsinc

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

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 Mishra A et al. Treatment of Chronic Elbow Tendinosis with Buffered Platelet-Rich Plasma: American Journal of Sports Medicine. 2006; 34: 1774-1778. copyrights:oibconsultantsinc

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 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. 2006. 77(5): 806-812. copyrights:oibconsultantsinc

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 No complications noted Scarpone MA, Davenport M, and Rauker N. PRP as a Treatment Alternative for Symptomatic Rotator Cuff Tendinopathy for Patients Failing Conservative Treatment. 2005. http://www.treatingpain.com/pages/int_pain/ScarponeRotatorCurrstudy.pdf. Last accessed 1/2/08. copyrights:oibconsultantsinc

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 Ventura A et al. Use of Growth Factors in ACL Surgery: Preliminary Study. Journal of Orthopaedic Traumatology. 2005; 6: 76-79. copyrights:oibconsultantsinc

Study Type (level of evidence) Clinical Evidence for Use for Platelet-Rich Plasma in Sports Medicine (Nonsurgical) Study Area of Treatment Study Type (level of evidence) No. of Patients PRP system Results Mishra and Pavelko Lateral and medial epicondylitis Prospective cohort (II; 10 patients randomized) 20 GPS III (Biomet, Warsaw, IN) 60% versus 16% VAS improvement at 8 wk; 93% improvement at mean 25.6 mo Gosens et al (unpublished preliminnary data, cited in Mishra et al) Lateral epicondylitis Randomized controlled trial (I) 100 GPS III (Biomet) Improved VAS and DASH compared with corticosteroid injection at 6 mo Kon et al Patellar tendinopathy Prospective cohort (II) Not reported 70% with complete or marked improvement; 80% satisfied Barrett and Erredge Plantar fasciitis Retrospective cohort (IV) 9 Seven of nine patients with complete pain relief at 1 year Sanchez et al Muscle injury PRGF System (BTI, Victoria, Spain) Full recovery in all patients in half the expected time Knee osteoarthritis 30 PRGF System (BTI) Improved pain and WOMAC scores versus HA injections at 5-wk follow-up copyrights:oibconsultantsinc

Study Type (level of evidence) Clinical Evidence for Use for Platelet-Rich Plasma in Sports Medicine (Surgical) Study Area of Treatment Study Type (level of evidence) No. of Patients PRP system Results Sanchez et al Achilles tendon repair Case-control (III) 12 PRGF System (BTI) Faster return of ROM, jumping and jogging compared with controls. No wound complications Randelli et al Rotator cuff repair Prospective cohort (II) 14 GPS II (Biomet) All pts improved VAS, Constant, and UCLA scores at 2 yr. No adverse effects Everts et al Open subacromial decompression Randomized controlled trial (I) 40 GPS III (Biomet) Faster recovery, earlier return to daily activities, less pain medication requirements Orrego et al Anterior cruciate ligament reconstruction Randomized controlled trial (II) 108 Reduced MRI signal intensity in graft at 6 mo. No difference in tunnel widening or bone-tendon interface Silva and Sampaio Mini GPS III (Biomet) No difference in MRI signal intensity at 3 mo Articular cartilage defect Case report (V) 1 Improved pain and return to activity copyrights:oibconsultantsinc

Refernces Mishra A, Pavelko T: Treatment of chronic elbow tendinitis with buffered platelet rich plasma. Am J Sports Med 2006; 34: 1774-1778. Mishra A, Woodall J Jr, Vieira A: Treatment of tendon and muscle using platelet-rich plasma. Clin Sports Med 2009; 28: 113-125. 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: 598-603. Barrett S, Erredge S: Growth factors for chronic plantar fasciitis. Podiatry Today. 2004; 17: 37-42. Sanchez M, Anitua E, Andia I: Poster presentation: Application of autologous growth factors on skeletal muscle healing. Regmed 2005. Available at: http://www.harvesttech.com/pdf/Orthopedic-PRP/Sports%20Medicine/66-SanchezRegMed2005.pdf. Accessed September 4, 2009. 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: 910-913. copyrights:oibconsultantsinc

References 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: 245-251. 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: 1584-1589. 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: 203-210. 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: 1373-1380. Silva A, Sampaio R: Anatomic ACL reconstruction: Does the platelet-rich plasma accelerate tendon healing? Knee Surg Sports Traumatol Arthrosc 2009; 17: 676-682. 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: 1648-1652. copyrights:oibconsultantsinc

Sanchez et al… Reported on case-control study of 12 athletes with complete Achilles rupture 14 vs. 21 weeks Measured All 12 had open Achilles repair IGF-1 6 had PRGF TGF-B1 PDGF-AB Treatment group had no wound complications & experienced earlier functional restoration EDF VEGF HGF ROM 7 vs. 11 weeks Noted that number of platelets held direct correlation to level of growth factors Jogging 11 vs. 18 weeks Training 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): 245-251. copyrights:oibconsultantsinc

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 Sanchez M, et al. Application of Autologous Growth Factors on Skeletal Muscle Healing. 2nd World Congress on Regenerative Medicine. Podium Presentation. May, 2005. copyrights:oibconsultantsinc

Ultrasound-Guided Needle Placement 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 copyrights:oibconsultantsinc

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

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 Sanchez M et al. Plasma Rich in Growth Factors to Treat Articular Cartilage Avulsion: A Case Report. Medicine & Science in Sports & Exercise. 2003. pp. 1648-1652. copyrights:oibconsultantsinc

Knee X-Ray copyrights:oibconsultantsinc

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

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

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 The Healing Effects of Autologous Platelet Gel on Acute Human Skin Wounds. Arch Facial Plast Surg. May-Jun 2007. 9(3): 174-183. copyrights:oibconsultantsinc

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 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. 2006 52(6): 68-87. copyrights:oibconsultantsinc

Pain Reduction With PRP \\HSUSA-MS\Documents\06-Jennifer\PRP September 23, 2011\REORGANIZED - Dr Tai PRP Workshop - 09-23-2011.pptx 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 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: 203-210. 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: 633-637. Vanhoutte PM. Platelet-derived serotonin, the endothelium, and cardiovascular disease. J Cardiovasc Pharmacol. 1991; 17S: S6-S12. copyrights:oibconsultantsinc

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

Joint copyrights:oibconsultantsinc

ESCs & MSCs ESCs (Embryonic) MSCs (Mesenchymal) 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

Synergy Between Stem Cells & PRP \\HSUSA-MS\Documents\06-Jennifer\PRP September 23, 2011\REORGANIZED - Dr Tai PRP Workshop - 09-23-2011.pptx 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 The Journal of Musculoskeletal Medicine, July 2009, pages 256-262. copyrights:oibconsultantsinc

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

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

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

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

copyrights:oibconsultantsinc PRP Video Hand Rejuvenation 0m 13s copyrights:oibconsultantsinc

Smart Skin Removes surface dead skin Recommended for daily use \\HSUSA-MS\Documents\06-Jennifer\PRP September 23, 2011\REORGANIZED - Dr Tai PRP Workshop - 09-23-2011.pptx Smart Skin Removes surface dead skin Progressive Recommended for daily use Non-invasive copyrights:oibconsultantsinc

Diamond Microdermabrasion \\HSUSA-MS\Documents\06-Jennifer\PRP September 23, 2011\REORGANIZED - Dr Tai PRP Workshop - 09-23-2011.pptx Diamond Microdermabrasion Innovative natural skin care therapy Rejuvenate/renew/resurface skin Promotes growth of Collage Elastin copyrights:oibconsultantsinc

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

MTS Roller™ copyrights:oibconsultantsinc

Laser Re-Surfacing vs. Microneedle Therapy copyrights:oibconsultantsinc

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

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

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

Absorbency 200 very fine needles Serum absorption 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

Absorbency copyrights:oibconsultantsinc

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

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

How Microneedle Therapy System Works copyrights:oibconsultantsinc

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 100-1000µm in length, 10-15µm in tip diameter Pierce stratum corneum Create microconduits Transport across stratum corneum copyrights:oibconsultantsinc

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

Frequently Asked Questions About MTS copyrights:oibconsultantsinc

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 5th or 6th treatment Patients experience results similar to deep chemical peel or laser resurfacing copyrights:oibconsultantsinc

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

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

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

Skin Thickness (µm) Control IPL Micro-needling 93 113 95 127 129 110 86 123 80 102 100 84 118 101 128 82 111 133 97 117 88 107 132 104 85 108 87 153 137 146 125 138 copyrights:oibconsultantsinc

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

Collagen Quantitative Analysis (ELISA) Control IPL Micro-needling 13.873 22.298 23.600 13.683 21.957 53.300 16.027 15.069 20.877 12.275 21.776 16.108 7.470 17.425 26.460 14.101 29.546 41.100 10.749 13.702 23.708 18.218 23.094 21.886 19.957 17.806 12.921 10.796 19.176 31.921 16.111 9.756 21.080 8.336 15.165 20.225 10.253 17.554 19.883 11.032 20.425 29.178 9.757 16.298 18.916 11.790 18.642 21.909 12.180 24.741 20.448 11.791 21.253 29.842 copyrights:oibconsultantsinc

Skin Thickness copyrights:oibconsultantsinc

Collagen Quantitative Analysis (ELISA) copyrights:oibconsultantsinc

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

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

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

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

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

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

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

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

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

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

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

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

Micro Needling & Injecting Platelet Rich Plasma 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

New Collagen & Elastin Formation Before After copyrights:oibconsultantsinc

Patients received three treatments at two week intervals Kim S.E., Ko D.S., and Lee A.Y., Moon H.S., Medical Conference Presentation, Dongguk University, 2005. 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

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

TGF-beta & PDGF TGF-beta PDGF 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 Choi, Y., Fuchs, E., 1990. TGF-beta and retnoic acid regulation of growth and modifiers of differentiation human epidermal cells. Crell regal. 1, 791-809. Ross, R., 1986. Platelet-derived growth factor. Am Rev. Med. 38, 71-79. 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, 2229-2233. copyrights:oibconsultantsinc

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 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), 244-255. copyrights:oibconsultantsinc

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

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

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

Before & After copyrights:oibconsultantsinc

SmartPReP Platelet Concentration System Performance copyrights:oibconsultantsinc