1. Platelet Rich Plasma: Emerging Role in Orthopaedic Surgery
Lucas J. Bader M.D.
Orthopaedic Surgeon
Fellowship Trained Foot & Ankle Surgeon

2. Disclosure
None

3. Goals Definition of PRP Review Basic Science
Current Clinical Applications
Review of the Literature
Future

4. Introduction Emerging field of Biologics
PRP utilized and studied since the 1970’s
Origins in fields of maxillofacial and general surgery

8. Definition Platelet Rich Plasma
Nonnucleated bodies in peripheral blood
Autoglous blood with a concentration of platelets above a baseline value
Fluid portion of blood

9. Bioactive Factors
Potentially enhance healing by delivery of various growth factors and cytokines
α granules
Dense granules

10. α-Granules Cell proliferation Chemotaxis Cell differentiation
Angiogenesis
Conductive Scaffold

11. Platelet Derived Growth Factor
Cell replication
Angiogenesis
Mitogen for fibroblasts

12. Vascular Endothelial Growth Factor
Angiogenesis

13. Transforming Growth Factor-β1
Regulator in balance between fibrosis and myocyte regeneration

14. Fibroblast Growth Factor
Proliferation of myoblasts,
Angiogenesis

15. Epidermal Growth Factor
Proliferation of mesenchymal and epithelial cells

16. Hepatocyte Growth Factor
Angiogenesis,
Mitogen for endothelial cells
Antifibrotic

17. Insulin-like growth factor-1
Stimulates myoblasts/fibroblasts
Mediates growth/repair skeletal muscle

19. Adhesive Proteins
Fibrinogen
Fibronectin
Vitronectin
“scaffold”

21. Dense Granules Non-Growth Bioactive Molecules
Fundamental effect on the biologic aspects of inflammation
Cell migration
Conductive Matrix

22. Serotonin & Histamine Increase capillary permeability
Inflammatory cell access
Macrophage Activation

23. Adenosine Receptor Activation
Modulates inflammation

25. Advantage
Normal biologic ratios vs Exogenous Factors

26. Formulation of PRP Can only be made from anticoagulated blood
Cannot be made form clotted whole blood
Cannot be made from serum

27. Preparation
30-60 cc Drawn
Add citrate to bind ionized calcium and prohibit clotting cascade

28. Centrifugation Step 1 Step 2 Red blood cells Leukocytes Platelets
Platelet-Poor Portion
Platelet-Rich Portion

30. Activating Agents Calcium Chloride and/or Thrombin (OR)
Collagen (Office)
Initiates
Platelet activation
Clot formation
Growth Factor Release

31. Growth Factor Release
70 % within 10 minutes
Nearly 100% within 1 hr

32. PRP Preparations Systems
Several Available
Qualitative and Quantitative Variability
Volume of autologous blood
Centrifuge rate/time
Delivery Method
Activating Agent
Leukocyte concentration (?)
Final PRP volume
Final Platelet and Growth Factor Concentration

34. Safety Concerns Autologous Blood Aseptic technique
Relative Contraindications
Hx of thrombocytopenia
Anticoagulant therapy
Active infection
Tumor
Metastatic Disease

35. Cost $150-$180 small kits $200 large Kits Centrifuge $1800
PRP is currently considered experimental and is not reimbursed by most third party payers

36. Effects of PRP on Soft Tissues & Bone- Basic Science
3 phases of healing
Inflammation
Proliferation
Remodeling
Basic Metabolic Processes
Chemotaxis
Angiogenesis
Differentiation
EC Matrix Production

37. Effects PRP on Tendon Collagen gene expression
Vascular endothelial growth factor
Hepatocyte growth factor
Matrix Metalloproteinase
Tendon strength and callus formation
Cell formation and angiogenesis

38. Effects PRP on Muscle
IGF-1 & basic FGF improve healing and increase fast twitch and tetanus strength
Accelerated satellite cell activation
Increased diameter of regenerating myofibrils

39. Effects PRP on Bone Stimulate Osteoblasts Stmulate Fibroblasts
Up regulate Osteoclacin
Encourage differentiation of MSC into bone forming cells

40. Further Study Acute injury Chronic injury Timing of injection
Effect of serial injections

41. Orthopaedic Applications for PRP
Chronic Tendinopathies
Bone healing
Acute Ligamentous Injuries
Muscle injuries
Intraoperative Augmentation

42. Chronic Tendinopathy Lateral/medial Epicondylitis
Achilles Tendinopathy
Patellar Tendinopathy
Posterior Tibial Tendinopathy
Plantar Fasciitis

43. Bone Healing
Fracture Healing
Distraction Osteogenesis
Osteoarthritis

44. Acute Ligamentous Injury
Knee medial collateral ligament
Ankle syndesmosis
Ankle lateral ligament complex

45. Intraoperative Use Total Knee arthroplasty ACL reconstruction
Achilles Tendon Repair
Rotator Cuff Repair
Acute Articular Cartilage Repair

46. Review of the literature
Numerous basic science, animal studies, and small case reports
Few controlled clinical studies
Majority of studies are small, anecdotal, and underpowered
Non-standardized techniques

48. Randomized controlled trial; Level 1 of evidence
Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-Year Follow-Up. Gosens T, Peerbooms JC, van Laar W, den Oudsten BL.
Randomized controlled trial; Level 1 of evidence
PRP group (n = 51) or the corticosteroid group (n = 49)
PRP group was more often successfully treated than the corticosteroid group (P < .0001). Success was defined as a reduction of 25% on VAS or DASH scores without a re-intervention after 2 years.

49. PRP group (n = 27) or placebo group (n = 27)
Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy A Randomized Controlled TrialRobert J. de Vos, MD; Adam Weir, MBBS; Hans T. M. van Schie, DVM, PhD; Sita M. A. Bierma-Zeinstra, PhD; Jan A. N. Verhaar, MD, PhD; Harrie Weinans, PhD; Johannes L. Tol, MD, PhD
Eccentric exercises (usual care) with either a PRP injection (PRP group) or saline injection (placebo group)
PRP group (n = 27) or placebo group (n = 27)
The mean VISA-A score improved significantly after 24 weeks in the PRP group and in the placebo group, but the increase was not significantly different between both groups

50. Sample size of 30 patients in each group
Platelet-rich Fibrin Matrix in Arthroscopic Rotator Cuff Repair: A Prospective, Randomized Study Stephen C Weber, MD Sacramento CA Jeffrey I Kauffman, MD Sacramento CA
Sample size of 30 patients in each group
Serial VAS scores were obtained, as well as SST scores at each interval. Final scores for each group included UCLA and ASES scores.
Early follow-up does not show significant improvement in perioperative pain or clinical outcome.

51. Prospective study of thirty patients No controls
Platelet Rich Plasma (PRP) Effectively Treats Chronic Achilles Tendonosis Raymond R Monto, MD
Prospective study of thirty patients
No controls
AOFAS scores improved to 92 at 6 months. Resolution of Achilles abnormalities were seen in post treatment MRI/ultrasound studies and 28/30 were clinically satisfied with their clinical results.

52. Literature Summary Greatest support in treating tendinopathy
Lateral Epicondylitis
Patellar Tendinopathy
Achilles Tendinopathy
Plantar Fasciitis
Caution with Acute Injuries
Risk of Fibrosis
Return to activity too early

53. Future PRP promising, but not proven Appropriately powered studies
Sophisticated models of healing
More precise formulations of PRP
Narrower indications, but more definitive

54. My Protocol Treatment of last resort prior to surgery
Indicated for chronic tendinopathies
Performed under ultrasound guidance
NSAIDS discontinuation 1 week prior and 2 weeks post procedure
Activity modification for 7 days

56. Thanks!