1. PRP Update
By Kenneth A. Jurist, M.D.

2. What is PRP?
PRP is simply whole blood that is centrifuged to create an increased concentration of platelets with or without WBC’s

3. What’s so special about Platelets?
Platelets contain granules that store large numbers of “growth factors”
Alpha granules released (activated) when platelets aggregate and adhere to a site of injury or inflammation
Listing of other growth factors: interleukin-1, tumor necrosis factor, transforming growth factor, insulin growth factor and more
It is the activation of platelets and release of the various growth factors that makes them special and is the key to enhancing tissue repair and healing!

4. Platelet Rich Plasma Biology
What do these Growth Factors Do??
Chemotaxis
Directional movement in response to a chemical stimulus
Stems cells are attracted to the growth factors and migrate into the area
Cell proliferation
Significant increase in cellular reproduction activity
Possibly even a systemc effect
Performance enhancing?

5. The Primary Growth Factors Role in Soft Tissue Healing and Repair
PDGF
2 polypeptide chains
AB, BB and AA types (AB in human platelets)
Stored in alpha granules in platelets
Receptors are found in tendon, cartilage, synovium and elsewhere
TGF beta
Also polypeptide, multiple chains, TGF beta-1 most studied form
Found in platelets and bone, cartilage
Also found in macrophages
Receptors are universal in cells throughout the body

6. Effect of PDGF on Tissues
Immediate (within 5 minutes)
Second messenger stimulation
Inflammatory response
Early (30min to 4 hours)
M-RNA stimulation, protein synthesis
Chemotaxis (draws cells to the area)
Late (4-24 hours)
Fibroblast mitosis

7. Effect of TGF-Beta on Tissues
Actually inhibits cell growth
More of a modulator of cell growth, differentiation
Very important in wound repair

8. Summary of Effect of Platelet Growth Factors on Tissues
It appears that through a complex series of biochemical and cellular events, these growth factors cause a rapid and sustained increase in the number of fibroblasts in an area and then through a poorly understood interaction among factors modulates cellular activity to cause stem cell maturation.

9. Breaking News? Is this Twitter Worthy News????
So when did all this information about platelets get discovered?
Is this Twitter Worthy News????

10. AOSSM sponsored Sports Induced Inflammation Workshop
AOSSM sponsored Sports Induced Inflammation Workshop. Bethesda, Maryland. May 1989.
“Although the cellular events involved in the healing and repair of musculoskeletal connective tissue injuries are reasonably well described, the molecular mechanisms regulating these responses are incompletely understood. New information, particularly on the roles of various cytokines and growth factors in inflammation and wound healing, however, is continually being published. This information may ultimately have far reaching therapeutic implications.”

11. Round Table Discussion on Clinical uses of PRP Dr
Round Table Discussion on Clinical uses of PRP Dr. Steven Arnoczky - moderator. Orthopedics Today March 2009
“Platelet rich plasma (PRP) is generically defined as an increase (above baseline) in the concentration of platelets and their associated growth factors. While the clinical benefits of PRP in enhancing the healing of musculoskeletal tissues are only beginning to be explored, the substantial amount of basic science data supporting the role of growth factors in enhancing cell migration, proliferation and matrix synthesis has provided a compelling rationale for use of PRP in the treatment and repair of various connective tissue structures.”

12. PRP IS NOT!
Stem cells
MSC’s
Lipocytes
Bone Marrow

13. Current Clinical Uses of PRP
Everything and anything!
Internet marketing for host of ailments
Snake oil of today
“Cures rheumatism, grows hair, gets rid of wrinkles, etc., etc.”

14. Current Clinical Uses of PRP
Compelling Rationale!
Meniscus repair
Tendonitis (office based injection)
Arthritis?
Ligament surgery?
Tendon repairs?
Acute injury?

15. Past Clinical Use in Improving Healing of Meniscus Repairs Using - Fibrin Clot
Dr. Warren and Dr. Arnoczky at HSS
Whole blood, clotted and injected
Difficult to handle, difficult to inject
No commercial backing
Fell out of favor

16. Why the interest in PRP?
Historically there has been interest for a long time at the research level.
Clinical interest started with an hypothesis by Mishra et al.
Could the treatment of a common clinical disorder - lateral epicondylitis be improved by injecting PRP into the tendon?

17. (aka lateral epicondylitis/tennis elbow)
Clinical Model
Lateral Tendinosis
(aka lateral epicondylitis/tennis elbow)
Common Disorder
5 per 1000 pts per year seen in general practice
Natural history—
Highly variable - lack of uniform response to treatment
Typically seen over age 35
Repetitive activities
Most common cause
May occur from injury (acutely)

18. Tendinopathy or Tendinosis
Definitions - Histologically Speaking
Loss of longitudinal alignment of collagen fibers
Hypercellularity with neovascularization
-No acute inflammatory cells
Angiofibroblastic Hyperplasia (Nirschl)
Grossly--no longer white but rather gray

19. Disappointing Effects of Current Clinical Rx of Inflammation
Oral NSAID’S or Corticosteroid injection
interrupts the inflammatory cycle
GI intolerance of many oral meds
decreases proteoglycan synthesis
weakens tendon tissue
atrophy of subQ fat
skin discoloration

20. Clinical Application for Use of PRP
In the Treatment of Tendinopathy - Mishra
Current clinical investigations being performed in the treatment of lateral epicondylitis
Difficult patient mix with some having failed surgery or multiple cortisone injections
Part of approval process for FDA certification for this use
First step towards insurance co recognition of this as treatment modality worthy of reimbursement

21. Office Injection of PRP
- The Protocol
PRP Application Technique
Withdraw 30 cc of peripheral blood
Place blood in GPS canister
Centrifuge for 15 minutes at 3200 RPMs

22. Office Injection of PRP - The Protocol
PRP Application Technique
Remove PPP
Shake vigorously for 30 seconds
Platelet Poor Plasma
(PPP)
Platelet Rich Plasma
(PRP)
Packed Red Blood Cells

23. Office Injection of PRP - The Protocol
PRP Application Technique
Inject 2-3 cc of PRP into the ECRB--Peppering technique
Average Dose 3.3 million platelets per patient

24. Post injection Management
Rest (sling/crutches) for a few days to a week
NO NSAID’S
PT (HEP or Rx)
Slow stretching program
Low weight/hi rep pain free isotonic PRE’s
No high loading activities until criteria met
No rest pain
Minimal tenderness
Full motion
Normal strength

25. Platelet Rich Plasma Conclusions
Platelet Rich Plasma has emerged as a valuable biologic treatment for chronic tendonitis of the elbow
Level I support for use only in the Elbow
Since giving in office injections I have
Only rarely needed to do surgery.
A recent study found that office injection
For tennis elbow was more cost effective
And just as successful as an outpatient
surgery.!

26. PRP use in RCR Despite a Compelling Rationale
There have been a handful of good Level I studies that have shown no benefit in terms of clinical scores or healing rate when PRP is used to augment the surgical repair of a rotator cuff tear.

27. Future of PRP
Expanding role in the treatment of many conditions and an adjunct to healing in the care of connective and musculoskeletal tissues.
We have only scratched the surface.
Future use will likely involve staged biochemical manipulation of the healing and inflammatory process.
The future is bright but uncertain until more clinical series are completed.

28. Limitations in the use of PRP
Efficacy
Lack of clinical data
Number of studies being done
Indications are being developed
Uniformity of prep
PRP classification
Insurance recognition
CMS tracking code
$$$$$$$ - Evidence based?
Shady clinics

29. My Experience with PRP Also used in OR for tendon repair Augment
Early but good for Office Injection
Achilles tendonitis
Lateral/Medial epicondylitis
Patella tendonitis
Chronic Hamstring
Labral tear shoulder
Rotator Cuff Tendonitis
Knee/Shoulder Arthritis
Also used in OR for tendon repair Augment

30. Thank you !