1/14/2010
Outline
Platelet-rich Plasma: Current
PlateletConcepts and Clinical Applications
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•
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•
Richard J. Mason, MD
PRP definition – what is it?
Preparation of PRP
Mechanism of action
Nonsurgical and Surgical applications
– Clinical Studies
• Future Directions
• Anti
Anti--Doping regulations/conflicts
• Summary
PRP – What is it?
Platelet Rich Plasma
• A sample of autologous blood with
•
•
•
• Public Awareness
concentrations of platelets above baseline
values
Pl l
Platelets
play
l a key
k role
l in
i healing
h li
response via secretion of growth factors
and recruiting reparative cells
Oral & plastic surgery use since early 90’s
Recent use in treating Sports injuries
•
PRP Preparation
Platelet Biology
• Platelets are formed in bone marrow from
•
•
precursor cells called megakaryocytes
Platelets have no nucleus, cannot
replicate, 5 to 9 day life span
Platelets are activated when exposed to
damaged blood vessels
– They aggregate at the site and form a clot
– At this time they release more than 30
bioactive proteins many of which have a
fundamental role in hemostasis and/or tissue
healing
increased after use in
Hines Ward and Troy
Polamalu to treat MCL
injuries prior to 2009
Superbowl
NY Times article
detailed its use and
quicker healing/return
to sports when
injected after injury
• Patients blood is taken
•
•
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and centrifuged to
separate red blood cells
from white cells and
platelets
Different
iff
systems give
i
different platelet
concentrations
Ideal concentration yet to
be defined
Multiple companies have
PRP preparation systems
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PRP - Preparation
PRP - Preparation
PRP - Preparation
• Final PRP preparation
yields 3 to 5 cc
• Site can be pre
•
PRP – General Information
• Since it is autologous, no rejection but
•
may have inflammatory reaction
Contraindications:
– Thrombocytopenia, anticoagulant rx,
infection, cancer, pregnancy
• Cost is $150 per syringe plus injection fee
• Considered experimental and not currently
i j t d with
injected
ith local
l
l
anesthesia
Use a multipass
“peppering” technique
to encourage healing
PRP – General Information
• Orthopedic uses of PRP fall into 4
categories
– Chronic tendinopathies
p
– Acute ligamentous injuries
– Muscle injuries
– Intraoperative augmentation
reimbursed by insurance
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PRP Mechanism of Action
• PRP may accelerate initial inflammatory
•
phase of tendon repair making cells more
receptive to earlier mechanical loading
I skeletal
In
k l l muscle
l PRP regulates
l
inflammatory phase and improves healing
after injury
– This increase healing is thought to be due to
the direct effects of the growth factors in PRP
on skeletal muscle (Table 1)
PRP – Historical Studies
• 1994 study in the maxillofacial surgical
•
literature showed earlier cancellous bone
graft consolidation (4wks vs. 8wks) when
platelet rich fibrin glue was added to bone
graft
This effect was thought to be secondary
to enhanced osteoconduction stimulated
by PDGF and TGF
TGF--B
PRP – Historical Studies
• The Studies in the maxillofacial and plastic
•
surgery literature are largely case studies
or case series
The PRP concentration and method of
delivery in these studies are case specific
and cannot be expanded to other
procedures without further study
PRP – Non Surgical Applications
• Used in epicondylitis, Patellar tendonitis, Plantar
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fasciitis, Muscle injuries, Acute ligamentous
injuries and Osteoarthritis.
The best studies have been done on lateral
epicondylitis, but, no double blind, randomized
studies to date
Remainder of studies are retrospective
– Show quicker recovery and good pain relief
(Table 3)
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PRP – Acute Ligamentous Injuries
PRP – Acute ligamentous injuries
• Grade 2 MCL injuries in professional soccer
players
• Treatment group received PRP within 72 hours
of injury
• Control group treated with rest and rehab
• Return to play time shortened by 27% compared
to control group
– Retrospective study, 22 participants,
• Mandelbaum, Gerhardt unpublished data
PRP – Acute Muscle Injuries
• 8 pro soccer & 6 pro basketball players with
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direct muscle trauma/tears
PRP injected with ultrasound guidance and
aspiration of hematoma
Greater than 50% reduction time in return to
play noted when compared to standard
treatment recovery times for similar injury
patterns
– Retrospective study, no control group
• Sanchez,Cugat et al; ISOAKS, 2005 unpublished data
Elbow Epicondylitis Study
• 20 patients who had failed Physical
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therapy and conservative treatment and
mean pain duration of 15 months
All patients
i
were considering
id i surgery
15 patients given PRP and 5 given
bupivicaine injection (control group)
™ Mishra
et al. AM J SportsMed. 2006;34:17742006;34:1774-1778
PRP – Osteoarthritis Knee
• 30 patients in each group matched for
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age, sex, BMI, radiographic severity OA
3 injection of PRP vs. 3 injections of HA
over 3 week period
PRP group significantly improved pain over
HA group
• Sanchez et al; Clin Exp Rheumatol.
2008;26(5):910--913
2008;26(5):910
Elbow Epicondylitis Study
• At 8 wks post treatment 60% of prp and 16%
control group improved
• 3 of 5 control group withdrew from study at this
point preventing further direct comparison
• At 6 months 81% of prp group improved
• At final follow up (mean 25 months) 93% of prp
patients improved and did not need surgery
™
Mishra et al. AM J SportsMed. 2006;34:17742006;34:1774-1778
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PRP – Surgical Applications
• Has been used to augment and accelerate
•
healing in Achilles tendon and Rotator Cuff
repairs
Has also been used to accelerate ACL
graft/tunnel incorporation with equivocal
results
PRP – Future Directions
PRP – Future Directions
• PRP represents a possible treatment
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option for stimulation and acceleration of
soft--tissue healing and regeneration
soft
Cli i l trials
Clinical
i l are underway
d
to determine
d
i
efficacy, standardized preparation and
application techniques
This will allow true comparison of results
and outcomes
PRP – Future Directions
PRP – Future Directions
• Reports of severe pain and acute
• PRP may violate current AntiAnti-Doping
•
inflammatory response to PRP injections
must be further investigated
Post procedure rehab protocols must also
be established to determine optimal
muscle and tendon healing
regulations
• Concerns center around the IGFIGF-1
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component off PRP (IGF iis currently
l
prohibited)
Concentrations of IGFIGF-1 in PRP are at a
level subtherapeutic to produce systemic
anabolic effects
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PRP – Future Directions
PRP – Future Directions
• United States AntiAnti-doping Agency issued
• The World AntiAnti-Doping Agency in
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an athletes advisory in April 2009 stating it
considers PRP injection equivalent to an
injection of growth factors and therefore is
prohibited
PRP can only be administered if the
athlete has a Therapeutic Use Exemption
determined by a “medical professional”
Summary
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September 2009 prohibited PRP
administration by an intramuscular route
O h routes off PRP administration
Other
d i i
i will
ill be
b
required to meet international standards
for Therapeutic Use Exemptions
These rules will be enforced effective
January 1, 2010
QUESTIONS?
• PRP holds great promise in accelerating healing
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from injury and surgery involving ligaments as
well as articular and meniscal cartilage.
Due to its safety profile and ease of preparation
the use of PRP in sports medicine will likely
continue to grow
Clinical use should proceed cautiously as there
is little highhigh-level clinical evidence supporting
its efficacy
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