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Platelet-Rich Plasma

Mridu Malik Soumit Saha

Michael Galatsky Soujanya S Karanth

Introduction

Background

Classification

  • Platelet-rich Plasma
  • Derived from patients' own blood via centrifugation techniques/kits
  • Composition of platelets, leukocytes and erythrocytes
  • Platelets - promote coagulation, angiogenesis, inflammation, antimicrobial host defense, and healing of wounds
  • 1100+ proteins that consist of immune system recruiters, growth factors and enzymes
  • Gowth Factors - speed up the healing process for most musculoskeletal injuries
  • U-shaped curve - limited number of repector sites
  • Concentrated PRPs can be used to help treat various musculoskeletal injuries
  • Pure platelet-rich plasma (P-PRP)

  • Leukocyte and platelet-rich plasma (L-PRP)

  • Pure platelet-rich fibrin (P-PRF)

  • Leukocyte and platelet-rich fibrin (L-PRF)

BioCartilage

Results

BioCartilage (Anthrex, Naples, FL)

Over 90% of the test subjects exhibited complete macroscopic regeneration of cartilage over a period of 9 weeks without any significant immunological reactions.

  • Dehydrated micronized allogenic cartilage platform with the addition of Platelet rich Plasma (PRP)

  • Stimulation and propagation of chondrogenesis along with its anabolic, anticatabolic and anti-inflammatory factors.

  • A 14 month pre-clinical feasibility study was conducted on the femoral chondyle of baboons in order to assess the efficacy of the BioCartilage.

Challenges

  • Test subjects with uniform injury profiles (n=100)

  • Post-operative tendon healing assessment

Musculoskeletal ultrasound (MSK US) is a point of care technology which can be easily applied in the office.

Discussion

Study Design

Discussion

  • Basic science and preclinical data support the use of PRP for a variety of sports related injuries and disorders

  • The published, peer reviewed, human data on PRP is limited

  • As the pathogenesis of tendinopathy is better understood as degenerative, therapies which attempt to initiate the bodies own healing mechanisms make sense.

3 Steps of tendon healing: Inflammatory, Proliferative and Remodeling

Expected Results

  • PRP could improve tendon healing with less fibrosis

  • Significant increase in The American Orthopedic Foot and Ankle Society score from pre-procedure, 12 months after injection.

  • Significant increase in The Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire at 12 months of follow-up.

  • Tendinopathy can be seen as hypoechoic, thickened tendon with a loss of the normal fibrillar architecture.

  • The size of a partial tendon lesion can be measured via ultrasound and recorded

Future Scope

Outcome measure and Follow up

  • Many questions remain to be answered regarding the use of PRP including optimal formulation, including of leukocytes and dosage

  • What may work for a chronic tendon lesion may be detrimental in an acute muscle injury

  • How PRP coordinates a proliferative, inflammatory, or remodeling response is not yet fully known

  • Rehabilitative protocols in humans such as when and how to load a tendon, muscle, or ligament after a PRP treatment need more evaluation

  • Combining PRP with gels, scaffolds and/or stem cells are exciting applications for exploration

Type of Design

  • Evaluation by questionnaire

  • Sonographic Evaluation

  • Follow up: 1 year (for every 6 weeks)

Placebo Controlled Study Design: 100 Patients [50 experimental group 50 control group]

Methodology

Goal

Mechanism of PRP action

Procedure

Administering injections guided by Ultrasonography

  • Provides a natural concentration of autologous growth factors.
  • Regenerates tissue with low healing potential
  • PRP has a mixture of growth factors and molecules that optimise the tissue environment and favour the healing process.
  • Growth factors are released from the a-granules (in platelets) in the first hour of injecting PRP into the damaged tissue
  • The growth factors present in the platelets are: platelet derived growth factor (PDGF), transforming growth factor (TGF-b), platelet-derived epidermal growth factor (PDEGF), vascular endothelial growth factor (VEGF)
  • Platelets remain viable for up to 7 days and growth factors are continuously released.
  • Platelets mediate healing

To prepare PRP that:

  • Has high purity yield
  • Is pure
  • Can secrete growth factors

Injury assessed

PRP Mechanism

Achilles Tendinopathy: 30 to 50 percent of all physical activity related injuries

PRP gels

Extraction Process

  • The liquid platelet suspensions are treated with bovine thrombin, calcium chloride etc. to activate them
  • The activated PRP starts to polymerise into a gel like structure.
  • Different from liquid PRP in terms of its use as biomaterials
  • Efficient against small diffuse bleeding and in plastic surgery to replace small flaps of skin

  • Whole blood drawn from patient
  • Anticoagulants : acid citrate dextrose-A and citrate-phosphate dextrose
  • No damage
  • Not necessary - must account for clotting cascade
  • Seperate PRPs
  • Centrifuge
  • Centrifuge stage 2
  • 16 commercially available kits
  • Up to 9x baseline PRP concentration

Subject Selection

PRP injections

  • Inclusion criteria

  • Exclusion criteria

  • Informed Consent

Centrifuge

  • Prepared from patient’s own blood using aseptic techniques (as described in the previous section)
  • The platelets are activated by centrifugation
  • They are injected into the affected tissue and growth factors are released
  • The reparative cells are proliferated.

Analysis of isolated PRP

  • Hematological analysis
  • Using a hemocytometer, platelets are counted in
  • Whole blood
  • PRP1
  • PRP2
  • PPP
  • This gives the platelet count in each of the fractions
  • Quantification of cytokine level
  • Each of the above mentioned fractions are analysed.
  • Several factors like interferons (IFN), tumor necrosis factors (TNF), growth factors, interleukins (IL) etc. are quantified.
  • Techniques like ELISA and cytokine assay can be used

WHY PRP?

Surgery

Applications of PRP

Stem Cell Treatment

PRP Treatment

  • Autologous – Few risks
  • Reduce need for surgery or can be combined with surgery treatment
  • Less invasive
  • Faster procedure and healing
  • Cost Effective

Cortisone Treatment

THANK YOU

Joint Replacement

Rotator Cuff Tear

Lower Disc Bulge

Anterior Cruciate Ligament Tear

Ankle Ligament Tear

  • Hip Pain
  • Trochanteric Bursitis
  • Hamstring Tendonitis
  • Quadriceps Tendonitis
  • Osteoarthritis
  • SI Joint Arthritis/Synovitis
  • Foot and Ankle Pain
  • Achilles Tendinosis
  • Plantar Fasciitis
  • Osteoarthritis
  • Chronic ankle sprain/ Tendinosis
  • Shoulder Pain
  • Rotator Cuff Tendinosis
  • Osteoarthritis
  • Arm Pain
  • Biceps Tendonitis
  • Tennis & Golfer’s Elbow
  • Wrist Tendonitis
  • Osteoarthritis of the Wrist or Fingers
  • De Quervain’s Tenosynovitis
  • Knee Pain
  • Patella Tendinosis (Jumper’s Knee)

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