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
- 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
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
- 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
Anterior Cruciate 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)