Lucas J. Bader M.D.Orthopaedic Surgeon
Fellowship Trained Foot & Ankle Surgeon
DisclosureNone
GoalsDefinition of PRPReview Basic ScienceCurrent Clinical ApplicationsReview of the LiteratureFuture
IntroductionEmerging field of
BiologicsPRP utilized and
studied since the 1970’s
Origins in fields of maxillofacial and general surgery
Definition Platelet Rich PlasmaNonnucleated
bodies in peripheral blood
Autoglous blood with a concentration of platelets above a baseline value
Fluid portion of blood
Bioactive FactorsPotentially enhance healing by delivery of
various growth factors and cytokines α granulesDense granules
α-GranulesCell proliferationChemotaxisCell differentiationAngiogenesisConductive Scaffold
Platelet Derived Growth FactorCell replicationAngiogenesisMitogen for
fibroblasts
Vascular Endothelial Growth FactorAngiogenesis
Transforming Growth Factor-β1Regulator in balance
between fibrosis and myocyte regeneration
Fibroblast Growth FactorProliferation of
myoblasts, Angiogenesis
Epidermal Growth FactorProliferation of
mesenchymal and epithelial cells
Hepatocyte Growth FactorAngiogenesis,Mitogen for
endothelial cellsAntifibrotic
Insulin-like growth factor-1Stimulates
myoblasts/fibroblastsMediates
growth/repair skeletal muscle
Adhesive ProteinsFibrinogenFibronectinVitronectin“scaffold”
Dense GranulesNon-Growth Bioactive MoleculesFundamental effect on the biologic aspects of
inflammationCell migrationConductive Matrix
Serotonin & HistamineIncrease capillary
permeabilityInflammatory cell
accessMacrophage
Activation
Adenosine Receptor ActivationModulates
inflammation
AdvantageNormal biologic ratios vs Exogenous Factors
Formulation of PRPCan only be made from anticoagulated bloodCannot be made form clotted whole bloodCannot be made from serum
Preparation 30-60 cc DrawnAdd citrate to bind
ionized calcium and prohibit clotting cascade
CentrifugationStep 1
Red blood cellsLeukocytes Platelets
Step 2Platelet-Poor
PortionPlatelet-Rich
Portion
Activating AgentsCalcium Chloride
and/or Thrombin (OR)
Collagen (Office)Initiates
Platelet activationClot formationGrowth Factor
Release
Growth Factor Release70 % within 10 minutesNearly 100% within 1 hr
PRP Preparations SystemsSeveral AvailableQualitative and Quantitative Variability
Volume of autologous bloodCentrifuge rate/timeDelivery MethodActivating AgentLeukocyte concentration (?)Final PRP volumeFinal Platelet and Growth Factor
Concentration
Safety ConcernsAutologous BloodAseptic techniqueRelative Contraindications
Hx of thrombocytopeniaAnticoagulant therapyActive infectionTumorMetastatic Disease
Cost$150-$180 small kits$200 large KitsCentrifuge $1800PRP is currently
considered experimental and is not reimbursed by most third party payers
Effects of PRP on Soft Tissues& Bone- Basic Science3 phases of healing
InflammationProliferationRemodeling
Basic Metabolic ProcessesProliferationChemotaxisAngiogenesisDifferentiationEC Matrix Production
Effects PRP on TendonCollagen gene expressionVascular endothelial growth factorHepatocyte growth factorMatrix MetalloproteinaseTendon strength and callus formationCell formation and angiogenesis
Effects PRP on MuscleIGF-1 & basic FGF improve healing and
increase fast twitch and tetanus strengthAccelerated satellite cell activationIncreased diameter of regenerating
myofibrils
Effects PRP on BoneStimulate OsteoblastsStmulate FibroblastsUp regulate OsteoclacinEncourage differentiation of MSC into bone
forming cells
Further StudyAcute injuryChronic injuryTiming of injectionEffect of serial
injections
Orthopaedic Applications for PRPChronic
TendinopathiesBone healingAcute Ligamentous
InjuriesMuscle injuriesIntraoperative
Augmentation
Chronic TendinopathyLateral/medial
EpicondylitisAchilles
TendinopathyPatellar
TendinopathyPosterior Tibial
TendinopathyPlantar Fasciitis
Bone HealingFracture HealingDistraction
OsteogenesisOsteoarthritis
Acute Ligamentous InjuryKnee medial
collateral ligamentAnkle syndesmosisAnkle lateral
ligament complex
Intraoperative UseTotal Knee
arthroplastyACL reconstructionAchilles Tendon
RepairRotator Cuff RepairAcute Articular
Cartilage Repair
Review of the literatureNumerous basic science, animal studies, and
small case reportsFew controlled clinical studiesMajority of studies are small, anecdotal, and
underpoweredNon-standardized techniques
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.
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
Platelet-rich Fibrin Matrix in Arthroscopic Rotator Cuff Repair: A Prospective, Randomized StudyStephen C Weber, MD Sacramento CA Jeffrey I Kauffman, MD Sacramento CA
Sample size of 30 patients in each groupSerial 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.
Platelet Rich Plasma (PRP) Effectively Treats Chronic Achilles TendonosisRaymond R Monto, MD
Prospective study of thirty patientsNo controlsAOFAS 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.
Literature SummaryGreatest support in treating tendinopathy
Lateral EpicondylitisPatellar TendinopathyAchilles TendinopathyPlantar Fasciitis
Caution with Acute InjuriesRisk of FibrosisReturn to activity too early
FuturePRP promising, but not provenAppropriately powered studiesSophisticated models of healingMore precise formulations of PRP Narrower indications, but more definitive
My ProtocolTreatment of last resort prior to surgeryIndicated for chronic tendinopathiesPerformed under ultrasound guidanceNSAIDS discontinuation 1 week prior and 2
weeks post procedureActivity modification for 7 days