1 / 42

Conflicts of Interest

Conflicts of Interest. I have no conflicts of interest regarding this presentation. Ramon Ylanan MD CAQSM Team Physician University of Arkansas Advanced Orthopeadic Specialists. Platelet rich plasma: an update where are we now?. Goals. Background Healing Response The Basic Science Uses

nita-coffey
Download Presentation

Conflicts of Interest

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Conflicts of Interest • I have no conflicts of interest regarding this presentation

  2. Ramon Ylanan MD CAQSM Team Physician University of Arkansas Advanced Orthopeadic Specialists Platelet rich plasma: an update where are we now?

  3. Goals • Background • Healing Response • The Basic Science • Uses • Evidence Based • Summary

  4. Goals • Background • Healing Response • The Basic Science • Uses • Evidence Based • Summary

  5. Background • What is PRP (Platelet Rich Plasma)? • Biologic, “regenerative biomedicine” • Concentrated platelets • Ideally 3-8X • Processed from autologous, whole blood • Provides “Supra-physiologic” concentrations of growth factors • No universal definition of what constitutes PRP vs PPP • Ideal concentration is opinion based

  6. Background • How is it made? • Centrifuged whole blood • Coagulation inhibitors may be used • Previous issues with bovine inhibitors • Platelet activators may be used • Volume produced depends on which system used • Applied in either • Injectable form • Solid, matrix form

  7. Background

  8. Goals • Background • Healing Response • The Basic Science • Uses • Evidence Based • Summary

  9. Background: The Healing Response • Inflammatory phase • First week after injury • Hemostasis  recruitment of macrophages and fibroblasts • Proliferative phase • Within first 2 days to 2 weeks • Formation of extra-cellular scaffold • Maturation/remodeling phase • Up to first year • Type 1 collagen replacing scaffold

  10. Background: The Healing Response • Growth factors • IGF-1  early inflammatory phase • Enhances collagen and matrix synthesis • TGF-B  pro-inflammatory • Enhances matrix and collagen synthesis, angiogenesis • PDGF  facilitates proliferation of other growth factors • Attracts stem cells and contributes to remodeling

  11. Background: The Healing Response • Growth factors • VEGF  peaks after inflammatory phase • Promotes angiogenesis and neo-vascularization • b-FGF  angiogenesis, cell migration, creates collagenase, production of granulation tissue

  12. Background: The Healing Response • What does PRP bring to the healing table? • Alpha granules • The storage packets of growth factors • Each platelet contains 50-80 granules • The de-granulation releases the growth factors needed to augment healing

  13. Background: The Healing Response • Alpha granules • Theory that activators will increase de-granulation • Reason why some systems include external activators • Some studies show injured collagen fibers will stimulate de-granulation as well

  14. Goals • Background • Healing Response • The Basic Science • Uses • Limit to Muscle, Tendon, Ligament • Evidence Based • Summary

  15. The Basic Science • Horse tendons • Schnabel et al. • Culture in PRP vs other blood products • Higher anabolic gene expression in PRP • Human tenocytes • de Mos et al. • PRP vs. PPP • PRP increase in matrix degrading enzymes (faster recovery)

  16. The Basic Science • Rabbit skeletal muscle stem cells • Gates et al. • Increased expression of myogenic activity • Mesenchymal stem cells • Mishra et al. • Buffered in PRP, increased proliferation

  17. Goals • Background • Healing Response • The Basic Science • Uses • Limit to Muscle, Tendon, Ligament • Evidence Based • Summary

  18. Uses: Muscle • Hammond et al (2009) • Animal study (rats) • Tibialis anterior strain • large strain vs small strain • PRP shortened healing by 14-21 days in small strain group • Little change in large strain group

  19. Uses: Tendon • Lots of studies • Lateral epicondylitis • Patellar tendinopathy • Achilles tendinopathy • Rotator Cuff tendinopathy

  20. Uses: Lateral Epicondylitis

  21. Uses: Lateral Epicondylitis • Mishra and Pavelko (2006) • One of the most cited articles • Chronic, refractory lateral epicondylitis • 15 patients, failed conservative measures • Single PRP injection • control was bupivicaine

  22. Uses: Lateral Epicondylitis • Mishra and Pavelko (2006) • Measures VAS and Mayo elbow scores at 2, 6 and 25 months • Outcomes • 2 months  60% vs 16% improvement (P=.001) • Final f/u 93% reduction in pain, no complications • 60% of control group withdrew for other treatment

  23. Uses: Lateral Epicondylitis • Peerbooms et al (2010) • RCT, Level 1 data • Only true RCT to date • 100 patients (51 PRP:49 CSI) • 1 yr f/u • 73% success in PRP group • 49% in CSI group

  24. Uses: Patellar Tendinopathy

  25. Uses: Patellar Tendinopathy • Human Data is limited • Filardo et al (2010) • Non-RCT, N=31 • Serial PRP + PT (15) vs. PT alone (16) • 3 PRP, 2 weeks apart with eccentric strengthening • PRP group • Improved in all measures • Continued to improve at 6 months • Higher improvement in sports activity

  26. Uses: Patellar Tendinopathy • Kon et al (2009) • Prospective, pilot study (no control) • 3 PRP injections, 15 days apart • 6 month f/u • 70% stated complete or significant improvement • 80% satisfied with results

  27. Uses: Achilles Tendinopathy

  28. Uses: Achilles Tendinopathy • de Vos et al (2010) • Double blinded, placebo control, RCT • N=54, chronic Achilles tendinopathy • 2 months of symptoms • Excluded if had previous eccentric strengthening program • 27 PRP, 27 isotonic saline, US guidance used

  29. Uses: Achilles Tendinopathy • de Vos et al (2010) • Double blinded, placebo control, RCT • N=54, chronic Achilles tendinopathy • Both did 12 week supervised eccentric program • f/u at 6, 12, 24 weeks • Both groups improved, No difference found • Used bupivicaine for anesthetic • ? Inhibit effectiveness

  30. Uses: Rotator Cuff • Mostly as surgical repair adjuncts • Studies have been +/- • Only one major prospective, Level 1 randomized research • Weber et al (2010) • No major difference in structural integrity compared with control • Repair with PRP vs repair without PRP

  31. Uses: MCL • No human studies • Letson and Dahners (1994) • Rat MCL injury • Injected with PDGF  • 73% (+/- 55%) stronger than contralateral controls • Human results anecdotal • 2-3 weeks earlier than anticipated

  32. Goals • Background • Healing Response • The Basic Science • Uses • Limit to Muscle, Tendon, Ligament • Evidence Based • Summary

  33. What does the evidence say? • Increasing number of basic science and animal studies • Paucity of human trials • No standardization of treatment • Anecdotally improves recovery by 2 weeks • 1 vs. multiple injections • 1 seems to be effective, fenestration may help • The multiple injection “protocol” is without consistency

  34. What does the evidence say? • When is best time to administer in acute setting? • Chan et al  • Better results at day 7 than day 3 • At elite level, who waits 7 days?

  35. What does the evidence say? • Exercise • Early ROM can be helpful • Early light aerobic activity can be helpful • I begin eccentric strengthening program as early as tolerated • Goal is RTP by 3 weeks

  36. What does the evidence say? • NSAIDs • Most hold for minimum of 10 days prior • Not proven to inhibit, but possible • Don’t withhold ASA if cardio-protective • Ideal platelet concentration • 600K-1mil per ml (no evidence for that)

  37. What does the evidence say? • WBC in preparation • Inhibit or help? • Help  anti-infective property • Inhibit  inhibitory effects on inflammatory mediators

  38. What does the evidence say? • Local anesthetics and corticosteroids • Carofino et al (2012) • Co-administration decreased PRP effectiveness • External platelet activators • No consensus on if or when

  39. What does the evidence say? • MSK US guidance improves results • 0232T tracking CPT code • Includes imaging assisted guidance • I use it with every PRP

  40. Where are we with PRP?

  41. Summary • Limited human research • Tendon>Muscle>Ligament for now • Limit NSAID use around the injection • Don’t add local anesthetic • Still more to learn • Medicare tracking code now • IOC had banned it in 2010, removed in 2011

  42. References • Nguyen RT, Borg-Stein J, McInnis, K. Applications of Platelet-Rish Plasma in Musculoskeletal and Sports Medicine: An Evidence-Based Approach. PM R 2011;3:226-250 • Schnabel LV, Mohammed HO, Miller BJ, et al. Platelet rich plasma (PRP) enhances anabolic gene expression patterns in flexor digitorum superficialis tendons. J Orthop Res 2007;25:230-240. • de Mos M, van der Windt AE, Jahr H, et al. Can platelet-rich plasma enhance tendon repair? A cell culture study. Am J Sports Med 2008; 36:1171-1178. • Mishra A, Tummala P, King A, et al. Buffered platelet-rich plasma enhances mesenchymal stem cell proliferation and chondrogenic differentiation. Tissue Eng Part C Methods 2009;15:431-435. • Gates CB, Karthikeyan T, Fu F, Huard J. Regenerative medicine for the musculoskeletal system based on muscle-derived stem cells. J Am Acad Orthop Surg 2008;16:68-76. • Hammon JW, Hinton RY, et al. Use of autologous platelet-rich plasma to treat muscle strain injuries. Am J Sports Med 2009;37:1135-1142 • Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006;34:1774-1778. • Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double- blind randomized controlled trial: Platelet-rich plasma versus cortico- steroid injection with a 1-year follow-up. Am J Sports Med 2010;38: 255-262. • Filardo G, Kon E, Della Villa S, Vincentelli F, Fornasari PM, Marcacci M. Use of platelet-rich plasma for the treatment of refractory jumper’s knee. Int Orthop 2010;34:909-915. • Kon E, Filardo G et al. Platelet-rich plasma: New clinical application: A Pilot study for treatment of jumper’s knee. Injury 2009;40:598-603 • de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: A randomized controlled trial. JAMA 2010;303:144-149. • WeberSC,PariseC,KatzSD,WeberSJ.Platelet-richfibrin-membrane in arthroscopic rotator cuff repair: A prospective, randomized study. Proc Am Acad Orthop Surg 2010;11:345. • Weber SC, Katz SD, Parise C, Weber SJ. Platelet-rich fibrin matrix in the management of arthroscopic repair of the rotator cuff: A prospec- tive, randomized study (SS-07). Arthroscopy 2010;26:e4. • Carofino B, Chowaniec Dm, et al. Corticosteroids and local anesthetics decrease positive effects of platelet-rich plasma: an in vitro study on human tendon cells. Arthroscopy. 2012 May;28(5):711-9 • Engebreatsen L, Steffen K et al. IOC consensus paper on the use of platelet-rich plasma in sports medicine. BJSM 2010;44:1072-81

More Related