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Platelet Rich Plasma

in
orthopaedics
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When was it first started?

 First developed as early as 1970

 First used in 1987 (Open heart surgery)

 Gained popularity in mid 1990s

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“Physicians report that the demand for PRP has soared after
pro golfer Tiger Woods received injections to accelerate healing
after knee surgery.”
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Components of our blood
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Definition

 Volume of plasma fraction of autologous blood having a platelet

concentration above baseline.

 3-5 fold increase above baseline.

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Healing Pathway
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What is PRP?

 Platelet Rich Plasma

 Utilizing growth factor (GF) content of platelets to aide in healing of
musculoskeletal tissue
 Predominately tendons, ligaments and muscles

 High concentration of GF deposited locally in the area of an

injury

 Anabolic effect enhances and supports healing

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Platelet Function

 Haemostasis
 Platelet plug
 Blood clot

 Secretion of active proteins

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What is the response to platelets

 Proliferation of Mesenchymal stem cells

 Proliferation of fibroblasts

 Production of Type 1 Collagen

 Platelets itself release Growth factors

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Growth factors present in PRP

o Platelet-derived growth factor

o Transformin growth factor beta
o Fibroblast growth factor
o Insulin-like growth factor 1
o Insulin-like growth factor 2
o Vascular endothelial growth factor
o Epidermal growth factor
o Interleukin 8
o Keratinocyte growth factor
o Connective tissue growth factor
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What does it lead to??

 Chemotaxis
 Directional movement in response to a chemical
stimulus
 Stems cells are attracted to the growth factors
and migrate into the area
 Cell proliferation
 Significant increase in cellular reproduction
activity

 Possibly even a systemic effect

 Performance enhancing?
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Effect of PDGF on Tissues

 Immediate (within 5 minutes)

 Second messenger stimulation
 Inflammatory response

 Early (30min to 4 hours)

 M-RNA stimulation, protein synthesis
 Chemotaxis (draws cells to the area)

 Late (4-24 hours)

 Fibroblast mitosis
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Summary of Effect of Platelet Growth
Factors on Tissues

 Through a complex series of biochemical and cellular events, these

growth factors cause a rapid and sustained increase in the number of
fibroblasts in an area and then cause stem cell maturation.
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Platelet Rich Plasma

HOW IS IT
OBTAINED??
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2 methods
1. Buffy coat method
2. Plasma based method
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Buffy coat method
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Plasma based PRP
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Activation of platelets??

No fixed guidelines

Some authors activate platelets with thrombin or calcium

Others apply platelets without being previously activated,

arguing that better results are obtained.
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What is the difference?
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What do we have???

 Plasma based method done here.

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Classification

1. Pure Platelet-Rich Plasma (P-PRP) or leucocyte-poor PRP

products

1. Leucocyte- and PRP (L-PRP) products are preparations with

leucocytes and with a low-density fibrin network after activation

1. Pure platelet-rich fibrin (P-PRF) or leucocyte-poor platelet-rich

fibrin preparations are without leucocytes and with a high-density
fibrin network

1. Leucocyte- and platelet-rich fibrin (L-PRF) or second-generation

PRP products are preparations with leucocytes and with a high-
density fibrin network.
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Advantages of having leucocytes??

Pure PRP has an advantage over traditional PRP in that

it eliminates red blood cells (RBCs) and neutrophils.

RBCs, have no therapeutic effect and more painful while

injecting.

Neutrophils, a type of white blood cell, have

inflammatory components which may increase pain and
inflammation post-treatment.
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 When used with local anesthetics, the pH is changed.

 This reduces the efficacy of PRP

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Where can it be used??

 Everything and anything!

 Internet marketing for host of ailments

 Snake oil of today

“Cures Rheumatism, Sports injuries, Grows hair, Gets rid of

wrinkles, etc., etc.”
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Meniscus repair
Tendonitis (office based injection)
Arthritis

Ligament surgery
Tendon repairs
Acute injury – Debatable!
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 Epicondylitis, Achillodynia

 Runners / Jumpers Knee

 Plantar fascitis

 Osteoarthritis (Grad I-III)

 Muscle- and Ligament Lesions - Ultrasound-Guided

Injections

 Peri – Post operatively

- Achilles Tendon Repair
- HTO, Microfracturing
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Indications & Use

 Analgesic?
 Potential primary analgesic effect
 Some human studies state decreased post-op pain levels
 Stimulation of thrombin receptors (ie, PAR-1) shown to increase pain
threshold in laboratory animals through opioid pathways and haemostasis

 Antimicrobial
 Against Staphylococcus aureus (Sutter 2012)
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Tendinopathy or Tendinosis

 Definitions - Histologically Speaking

– Loss of longitudinal alignment of collagen fibers

– Hyper cellularity with neovascularization (irregular)

-No acute inflammatory cells

– Angiofibroblastic Hyperplasia or Degeneration

(Nirschl)

– Grossly--no longer white but rather gray

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Tennis elbow

• Common Disorder

• Repetitive activities
– Most common cause
– May occur from injury (acutely)
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 Office Injection of PRP

• PRP Application Technique

– Inject 2-3 cc of PRP into the ECRB--Peppering technique
– Average Dose 3.3 million platelets per patient
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Tendo Achilles
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Plantar fascitis
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Subacromial bursitis
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Trochanteric Bursitis
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OA knee

 Different conservative treatment options include

 Steroid injections
 Hyaluronic acid and
 PRP
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PRP vs. Hyaluronic acid
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PRP for Muscle strains

 The exact location of the lesion is confirmed on MRI

 USG guided injection is given

 Time taken to return to sports activities is significantly less in

patients treated with PRP
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Peri-operative and Post-operative

 Meniscus repairs

 ACL repairs

 OCD – Post microfracturing

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1. Pure
platelet-rich fibrin (P-PRF) or
leucocyte-poor platelet-rich fibrin
preparations

1. Leucocyte-
and platelet-rich fibrin (L-
PRF) or second-generation PRP
products
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ACL tears

- Fehske, Eichhorn et al : Arthroskopie 2013 -

Intraoperative biological Augmentation on Ligaments

Treatment of Partial Ruptures of the ACL with

ACP n=207 + Control Group without ACP (32% good
results)

Group 1,2 : 98%

Group 3 : 85% (partial torn ACL)
Group 4 : 70% (partial 2 Bundle Lesion)
Group 5 : <30% (some fibers left)
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FUTURE OF ACL REPAIR??

ACL Repair:

• Collagen-platelet scaffolding for ACL

healing (Animal Studies)
M.Murray - Harvard: J Bone Joint Surg Am

• ACL Repair with internal Brace + PRP

• Stem Cells through Microfracturing + PRP Scaffold?!

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How to use??

 2- 3 Injections every 4-7 days

 Interaction between Steroides and α-Granules.

 Lidocaine deactivates α-Granules because of a decreased pH

value (AVOID)

 Benefit in chronic Cases (Restart Inflammation-Phase)

 No Change of Rehabilitation Program

 No need for Heparin

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Post Injection Theraphy

 Rest (sling/crutches) for a few days to a week

 NO NSAID’S

 Slow stretching program

 No high loading activities until

 No rest pain
 Minimal tenderness
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COMPLICATIONS

 No adverse complications have been reported

 Symptoms may be worsened for few days because of induced

inflammation

 Infection

 Persisting symptoms
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 Clinical use has outpaced scientific investigations

 Less restrictions vs. pharmaceuticals
 Readily available
 Safe

 Autologous = up regulation of normal physiology

 “Regenerative”

 $$$
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Limitations

 Efficacy
 Lack of clinical data
 Number of studies being done
 Indications are being developed

 Uniformity of prep
 PRP classification

 Insurance recognition
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QUESTIONS