Update on Platelet-Rich Plasma August 2012

1. Platelet-Rich Plasma
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder surgery
Medical Director Team Physician Consultant
Sacramento State Athletics Sacramento River Cats Oakland A’s
MiLB - AAA

2. BASIC SCIENCE

3. Healing Cascade
Injury
Inflammation Clotting
Cascade
Platelet-Derived Growth
Platelet Factor (PDGF)
Aggregation
Formation of Transforming Growth
Fibrin Clot Factor-Beta (TGF-B)
Hemostasis
Proliferation
Remodeling
Diegelmann et al. Frontiers in Bioscience, 2004.

4. Clotting Cascade
• Intrinsic pathway
– Activated by contact with exposed
collagen or foreign surface (ie glass)
• Extrinsic pathway
– Activated by tissue factors external
to blood (tissue thromboplastin)
Clot formation occurs in 3 – 6 minutes
• Ultimate Goal:
– Fibrin Clot
Hoffman, Hematology: Basic Principles & Practice, 4th Ed.
Sherwood, Human Physiology, 5th Ed.

5. Thrombin
 Converts Fibrinogen to Fibrin
 Activates Factors V, VIII, XI, XIII
 Activates Platelets
Thrombin

6. Platelet Function
• Hemostasis
– Platelet plug
– Blood clot
• Secretion of active proteins
– Cellular chemotaxis, proliferation, & differentiation
– Angiogenesis
– Regeneration of appropriate tissue

7. Platelet Function
• Dose-Response relationship of [Platelets] to
– Proliferation of human adult MSC’s
• Mesenchymal stem cells
– Proliferation of fibroblasts
– Production of type I collagen
• MSC proliferation directly related to PDGF release by α
granules from platelets

8. Platelet-Rich Plasma (PRP)
• Current definition:
– Volume of the plasma fraction of autologous blood having a platelet
concentration above baseline
Marx et al, Implant Dent, 2001.

9. Consensus?
• Marx states PRP = 1,000,000 platelets/uL
• Anitua claims PRP = 300,000 platelets/uL
• Others discuss 3 – 5 fold increase [platelet] > baseline
• What level needed to improve healing?
– Weibrich suggests that each individual requires a different platelet
concentration ratio
– Graziani found 2.5x to be ideal level for osteoblast & fibroblast
proliferation. Greater levels reduced response Marx et al, J Oral Maxillofac Surg, 2004.
Marx et al, Imp Dent, 2001.
Anitua et al, Thromb Haemost, 2004.
Marx et al, Bone Engineering, 2000.
Kevy et al, J Extra Corpor Technol, 2004.
Gonshor, Int J Periodontics Restorative Dent, 2002.
Weibrich, J Craniomaxillofac Surg, 2002.
Graziani et al, Clin Oml Impl Res, 2006

10. Creating PRP
• After centrifuge, we see 3 layers:
– Top layer: Plasma (PPP) (spec grav = 1.03)
– Middle layer: Platelets (spec grav = 1.04-5)
– Middle layer: WBC’s (spec grav = 1.06)
– Bottom layer: Red blood cells (specific gravity = 1.09)
• Variable result based on:
– Speed, Duration, & Technique of spin
Welsh et al, Cosmetic Derm, 2000.
Marx et al, Imp Dent, 2001.

11. Two Types of Systems
Buffy Coat Systems Plasma Based Systems
• Biomet (GPS) • ACP (Arthrex)
• Harvest (Symphony) • MTF Cascade (FibriNet)
• Arteriocyte (Magellan) • BTI (Anitua / Sanchez)
• Exactech (Accelerate) • OrthoVita (?)

12. Buffy Coat Systems
• One or two centrifugations: End product = Buffy-coat PRP layer
– Expensive capital & kits
– Ancillary staff required
– Anticoagulant required
– Long procedure time (15-30 minutes)
– Increased concentration platelets
– BUT, also increased concentration WBC’s & RBC’s
Blood + anticoagulant PPP
Plasma
1st centrifugation 2nd centrifugation
PRP
RBC
RBC

13. Plasma Systems
Autologous Conditioned Plasma

14. WHAT WE’VE LEARNED

15. Risks
Other Options PRP
• Cortisone • Infection from needle
– Infection from needle
• *** ACD-A ***
– Soften cartilage
– Weaken tendons • *** WBC’s ***
– AVN of bone
• Allograft / Pooled source
– Infection from needle
– Infection from source

16. ACD-A
• Anticoagulant Citrate Dextrose Solution A
– Binds free Ca++ in blood, preventing clotting cascade
– pH = 5.0  OUCH!!!
• Indications for injections without ACD-A
– Intra-articular injections
– Ligament irritations or injuries
– Any tissue that is well supplied with blood
• Draw / Spin / Inject < 20 min

17. ACP Concentrates GF & Platelets

18. Effect on Tenocyte Cultures
2% FBS (Fetal Bovine Serum): Negative control. Minimum amount of nutrients needed to
maintain tendon cell viability
10% FBS: Positive control. Used to encourage tendon cell proliferation
Courtesy of Gus Mazzocca, U Conn

19. Local Anesthesics / Cortisone
Potential Harmful effects on tenocytes & chondrocytes (Chu,C)
Courtesy of Gus Mazzocca, U Conn

20. Multiple Dosings
Tendon cells in vitro treated with ACP every 4 days & cell proliferation measured
Tenocyte proliferation increased with additional ACP treatments
Courtesy of Gus Mazzocca, U Conn

21. Comparing the Systems
• All far better than
positive control
• Terminal velocity?
Courtesy of Gus Mazzocca, U Conn

22. In Vitro Effects
Tenocyte Proliferation Tenocyte Proliferation
• Statistically significant increase in
proliferation
Positive Control ACP

23. PRP Clinical “Cartilage” Studies
Trial type Classification of PRP Method of PRP Study outcome – Reference
(Dohan Ehrenfest, application to effects due to PRP
2010) joint
Case report Platelet and leucocyte CaCl2 –activated Returned to play Sanchez, 2003
concentrations not injected between soccer at 18 weeks
reported fragment and its bed
Pilot study PRP in combination with Bone marrow stem Improved Lysholm and Haleem, 2010
PR-FG, platelet but no cells on PRP scaffold RHSSK at 6 scores at
leucocyte concentrations 6 and 12 months
reported
Prospective P-PRP 3 weekly injections Decreased pain and Sanchez, 2008
cohort of PRP improved WOMAC
vs hyaluronic scores at 6 months
acid
Prospective Platelet but no leucocyte 4 injections every 21 Improved IKDC and Kon, 2010
clinical trial concentrations reported days EQ VAS scores at 6
and 12 months
Fortier, Cole et al. OTSM 2011.
Clinical impression: pain relief before functional tissue regeneration

24. Pain, OA, and PRP
• PRP ↑ HA synthesis in synoviocytes
– Anitua, Rheum, 2007
• PRP ↓NFκβ, COX-2, CXCR-4
– Bendinelli, J Cell Physiol, 2010
• PRP ↓ RA in pig model
– Lippross Arthr and Rheum, 2011

25. WBC’S:
EVIL OR JUST MISUNDERSTOOD?

26. Controversy: White Blood Cells
• No single cell necessary or required for healing
• Appropriate inflammation necessary for healing as initiates the
healing cascade
• Control infection
• Aid in debridement & opens channels for influx of serum
Martin et al. Trends in Cell Biology. 2005.
Simpson et al. J Clin Invest. 1972.
Szpaderska et al. J Invest Dermatol. 2003.
Dovi et al. J Leukoc Biol. 2003.
Egozi et al. Wound Rep Regen. 2003.
Martin et al. Curr Biol. 2003.

27. WBC’s: Harmful to Healing
• The inflammatory response can cause muscle damage
– Neutrophils can delay regenerative healing capacity1
– Neutrophils cause cytotoxic destruction of muscle2
• WBCs can suppress bone formation and bone healing
– Neutropenic mice—higher bending moment at fracture callus site3
– Immunosuppressed rats; implanted DBM had enhanced bone formation4
• Concentrated WBCs may be detrimental toward wound healing
– Neutropenic mice had accelerated wound closure and healing5
– PU.1 null mice (lack neutrophils and macrophages) repair wounds in a scar-free manner, similar to
embryonic healing6
– Oral mucosa wounds heal fast without scarring—have reduced influx of neutrophils and macrophages7
1. Toumi H et al. The inflammatory response: friend or enemy for muscle injury? Br J Sports Med 2003; 37(4): 284-6.
2. Schneider BS et al. Neutrophil infiltration in exercise-injured skeletal muscle: how do we resolve the controversy? Sports Med 2007; 37(10): 837-56.
3. Grogaard B et al. The polymorphonuclear leukocyte: has it a role in fracture healing? Arch Orthop Trauma Surg 1990; 109(5): 268-71.
4. Voggenreiter G et al. Immunosuppression with FK506 increases bone induction in demineralized isogenic and xenogenic bone matrix in the rat. J Bone Miner Res 2000; 15(9): 1825-34.
5. Dovi JV et al. Accelerated wound closure in neutrophil-depleted mice. J Leukoc Biol 2003; 73(4): 449-55.
6. Martin P et al. Wound healing in the PU.1 null mouse—tissue repair is not dependent on inflammatory cells. Curr Biol 2003; 13(13): 1122-8.
7. Szpaderka AM. Differential injury responses in oral mucosal and cutaneous wounds. J Dent Res 2003; 82(8): 621-6.

28. Buffy-coat PRP
Mass density distribution
of blood components:
A – Platelets
Platelets Neutrophils
B – Monocytes
C – Lymphocytes
D – Basophils
E – Neutrophils
F – Erythrocytes
G – Eosinophils

29. Plasma Based PRP
Platelets Neutrophils
Mass density distribution of blood components:
A – Platelets B – Monocytes C – Lymphocytes D – Basophils
E – Neutrophils F – Erythrocytes G – Eosinophils

30. INCREASED CONCENTRATION OF
WHITE BLOOD CELLS IN PRP
WEAKENS ROTATOR CUFF TENDONS
WHEN USED FOR PASTA REPAIRS
Alan M Hirahara, MD, FRCSC
*Submitted for Presentation

31. Study Design
• Case-Control study design
• 3 Groups
– Group 1: 14 patients, PASTA repair without PRP
– Group 2: 72 patients, PASTA repair with PRP with concentrated WBC’s
– Group 3: 29 patients, PASTA repair with PRP with reduced WBC’s
• MRA or surgery was performed for people having persistent pain or
complaints at four to six months post-operatively to evaluate healing

32. Study
• No significant difference in improvement of ASES &
VAS scores
• Significant difference in Modes of Failure
– Group 1: 2 (14%) fail by non-healing of primary lesion
– Group 2: 10 (14%) fail by cut-through from sutures
• 2 (3.5%) fail by non-healing of primary lesion
– Group 3: 1 (3.5%) fail by different, new delamination tear

33. Study
• Conclusion
– PRP aids healing of PASTA repairs
– PRP with concentrated WBC’s may create a
“Zone of Weakness”
– Neutrophils most likely culprit

34. NON-SURGICAL USE OF PRP /
ULTRASOUND

35. Ultrasound
• Inexpensive
• Portable
• Non-Invasive
• No radiation / Harmless
• Easy to use
• Visualizes pathology
• Aids in surgery or needle
guidance

36. Why Are We Discussing Ultrasound?

37. Ultrasound – Accurate / Versatile
• 30% of injections miss subacromial bursa – Experts
– Eustace (1997)
– Yamakado (2002)
– Henkus (2006)
– Sethi (2006)
• Naredo et al. (2004)
– Randomized cohort (41 patients) to blind vs. U/S guided subacromial
cortisone injection
– VAS (p=0.001) & SFA (p=0.012) sig better in
U/S guided group

38. Better Accuracy
• Despite overwhelming evidence that accuracy in injections is quite low
and ultrasound significantly improves this accuracy, many DO NOT
BELIEVE
• Many physicians will feel that they are “excellent” at injections and
“never” miss

39. My Experience
• “My patients have significantly less pain when
done under ultrasound guidance”
• My Explanation:
– “I was missing some!”

40. Ultrasound
• Already used in OB/GYN, emergency medicine
• Becoming accepted in Orthopaedic Sports Medicine
• Sidelines of sports events for immediate diagnosis
• Courses in ultrasound filling up everywhere

41. NBA Team Physicians
May 2011, Chicago

42. Localization of Biceps/Notch

43. Calcific Tendonitis

44. Injections

45. What Do You Need?
• Sterile gloves / gown
– with mask/hat
• Sterile drapes
• Sterile transducer sheath or cover
• Sterile gel
• Sterile operating room

46. Sterile Technique

47. Non-Surgical Use of ACP
Adhesive Capsulitis 70
RCT 26
pPatellar tendon tear 24
pRCT 23
DJD - Knee 23
Lateral Epicondylitis 21
Tendonopathy 19
DJD - Shoulder 19
0 10 20 30 40 50 60 70

48. Non-Surgical Use of ACP
pUCL tear 15
Meniscus tear 14
Ca tendonitis 13
Achilles tendonopathy 9
SLAP lesion 8
Quad Tendonopathy 8
Plantar Fasciitis 6
Muscle strain 6
Sprained ankle 5
Valgus Extension Overload 4
Pes Anserine Bursitis 4
Medial Epicondylitis 4
Instability 4
Biceps tendonitis 4
MCL tear 1
0 2 4 6 8 10 12 14 16

49. Platelet-Rich Plasma vs. Cortisone
Injections for the Non-surgical
Treatment of Shoulder Pain
Alan M Hirahara, MD, FRCSC
*Presented @ AANA, WOA 2011 & COA 2012
* Accepted for Presentation @ WSTC & EFOST 2012

50. Study
• Case-Control study design
• 485 patients with injection of cortisone or PRP for shoulder pain under ultrasound
guidance
– 186 Study patients / 299 Control patients
• Results
– Statistical significance between groups for pain (mo 4-6) & ASES scores (mo 3-6)
• Conclusion
– PRP is as more effective than cortisone for relief of shoulder pain but with less risk
– But varied based on diagnosis

51. More Effective – Specific
VAS – PASTA Lesions
Pathologiesimprovement
Significant
8.0
7.0
6.0 • Partial tears & degenerative
5.0
– Tendon, ligament, muscle
4.0
3.0
2.0
1.0
• Inflammatory & calcific
- Study – = 23
n Tendonopathy
Control n = 24
* p < 0.05 for Wk 3 - Mo 6

52. Anti-Pain/Anti-Inflammatory
VAS – RC Tear No significant difference
8.0
7.0
6.0 • Full thickness tears
5.0
– Rotator cuff, SLAP, meniscus
4.0
3.0
2.0
• Joint problems
1.0
- Study– DJD, RA, chondral lesions
n = 26
Control n = 48
* No statistical significance between groups

53. ACP Decreases Pain
TNF-α in “joint fluid”
12
A
10
TNF-α (pg/ml)
8 B
B
6
4
2
0
Control ACP HA
HA in synoviocytes MMP 13-in synoviocytes
1.4 0
log HAS-2 Fold Change over
A
log MMP-13 Fold Change over
1.2 Control ACP HA
-0.2 A
1
-0.4
0.8 A
Control
Control
0.6 -0.6
0.4 -0.8
B
0.2 B
-1
0
Control ACP HA -1.2 B
Courtesy of Lisa Fortier, Cornell

54. All Patients
Pain Scores ASES Scores
7.0 80.0
6.0 70.0
60.0
5.0
50.0
4.0
40.0
3.0
30.0
2.0
20.0
1.0 10.0
0.0 0.0
Study n = 186
* p < 0.05 for Months 4 – 6 & 3 – 6
Control n = 299

55. Subacromial Injection

56. Bursitis – Subacromial Injection

57. Subacromial Injection – Arm Neutral

58. Pain Scores: Tendonopathy
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
-
Study n = 19
* No statistical significance between groups Control n = 68

59. Partial-thickness RC Tears

60. Pain Scores: Partial RC Tears
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
-
Study n = 23
* p < 0.05 for Wk 3 - Mo 6 Control n = 24

61. Massive RCT – Injection

62. Pain Scores: Full RC Tears
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
-
Study n = 26
* No statistical significance between groups Control n = 48

63. Pain Scores: Adhesive Capsulitis
6.0
5.0
4.0
3.0
2.0
1.0
-
Study n = 70
* No statistical significance between groups Control n = 84

64. Shoulder Joint Injection

65. Pain Scores: Shoulder DJD
7.0
6.0
5.0
4.0
3.0
2.0
1.0
-
Study n = 19
* No statistical significance between groups Control n = 39

66. Calcific Tendonitis

67. Calcific Tendonitis
7.0
6.0
5.0
4.0
3.0
2.0
1.0
-
Study n = 13
* No statistical significance between groups Control n = 7

68. Knee Suprapatellar Injection

69. Pain Scores – DJD Knee
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
-
ACP Cortisone Supartz
Study n = 23
Cortisone n = 54
* No statistical significance between groups Hyaluronic acid n = 61

70. Pain Scores – Meniscus Tear
7.0
6.0
5.0
4.0
3.0
2.0
1.0
-
ACP Cortisone
Study n = 14
* No statistical significance between groups Control n = 28

71. Partial Patellar Tendon Tear
Treated with ACP
ACP
3 Months

72. Pain Scores –
Partial Patellar Tendon Tears
7.0 6.1
5.9
6.0
5.0
3.6
4.0
2.9 3.2 3.3 3.3
3.0 3.0
3.0 2.7 2.6
2.3 2.4
1.9 2.0
1.7
2.0
1.0
-
n = 12

73. Lateral Epicondyle Injection

74. Pain Scores – Lateral Epicondylitis
7.0 6.3 6.2
6.1 6.0
6.0
5.1
4.9
4.7
5.0 4.4
4.2 4.2
3.8
4.0
3.2 3.0
3.0 2.4
1.9
2.0 1.4
1.0
-
n = 21

75. Proximal pUCL Tear – PRP
Injection

76. Pain Scores – pUCL Tears
6.5
7.0
6.0 5.3
5.0
4.4
3.5
4.0
3.0
3.0 2.5
2.1
1.7
2.0
1.0 0.8 0.8 1.0 1.0 1.0
1.0
0.7 0.7
-
n = 15

77. Plantar Fasciitis
Transverse / In-Plane

78. Pain Scores – Plantar Fasciitis
6.4
7.0
6.0
4.7
5.0
4.0
4.0 3.3
3.0
2.0 2.0
1.7 1.7
2.0 1.3 1.3
1.0
1.0 0.3 0.3
- - -
-
n=6

79. ORTHOBIOLOGICS IN
ARTHROSCOPIC SURGERY

80. Surgical Use of PRP
Shoulder Arthroscopy Knee Arthroscopy
• SLAP lesions • ACL reconstructions
• RC repairs • Meniscal repairs
• Stabilizations • Menisectomy
• Chondroplasty

81. Delivery Options
Viscous-Gel
Tuohy Delivery Needle
Viscous-Spray
Fenestrated Delivery Needle

82. Summary of Literature
• RC Repairs
– 5 – 10% failure (worse with increasing size)
Burkhart, Arthroscopy, 2001; 17:905-912.
Gartsman, JBJS Am, 1998; 80:832-840.
Yamaguchi et al, ICL Shoulder & Elbow, 2005.
• Instability Repairs
– Anterior: 10%, but have ranged from 0 – 33%
– Posterior: 50% failure (open) & 25% (arthroscopic)
– MDI: 2 – 5%, but up to 25% Cole et al. ICL Sports Medicine, 2005.
Metcalf et al. ICL Shoulder & Elbow, 2005.
Gartsman et al. Arthroscopy. 2001; 17:236-243.
Wolf et al. J Southern Orthop Assoc. 2002; 11:102-9.
Fischer. Sports Med Arthrosc Rev. 2004; 12:127-134.
• SLAP Repairs
– 85% excellent & good results but little data on non-healing. One study shows
20% failure
Morgan et al, Arthroscopy, 1998, 14:553-565.
Snyder et al, AJSM, 2003, 31(5): 798-810.

83. RC Repair

84. PASTA Bridge

85. ACL Reconstruction

86. Menisectomy

87. The Literature
Pro Con
• Randelli – RC Repair (JSES) • deVos - Achilles Tendonitis (AJSM)
• 2 Year results • Treatment regime
• Buffy Coat + Plasma Based • Primary application
• Concentration likely ~2-3X • No characterization of lesion
• Lower WBCs • Tendonitis / tendinosis
• Activated PRP but not a Fibrin • Weber / Rodeo / Castricini - RC Repair
Matrix
• PRP type? (ALL Cascade)
• Peerbooms - Lat epicondylitis • Surgical method (on cuff)
(AJSM) • Inconsistent processing
• PRP vs. Triamcinolone method (Weber)

88. Enhancing SLAP repairs with
Fibrin-PRP Clots
Alan M Hirahara, MD, FRCSC
Kyle Yamashiro, PT
Russ Dunning, MSPT
*Presented @ AANA, COA, AOSSM, WOA 2009

89. SLAP Repair

90. Study
• Case-Control study design
• 178 patients with SLAP repair with & without PRP
• Study group had statistically significant:
– Improved pain scores from 3 months & on
– Improved ASES scores from 1 month & on
– Improved time to discharge by 91 days
– Improved return to work by 59.4 days
– Improved failure rate from 10.3% (Control) to 0.7% (Study)
• Conclusion
– PRP ensures the healing process is initiated properly where placed

91. My PRP Experience
2009 2010 2011 2012 Totals
Injections 155 64 100 30 349
Surgery 308 380 367 200 1255
Totals 463 444 467 230 1604

92. CPT Code for PRP
• 0232T –
• Many insurances have denied payment,
claiming PRP is experimental, investigational,
or not medically necessary

93. PRP for ALL
• As the data continues to stockpile about its
efficacy, it is inappropriate to deny patients a
potential treatment option over surgery
• Patients can legally opt-out of their insurance
and pay cash for the treatment

94. 0232T - Medicare
• Considered a Non-Covered Benefit by
Medicare
• Able to bill patient if prior informed consent
to pay for non-covered benefit
– ABN Form from Medicare website required

95. Bottom Line
• Some WC / HMO / PPO carriers have paid on
the T-Code
• Cash Pay Model
– Patients sign an Opt-Out form with informed
consent similar to the ABN PRIOR to performing
the procedure if they wish to proceed with PRP

96. Ultrasound
• Ultrasound and any other imaging is included in the T-
Code so we do not use the CPT code 76942
• When medically necessary, we will do a separate
diagnostic ultrasound evaluation (complete or limited
- 76881 & 76882) at the same appointment, which
requires a separate procedure note and permanently
recorded images

97. Thank You!