Intraarticular platelet-rich plasma (PRP) injections involve extracting a patient's own blood, concentrating the platelets, and reinjecting the platelet-rich plasma into injured tissues like tendons or ligaments. PRP contains growth factors that promote healing. A typical treatment involves 3 weekly injections of 3-8 mL of PRP with ultrasound guidance. PRP appears safe but may cause minor temporary discomfort. While PRP shows promise for cartilage injuries, its benefits are usually limited and best for younger patients without advanced tissue degeneration.

1. INTRAARTICULAR
PLATELET-RICH PLASMA
Ade Wijaya, MD – April 2018

2. Outline
◦ Introduction
◦ Anatomy
◦ PRP
◦ Administration
◦ Safety
◦ Conclusion

3. Introduction
◦ According to the World Health Organization (WHO), musculoskeletal injuries are the most
common cause of severe long-term pain and physical disability, and affect hundreds of millions
of people around the world.
◦ Soft tissue injuries including tendon and ligament trauma represent 45% of all musculoskeletal
injuries in the USA.
◦ Platelet-Rich Plasma (PRP); The use of autologous PRP was first used in 1987 by Ferrari et al
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Praemer AF. Musculoskeletal conditions in the United States. 2nd ed. Rosemont: American Academy of Orthopaedic Surgeons; 1999.
Ferrari M, Zia S, Valbonesi M. A new technique for hemodilution, preparation of autologous platelet-rich plasma and intraoperative blood salvage in cardiac surgery. Int J Artif Organs. 1987;10:47–50.

4. Anatomy
Lories RJ (2008) Joint homeostasis, restoration, and remodeling in osteoarthritis. Best Pract Res Clin Rheumatol 22(2):209–220

5. Homeostasis
Damage
Remodelling
Restoration
Lories RJ (2008) Joint homeostasis, restoration, and remodeling in osteoarthritis. Best Pract Res Clin Rheumatol 22(2):209–220

6. Platelet-Rich Plasma (PRP)
◦ A blood derivative that has a higher platelet concentrate (94%) than whole blood.
◦ 1 million platelets / uL
◦ Platelets release a group of biologically active proteins 
◦ Bind to the transmembrane receptors of their target cells, 
◦ Leading to the expression of gene sequences 
◦ Promote cellular recruitment, growth, and morphogenesis, and modulating inflammation as well
Anitua E, Sánchez M, Orive G (2010) Potential of endogenous regenerative technology for in situ regenerative medicine. Adv Drug Deliv Rev 15;62(7–8):741–752
Marx R, Garg A. Dental and craniofacial applications of platelet-rich plasma. Carol Stream: Quintessence Publishing Co, Inc.; 2005.

9. Administration
◦ Usually 3 weekly injections
◦ 3-8 mL of PRP each injection
◦ USG guided with or without lidocaine
◦ Calcium chloride and thrombin may be added to provide a gel matrix for the PRP to adhere to,
potentially maximizing the benefit in the case of a joint space.
◦ Using a peppering technique spreading in a clock-like manner to achieve a more expansive zone of
delivery.
◦ The patient is observed in a supine position for 15–20 min afterwards.
◦ Patients typically experience minimal to moderate discomfort following the injection which may last
for up to 1 week.
◦ They are instructed to ice the injected area if needed for pain control in addition to elevation of the
limb and modification of activity as tolerated.
◦ Acetaminophen as the optimal analgesic, or Vicodin for break through pain.
Filardo G, Kon E, Roffi A, Di Matteo B, Merli ML, Marcacci M. Platelet-rich plasma: why intra-articular? A systematic review of preclinical studies and clinical evidence on PRP for joint degeneration. Knee Surgery, Sports
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Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Current reviews in musculoskeletal medicine. 2008 Dec 1;1(3-4):165-74.

10. Safety
◦ Relative contraindications include the presence of a tumor, metastatic disease, active infections,
or platelet count < 10 5/ul Hgb < 10 g/dl.
◦ Contraindications: Pregnancy or active breastfeeding.
◦ The patients should be informed of the possibility of temporary worsening symptoms after the
injection. This is likely due to the stimulation of the body’s natural response to inflammatory
mediators.
◦ Although adverse effects are uncommon, as with any injection there is a possibility of infection,
no relief of symptoms, and neurovascular injury. Scar tissue formation and calcification at the
injection site are also remote risks.
◦ An allergic reaction or local toxicity to Bupivacaine HCL or Lidocaine
◦ This bovine thrombin which is used to activate PRP, in the past has been associated with life
threatening coagulopathies as a result of antibodies to clotting factors V, XI, and thrombin.
Everts P, Knape J, Weirich G, Schonberger J, Hoffman J, Overdevest E, et al. Platelet-rich plasma and platelet gel: a review. JECT. 2006;38:174–87.
Zehnder JL, Leung LLK. Development of antibodies to thrombin and factor V with recurrent bleeding in a patient exposed to topical bovine thrombim. Blood. 1990;76:2011–6.
Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Current reviews in musculoskeletal medicine. 2008 Dec 1;1(3-4):165-74.

12. Conclusion
◦ PRP might useful for cartilage degeneration and OA
◦ Improvement limited over time and mainly in younger patients not affected by advanced
degeneration