PRP therapy is a new branch gaining popularity in the recent past. This ppt gives a brief advantages and applications of PRP in field of orthopaedics.

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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