8. +
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
10. +
What is the response to platelets
Proliferation of Mesenchymal stem cells
Proliferation of fibroblasts
Production of Type 1 Collagen
Platelets itself release Growth factors
11. +
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
12. +
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?
13. +
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
14. +
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.
20. +
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.
22. +
What do we have???
Plasma based method done here.
23. +
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.
24. +
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.
25. +
When used with local anesthetics, the pH is changed.
This reduces the efficacy of PRP
26. +
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.”
29. +
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)
30. +
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
31. +
Tennis elbow
• Common Disorder
• Repetitive activities
– Most common cause
– May occur from injury (acutely)
32. +
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
43. +
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
49. +
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)
50. +
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?!
51. +
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
52. +
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
53. +
COMPLICATIONS
No adverse complications have been reported
Symptoms may be worsened for few days because of induced
inflammation
Infection
Persisting symptoms
54. +
Clinical use has outpaced scientific investigations
Less restrictions vs. pharmaceuticals
Readily available
Safe
Autologous = up regulation of normal physiology
“Regenerative”
$$$
55. +
Limitations
Efficacy
Lack of clinical data
Number of studies being done
Indications are being developed
Uniformity of prep
PRP classification
Insurance recognition
My topic for today is PRP in Ortho. This is one genuine recent advances in our field. And as I speak, more new things and implementations are being developed for the same!
Since then it has been used in different medical fields such as cosmetic surgery, dentistry, sports medicine and pain management.
----- Meeting Notes (11/6/15 13:59) -----
kjug
But, awareness among general public increased after famous sportsmen have confessed to using this drug post injury!
7% of body weight
Before I go into the details abt PRP and why its useful..
I would like to refresh your memory abt the healing pathways in our body.
The proliferation of MSC is directly related to PDGFr released by alpha granules of platelets!
Cellular chemotaxis, proliferation and differentiation
Angiogenesis
Regeneration of appropriate tissue
WB should be stored at 20°C to 24°C before centrifugation.
Centrifuge WB at a ‘high’ speed.
Three layers are formed because of its density: The bottom layer consisting of RBCs, the middle layer consisting of platelets and WBCs and the top PPP layer.
Remove supernatant plasma from the top of the container.
Transfer the buffy-coat layer to another sterile tube.
Centrifuge at low speed to separate WBCs or use leucocyte filtration filter.
Obtain WB by venipuncture in acid citrate dextrose (ACD) tubes
Do not chill the blood at any time before or during platelet separation.
Centrifuge the blood using a ‘soft’ spin.
Transfer the supernatant plasma containing platelets into another sterile tube (without anticoagulant).
Centrifuge tube at a higher speed (a hard spin) to obtain a platelet concentrate.
The lower 1/3rd is PRP and upper 2/3rd is platelet-poor plasma (PPP). At the bottom of the tube, platelet pellets are formed.
Remove PPP and suspend the platelet pellets in a minimum quantity of plasma (2-4 mL) by gently shaking the tube.
are preparations without leucocytes and with a low-density fibrin network after activation.
It is in this family that the largest number of commercial or experimental systems exist.
These products only exist in a strongly activated gel form, and cannot be injected or used like traditional fibrin glues.
3 and 4 are gelatinous plugs!
But some ppl argue that with leucocytes is better than without leucocytes!
Inflamation of Achilles tendon or the bursa associated with it.
PatelloFemoralPain syndrome – runners knee
Patellar tendinitis – jumpers knee
ACP – plasma based plasma
ACP – Autolog Conditioned plasma