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Clinical Applications Truth or Myth? - California …€¦ · · 2015-08-30Clinical Applications...
Transcript of Clinical Applications Truth or Myth? - California …€¦ · · 2015-08-30Clinical Applications...
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Platelet Rich Plasma Clinical Applications
Truth or Myth?
Lesley J Anderson MD California Pacific Medical Center
San Francisco, Ca
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No disclaimers
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Platelet-Rich Plasma (PRP)
Caption™ Smith & Nephew
Cascade™ MTF Symphony II™ DePuy
Magellan™ Medtronic GPS®III Biomet
Arthrex ACP™ Arthrex
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Claims of PRP Reduce blood loss Improve wound healing Reduce infection (due to presence of
WBC) Improve ligament integration into bone Reduce Pain Heal tendons Treat arthritis Grow cartilage
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Truth or Myth?
Hair Transplant Surgery Coupled With PRP Therapy - Is This The Next Generation of Hair Restoration?
http://hairloss.iahrs.org/hair-transplant/hair-loss-prp-therapy-hair-transplant/
Can Even Grow Hair!
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http://exploreplasticsurgery.com/category/platelet-rich-plasma/
Vampire Facelift
(Selphyl) uses the patient’s own blood to make the injectable filler.
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Truth or Myth? Which is better?
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How is PRP Prepared?
Single spin systems Use for tendon, joint
or ligament injections
WBC = may or may not be present
Double spin Gels Matrices Membranes
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Nonsurgical uses All companies have injectable PRP Tendinosis- Achilles/quad/patellar
tendon/elbow Soft tissue pain; bursitis/fasciitis OA of the knee Ultrasound can facilitate placement
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Nonsurgical use All companies have injectable PRP Tendinosis- Achilles/quad/patellar
tendon/elbow Soft tissue pain; bursitis/fasciitis OA of the knee Ultrasound can facilitate placement
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PRP and Tendinosis Alternative to corticosteroids Precise introduction of growth factors to
the tendinopathic areas Chemotactic properties create an
inflammatory response and invoke the healing cascade with
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Peer Review Articles
Aspenberg: Percutaneous injection into hematoma of rat
Achilles tendon tear showed increased tendon callous strength and stiffness (Acta Ortho Scand. Feb 2004
Hammond: Injection of PRP into Ant tibial muscle vs.
controls that had set stretch showed earlier healing and return to normal. (AJSM Vol. 37 2009)
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Patellar Tendinosis 15 pts w PRP + PT vs. 16 pt w PT alone 3 PRP injections 2 wks apart No adverse effects Earlier return to sport Statistically significant improvement in all
parameters
Filardo et al. Injury July 2009
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Patellar Tendinosis and PRP
Level 1 -10 pts Eccentric PT + dry
needling under UTZ Eccentric PT + dry
needling + UTZ + PRP
Dragoo- Arthroscopy Oct 2011
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Patellar Tendinosis and PRP
PRP group – sign improve p=0.01
Dry needling - decreased over 12 weeks
Dragoo- Arthroscopy Oct 2011
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Achilles Tendinopathy AJSM deJong, de Vos 8/11
Level 1 Randomized controlled trial PRP vs. saline + eccentric rehab program 54 pts- all improved (59%) VAS; and Ultrasound exam- both
improved significantly but not different Conclusion; No difference at 1 year;
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Elbow tendinopathy Mishra: AJSM 2006
15 patients Original Paper:
93% reduction in pain at 2 years
VAS; 8 wks 60% decrease vs. controls (16% ) p=.001
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Lateral Epicondylitis Peerblooms; AJSM Vol 38 No 2; 2010
Level 1 Study ; Steroid vs. PRP Injection- 100 pts Treatment with PRP reduced pain and increased
function (VAS p<.001; DASH p = .005) 18/100 required subsequent intervention
5 PRP group ; 3 operations; 2 steroid inj. 13 steroid group; 6 operations; 6 PRP inj + 1
steroid 2 yrs fu study confirmed ongoing improvement
compared to steroids (AJSM Vol 39 2011)
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PRP and Lateral Epicondylitis Hechtman, Uribe; Orthopedics 2011
31 pts- 6 mos failed treatment including
steroids 90% reduction of 25% of VAS and DASH at
least 6 mos Important point; many were worse at 6 weeks,
but then improved.
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Rotator Cuff Tendinosis
Use ultrasound control Consider for tendinosis ?Partial cuff tears
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Technique
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PRP results
Hansen; not published- observational 20 SS tears +MRI + US 2 injections MRI + US at 6 mos; all had evidence of
new tissue formation 14/20 excellent results and avoided
surgery They hurt for 2-7 days
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My Opinion Not ready for generalized use in RC
tendinopathy Could be used in repairs of partial tears In my hands, not an outpatient procedure-
it really hurts to do
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Knee OA and PRP Kellgren Lawrence Grading System
Grade 1 Doubtful narrowing of the joint space and poss osteophytic lipping
Grade 2 Definite osteophytes, definite narrowing of the joint space
Grade 3 Moderate mult. Osteophytes, def narrowing of joint space, some sclerosis and poss. deformity of bone contour
Grade 4 Large osteophytes, marked narrowing of the joint space, severe sclerosis and def deformity of bone contour.
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Osteoarthritis and Knee PRP vs. HA
Cerza; Compared PRP and HA (AJSM 2012)
Level 1 - 60 pts each received 4 injections Fu 6 months
HA with Grade 3 arthritis had no improvement
PRP – had sign effect after final injection and continued to 24 weeks and sign better than HA (P<0.001)
ACP grade of OA was no different
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Osteoarthritis and Knee PRP vs. HA
Sanchez; Arthroscopy 2012 Level 1; BMI<32, no malalignment; No
Grade 4 changes, 176 pts 6 mo followup Safe and efficacious in treating mild to
moderate OA. Better pain relief compared to HA, but fu short, and no stat significant difference in stiffness and function.
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OA and Knee PRP vs. Saline
AJSM 2013 PRP vs. Placebo Level 1: 3 Groups A = 1 PRP injection (WBC filtered)- 52 pts B = 2 PRP injections 3 wks. apart- 50 pts C = Saline- 46 pts
Patel AJSM Feb 2013
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OA and Knee Groups A and B (PRP) stat. better
outcomes in WOMAC, VAS up to 6 mo. P< .001
Group C (saline) deteriorated over 6 mo. No difference in 1 or 2 injections No difference in age, sex, weight or BMI in
the outcome Complications; dizziness and nausea
Patel
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OA and Knee Groups A and B (PRP) stat. better
outcomes in WOMAC, VAS up to 6 mo. P< .001
Group C (saline) deteriorated over 6 mo. No difference in 1 or 2 injections No difference in age, sex, weight or BMI in
the outcome Complications; dizziness and nausea
Patel
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Clinical and MRI after PRP in OA
Early OA (Kellgren 0-2) 30-70 yrs
17 pts single 6 cc injection PRP
Fu to 1 yr with MRI pre and at 1 yr.
VAS, WOMAC
Halpern, Rodeo et al; HSS Clin J Sport Med 2012
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Clinical and MRI after PRP in OA
15 knees underwent MRI 73% showed no worsening of OA at 1 year May work by increasing HA production,
proliferation of Chondrocytes and MSC and reduced inhibition of enzymes that breakdown cartilage in OA
Halpern, Rodeo et al; HSS Clin J Sport Med 2012
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Clinical and MRI after PRP in OA
15 knees underwent MRI 73% showed no worsening of OA at 1 year May work by increasing HA production,
proliferation of Chondrocytes and MSC and reduced inhibition of enzymes that breakdown cartilage in OA
Normally OA progresses about 4% a year radiographically
Halpern, Rodeo et al; HSS Clin J Sport Med 2012
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Summary-Nonsurgical Uses Not all PRP is the same
Know your vendor- If its red, there are more WBC’s. Evidence based studies Effective in Elbow- better outcomes than
steroid Effective in the Knee for OA Not clear in Achilles and Patellar tendinopathy Injections for muscle strain or small series
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Surgical Uses
RC Repair Knee Tendon repair Achilles tendon repair Ligament
reconstruction
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If you add a second spin or add an activator
Gels
Matrix
Membrane
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Platelet Concentrate Systems
Ideally can be sutured and placed arthroscopically
Ease of Use Cost factors Delayed
activation
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Patellar Tendon Healing after ACL
De Almeida AJSM 2012 Randomized clinical trial 28 pts Gel placed in Patellar tendon defect Reduces postop pain and MRI tendon gap
was 4.9 mm +/- 5.3 mm vs. control 9.4 +/- 4.4mm
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Gels
Second spin: Add bovine thrombin to
allow a workable/injectable form through large gauge catheters
Remember growth factors are all activated in face of thrombin within 1 hour
Most have WBC’s and some RBC’s
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Platelet Rich Fibrin Matrix
Second spin; Uses 0.01% CaCl
to neutralize the anticoagulant from first spin
Uses PRP (growth factors) + PPP (fibrin) to allow growth factors to adhere and forms a lattice
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Platelet Rich Fibrin Matrix no thrombin
Produces a scaffold as well as a reservoir of growth factors
Nonactivated platelets- released over 7 days
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Matrix
Scaffold; makes it easier to suture and pass through cannulas
Meniscal repairs, Labral repairs
“Barbie Boobs”
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Membrane
Concentrates platelets up to 52X
Much more robust Excellent for
incorporating into soft tissue repairs (Quad, ACL, RC)
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Sanchez- Achilles Tendon
AJSM 2007 12 athletes; 40 cc blood; used CaCl No
thrombin; Used glass container to develop fibrin matrix
6 PRGF; 6 no PRGF Running 11 vs 18 wks (p=.024)
Training 14 vs 21 wks (p=.004)
PRGF system II, Spain
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Achilles Tendon- caveat- these wounds look great
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Ligament Reconstruction Fanelli; Reduced tunnel widening in ACL patients
at 6 weeks compared to controls Controls 52% incidence of tunnel widening
vs. 6.7% in PRFM Less soft tissue swelling / inflammation in
extraarticular work.
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Meniscal Repair
Integrate into the repair much like a fibrin clot
Use a passing suture to pull the matrix into the repair site or inject directly
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Rotator Cuff Tears
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Rotator Cuff Repair
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RC Repair Castricini- AJSM Dec 2010
Level 1 study n = 80 Used PRFM No difference in Constant score Error in statistics on MRI - they said no
difference in footprint coverage and quality of the tendon- but in fact there was a statistically sign improvement in footprint and quality !
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Rodeo ASES 2010
Level 1 –PRFM vs Control 1 yr followup No difference by ultrasound at 1 year Platelet count not related to healing
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Barber Arthroscopy 8/11
Level 3 40 pts ; PRFM and control 31 months MRI – persistent FT defects in 60% of
controls vs 30% of PRFM p=.03 If tear < 3 cm controls- 50% healed PRFM – 86% healed; P<.05 No difference in standard outcome measures
except Rowe score
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Materials and Methods Cohort study – Retrospective consecutive series-2005-2007 Rotator cuff tears in patients failing conservative
treatment Matched control group during the same period Standard demographics as well as technique,
tear size, medication use, sleep patterns, workers compensation status, range of motion and strength were documented
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Current technique PRF Membrane
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Return to Work
WC-PRFM
WC- Non PRFM
Full duty 15 71% 21 60% Modified 5 24% 12 34% Retired 1 5% 2 6%
21 35
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Conclusions The use of platelet rich fibrin matrix
reduces pain (p<0.01) and improves sleep (p = 0.013) in pts undergoing rotator cuff repair
A high percentage of PRFM WC patients return to full duty (71%) vs. 60% controls
The use of PRFM may improve healing in patients with large-massive rotator cuff repairs
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Current Uses Indications
OA and Knee Epicondylitis Rotator cuff
tendinosis; Achilles tendinosis, Plantar fasciitis
Surgical adjunct
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New Directions Indications
OA and Knee Epicondylitis Rotator cuff
tendinosis; Achilles tendinosis, Plantar fasciitis
Using with MSC in tendon repair and ligament repair AAOS NOW Feb 2013
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