Platelet Rich Plasma & Shockwave Therapy

Platelet Rich Plasmainorthopaedics

Chairperson Dr. Deepak KaladagiPresenter - Dr. Srinath Gupta

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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!1

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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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) -----kjug2

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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But, awareness among general public increased after famous sportsmen have confessed to using this drug post injury!3

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Components of our blood

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7% of body weight5

DefinitionVolume 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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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.7

What is PRP?Platelet Rich PlasmaUtilizing growth factor (GF) content of platelets to aide in healing of musculoskeletal tissuePredominately 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 FunctionHaemostasisPlatelet plugBlood clot

Secretion of active proteins

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What is the response to platelets

Proliferation of Mesenchymal stem cellsProliferation of fibroblastsProduction of Type 1 Collagen

Platelets itself release Growth factors

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The proliferation of MSC is directly related to PDGFr released by alpha granules of platelets!10

Growth factors present in PRPPlatelet-derived growth factorTransformin growth factor betaFibroblast growth factorInsulin-like growth factor 1Insulin-like growth factor 2Vascular endothelial growth factorEpidermal growth factorInterleukin 8Keratinocyte growth factorConnective tissue growth factor

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What does it lead to??ChemotaxisDirectional movement in response to a chemical stimulusStems cells are attracted to the growth factors and migrate into the area

Cell proliferationSignificant increase in cellular reproduction activity

Possibly even a systemic effect Performance enhancing?

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Cellular chemotaxis, proliferation and differentiationAngiogenesisRegeneration of appropriate tissue

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Effect of PDGF on TissuesImmediate (within 5 minutes)Second messenger stimulationInflammatory response

Early (30min to 4 hours)M-RNA stimulation, protein synthesisChemotaxis (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 PlasmaHOW IS IT OBTAINED??

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2 methodsBuffy coat methodPlasma based method

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Buffy coat method

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WB should be stored at 20C to 24C 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.

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Plasma based PRP

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Obtain WB by venipuncture in acid citrate dextrose (ACD) tubesDo 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.

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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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ClassificationPure Platelet-Rich Plasma (P-PRP) or leucocyte-poor PRP products

Leucocyte- and PRP (L-PRP) products are preparations with leucocytes and with a low-density fibrin network after activation

Pure platelet-rich fibrin (P-PRF) or leucocyte-poor platelet-rich fibrin preparations are without leucocytes and with a high-density fibrin network

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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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!23

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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But some ppl argue that with leucocytes is better than without leucocytes!24

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 repairTendonitis (office based injection)ArthritisLigament surgeryTendon repairsAcute 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- Meniscal Suture, RC Repair etc

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Inflamation of Achilles tendon or the bursa associated with it.PatelloFemoralPain syndrome runners kneePatellar tendinitis jumpers knee28

Indications & UseAnalgesic?Potential primary analgesic effectSome human studies state decreased post-op pain levelsStimulation of thrombin receptors (ie, PAR-1) shown to increase pain threshold in laboratory animals through opioid pathways and haemostasis

AntimicrobialAgainst Staphylococcus aureus (Sutter 2012)

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Tendinopathy or TendinosisDefinitions - Histologically SpeakingLoss 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 elbowCommon Disorder

Repetitive activitiesMost common causeMay occur from injury (acutely)

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Office Injection of PRPPRP Application TechniqueInject 2-3 cc of PRP into the ECRB--Peppering techniqueAverage 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 kneeDifferent conservative treatment options includeSteroid injectionsHyaluronic acid andPRP

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PRP vs. Hyaluronic acid

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PRP for Muscle strainsThe 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-operativeMeniscus repairs

ACL repairs

OCD Post microfracturing

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Pure platelet-rich fibrin (P-PRF) or leucocyte-poor platelet-rich fibrin preparations

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 withACP 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 :