Platelet-rich Plasma Update from Toronto, ISAKOS 2013

The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) is a gathering of several thousand professionals that is presently taking place in Toronto, Canada.  Today, a platelet-rich plasma (PRP), Instructional Course Lecture was offered to over 100 participants.  Lectures about how to use or not use PRP were given by Dr. Rogerio Silva, Dr. Allan Mishra, Dr. Nicola Maffuli and Dr. Steven Arnoczky.  At least ten other PRP lectures were given at the conference including Dr. Mandeep Dhillion from India presenting his excellent study showing the value of PRP for knee osteoarthritis.  Basic science papers by Dr. Joon Lee et al from Korea also showed a chondro-protective effect of PRP after acute ACL tears.  It is becoming increasingly difficult to keep up with the dramatic rise in PRP related presentations and papers.  Overall, it is clear that there is increasing worldwide interest in this point-of-care, blood-derived bioactive treatment.  As the data matures we will better understand how to use PRP to help care for patients.  Presently, there is excellent level one support for its use in chronic tennis elbow.

AM

Orthopedic Innovation

Innovation within medicine more often arises via persistence and determination than from dramatic breakthroughs.  In fact, many paradigm shifting advancements are not initially embraced by the medical establishment.  In orthopedics, total joint replacement and arthroscopy are two excellent examples.  Sir John Charnley deserves much of the credit for the modern development of hip replacement surgery.  His initial designs used Teflon and those implants typically failed early.  He redesigned his implant to use a novel liner that significantly improved  its longevity.  Use of other materials and techniques over several decades via the hard work of many have led us to the point where we complain when a total hip lasts less than 10 or even 15 years.  (Read more)

Arthroscopy, one of the first minimally invasive types of surgery, at its beginning took longer and was more complicated than open surgery.  The first examination of joint via a "scope" was close to 100 years ago.    Over the last 30 years, it has become the standard of care for evaluating and treating many joint injuries such as ACL reconstruction and Rotator Cuff Repair.  This innovation is the result of contributions of thousands of researchers, surgeons and their patients.  It is also led to less invasive surgery for spine disorders.  (See Spine Surgery Video) (Read more/source)

We are now about a decade into "Biologic Orthopedics".  Therapies such as Platelet Rich Plasma, Stem Cells, Genetic Engineering, and Genome Sequencing are revolutionizing how we evaluate and treat patients.  As we surf the choppy waters of innovation, however, we will not always embrace ideal ideas.  Some "innovations" will fade as fads but others will emerge as commonplace treatments that significant improve the lives of millions of patients.  We need to balance our approach to novel methods of helping our patients.  We must seek their safety and benefit first.   In doing so, we are obligated to consider emerging biologic treatment options because they may be the best and most appropriate.

Allan Mishra, MD
@BloodCure

Platelet Rich Plasma Helps Heal Patellar Tendon Graft Site after ACL Surgery

In a prospective, randomized controlled trial, platelet rich plasma was found to improve patellar tendon graft site healing and decrease pain in the immediate post operative period.  See abstract below:

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TotalTendon

From the American Journal of Sports Medicine

Patellar Tendon Healing With Platelet-Rich Plasma: A Prospective Randomized Controlled Trial

1. Adriano Marques de Almeida, MD, MS (adrianoalmeida@usp.br),
2. Marco Kawamura Demange, MD, PhD, 
3. Marcel Faraco Sobrado,
4. Marcelo Bordalo Rodrigues, MD, 
5. André Pedrinelli, MD, PhD and
6. Arnaldo José Hernandez, MD, PhD

+Author Affiliations

1. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil
2. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil
3. São Paulo University Medical School, São Paulo, Brazil
4. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil
5. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil
6. Department of Orthopedics and Traumatology, São Paulo University Medical School, São Paulo, Brazil

Abstract

Background: The patellar tendon has limited ability to heal after harvesting its central third. Platelet-rich plasma (PRP) could improve patellar tendon healing.

Hypothesis: Adding PRP to the patellar tendon harvest site would improve donor site healing and improve clinical outcome at 6 months after anterior cruciate ligament (ACL) reconstruction with a patellar tendon graft.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Twenty-seven patients were randomly divided to receive (n = 12) or not receive (n = 15) PRP in the patellar tendon harvest site during ACL reconstruction. The primary outcome was magnetic resonance imaging (MRI) assessment of patellar tendon healing (gap area) after 6 months. Secondary outcomes were questionnaires and isokinetic testing of ACL reconstruction with a patellar tendon graft comparing both groups.

Results: Patellar tendon gap area was significantly smaller in the PRP group (4.9 ± 5.3 mm²; 95% confidence interval [CI], 1.1-8.8) than in the control group (9.4 ± 4.4 mm²; 95% CI, 6.6-12.2; P = .046). Visual analog scale score for pain was lower in the PRP group immediately postoperatively (3.8 ± 1.0; 95% CI, 3.18-4.49) than in the control group (5.1 ± 1.4; 95% CI, 4.24-5.90; P = .02). There were no differences after 6 months in questionnaire and isokinetic testing results comparing both groups.

Conclusion: We showed that PRP had a positive effect on patellar tendon harvest site healing on MRI after 6 months and also reduced pain in the immediate postoperative period. Questionnaire and isokinetic testing results were not different between the groups at 6 months.

Platelet Rich Plasma and ACL Surgery

The use of Platelet Rich Plasma to augment anterior cruciate ligament reconstruction has been much discussed but not well studied until now. In a prospective randomized trial, Nin et al studied allograft ACL surgery with and without PRP.

"We prospectively randomized 100 patients undergoing arthroscopic patellar tendon allograft ACL reconstruction to a group in whom platelet-enriched gel was used (n = 50) and a non-gel group (n = 50). The platelet concentration was 837 x 10(3)/mm(3), and the gel was introduced inside the graft and the tibial tunnel. The use of PDGF, on the graft and inside the tibial tunnel, in patients treated with bone-patellar tendon-bone allografts has no discernable clinical or biomechanical effect at 2 years' follow-up." Read Full Abstract

This is a good example of where PRP may NOT be helpful.

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Total Tendon