PRP enhances healing after Achilles Tendon Rupture

PRP being added to an Achilles Tendon Repair

If you rupture your Achilles tendon, new data suggests platelet rich plasma can enhance the healing.  In an abstract published by the journal Lancet, researchers from England discussed how they treated patients who had ruptured their Achilles with either PRP or a placebo.  Six weeks later, they biopsied the healing tendons under ultrasonic guidance.  In the study, they found improved cell content, better tendon fiber structure and more normal collagen (type 1) in the tendons treated with PRP.  The study included 20 patients (10 PRP, 10 Control) and is the first investigation in humans showing the significant value of using PRP to help treat Achilles tendon ruptures.  Of course, more data will be needed to confirm these important findings.  For years, I have been adding PRP to my achilles tendon repairs and if I ever rupture my own, I will certainly request that PRP is included in the treatment protocol.

AM 

Total Tendon

Microfracture Surgery Jadaveon Clowney

The Houston Texans' Jadeveon Clowney recently underwent "microfracture" surgery on his ailing right knee.  (See ESPN report)

The report suggests the talented Mr. Clowney will be out for 9 months or more.  Just what is microfracture surgery and why does it take as long to recovery as it does for a baby to born?

Microfracture Surgery

Let's start with the basics.  There are two types of cartilage in the knee.  The surface cartilage which covers the bone.  This is known as articular cartilage and can be thought of a type of cap or covering of the end of the bone.  This cartilage is present in any joint.  In the knee, there is another type of cartilage, the meniscus cartilage.  There are two menisci in the knee--medial (inside) and lateral (outside).  When the surface "articular" cartilage is damaged, the knee can become quite painful especially with loading and twisting.  Think rushing a passer for example.  Similar symptoms can occur when the meniscus is torn.  It is often difficult to distinguish between the two in terms of which one is the pain generator.

Microfracture surgery is an attempt to create a tire patch over a cartilage defect by poking a hole in the end of the bone and creating an access channel to the bone marrow.  The bone marrow then leaks out via the holes that are created and forms a clot which over time can help cover the defect.  It takes time, many months, for this surgery to work because the "patch" needs to mature.  This technique is useful for small defects in the cartilage but hasn't proven to be great for larger defects.  We do not know the size of Mr. Clowney's knee cartilage injury.

Recent evidence suggests that the addition of platelet-rich plasma can enhance microfracture surgery results.  This has been shown in basic science, preclinical and now clinical studies.

This type of surgery at such a young age is clearly not a good sign.  In the long run, he may require further intervention.  Please read the post below for further information about why we need to accelerate our regenerative medicine efforts.  Mr. Clowney is one of tens of millions of people worldwide with symptomatic cartilage damage.  We need to maximize outcomes of today's surgical techniques and develop new procedures to help keep our athletes and patients in the game.

AM

TotalTendon

Platelet Rich Plasma Significantly Improves Outcomes for Tennis Elbow in a 230 Patient Study

The American Journal of Sports Medicine (AJSM) has just published the largest study evaluating platelet-rich plasma.  The 230 patient study was conducted over the course of more than five years and represents the work of dozens of clinicians and researchers.  Overall, it is clear from the data that the use of PRP to treat chronic tennis elbow results in significant reductions in pain and elbow tenderness compared to an active control of needling of the elbow without PRP.  It is also safe and cost effective compared to cortisone and surgery.  This type of study is time consuming and expensive but will help guide patient and physicians decisions about how to best treat chronic tennis elbow.

Here is a lay press article on the article from Healio.

Read the full AJSM Abstract below.

AM
Total Tendon


Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow
A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients

1. Allan K. Mishra, MD*,†, 
2. Nebojsa V. Skrepnik, MD, PhD‡,
3. Scott G. Edwards, MD§, 
4. Grant L. Jones, MD‖, 
5. Steven Sampson, DO¶,
6. Doug A. Vermillion, MD#, 
7. Matthew L. Ramsey, MD**, 
8. David C. Karli, MD, MBA†† and 
9. Arthur C. Rettig, MD‡‡

1. ^†Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California
2. ^‡Tucson Orthopaedic Institute, Tucson, Arizona
3. ^§Division of Hand and Elbow Surgery, Georgetown University Hospital, Washington, District of Columbia
4. ^‖Department of Orthopaedic Surgery, The Ohio State University, Columbus, Ohio
5. ^¶The Orthohealing Center and The Orthobiologic Institute, Los Angeles, California
6. ^#Orthopaedic Research Clinic, Anchorage, Alaska
7. ^**Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
8. ^††The Steadman Clinic, Vail, Colorado
9. ^‡‡Methodist Sports Medicine, Indianapolis, Indiana
10. Investigation performed at Department of Orthopaedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California

1. *Allan K. Mishra, MD, Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, 1300 Crane Street, Menlo Park, CA 94025 (e-mail: am@totaltendon.com).

Abstract

Background: Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow.

Purpose: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group.

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

Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study.

Results: Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .094). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .027). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .036). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P < .001). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P= .012). No significant complications occurred in either group.

Conclusion: Treatment of chronic tennis elbow with leukocyte-enriched PRP is safe and results in clinically meaningful improvements compared with an active control group.

The Biomet Biologics GPS device was used to prepare the PRP for this study.

Platelet Rich Plasma and Knee Arthritis

Knee arthritis is a very common problem for patients worldwide.  With the aging of the population this will become one of the most important medical issues to address with biologic therapies.

Conflicting results have recently been published about the use of platelet rich plasma in the treatment of knee arthritis.  Filardo, Kon et al found no significant differences between PRP and hyaluronic acid injections.  (see full abstract).  Conversely, Cerza et al did find significantly better clinical outcomes when patients were treated with PRP vs hyaluronic acid injections. (see full abstract) The version of PRP used in these two studies were different.  The first study also used three injections and the second four weekly injections.  Clearly, more research is needed to clarify the value of PRP for knee arthritis and determine the optimal formulations and techniques.

AM
TotalTendon

See the video below for a brief description of knee arthritis

Systemic Effects of Platelet Rich Plasma

In a well done study, researchers have shown when athletes are given an intratendinous injection of leukocyte-enriched platelet rich plasma (PRP), they will have elevated levels of growth factors in their blood up to four days after the procedure.  (see abstract below)

Vascular-endothelial growth factor  (VEGF), a molecule known to enhance angiogenesis (new blood vessel formation), was elevated in all 25 patients after injection.  This is very interesting and important data suggesting PRP may trigger a systemic response.  It also helps explain why PRP may be a useful treatment for tendon related injuries and disorders.   Several controlled studies confirm PRP can be an effective treatment for chronic tennis elbow and this study may reveal one of the mechanisms of action.
Tennis Elbow Study 1,  Tennis Elbow Study 2

It would be quite interesting and important to also measure growth factors in athletes who have received a saline injection or dry needling of their tendons to see if the act of introducing a needle into a damaged tendon produces a similar or different systemic response.

AM
TotalTendon.com

Am J Sports Med. 2012 Dec 4.

The Systemic Effects of Platelet-Rich Plasma Injection.

Wasterlain AS, Braun HJ, Harris AH, Kim HJ, Dragoo JL.

Source

Department of Orthopaedic Surgery, Stanford University, Stanford, California.

Abstract

BACKGROUND:Platelet-rich plasma (PRP) is an autologous blood product used to treat acute and chronic tendon, ligament, and muscle injuries in over 86,000 athletes in the United States annually. The World Anti-Doping Agency (WADA) banned intramuscular PRP injections in competitive athletes in 2010 because of concerns that it may increase performance-enhancing growth factors. The ban on PRP was removed in 2011 because of limited evidence for a systemic ergogenic effect of PRP, but the growth factors within PRP remain prohibited. PURPOSE:To quantify the effect of PRP injection on systemic growth factors with performance-enhancing effects and to identify molecular markers to detect treated athletes. STUDY DESIGN:Descriptive laboratory study. METHODS:Six ergogenic growth factors monitored by WADA-human growth hormone (hGH), insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), basic fibroblast growth factor (bFGF or FGF-2), vascular endothelial growth factor (VEGF), and platelet-derived growth factor-BB (PDGF-BB)-were measured in 25 patients before (baseline) and at 0.25, 3, 24, 48, 72, and 96 hours after intratendinous leukocyte-rich PRP injection. Eating and exercise were prohibited for 3 hours before testing. Growth factors were quantified by enzyme-linked immunosorbent assay, and the change relative to each patient's baseline was calculated. RESULTS:Relative to serum, PRP contained significantly more bFGF (226 vs 5 pg/mL), VEGF (1426 vs 236 pg/mL), and PDGF-BB (26,285 vs 392 pg/mL), but IGF-1 and hGH were not elevated. Serum levels increased significantly for IGF-1 at 24 and 48 hours, for bFGF at 72 and 96 hours, and for VEGF at 3, 24, 48, 72, and 96 hours after PRP injection. Additionally, VEGF was increased in all 25 patients after PRP treatment. CONCLUSION:Serum IGF-1, VEGF, and bFGF levels are significantly elevated after PRP injection, supporting a possible ergogenic effect of PRP. An indirect marker for hGH doping, the product of IGFBP-3 × IGF-1, also significantly increased after PRP. Platelet-rich plasma appears to trigger an increase in circulating growth factors through activating biological pathways rather than by serving as a vehicle for the direct delivery of presynthesized growth factors. Elevated VEGF was observed in all patients after PRP, and ≥88% of patients had elevated VEGF at each time point from 3 to 96 hours after PRP, suggesting that VEGF may be a sensitive molecular marker to detect athletes recently treated with PRP. CLINICAL RELEVANCE:This is the first and only adequately powered study of the systemic effects of PRP. We present evidence that PRP contains and may trigger systemic increases in substances currently banned in competitive athletes. Finally, we provide evidence that VEGF could serve as a useful molecular marker to detect athletes treated with PRP.

Platelet Rich Plasma useful for Chronic Tennis Elbow

For more than a decade now, platelet rich plasma has been used to treat chronic tennis elbow.   A recently published review article in Hand Clinics reviewed the literature for the use of PRP in the upper extremity.  It was concluded that multiple controlled trials support the use of PRP for tennis elbow.  The literature supporting the its use for rotator cuff tears, however, was not yet conclusive.  (See Abstract Below)

PRP Injection into left elbow

Hand Clin. 2012 Nov;28(4):481-91. doi: 10.1016/j.hcl.2012.08.008.

Platelet-rich plasma and the upper extremity.

Mishra A, Randelli P, Barr C, Talamonti T, Ragone V, Cabitza P.

Source

Department of Orthopaedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, 1300 Crane Street, Menlo Park, CA 94025, USA. 

Abstract

Platelet-rich plasma (PRP) is a fraction of whole blood containing powerful growth factors and cytokines. Preclinical studies suggest PRP may be useful for tendon repair or regeneration. Clinical investigations have focused on the treatment of chronic lateral epicondylar tendinopathy and rotator cuff pathology. Multiple controlled studies support the use of PRP for chronic tennis elbow. Rotator cuff studies, however, have produced conflicting results based on PRP formulation, surgical technique, and size of tendon tear. This article explores the scientific rational for using PRP, its various formulations, and the emerging clinical data. Future potential applications are also explored.

AM

Total Tendon

For more information about Platelet Rich Plasma, visit:  ApexPRP.com