Platelet Rich Plasma used to treat Nadal's Knees

 
It appears as if Nadal has had his creaky knees treated with platelet rich plasma.  He has described it himself but only incompletely.  What we do not know is what type of PRP was used,  how it was injected and how he is being treated after the procedure.  These are all critical issues.  Presently, PRP with platelet concentrations around 5x baseline combined with concentrated white blood cells has the best published data supporting its use. 

It is clear that Nadal has chronic, severe tendonitis also know as tendinopathy.  It will help all of us who are studying how to best use PRP we knew more about his specific treatment.  Does anyone out there know any of the details?

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Orthopedics Article

Dr. Allan Mishra recently had his commentary about the state of platelet rich plasma published in Orthopedics. 

Allan Mishra

Is PRP a better solution than cortisone for treating tendon injuries? If so, why? 

"Platelet-rich plasma is clearly a better treatment for tendon injuries than cortisone. A recent double-blind randomized trial found significantly better outcomes in the treatment of tennis elbow in patients who received PRP when compared to cortisone.^3,4 There is also a risk of dermal atrophy or even tendon rupture when using cortisone. For these reasons, I rarely, if ever, use cortisone in the treatment of a tendon problem in my practice."

Read more of the article...


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ApexPRP.com

Orthopedics Today PRP Discussion

Orthopedics Today recently published a discussion about platelet rich plasma.  Dr. Allan Mishra, Dr. Steven Arnoczky, Dr. Freddie Fu and Dr. Nicolas Sgaglione commented about the state of PRP. 


“The lay press does not understand the complexity of PRP,” Allan Mishra, MD, said. “As more data emerge, it will become clear to both physicians and surgeons that the specific formulation of PRP matters significantly in terms of bioactivity.” 

“The thing I would emphasize is that we have got to get a better understanding of the formulations in order to figure out whether PRP is valuable or not,” he added. “What is missing in the lay press – but also in the medical literature – is the discussion of what PRP is.”
Mishra pointed out that a formulation of PRP containing only concentrated platelets differs greatly from a formulation composed of concentrated platelets and white blood cells. 

Read more of the artilcle.... 

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ApexPRP

Tennis Elbow PRP Discussion at ESSKA in Oslo, Norway

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Dr. Pietro Randelli moderated an excellent discussion of the treatment of tennis elbow (lateral epicondylitis) at the recent ESSKA meeting in Oslo, Norway.  Presentations about conservative care, platelet rich plasma injections and surgical treatment were given, including a debate about open versus arthroscopic techniques.  It is clear there are a variety of treatment options for this problem.  Platelet rich plasma is now considered a viable non-operative option.  Further data is presently being developed about the value of PRP vs surgery.  Stay tuned.

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ApexPRP.com

Blood Spinning vs Blood Doping San Francisco Chronicle PRP

There is WAY too much confusion about the differences between blood spinning and blood doping.  Put simply, blood spinning is the separation of the whole blood into its components:  red blood cells, white blood cells, platelets and plasma.  Various techniques concentrate the components and then are used either individually or in combination.  Platelet rich plasma can be the product of blood spinning.  It is used immediately after preparation and for injuries.

Blood Doping is the collection and storage of typically whole blood to be used to enhance performance.  Blood is drawn, stored and then reinjected at later date typically right before a race to improve endurance.  Cyclist Floyd Lanis has recently admitted to blood doping and accused Lance Armstrong of the same. 

Gwen Knapp of the San Francisco Chronicle discusses these issues in conjunction with Dr. Tony Galea a Canadian doctor who has treated Tiger Woods and several other US athletes.  Read her article here.

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HalfDome.tv

Pac-10 Athletic Trainer Conference

Platelet rich plasma was discussed in depth at the Pacific 10 Athletic Trainer conference in Berkeley yesterday by Dr. Allan Mishra.  Almost all of the schools represented had used PRP to treat their athletes.  It was clear from the discussion, however, that the various forms of PRP (with and without white blood cells) were not well known to the group.  Moving forward, it was noted that the type of PRP should be recorded and studied in greater detail.  Also, the use of ultrasound to guide PRP injections and follow patients was found to have value.  Better and more specific post PRP protocols were found to be lacking.  Overall, it was interesting to note how much PRP was being used.  Clearly, the need for better indication data was still needed.  More later....

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LA Dodgers and Seattle Mariners using PRP to treat players

Seattle Mariner Cliff Lee pitched 7 innings yesterday of shut out baseball after receiving a platelet rich plasma injection for an abdominal strain.  The Safeco field crowd of 34,055 were treated to 93 mile per hour fast balls and eight strikeouts.  An impressive return to pitching. 

Did PRP help him in his return?  That is a good question to ask Mr. Lee.  Clearly, it didn't hurt him.  We need to follow his progress and better understand if PRP can treat abdominal strains and or sports hernia type injuries.

Los Angeles Dodger Rafael Furcal also has used PRP.  In his case, the platelet rich plasma was used to treat a hamstring injury.  We clearly need better data on whether PRP really helps these problems but for now it is clear that major league players and their doctors are using it.

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Ultrasound and Platelet Rich Plasma

 

Ultrasound of a Partial Elbow Extensor Tendon Tear

Ultrasound is a powerful non-invasive tool to evaluate soft tissue.  It can be especially helpful when imaging tendons.   Platelet rich plasma has been used extensively in tendinopathy and I believe ultrasound could provide an objective endpoint for future studies.  The size of the lesion could be measured before and after treatment.  Calculation of reduction of the pathologic hypoechogenic area could then be made.  We are beginning to evaluate a variety of ways to use ultrasound and would welcome any questions, comments or suggestions. 

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HalfDome.TV

Mishra Platelet Rich Plasma Classification

Not all platelet rich plasma (PRP) is the same.  In order to be able to compare PRP, I am proposing a new classification system based on the presence or absence of white blood cells, activation status and platelet concentration.  Activation implies the use of thrombin and or calcium to cause the platelets to gel and release their bioactive molecules.  No activation implies in vivo activation by collagen. 

Platelet Concentration:   
A = 5 x baseline or higher
B =  Less than 5 x baseline

Type          White Blood Cells              Activation    

Type 1:       Increased WBCs                  Unactivated

Type 2:       Increased  WBCs                 Activated

Type 3:       Few/None WBCs                 Unactivated

Type 4:       Few/None WBCs                 Activated

Example:

Type 1A PRP:    Formulation with increased WBCs, 5.5x baseline platelets injected in an unactivated fashion.

The system is meant to be simple for now.  Clearly, there are other components to PRP including anticoagulation and buffering.  Importantly, new formulations may arise but for now we need a simple reproducible structure to discuss the different types of PRP.  I hope this represents a start.

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Platelet Rich Plasma and Abdominal Strains

Cliff Lee from the Seattle Mariners was recently treated with PRP for an abdominal strain.  This is a novel but potential valuable application for platelet rich plasma. Presently, there is no data to suggest it may work for this problem.  Basic science and preclinical work, however, suggest it may be helpful. 

I must applaud the doctors who made this choice because if it does help Mr. Lee return to the mound without surgery they will have helped many other athletes and physicians.  I would recommend, however, this case be documented in the medical literature so we all can follow the specifics.

As new potential applications arise, we must be aware of the value created by the researchers, physicians and patients who make that initial decision to try something that no one else has done. 

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Platelet Rich Plasma Debated at AAOS meeting in New Orleans

 Dr. Taco Gosens and Dr. Allan Mishra at AAOS New Orleans 2010

The concept of using platelet rich plasma for orthopedic applications was vigorously debated at the recent AAOS meeting in New Orleans.  Dr. Gosens presented his prospective randomized trial of 100 patients with chronic tennis elbow.  They found PRP was significantly better than cortisone at one year.  This has been published in the American Journal of Sports Medicine in Feb. 2010.  See Abstract

Dr. Gosens and his colleagues used PRP in a form that contains both concentrated platelets and white blood cells in an unactivated (no addition of thrombin or calcium) composition.  The details of this are critical as other forms of PRP may not have the same efficacy.  As the debate about PRP continues it will be paramount for researchers, clinicians and patients to understand that not all PRP is the same.  Presently, the lay press is trying to state that PRP either works or does not work.  This is too simple.  We need more studies such as the one presented by Dr. Gosens to understand when and where to apply PRP and in what form.  We may conclude from his study that unactivated platelets in combination with concentrated white blood cells is more effective than cortisone for chronic elbow tendinosis.  That is important.  More soon on the other data presented at AAOS on PRP. 

WebMD Article        

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