Basic Science Data Clearly Supports Platelet Rich Plasma

Platelet rich plasma (PRP) has been around for decades.  Only recently has it been utilized clinically to treat orthopedic conditions with frankly mixed results.  Several studies support its use for chronic tennis elbow.  Emerging data also suggests it may play a role in the treatment of knee osteoarthritis.  It clearly is not helpful for patients with mild untreated achilles tendonitis and may or may not have a role as a adjuvant treatment for rotator cuff tears.  We are, however, only now beginning to understand why PRP may be useful and how it works.

Today, the Journal of Orthopedic Research published data confirming PRP may have significant value in the treatment of tendon and cartilage injuries.  One study suggested "that human PRP may enhance the migration and simulate the chondrogenic differentiation of human subchondral progenitor cells".  These cells are the ones that are found after the common procedure known as "microfracture"  (Full abstract)  Another paper declared that the releasate from PRP "can induce human tenocyte proliferation and collagen synthesis which could be implemented for future tendon regeneration in reconstructive surgeries."  (Full Abstract)  A final paper noted the "synergy of tendon stem cells and platelet rich plasma in tendon healing".  (Full abstract)


Taken together this elite research data fully supports further clinical investigations into the use of PRP for tendon and cartilage disorders.  Human clinical trials are expensive and difficult to execute in any field even more so in autologous biologic treatments such as PRP.  This is partially true because there  is dramatic variability in PRP preparations.  This has led to confusing results.  We need to focus on specific formulations for specific indications and then conduct well powered human trials.  This will not be a simple task.  Worldwide collaboration will be needed.   The basic science data, however, are quite clear, PRP has impressive potential.

AM
TotalTendon

Biologic Orthopedic Meeting Summary

The first International Biologic Orthopedic meeting was held today in Mumbai, India.  Respected surgeons from the all parts of the globe presented their latest research on platelet rich plasma (PRP) stem cells and other biologic treatments for orthopedic related injuries and disorders.  Data was presented that has not yet been published including controlled trials supporting the use of PRP for knee osteoarthritis, plantar fasciitis and tennis elbow.  Other evidence supporting the use of mobilized peripheral derived stem cells in combination with microfracture was outlined in detail.  Fixation of articular cartilage defects in the hip with fibrin glue was yet another example of biologic orthopedics in action.

The consensus of the meeting was that biologic orthopedics was still in its infancy and it is important to proceed with caution.  There was also, however, a palpable level of optimism that these techniques and others that are still in development will contribute significantly to the well being of patients within the next five years.  Iterative and transformative improvements will be made as the research matures.

Significant credit must be given to Dr. Vijay Shetty for organizing the meeting and the Hiranandani Hospital for sponsoring it.  We are all looking forward to the publication of the data that was presented today and for the exciting collaborations that will arise from this meeting.  

Allan Mishra

International Biologic Orthopedic Meeting

Biologic treatments for orthopedic related diseases and disorders are rapidly growing worldwide.  The use of platelet rich plasma, bone marrow concentrates and stem cells is only in its infancy.  On March 9, 2012 in Mumbai, India, a group of orthopedic surgeons will gather to discuss this new field.

Faculty from India, the United Kingdom, Oman, Malaysia, and the United States will gather to discuss the latest research.  To learn in real time, follow @bloodcure on Twitter.

Further information about the meeting will be posted here later.

Here is a link to agenda of the meeting:  International Biologic Orthopedic Meeting

AM

Exercise Bike Intervals: The Fountain of Youth?

For years now, I have been preaching to my patients about why it is important to ride an exercise bike 30 minutes three times a week to improve their knee function.  It does help strengthen their leg muscles especially the quadriceps, hamstring and gluteal muscles if done consistently.  These are patients with all types of knee issues from meniscus tears to advanced knee osteoarthritis.
See a video of an exercise bike program.

Recent research also suggests that short intense intervals on a bike of one minute with a one minute recovery can significantly improve cardiovascular fitness and also lower blood sugar in patients with Type 2 Diabetes.  Below is an excerpt from a recently published NY Times article about the subject:

"Several years ago, the McMasters scientists did test a punishing workout, known as high-intensity interval training, or HIIT, that involved 30 seconds of all-out effort at 100 percent of a person’s maximum heart rate. After six weeks, these lacerating HIIT sessions produced similar physiological changesin the leg muscles of young men as multiple, hour-long sessions per week of steady cycling, even though the HIIT workouts involved about 90 percent less exercise time.

Recognizing, however, that few of us willingly can or will practice such straining all-out effort, the researchers also developed a gentler but still chronologically abbreviated form of HIIT. This modified routine involved one minute of strenuous effort, at about 90 percent of a person’s maximum heart rate (which most of us can estimate, very roughly, by subtracting our age from 220), followed by one minute of easy recovery. The effort and recovery are repeated 10 times, for a total of 20 minutes."  Read the full article here.  

I think the point is clear.  Almost anyone can begin with one minute intervals.  The data suggests that if you can build on that, your heart and blood sugar will improve in addition to strengthening your knees.  Not a bad suggestion for all of us.

AM

Total Tendon

Platelet Rich Plasma Effective in the Treatment Elbow Ligament Injuries

Ulnar collateral ligament (UCL) injuries of the elbow occur most commonly in throwing athletes such as baseball players.  There is no perfect answer for patients who partially tear the ligament.  Full thickness tears are typically repaired via so called "Tommy John Surgery".  At the American Academy of Orthopedic Surgery Meeting this week, data was presented suggesting platelet rich plasma has value in the treatment of partial UCL tears.

Dr. Scott Crow of the Kerlan-Jobe Clinic in Los Angeles studied the use of PRP for elbow ligament injuries.  Here is part of his report:

"The researchers followed 17 athletes with a partial UCL tear. All patients had failed conservative treatment, including rest and physical therapy. Baseline questionnaires, including the Kerlan-Jobe Shoulder and Elbow Score (KJOC Score) and Disability of the Arm, Shoulder, and Hand Score (DASH Score) were completed for each patient prior to the PRP injection. Each patient underwent a single PRP injection at the ulnar collateral ligament under ultrasound guidance.

At an average follow-up of 18 weeks (range 12-46 weeks), 16 of 17 athletes had returned to play. The average time to return to play was 10 weeks (range 8-12 weeks). The average KJOC Score improved from 47 to 93, p=.0001. The average DASH Score improved from 24 to 3, p=.003. The Sports Module of the DASH questionnaire improved from 74 to 6, p=.0001.

"There is little information in the literature regarding non-surgical treatment of UCL tears. Our results show that PRP may be an option to return players to the field without having to place them under the knife," said Crow."

Read full article  

This represents the first presented data on the topic of using platelet rich plasma for elbow ligament injuries.  The data supports further investigation and design of randomized trials to confirm these findings.

AM, Total Tendon

Kobe Bryant Orthokine Treatment Explained

Kobe Bryant (LA Lakers) is averaging 29 points per game in his 15th season in the NBA.  Is it because of a blood derived treatment he had done on his knee?  Other elite athletes such as Alex Rodriguez (NY Yankees) and Fred Couples (PGA Golfer)  have been treated with Orthokine in Germany.  But what is Orthokine?  That is a question that needs to be answered.


Orthokine is a form of autologous conditioned serum (ACS) that contains a high concentration of a molecule called IL-1 RA.  This stands for interleukin-1 receptor antagonist (IL-1 RA).  Interleukin-1 (IL-1) is an important mediator of inflammation and tissue damage.  Balancing IL-1 with IL-1 RA is important.  Read more about IL-1/IL-1 RA


Orthokine to the best of my knowledge is only available in Germany and has mainly been used to treat knee osteoarthritis.  A study of 376 patients was done comparing Orthokine (ACS) with hyaluronic acid (HA) and saline injections for knee osteoarthritis.  The "effects of ACS were significantly superior to those of HA and saline for all outcome measures and time points."  See Abstract of Article


From the available evidence, it appears as though this is a reasonable treatment.  I do not, however, know many of the details.  This treatment is not available in the United States.  It is produced by incubating a patient's blood in a sterile container with beads over a period of 6-8 hours or more.  The IL-1 RA and other growth factors are concentrated and injected back into the patient.


This is different than platelet rich plasma (PRP) in that PRP is made at the point of care and can be delivered back to the patient within 15-20 minutes.  No incubation period is needed.  


I will try to learn more about Orthokine and report back.  Please post any comments that may contribute to the conversation and help us all better understand the potential value of this approach.


Allan Mishra, MD

@BloodCure

Platelet Rich Plasma beats Cortisone for Plantar Fasciitis

In a paper presented today at the American Academy of Orthopedic Surgery Meeting in San Francisco, platelet rich plasma was found to be a significantly better treatment for plantar fasciitis when compared to the standard treatment of cortisone.  See the details outlined below in the abstract presented by Dr. Monto. 

Raymond R. Monto, MD, Nantucket, Massachusetts, United States

INTRODUCTION Chronic plantar fasciitis is a common but sometimes difficult condition to successfully treat. Platelet rich plasma (PRP), a concentrated bioactive component of autologous blood that is rich in cytokines and other growth factors, was compared with cortisone injection in the treatment of severe cases of plantar fasciitis resistant to traditional non-operative paradigms. METHODS Thirty-six patients (16 males, 20 females) with severe chronic plantar fasciitis who had failed traditional non-operative treatment (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) were randomized into two study groups and evaluated prospectively. All patients had pre-treatment MRI and ultrasound studies consistent with plantar fasciitis. Group 1 was treated with a single ultrasound-guided injection of 40 mg methylprednisolone at the injury site and Group 2 was treated with a single ultrasound-guided injection of un-buffered autologous PRP at the injury site. All patients were then immobilized fully weight bearing in a cam walker for two weeks, started on eccentric home exercises and then allowed to return to normal activities as tolerated and without support. RESULTS Group 1 had an average age of 59 (24-74) and had failed 5.4 months (4-24) of standard non-operative management and had pre-treatment AOFAS scores of 52 (24-60). The PRP group had an average age of 51 (21-67) and had failed 5.7 months (4-26) of standard non-operative management and had pre-treatment AOFAS scores of 37 (30-56). Post-treatment AOFAS scores in Group 1 initially improved to 81 (60-90) at three months but decreased to 74 (56-85) at six months and dropped further to 58 (45-77) at 12 months follow up. Post-treatment AOFAS scores in Group 2 improved to 95 (84-90) at three months and remained excellent at 94 (87-100) at six months and stayed at 94 (86-100) at 12 months follow up (CI 95% P=0.001). No patients were lost to follow up. DISCUSSION AND CONCLUSION This study suggests that platelet rich plasma injection is significantly more effective and durable than cortisone injection for the treatment of severe chronic plantar fasciitis refractory to traditional non-operative management. AM Total Tendon

AAOS Platelet Rich Plasma Symposium

The American Academy of Orthopaedic Surgeons (AAOS) will be holding its annual meeting this week in San Francisco.  The AAOS is sponsoring a symposium on Platelet Rich Plasma on Wednesday Feb. 8th at 10.30 am PST.  This will feature talks about the use of PRP in the office or operating room for achilles tendonitis, rotator cuff tears, tennis elbow, ligament injuries, and knee osteoarthritis among others.  Leading experts will debate its value.

I will be sending out live updates via my twitter account:  @BloodCure

Follow if you would like to view them in real time.  

This symposium will present some of the latest research on the topic of PRP for musculoskeletal injuries and disorders.

AM

Total Tendon

Super Bowl High Ankle Sprain and Platelet Rich Plasma

Rob Gronkowski of the SuperBowl New England Patriots apparently has a "high ankle" sprain.  First let's define a high ankle sprain.  This is a stretching or tearing of the ligaments that connect the two bones of the just above the ankle, the fibula and tibia.  That is why it is called a "high" ankle sprain as opposed to a typical less serious ne that involves the ligaments just below the joint line.  It can lead to significant instability of the ankle that at times requires surgery.  It also takes between 6-8 weeks to heal even if surgery is not needed.  

The details about his injury are little sketchy but here is what I can find so far.   He did not practice on Monday and has been wearing a boot.  He injured it in the AFC championship game 10 days ago.  I think it is possible the doctors may have given him platelet rich plasma to speed the healing of his injury.  There is no published data supporting this application but based on preclinical studies, it may be an effective treatment.  Here is a link to a story that fuels that speculation.    He will also likely to receive game time treatment in the form of tight taping or bracing and perhaps even a pain killing shot into the joint. 

Here is what to watch for.  Will he be able to block and make sharp cuts during his recieving routes?  A high ankle sprain by definition injuries the ligaments that stablize and support these moves.  Can he somehow become the Hines Ward of 2012 and make a catch in the first series that helps his team ultimately win the Super Bowl?  The first quarter of the game will help all of us better understand.  Hopefully, after the game we will learn more about his actual injury and treatment. 

Read more about High Ankle Sprains

Read more this speculation on ESPN. 

AM
@BloodCure on Twitter

Total Tendon 

Platelet Rich Plasma vs Hyaluronate for Ankle Pain and Disability

Am J Sports Med. 2012 Jan 17. 

Platelet-Rich Plasma or Hyaluronate in the Management of Osteochondral Lesions of the Talus.

Mei-Dan O, Carmont MR, Laver L, Mann G, Maffulli N, Nyska M.

Source

Department of Orthopedic Surgery, Meir University Hospital, Kfar-Saba, Israel.

Abstract

BACKGROUND:

Nonoperative options for osteochondral lesions (OCLs) of the talar dome are limited, and currently, there is a lack of scientific evidence to guide management.

PURPOSE:

To evaluate the short-term efficacy and safety of platelet-rich plasma (PRP) compared with hyaluronic acid (HA) in reducing pain and disability caused by OCLs of the ankle.

STUDY DESIGN:

Randomized controlled trial; Level of evidence, 2.

METHODS:

Thirty-two patients aged 18 to 60 years were allocated to a treatment by intra-articular injections of either HA (group 1) or PRP (plasmarich in growth factors [PRGF] technique, group 2) for OCLs of the talus. Thirty OCLs, 15 per arm, received 3 consecutive intra-articular therapeutic injections and were followed for 28 weeks. The efficacy of the injections in reducing pain and improving function was assessed at each visit using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHFS); a visual analog scale (VAS) for pain, stiffness, and function; and the subjective global function score.

RESULTS:

The majority of patients were men (n = 23; 79%). The AHFS score improved from 66 and 68 to 78 and 92 in groups 1 and 2, respectively, from baseline to week 28 (P < .0001), favoring PRP (P < .05). Mean VAS scores (1 = asymptomatic, 10 = severe symptoms) decreased for pain (group 1: 5.6 to 3.1; group 2: 4.1 to 0.9), stiffness (group 1: 5.1 to 2.9; group 2: 5.0 to 0.8), and function (group 1: 5.8 to 3.5; group 2: 4.7 to 0.8) from baseline to week 28 (P < .0001), favoring PRP (P < .05 for stiffness, P < .01 for function, P > .05 for pain). Subjective global function scores, reported on a scale from 0 to 100 (with 100 representing healthy, preinjury function) improved from 56 and 58 at baseline to 73 and 91 by week 28 for groups 1 and 2, respectively (P < .01 in favor of PRP).

CONCLUSION:

Osteochondral lesions of the ankle treated with intra-articular injections of PRP and HA resulted in a decrease in pain scores and an increase in function for at least 6 months, with minimal adverse events. Platelet-rich plasma treatment led to a significantly better outcome than HA.

Interesting new data.

AM

Total Tendon

ApexPRP.com

Platelet Rich Plasma Classification and Tennis Elbow Data

	PRP Classification
	White Blood Cells	Activated?
Type 1	Increased over Baseline	No
Type 2	Increased over Baseline	Yes
Type 3	Minimal or No WBCs	No
Type 4	Minimal or No WBCs	Yes
	A:  > 5x Platelets B:  < 5x Platelets

The classification system outlined above has been published in a peer reviewed journal by Mishra et al.  Published Reference

The use of platelet rich plasma has grown significantly worldwide.  Not all PRP, however, is the same.  This is crucial for patients, providers and hospital administrators to understand.  The most studied clinical problem so far is chronic tennis elbow.  Elite data supports the use of PRP that contains white blood cells applied in an unactivated fashion.  This is type 1 PRP according to the classification.  PRP formulations that do not contain white blood cells have NO controlled data supporting their use for chronic tennis elbow.  Below is a list of the PUBLISHED controlled data supporting the use of PRP for tennis elbow.

Gosens et al:  PRP with white blood cells 77% success vs 43% for cortisone at 2 years (p < 0.0001)

Peerbooms et al:  PRP with white blood cells 64% pain improvement vs 24% for cortisone at 1 year ( p < 0.001)

These are level one studies of 100 patients done using the Biomet GPS system.  It is clear from this data that PRP is a better option than cortisone for chronic tennis elbow.  When debating about whether PRP is effective, it is paramount to ask:

What TYPE of PRP?  and for What APPLICATION?

PRP research is continuing to evolve but the debate should take place in the context of data whenever possible.

AM