CLINICAL USE OF PLATELET-RICH PLASMA IN ORTHOPAEDICS

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CLINICAL USE OF PLATELET-RICH PLASMA IN ORTHOPAEDICS

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- PRP (1970) - Recent technologic advances : the hospital  outpatient and ambulatory surgical centers…even into physicians’ offices. The following growth factors can be found in the environment of a blood clot: - Transforming growth factor beta (TGF-b) - Platelet-derived growth factor (PDGF) - Insulin-like growth factor (IGF) - Vascular endothelial growth factors (VEGF) - Epidermal growth factor (EGF) - Fibroblast growth factor-2 (FGF-2)

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  1. CLINICAL USE OF PLATELET-RICH PLASMA IN ORTHOPAEDICS - PRP (1970) - Recent technologic advances : the hospital  outpatient and ambulatory surgical centers…even into physicians’ offices. The following growth factors can be found in the environment of a blood clot: - Transforming growth factor beta (TGF-b) - Platelet-derived growth factor (PDGF) - Insulin-like growth factor (IGF) - Vascular endothelial growth factors (VEGF) - Epidermal growth factor (EGF) - Fibroblast growth factor-2 (FGF-2)
  2. Many of these factors : + osteogenesis ( PDGF, EGF, and FGF-2 : stimulate proliferation of osteoblastic progenitors )(TGF-b increases matrix synthesis (eg, type I collagen) in vitro and in vivo. + Angiogenic factors (VEGF and FGF-2 : angiogenesis and revascularization ) -The repair response: The formation of a blood clot and degranulation of platelets,  growth factors and cytokines ( microenvironment) : chemotaxis of inflammatory cells + the activation and proliferation of local progenitor cells  fibroblastic scar tissue : a fracture callus, these conditions can also facilitate the formation of new bone tissue. - Enriching a rich environment: +The result is an autologous PRP that contains a biologically active mixture of growth factors without the potential for an immune response. +The effect of the clot microenvironment or concentrates of PDFGs on fracture repair + Clots also contain bone morphogenetic proteins (BMPs). +The growth factors associated with PRP also promote fibroblastic growth, differentiation, and scar formation. The most common applications include: - Tennis elbow (lateral epicondylitis); - Achilles tendonitis (inflammation and swelling of the Achilles tendon); - Patellar tendonitis (inflammation of the patellar tendon, also called "Jumper's Knee"); - Rotator cuff tendonopathy….
  3. Rotator cuff tendonopathy. Tennis elbow (lateral epicondylitis
  4. Achilles tendonitis (inflammation and swelling of the Achilles tendon)
  5. - Patellar tendonitis (inflammation of the patellar tendon, also called "Jumper's Knee"). - Femoral quarter tendonitis - Trochanteric bursitis - Lumbago
  6. A basic understanding of the components within blood is important to understanding the therapeutic value of PRP. Blood contains plasma (made mostly of water and acts as the transporter), red blood cells (carries oxygen to the cells), white blood cells (fights infection), and platelets. Platelets are responsible for revascularization of injured area (new blood vessels in injured area), construction of new tissue, and hemostasis (stops bleeding). According to an article in the Current Reviews in Musculoskeletal Medicine by Sampson, S., Gerhardt, M., and Mandelbaum, B. (July, 2008), blood normally contains 93% red blood cells, 6% platelets, and 1% white blood cells. The concept behind PRP is to change the ratios by significantly increasing the percentage of platelets in the sample (94%). Physiological Effects of PRP Therapy Because platelets play a significant role in the healing of tissue, reintroducing a high concentration of platelets directly into the injured area should theoretically enhance the healing process. The physiological effects include: Increase tissue regeneration (tendon, ligament, soft tissue) Decrease inflammation Decrease pain Increase collagen (base component of connective tissue) Increase bone density Increase angiogenesis (development of new blood cells) PRP Preparation and Treatment Platelet-rich plasma therapy is an outpatient procedure. The patient’s blood is drawn and placed in a centrifuge separating the components of the blood. The platelet-rich plasma is separated via the centrifuge and withdrawn for the procedure. The patient is prepared with a local anesthetic (lidocaine) if desired. A musculoskeletal ultrasound is used to guide the physician to the exact injury site. Treatment typically consists of three to six injections four weeks apart.
  7. Patients are observed for 15-20 minutes after the injection and then discharged. Ice can be applied at home to reduce injection site soreness. Acetominophen is recommended for initial use after the injection rather than nonsteroidal anti-inflammatory drugs (NSAIDs). Nonsteroidal anti-inflammatory drugs block the inflammatory process. The inflammatory process is necessary to promote healing and is the purpose of the PRP therapy. Platelet-rich therapy is considered safe because the blood used for the procedure is taken directly from the patient (no risk of rejection). Although uncommon, there are possible side- effects that the patient should be aware of including allergic reaction, infection, scar tissue formation, no relief of symptoms, and neurovascular injury (Sampson, S., Gerhardt, M., & Mandelbaum, B, July, 2008). PRP Therapy in Chronic Tendon Injuries There is an increase in the use of PRP therapy for chronic tendon injuries including elbow, patella, and achilles. Tendons are dense connective tissue that connect bone to bone. They are susceptible to overuse injuries resulting in micro tears of the tissue. These types of injuries are difficult to heal and are a risk for re-injury. A recent study published in the American Journal of Sports Medicine (2006) reviewed the effectiveness of PRP therapy in patients with chronic elbow pain. Fifteen patients were treated with PRP therapy. The results documented a 60% improvement at eight weeks, 81% at six months, and 93% at final follow-up (12-38 months). There were no side effects or complications reported. Although this study documents PRP therapy's effectiveness, it is a small study with only 15 patients. Hopefully with the increased clinical use of this therapy, larger controlled studies will be published to better understand its effectiveness and clinical use.
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