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Platelet Rich Plasma

A new procedure that is gaining popularity across the world in the treatment of tendinopathies and arthropathies is platelet rich plasma administration. This procedure is analogous to autologous blood injections, but involves delivery of the concentrated platelet rich plasma, which is rich in growth factors.

Blood platelets are responsible for bringing white blood cells to the injured area to clean up the remains of dead and injured cells. Most importantly to this discussion, blood platelets release growth factors that are directly responsible for tissue regeneration. These substances are called cytokines and include platelet derived growth factor, epithelial growth factor, and other important growth factors.

PRP has been used for years in surgical centers around the US and abroad to improve the success of bone grafting (especially in dental surgery) and also by cosmetic surgeons for speeding healing time and decreasing the risk of infection after surgery. Only in the last few years have doctors and surgeons been experimenting with injecting PRP for the treatment of chronic pain. Tennis elbow, plantar fasciitis, Achilles tendonitis/tendonosis, rotator cuff tears, meniscal tears, osteoarthritis and chronic low back and neck pain are all being treated with the injection of PRP with the goal of regenerating degenerated connective tissue with reports of success.

A PRP treatment looks like this: a patient's blood is drawn and placed into a special collection kit. Using the person's own blood eliminates the risk of transmission of any blood-borne disease. This kit is placed in a centrifuge for 15 minutes and the platelets and plasma are separated from the red and white blood cells. Two thirds of the plasma is removed and discarded and the remaining plasma is mixed with the platelets. This higher than normal concentration of platelets is what gives us platelet rich plasma. The PRP is drawn into a syringe. The area to be treated is injected with a local anesthetic and after waiting five minutes for the anesthetic to take effect, the PRP is injected.

The injection technique is identical to prolotherapy/regenerative injection therapy, only the solution injected is different. Same instrument, different sheet music. People generally report two days of being sore and then usually pain relief occurs within the first week and continues to improve over a period of months. To date, my experience is that one PRP treatment is the therapeutic equivalent of three or four prolotherapy/regenerative injection therapy treatments using dextrose. One of the attractive aspects of this treatment is the use of a person's own blood to eliminate the risk of the transmission of disease. The same lab that has developed the preparation kit for production of PRP has also developed a method to collect a person's own stem cells which eliminates the need for embryonic, umbilical or placental stem cells. This procedure is much more invasive as it requires a bone marrow biopsy and it is quite expensive compared to PRP which is safe, easy and inexpensive.

1. References:

  • Marx RE, Garg AK. Dental and Craniofacial Applications of Platelet-Rich Plasma. 2005. Quintessence Publishing. Chicago.
  • Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. 2008. Curr Rev Musculoskeletal Med. DOI 10.1007/s12178-008-9032-5
  • Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet rich plasma. 2006. Am J Sports Med. 34, 1774-8.

2. Indications:

  • Chronic tendonopathies unresponsive to conservative measures.
  • Partial thickness tendon/muscle tears either not amenable to surgical repair or when the patient does not want a surgical option.
  • Arthropathies unresponsive to conservative measures.

3. Procedures:

  • Informed Consent: PRP is an elective procedure for chronic musculoskeletal complaints. It involves drawing up to 60 cc of the patients’ blood into a syringe with ADCA anticoagulant, placing that blood into a specially designed container, conducting a 1 phase centrifuge to concentrate the platelet rich fraction of the blood, and then injecting this platelet rich plasma into the injured tissue. This procedure will make you very sore at the site of injection for at least three days, and for up to two weeks. Pain medicine will be prescribed. In rare cases it may produce a reactive synovitis in the joint injected (a synovitis results in a painful, but not damaged, joint) that may require a corticosteroid injection to relieve the pain. PRP is inherently antimicrobial, and the risk of infection is extremely low. As with any injection, there is a small risk of bleeding and bruising. You will need to follow the post-injection instructions and follow up in 2 weeks. Although many conditions will resolve in 1 or 2 injections spaced 4 to 6 weeks apart, some conditions may require 3 or more injections to achieve a satisfactory result.

4. After Care:

  • It is important to re-emphasize that NSAIDs, aspirin, or acetaminophen may not be used for post injection pain control as these medications will inhibit the necessary inflammatory phase.
  • Clearly explained that the patient may have significant pain for up to 3 weeks, although the pain usually improves after 3 days.
  • They may keep the injected part relatively immobilized for comfort for the first 2 days. After 2 days the affected part should be moved through its full range of motion along with gentle negative eccentric exercise.  Increase activity as tolerated after 2 weeks.
  • Prescribe tramadol as needed as well as 3 days of narcotic analgesia.
  • Some ice application sessions of 15 minutes in length may be used, but only absolutely if needed for pain control. Not using ice is preferable for this pro-inflammatory process.

5. Re-evaluate in 4-6 weeks

  • Re-evaluate patient’s pain levels, functionality and consider using a written functional assessment tool such as a “quick DASH score.”
  • Be aware that tissue changes on imaging may lag 3 – 6 months behind clinical improvement.
  • If patient was still very sore at 2 weeks, consider re-injecting at 6 weeks.
  • If the patient was over most of the soreness by 2 weeks, consider repeating therapy at 4 to 6 weeks if treatment goals have not been met.
  • These PRP grafts can be repeated as early as 2 weeks, although 4 – 8 weeks is a more usual timeframe.
  • If the patient is >80% improved or has met goal activity level, then the therapy is considered successful and  complete
  • .If the patient is <80% improved or goal activity level has not been met, repeat PRP graft placement every 4 – 6 weeks until success met or a maximum of 4 grafts placed.

1.Safety Considerations:

  • Centrifuge:  Arteriocyte
  • Plasma:  This is entirely an autologous graft. Only one patient and one graft are prepared at a time. At no time are 2 patients blood to be processed at the same time or in the same time slot.
  • Infectious Disease:  PRP is antimicrobial and effective against most bacteria classes except Klebsiella, Enterococcus and Pseudomonas. Standard skin disinfection is used before injection (choloprep x 1 or betadine x3)

CONTRAINDICATIONS TO PRP THERAPY
 Absolute contraindications

  • Platelet dysfunction syndrome
  • Critical thrombocytopenia
  • Hemodynamic instability
  • Septicemia

Relative contraindications

  • Consistent use of NSAIDs within 48 hours of procedure
  • Corticosteroid injection at treatment site or systemic use of corticosteroids
  • Tobacco use
  • Recent fever or illness
  • Cancer- especially hematopoietic or of bone
  • HGB < 10 g/dl
  • Platelet count < 105/ul

Post PRP Instructions
Articles on Platelet Rich Plasma:
Treatment of Tendon and Muscle Using Platelet-Rich Plasma by
Allan Mishra M.D., James Woodall M.D. and Amy Viera PA-C

How can one platelet injection after tendon injury lead to a stronger tendon after 4 weeks? by Olena Virchenko and Per Aspenberg

Clinical Updates in Platelet Gel: Sports Medicine by Michael A. Scarpone D.O.

Non-Surgical Repair of Patellar Tendonitis with Autologous Platelet Concentrate Using Ultrasound Guidance:Two Case Reports by Henry Stiene M.D.

Autologous Blood Injection for the Treatment of Chronic Recurrent Temporomandibular Joint Dislocation by Vladimir Machon M.D., D.M.D., Shelly Abramowicz D.M.D., M.P.H., Jan Paska M.D. and M. Franklin Dolwick D.M.D., Ph.D.

Treatment of Chronic Elbos Tendinosis with Buffered Platelet-Rich Plasma by Allan Mishra M.D. and Terri Pavelko P.A.C., P.T.