The Role of Platelet-Rich Plasma and Other Biologic Factors

Educational Objectives

The goal of this program is to improve the appropriate use of platelet-rich plasma in orthopedic practice. After hearing and assimilating this program, the clinician will be better able to:

1. Assess the effectiveness of platelet-rich plasma for promoting healing of different musculoskeletal injuries.

2. Consider the use of platelet-rich plasma for the treatment of osteoarthritis.

Summary

Platelet-rich plasma (PRP): broad spectrum of different preparations; attempt to create biologic milieu of variety of growth factors; encourages release of growth factors

Elements to consider: patient demographics; presence or absence of white blood cells; activated vs activated by tissue at time of delivery; concentration of platelets; effects of leukocyte-poor PRP can be dramatically different from those of leukocyte-rich PRP, depending on environment; concentration of platelets correlated with concentration of degranulated cytokines

Activation: platelets contain α-granules and growth factors; degranulation event occurs; PRP activated by calcium and (in patient) by adhesion to clot; proteins found in plasma important for healing and inflammatory response; many growth factors chemotactic and influence behavior of leukocytes

Basic principles: concentrated source of autologous platelets delivered; degranulated cytokines released; activated PRP leads to physiologic ratio of growth factors that may affect healing of musculoskeletal tissues; end effect of growth factors depends on target tissue

Shoulder: for applications of cartilage and osteoarthritis in shoulder, data indicate treatment of chondrocytes with PRP increases proteoglycans and type II collagen

Basic science data: growth factors can promote mitosis and cell proliferation, and potentially lead to deposition of collagen and matrix

Patellar tendinopathy: data indicate PRP safe and promising treatment for recalcitrant tendinopathy of patellar tendon; Dragoo et al (2014) compared outcomes of ultrasonography-guided leukocyte-rich injection of PRP vs dry needling in patients with patellar tendinopathy and found accelerated recovery associated with PRP, but difference decreased over time

Lateral epicondylitis: studies indicate PRP effective; potentially one of strongest applications; repeated injections of corticosteroids lead to paradoxic damage to tendon, compromises lateral ulnar collateral ligament complex, and results in rotary instability; Mishra et al (2006) found buffered PRP significantly reduced pain in patients with chronic tendinopathy of elbow, compared with alternative options; further studies showed reduced pain and improved function with PRP compared with corticosteroids

Rotator cuff: study found superior structural healing after arthroscopic repair of large rotator cuff tear treated with moderately concentrated PRP, compared with controls; data conflicting; Jo et al (2015) found rate of retear in PRP group 3%, compared with 20% in conventional group; meta-analysis showed, considering cost, improvement in rate of retear insufficient to justify use of PRP; Flury et al (2016) found no greater improvement in function with PRP at footprint vs ropivacaine in subacromial region; data indicate PRP does not improve overall outcomes for rotator cuff repair

Dragoo et al (2014): showed leukocyte-rich PRP increased synovial site depth and led to cartilage cell apoptosis

Osteoarthritis: may be important application of PRP; series of studies found favorable outcomes in treatment of osteoarthritis of knee; similar data emerging for hip; Smith (2016) performed randomized controlled trial and found PRP may be more effective than injections of corticosteroid, with good longevity of effect

Readings

Dragoo JL et al: Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med 2014 Mar;42(3):610-8; Flury M et al: Does pure platelet-rich plasma affect postoperative clinical outcomes after arthroscopic rotator cuff repair? a randomized controlled trial. Am J Sports Med 2016 Aug;44(8):2136-46; Hsu WK et al: Platelet-rich plasma in orthopaedic applications: evidence-based recommendations for treatment. J Am Acad Orthop Surg 2013 Dec;21(12):739-48; Jo CH et al: Platelet-rich plasma for arthroscopic repair of medium to large rotator cuff tears: a randomized controlled trial. Am J Sports Med 2015 Sep;43(9):2102-10; Mishra A et al: Platelet-rich plasma and the upper extremity. Hand Clin 2012 Nov;28(4):481-91; Smith PA: Intra-articular autologous conditioned plasma injections provide safe and efficacious treatment for knee osteoarthritis: an FDA-sanctioned, randomized, double-blind, placebo-controlled clinical trial. Am J Sports Med 2016 Apr;44(4):884-91.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Bedi was recorded at the 33rd Annual Shoulder Course, held June 22-25, 2016, in San Diego, CA, and presented by the San Diego Shoulder Institute. For information about upcoming CME opportunities from the San Diego Shoulder Institute, please visit sdsi-shoulder.com. The Audio Digest Foundation thanks the speakers and the San Diego Shoulder Institute for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR392303

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.