Platelet Rich Plasma is an excellent option, often with far better results than traditional methods, for musculoskeletal problems involving joint, tendons, and ligaments.
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Using Platelet Rich Plasma for Orthopedic Conditions
1. Musculoskeletal Regenerative Medicine:
Platelet Rich Plasma
Orthopedic Regenerative Medicine and Joint
Preservation Center of Santa Rosa
Raymond Severt, M.D. - Director
1144 Sonoma Avenue, #121
Santa Rosa, CA 95405
(707) 978-4322
RegenMedSR.com
2. What is Regenerative Medicine
Branch of medicine
replacing, engineering, or
regenerating human cells,
tissues or organs
to restore or establish
normal function
3. What is Orthopedic Regenerative
Medicine
Augment the natural healing
process to heal or even “grow
back” the damaged tissue
muscle
tendon
ligament
cartilage
4. What is PRP (Platelet Rich Plasma)?
Concentration of platelets in plasma
typically 5X - 10X concentrated
(250K/microlitres = normal count)
With RBC/WBC - red
Without RBC/WBC - clear
5. How Do You Make PRP?
Blood draw from patient
30 - 60 ml
Process in centrifuge to
get the type of PRP you
want
6. What are Platelets?
come from megakaryocytic
contain growth factors in
alpha-granules
become activated and
release factors
7. Platelet Activation Releases Factors
Platelets
release various
growth factors
when activated
Growth factors
have various
effects
14. What About “GOOD” Molecules?
TGF - tissue growth factor
TIMP-1&2 - tissue inhibitor of
metalloproteinases
IRAP - interleukin receptor antagonist protein
A2M - alpha 2 macroglobulin (useless by itself
- so drug companies barking up the wrong
tree)
Block the BAD molecules -
ANTI-CATABOLIC (ANABOLIC)
16. What About “Traditional” Treatments?
Are there problems?
NSAIDS
Corticosteroids
Surgery
(Physical Therapy ALWAYS GOOD!)
17. NSAIDS
Commonly taken
Multitude of side-effect
Very significant problems
ulcers, bleeding, heart attack, stroke,
kidney and liver failure
Inhibit chondrocytes and stem cells
18. NSAIDS - Black Box Warning
“Strongest warning
that the FDA
requires. Reserved
for drugs that pose a
significant risk of
serious or life-
threatening adverse
effects, based on
medical studies”
Cardiovascular Risk
• NSAIDs may cause an increased risk of serious
cardiovascular thrombotic events, myocardial
infarction, and stroke, which can be fatal. This risk
may increase with duration of use. Patients with
cardiovascular disease or risk factors for
cardiovascular disease may be at greater risk (See
WARNINGS).
• These drugs are contraindicated for treatment of peri-
operative pain in the setting of coronary artery bypass
graft (CABG) surgery (see WARNINGS).
Gastrointestinal Risk
• NSAIDs cause an increased risk of serious
gastrointestinal adverse events including bleeding,
ulceration, and perforation of the stomach or intestines,
which can be fatal. These events can occur at any time
during use and without warning symptoms. Elderly
patients are at greater risk for serious gastrointestinal
events (See WARNINGS).Some taken off market - Vioxx, Bextra
20. These Medications:
Don’t Fix ANYTHING
Can accelerate damage to
the joint
Inhibit good cells and healing
These medication are
COUNTERPRODUCTIVE
21. Surgery
Surgery is necessary is
some situations
Could it be done too often?
Some common procedures
have no benefit.
22. So is PRP Better?
Uses your own blood components
No medications - nothing from a drug
company
Provides a natural way to stimulate the body
to heal damaged tissue
Balances the “environment” of the joint to
reduce symptoms
Essentially no side effects
23. What Does PRP Do In an Arthritic Joint?
Rebalance environment
Improves lubrication properties
Stimulates cartilage survival and
repair
Mobilizes stem cell migration
Restabilize an unstable joint
24. PRP Intra-articular
Pathways
Decreases BAD molecules -
MMP, IL - reduces CATABOLIC
PROCESSES
Increases GOOD molecules -
TGF, TIMP, IRAP, A2M
REBALANCES the micro-
environment of the joint - back to
favoring the normal healing status
25. PRP Stimulates Hyaluronic Acid
Production
Produced by synovial cells
Important for lubrication/viscosity
of joint fluid
Hyaluronic Acid - Hyaluronan
Viscosupplementation - Synvisc,
Orthovisc - from rooster combs
HA alone not enough to protect
the joint
26. PRP Stimulates Lubricin
(Proteoglycan 4) Production
Lubricin - other names Superficial Zone Protein (SZP),
Proteoglycan 4 (PRG4)
Incredible lubricating qualities
When joint compressed - repels surfaces
Acts synergistically with HA to reduce friction and
protect the joint surfaces
Expression of PRG4 gene stimulated by the GF’s in
PRP
All of this is inhibited by NSAIDS and corticosteroid
Supplementing Joint with HA alone is not enough!
(Without Lubricin, HA is useless)
Lubricin molecules on
cartilage surface push the
surfaces apart apart
27. PRP Reduces Cartilage Breakdown
Reduces cartilage breakdown -
Am J Sports Med 2015
Early PRP inhibits cartilage cell
injury - Arthroscopy 2015
PRP stimulates Anabolic molecules -
Vet Med Int 2015
28. So Which Do You Choose?
Treatment that temporarily
improves symptoms, BUT
causes more problems
OR, treat the joint in a way to
rebalance and heal it, naturally,
the way it was meant to be.
Avoid complication
Avoid Surgery
32. What Happens When a
Ligament/Tendon Is Injured?
Macro or Micro Tears
Can get bleeding in the substance of the tear
Less bleeding with tendon than with ligaments
Bleeding initiates a healing cascade
33. Phases of Healing
Inflammatory Phase - local chemicals
released - few days
Repair Phase - mediated by blood
clot/platelets - new cells - new
blood supply - few weeks
Remodeling Phase - transitions Type 3 to
Type 1 collagen - more organized - few
months
34. What If Healing Does Not
Progress?
Poor environment/poor
vascularity
Things get stuck in the inflammatory
phase
Or stop in the early repair phase
Pain, Inflammation, non-healing persist
Structure is weak - poor integrity - poor
function
35. What Does Traditional Treatment
Do To Ligaments and Tendons?
Rest/Immobilization
NSAIDS
Corticosteroids
Surgery
37. NSAIDS
All their side effects
Inhibit inflammation -
1st phase of healing
Inhibit repair
mechanism
COUNTERPRODUCTI
VE
38. Corticosteroids
Inhibit inflammation - important component of healing
Inhibit repair - detrimental to stem
cells/tenocytes/fibroblasts
Weaken ligament and tendon - additional
ruptures/tears
COUNTERPRODUCTIVE
39. Surgery
Invasive
Denudes entire area of its native
blood supply
Massive scaring/adhesions
Alters normal anatomy/function
THEN has to go through all phases of
healing - all over again
COUNTERPRODUCTIVE
40. How Does PRP Work in
Treating Ligaments and
Tendons
Re-initiate inflammatory phase
Stimulates repair phase -
release of multiple growth factors
stem cell migration - fibroblasts/tenocytes
Balance inflammation/anti-inflammation
and reduce pain pathways
Non-invasive/maintains anatomy/function
41. So Which Do You Choose?
Treat in ways that could create more
adverse effects - stiffness, impairment,
long recovery
Use medications that reduce pain and
inflammation, but inhibit healing
Or, treat the injury with a product that
stimulates the normal healing process, is
non-invasive, maintains normal anatomy
Avoids complications, avoids surgery
42. Comparing:
Traditional vs. PRP
Traditional:
hides pain, shuts
down healing,
complications,
paves the way to
more injury and
surgery
PRP: Rebalances
natural
healing/repair
environment,
paves the way to
cure
43. Some Problems That PRP
Treats Very Well
Knee Arthritis
Shoulder Impingement
Lateral Epicondylitis
Wrist Arthritis/Ligament Injuries
Ankle Sprains
Plantar Fasciitis
45. Arthroscopic Debridement for Painful
Arthritic Knee - With Meniscal Tear
One of most common surgeries done
Studies:
Incidental meniscal tears - no relationship between
tear or cartilage loss and symptoms
Meniscal surgery patients did no better than those
who had no surgery and PT - NEJM 2012
Surgery has no benefit over “sham” (even with
mechanical sx)- Annals of Int Med 2016
Menisectomy causes increase forces and a more
rapid progression of arthritis - J Biomech 2014
46. Knee Joint Replacement
10 million people in US have Knee
OA
$30 Billion spent annually on Knee
Replacements alone
Perhaps need a new paradigm for
Knee OA
Try to delay or prevent people from
needing joint replacement
47. Can Knee Arthritis Be Slowed Down?
More effective than viscosupplemenation -
J Arthroscopy 2015
Reducing the rate of cartilage wear and tear-
HSS 2013
Reduces cartilage breakdown - Am J Sport Med
2015
Inhibits cartilage cell injury - Arthroscopy 2015
Stimulates ANABOLIC pathways/molecules -
Vet Med Int 2015
Platelet Rich Plasma
48. Shoulder Impingement
Rotator cuff tendons weaken, develop
tears, degenerative changes
Poor blood supply
Unable to heal itself
Gets stuck in early phase of repair
Chronic changes, inflammation, pain
Poor healing environment
49. Shoulder Impingement
NSAIDS - minimal benefit, inhibit healing
Corticosteroids -
if used - no longer see healing
response - Br J Sports Med 2014
kill rotator cuff cells - Bone Joint Res
2014
50. Shoulder Impingement
Surgery - Acromioplasty
structures - bone and ligaments -
with pain = without pain
Altering bony and ligamentous structure
DOES NOT LEAD TO SYMPTOM
IMPROVEMENT
JBJS Am 2011
51. Shoulder Impingement - PRP
PRP more effective than corticosteroid
in pain relief (30% better)
in ROM improvement (3X more improvement)
16X less likely to undergo surgery (3/100
vs 48/100)
O’Donnell, et al. AAOS 2013
52. Lateral Epicondylitis
Common Extensor tendon becomes
weakened, tears, degenerative changes
(really a tendinopathy)
Poor blood supply
Gets stuck in early phases of healing
Chronic changes, inflammation, pain
Poor healing environment
53. Lateral Epicondylitis
NSAIDS - minimal benefit, inhibit healing
Corticosteroids -
inhibit healing process
can additionally weaken the tendon
fat and skin atrophy
Corticosteroid actually WORSE than NO
TREATMENT at 6 months and beyond
WHAT ARE WE DOING????????
Orthopedics 2010
54. Lateral Epicondylitis - PRP
PRP provides excellent and superior
results
Results are longer lasting
Particularly better than corticosteroid
injection
Am J Sports Med 2006, 2014, J Clin Diag Res 2015,
J Hand Microsurg 2015
55. Lateral Epicondylitis - PRP
Compared to Surgery:
PRP - showed 83% improvement
Surgery - showed 46% improvement
PRP improved 2X as much as
surgery
SO WHY ARE WE STILL DOING
SURGERY FOR THIS PROBLEM?
J Orthopaedics March 2016
56. Wrist and Thumb Arthritis
Instability is a hallmark
Progressive Degeneration
Traditional Treatments -
Corticosteroids -
Surgery -
57. Wrist and Thumb Arthritis - PRP
Treat all inherent problems:
arthritic joint - balance environment
instability - balance ligaments
nerve issues
58. Wrist TFCC Tear/Ligaments Tears
TFCC degenerative tears similar to
problem with meniscal tear
Same issues
Structural abnormality does not correlate
with symptoms
Questionable how much debridement
help
PRP rebalances joint
environment/improves stability
59. Ankle Sprains
Immobilization - stiffness, atrophy
NSAIDS/Corticosteroids - inhibit healing,
weaken structures
Surgery - try to avoid
PRP
more rapid return to activities (1/2 the time)
better stability and pain (2X improvement)
AAOS Now 2014, Knee Surg Sport Traum 2015)
60. Plantar Fasciitis
Tear/degenerative changes at plantar fascia origin
Poor blood supply/chronic changes/inflammation
Stuck in early phases of repair
PRP
more effective and durable than
corticosteroid
3X (300%) the functionality and
improvement of pain
Actually heal structures - rather than mask
Sx
(Foot Ankle Int, April 2014)
61. Stem Cell Therapy
Bone Marrow Aspirate
Adipose Derived Stem Cells
A more “potent” form of PRP.
(Not amniotic products)
63. Orthopedic Regenerative Medicine
Allows the body to heal itself
PRP is a way to treat many
musculoskeletal problems
Interventional Orthopedics will
continue to grow
Will be able to replace many types of
current therapies
BRIGHT FUTURE
