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Intraoperative use of platelet-rich plasma (arrows) during patellar tendon repair (PRGF System, BTI, Victoria, Spain). Adapted with permission from Sánchez M, Anitua E, Orive G, Mujika I, Andia I: Platelet-rich therapies in the treatment of orthopaedic sports injuries. Sports Med 2009;39:345-354.

AAOS Now

Published 11/1/2009

'Bloody' treatment holds promise

Platelet-rich plasma (PRP) is currently used as an alternative treatment method for several common orthopaedic-related sports medicine conditions. According to a review article in the October 2009 Journal of the American Academy of Orthopaedic Surgeons (JAAOS), early outcomes of PRP appear promising; however, larger clinical studies are still needed to determine the benefits of its use.

“Some proponents believe that PRP may catalyze the body’s repair mechanisms at areas of injury, improve healing, and shorten recovery time,” said study coauthor Michael Hall, MD, a senior orthopaedic surgery resident at the NYU Hospital for Joint Diseases in New York. “Clinically, however, minimal evidence exists to support this theory and more research must be performed.”

A simple process and procedure
Obtaining and utilizing PRP is a relatively simple process: a patient’s own blood is placed into a centrifuge that rotates at high speed to separate the red blood cells from the platelets, which are blood cells that release growth factors that help the body heal itself.

Next, the physician takes the platelet-rich portion of this blood (the PRP) and injects it directly into the injured area, with or without an activating agent such as thrombin or calcium chloride. When combined with an activating agent immediately prior to the injection, PRP facilitates the formation of clots, activates platelet action, and releases growth factors at the injection site. When PRP is used alone, the exposure to tendon-derived collagen has been shown to slowly activate platelets.

For use during surgery, PRP is treated with calcium chloride or thrombin to create a putty-like clot. Several studies have found that patients treated with PRP experience earlier functioning and healing.

Use in chronic conditions
PRP treatments have been used for the past two decades to improve wound healing and bone grafting procedures by plastic and maxillofacial surgeons. It is only in recent years that orthopaedic surgeons and sports medicine specialists have employed this technology.

In sports medicine, PRP has primarily been used to treat chronic tendon conditions. It has also been used in treating acute muscle injuries and augmenting tendon repair in the operating room.

The following are the most common applications for PRP:

  • tennis elbow (lateral epicondylitis)
  • Achilles tendinitis
  • patellar tendinitis
  • rotator cuff tendinopathy

As the authors point out, however, “An important consideration for future use of PRP is concern regarding antidoping regulations.” PRP does contain insulin-like growth factor-1 (IGF-1), and the use of all growth factor therapies are prohibited in elite sports by the World Anti-Doping Agency. But the authors note that “the unbound IGF-1 in PRP has an inadequate half-life to exert systemic effects,” which seems to indicate that the treatment will not produce systemic anabolic action.

Piquing patient interest According to Dr. Hall, PRP use has increased in recent years, and it has become a popular topic of discussion because the process is “simple, quick, and relatively safe for patients.”

Intraoperative use of platelet-rich plasma (arrows) during patellar tendon repair (PRGF System, BTI, Victoria, Spain). Adapted with permission from Sánchez M, Anitua E, Orive G, Mujika I, Andia I: Platelet-rich therapies in the treatment of orthopaedic sports injuries. Sports Med 2009;39:345-354.
Example of a platelet-rich plasma preparation device (GPS III, Biomet, Warsaw, IN). The buffy coat is platelet-rich plasma. Adapted with permission from Biomet

“Use of PRP has increased, in large part due to new devices that enable fast preparation in the outpatient setting. A patient who gives a blood sample can receive the injection 30 minutes later,” he explained. But the procedure does have some risks, including the possibility of infection. “Some patients have also reported increased pain or inflammation at the injection site, but otherwise the risks with PRP appear minimal,’ says Dr. Hall.

PRP use in some patients, however, is contraindicated. Among those who should not be considered for PRP therapy are patients who have a history of thrombocytopenia, are using anticoagulant therapy, have an active infection, tumor, or metastatic disease, or are pregnant.

When is PRP useful?
Because each patient and injury is unique, orthopaedic surgeons should take a cautious approach in recommending this treatment. Before embarking on PRP therapy, Dr. Hall suggests that physicians and patients try conventional treatments, such as anti-inflammatory medications, physical therapy, massage, activity modification, bracing, and even cortisone injections. Currently, most insurance companies do not cover PRP therapy, which may be a factor when discussing this treatment with patients.

“The bottom line is that some studies indicate that PRP may be beneficial in the healing process. But we don’t really know whether it really has a positive effect clinically,” said Dr. Hall. “The good news is that several studies are underway and may, in the next few years, help us determine the true benefit of PRP.”

Dr. Hall reports no conflicts of interest. Disclosure information for other article authors can be found with the JAAOS article, “Platelet-rich Plasma: Current Concepts and Application in Sports Medicine.

Related Articles:

AAOS fellow takes European ‘PRP Tour’

Platelet-rich Plasma: Current Concepts and Application in Sports Medicine

New Biologic Treatment for Tennis Elbow May Replace Surgery For Chronic Sufferers

Clinical use of platelet-rich plasma in orthopaedics