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Knee Surgery & Sports Medicine Unit
IRCCS Humanitas Clinical Institute, Milan
P. Volpi - M. Denti
C.Bait
M. Cervellin, E. Prospero
A. Quaglia
PRP in patellar tendinopathies
Corrado Bait, MD
LONDON, 18 Oct 2012
I have no financial relationships to disclose
Corrado Bait, MD
WHAT IS PRP
• Platelet Rich Plasma (PRP) is a therapy that utilizes a patient’s own
blood to stimulate a healing response within a damaged tissue or joint
• PRP is made by taking a small sample of a patient’s own blood and
spinning in a centrifuge for fifteen minutes
• This process concentrates platelets and white blood cells in what is
called “buffy coat” that is extracted and delivered to the injuried area
• PRP is a sample of autologous blood with concentrations of platelets
above baseline values
• Growth factors in the platelets recruit and produce cells necessary for
healing
Arnoczky et al 2011;19(3):142-148
GROWTH FACTORS
Factor
Principal Source
Primary Activity
Comments
PDGF
platelets, endothelial cells,
placenta
promotes proliferation of
connective tissue, glial and
smooth muscle cells
two different protein chains
form 3 distinct dimer forms;
AA, AB and BB
EGF
submaxillary gland,
Brunners gland
promotes proliferation of
mesenchymal, glial and
epithelial cells
TGF-a
common in transformed
cells
may be important for
normal wound healing
related to EGF
wide range of cells; protein
is associated with the ECM
promotes proliferation of
many cells; inhibits some
stem cells; induces
mesoderm to form in early
embryos
at least 19 family members,
4 distinct receptors
promotes neurite outgrowth
and neural cell survival
several related proteins first
identified as protooncogenes; trkA (trackA),
trkB, trkC
FGF
NGF
kidney
promotes proliferation and
differentiation of
erythrocytes
TGF-b
activated TH1 cells (Thelper) and natural killer
(NK) cells
anti-inflammatory
(suppresses cytokine
production and class II
MHC expression), promotes
wound healing, inhibits
macrophage and
lymphocyte proliferation
at least 100 different family
members, including BMPs
IGF-I
primarily liver
promotes proliferation of
many cell types
related to IGF-II and
proinsulin, also called
Somatomedin C
IGF-II
variety of cells
promotes proliferation of
many cell types primarily of
fetal origin
related to IGF-I and
proinsulin
Erythropoietin
Kon E. et al. Platelet-rich plasma (PRP) to treat sports injuries:
evidence to support its use. Knee Surg Sports Traumatol Arthrosc (2011) 19:516–527
PRP PROCEDURE
Type of PRP
P-PRP
L-PRP
P-PRF
Pure-PRP
Leukocyte rich
PRP
Pure Platelet rich
Fibrin
• Autologous
Conditioned
Plasma (ACPTM)Arthrex 2.0 x
• Preparation
Rich in Growth
Factor (PRGF) Biotechnology Institute
• GPS
3.2 x
®
-
Biomet
• Symphony TM
II –DePuy 4.0 x
• Cascade
®
-
Muscoloskeletal
transplantation foundation
1.6 x
• PRGF scaffold Biotechnology Institute
Leukocyte
and Platelet
Rich Fibrin
No specific
sistem
PRP PROCEDURE
Wide variations of Platelets numbers




Different preparation methods
Intra-individual variability
Inter-individual variability
Age variability
Mazzocca A., et al - 2012
Platelet-rich plasma differs according to
preparation method human variability.
Are all PRP treatments the same ?
NO !!!
Because one treatment is not the same as another treatment for
different reasons:
• Platelets level base it’s different in every patient
• There are different type and use of PRP (liquid or gel forms)
• Some treatments contain red or white blood cells, thrombin or
calcium chloride
• The right indications for use are important to understand and
for talking about the outcomes of PRP treatments…..we need to
make sure we are talking about similar comparisons
Vol. 28, N 7, 2012 :pag 998 - 1009
“PAW classification system offers a simple, effective method for quickly
documenting the cellular components and activation method used. The
acronym PAW is for Platelets, Activation, and White cells, and the
subcategories are thoughtfully organized to enhance recall”
ITALIAN RULE
All blood manipulation must be done under
Hospital Hematologic Service Control
(DL 19-08-2005 N° 191)
PRP CONCENTRATION
•Effective concentration it’s about
1 milion/µL, 3 to 5X platelet level
baseline
• Fibroblasts are better stimulated
with concentration around 2,5X
Platelet baseline
• Expression of Growth Factors
receptors decrease with age
Weibrich g et al, Bone
34:665-671, 2004
De Mos et al. Am J sports Med
36:1171-1178, 2008
Vavaken P. et al. Age dependence of
expression of growth factor
receptors in porcine ACL fibroblasts
2010, J Orthop Res 28:1107-1112.
PRP in Patellar Tendinopathies
• Injection therapy: biological & mechanical action
• Improve surgical procedure
Clinical applications
Multiple PRP injections in
patellar tendon
with good results
Better clinical results
Physiotherapy & multiple
PRP injection (3 injection)
Vs only Physioth
• 31 patients
• 6 months of follow up
PRP PROCEDURE
Clinical applications
JAMA 2010;13(303):144–149
NO significant difference in painless or functional
recovery in PRP Vs placebo study
54 patients (27 each group)
• 24 months of follow up
• Level 1 of evidence
PRP PROCEDURE
Clinical applications
FINDING NO DIFFERENCE
DOES NOT
MEAN THERE IS NO
DIFFERENCE
PRP PROCEDURE
Our experience
MATERIAL & METHODS
Blood sample of 30 ml
Spinning
GPS® - Biomet 3,2 X
PRP PROCEDURE
Extraction of
Platelet Poor Plasma
(PPP)‫‏‬
Extraction of
Platelet Rich Plasma
(PRP)‫‏‬
Added to the PRP of sodium
bicarbonate (8.4%)
to neutralize the PH
PRP PROCEDURE
Our experience in patellar tendinopathies
US guide multiple injection of L-PRP
PRP PROCEDURE
Post Injection
•
after 7 days for 3 weeks
• swim
• ROM recovery
• stretching
• after 5 weeks
• excentric & concentric exercise
• after 7 weeks
• running
• after 9 weeks
• sport-specific training
• after 12 weeks return to sport
PRP PROCEDURE
Volpi P et Al.
Med Sports 2007;60: 595-603
Statistically significant
painless reduction at
90 days of follow up
after L-PRP treatment
Volpi P et Al
J Sports Med Phys Fitness
2010; 50: 494-500
Same better
results in other
site at 24 months
of follow up
PRP PROCEDURE
Our experience
post 120 gg
80
75,00
70
controllo a 24
mesi
Visa Score
60
70,29
50
40
Pre
39,25
30
20
10
PRE
POST
PRP PROCEDURE
•Randomized control trial
VAS
•2008-2009 :40
patients:
Pre
Post
Pre
Post
CTRL
Group
3.8±2.1
1±1.4
59.8±23.2
84.5±
11.8*
PRP
Group
1.2±2.2
0.6±0.
64.4±18.2
9
97.8±
2.5*§
20 control group (A)
20 PRP group (B)
•F.U. :12 mths (VAS,
VISA, RM)
VISA
PRP PROCEDURE
Our experience
GOLD MEDAL 1500 MT WOMAN
PRP PROCEDURE
Multiple scar & L-PRP
WADA
(The World Anti-Doping Agency)
World Anti-doping Code
The prohibited list 2010
S2. Peptide Hormones, Growth factors
and related substances
Platelet-derived preparations (e.g. Platelet
Rich Plasma, “blood spinning”)
administredred by intramuscolar route.
Other routes of administration will require a
declaration of use in compliance with the
international Standard for Therapeutic Use
Exemptions.
World Anti-doping Code
The prohibited list 2011 –
Summary of modifications
S2. Peptide Hormones, Growth
factors and related substances
Intramuscle injection of PRP
was removed of WADA
prohibited list
Take Home Message
• More talk than outcomes. Fashion topic
• Larger preclinical and clinical studies
(RCT) are still needed to define the real
benefits and indications of its use
• Different procedure and type of PRP,
extreme variability of GF.
• No standardized indications
• Rules & Costs
The current evidence shows that stem cells can
have a positive effect on tendon healing. This is
most likely because stem cells have regeneration
potential, producing tissue that is similar to the
preinjury state but the results can be variable
“The use of adjuncts such as molecular
signaling, mechanical stimulation, and
augmentation devices can potentially
enhance stem cell therapy”
Ahmad Z et al; Arthroscopy, Vol 28, No 7 (July), 2012: pp 1018-1029
CONCLUSION
GOOD MEDICAL PRACTICE
CORRECT INDICATION
& THERAPY
HIGH LEVEL RESEARCH
BIOTECHNOLOGY
INNOVATIONS
PRP in patellar tendinopathies
Corrado Bait, MD
LONDON, 18 Oct 2012