Emerging Insights On Platelet-Rich Plasma

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How To Acquire And Activate PRP

To acquire autologous PRP, a technician collects blood from the cubital vein. The amount of blood acquired depends on the clinical application (treatment area) and desired concentration. A centrifuge or filtration then separates the platelets from the plasma. Many different systems are available on the market today to obtain the PRP.

   When using a simple centrifugation process, the collected blood spins down between five and 20 minutes. This is determined by the speed of the centrifuge and the concentration desired. A technician then collects the PRP from the tube using a syringe and 18-gauge needle, being careful not to collect any platelet poor or red cells.

   A similar method of collection uses an automated centrifugation process that separates the platelets from the whole blood and then automatically sends the product to a separate syringe, using an infrared micro-processing sensor to differentiate between red blood cells and platelet-rich plasma. This type of system seems to lead to more accuracy and allows for more reproducible concentrations.

   One such device is the Magellan Autologous Platelet Separator System (Arteriocyte Medical Systems). With either method, the tube that initially collected the blood must have an anticoagulant. The kits that come with the products usually have tubes that already have anticoagulant or come with a separate anticoagulant.

   The literature seems to be mixed on the idea of activating the platelets before use. De Vos and colleagues presented a study on the effects of PRP on Achilles tendinopathy without mentioning activation.10 In their review article, Foster and co-workers suggest activation with bovine thrombin.11 Thomas and colleagues mention use of a combination of calcium and thrombin (bovine, human or recombinant).12 Fufa and co-workers used type I collagen to activate PRP and create a collagen-PRP gel.13 The brochure for the Magellan system calls for the activation of PRP by using adenosine diphosphate. The proper way to activate the platelets depends on the intended use of the PRP.

   Thrombin and calcium can activate the PRP into a platelet gel. This creates a product that can distribute growth factors to stimulate wound healing while constricting blood vessels to reduce bleeding. In addition, the PRP activation will increase the function of the platelets. The gel can improve tissue adhesion as a scaffold and protect from infection with its concentration of leukocytes. The gel has also reduced pain postoperatively. The platelet gel material is in use mostly for intraoperative situations to promote bone healing as well as being a wound sealant.2,5,6

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Author(s): 
David J. Soomekh, DPM, FACFAS

   Confirm the diagnosis with ultrasound and/or MRI. Place a local anesthetic block well above the site of injection. Then prepare the PRP at the desired concentration from the whole blood collection and activate it with calcium citrate. Inject between 6 and 10 cc of PRP within the substance of the tendon, beginning at the site of pathology (pain and any bulbous mass). Approach the medial or lateral aspect of the tendon under ultrasound guidance with the patient in a prone position. Inject several pulsed (peppered) doses of about 0.25 cc at a time, using a 25-gauge needle to fenestrate the tendon.

   Have the patient use a walking boot or crutches for up to one week after the procedure. Then allow the patient to bear weight in the boot for the next one to three weeks. Subsequently transition the patient into an athletic shoe with a gradual increase in weightbearing activity over a four-week period.

   I have seen a significant reduction in pain, a decrease in the size of fibrous nodules within the tendon and a sooner return to regular and sporting activity after PRP. Most patients have been able to return to increased exercise and activity within two months of the injection. Again, some patients have benefited by a second injection about six weeks after the first injection.

Key Pointers On Using PRP To Help Address Cartilage Issues With OA

Many studies have examined the role of PRP in aiding the repair of cartilage in early osteoarthritis (OA). In vitro studies have shown that PRP has the potential of increasing proteoglycan and collagen synthesis in chondrocytes.16 In vivo studies have also been promising.17,18

   Sánchez and colleagues reported results on a retrospective study for human patients with OA of the knee.19 They compared PRP injections and hyaluronan injections with three injections over three weeks. By week five, the pain scale success reached only 10 percent for the hyaluronan group and 33.4 percent for the PRP group.

   Kon and colleagues studied the use of PRP injections in 115 osteoarthritic knees.20 They found improvements in pain at six months. Cugat and co-workers investigated plasma rich in growth factors (PRGF) on athletes with chondral defects with positive results.21

   Mesenchymal stem cells can differentiate into chondrocytes and cartilage. Mishra and colleagues studied the effect of mesenchymal stem cells treated with PRP on cartilage regeneration in vitro.22 They found that a 10 percent PRP treatment increased cellular proliferation of chondrogenic differentiation over 10-fold versus the control.

   An investigation by Wu and co-workers suggested promising results with using PRP as a chondrocyte carrier to fill acute cartilage lesions in the knee.23 A scaffold made with PRP and thrombin transferred chondrocytes to the lesion.

   I have not found studies that show the effect of PRP on OA of the foot and ankle. Theoretically, however, there is evidence that suggests improvement in pain and cartilage regeneration could prove effective in the treatment of OA in the foot and ankle. At present, foot and ankle surgeons perform microfractures into cartilage lesions (osteochondral drilling) to initiate fibrocartilage repair. The marrow cells that infiltrate the joint after microfracture are similar to those from bone marrow aspirate, mesenchymal stem cells and PRP. It would seem logical that the introduction of such cell products by percutaneous injection or surgical transfer would, in fact, increase cartilage regeneration and repair.

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Anonymoussays: May 6, 2010 at 11:07 am How do you bill for this? Reply to this comment »
Anonymoussays: May 6, 2010 at 1:58 pm I would also like to know what coding is being used for this and do most insurance companies recognize PRP treatment for plantar fasciitis? Reply to this comment »
Anonymoussays: August 5, 2010 at 5:11 pm

There is a new code for this. 0232T Came out in January 2010 but only became valid July, 2010.

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