PLATELET RICH PLASMA:
Platelet rich plasma (PRP) can be an alternative treatment for chronic degenerative changes as well as for acute tendon and ligament injuries.
Many famous athletes — Tiger Woods, tennis star Rafael Nadal, and several others — have received PRP for various problems, such as sprained knees and chronic tendon injuries. These types of conditions have typically been treated with medications, physical therapy, or even surgery. Some athletes have credited PRP with their being able to return more quickly to competition.
What Is Platelet-rich Plasma (PRP)?
Although blood is mainly a liquid (called plasma), it also contains small solid components (red cells, white cells, and platelets.) The platelets are best known for their importance in clotting blood. However, platelets also contain hundreds of proteins called growth factors which are very important in the healing of injuries.
PRP is plasma with many more platelets than what is typically found in blood. The concentration of platelets — and, thereby, the concentration of growth factors — can be 5 to 10 times greater (or richer) than usual.
To develop a PRP preparation, blood must first be drawn from a patient. The platelets are separated from other blood cells and their concentration is increased during a process called centrifugation. Then the increased concentration of platelets is combined with the remaining blood. Below are links to recent research data demonstrating efficay in the treatment of both tendonopathy and arthritis.
How Does PRP Work?
Although it is not exactly clear how PRP works, laboratory studies have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process.
To speed healing, the injury site is treated with the PRP preparation. This can be done in one of two ways:
PRP can be carefully injected into the injured area. For example, in Achilles tendonitis, a condition commonly seen in runners and tennis players, the heel cord can become swollen, inflamed, and painful. A mixture of PRP and local anesthetic can be injected directly into this inflamed tissue. Afterwards, the pain at the area of injection may actually increase for the first week or two, and it may be several weeks before the patient feels a beneficial effect.
PRP may also be used to improve healing after surgery for some injuries. For example, an athlete with a completely torn heel cord may require surgery to repair the tendon. Healing of the torn tendon can possibly be improved by treating the injured area with PRP during surgery. This is done by preparing the PRP in a special way that allows it to actually be stitched into torn tissues.
What Conditions are Treated with PRP? Is It Effective?
Research studies are currently being conducted to evaluate the effectiveness of PRP treatment. At this time, the results of these studies are inconclusive because the effectiveness of PRP therapy can vary. Factors that can influence the effectiveness of PRP treatment include:
The area of the body being treated
The overall health of the patient
Whether the injury is acute (such as from a fall) or chronic (an injury developing over time)
Chronic Tendon Injuries
According to the research studies currently reported, PRP is most effective in the treatment of chronic tendon injuries, especially tennis elbow, a very common injury of the tendons on the outside of the elbow.
The use of PRP for other chronic tendon injuries — such as chronic Achilles tendonitis or inflammation of the patellar tendon at the knee (jumper's knee) is promising. However, it is difficult to say at this time that PRP therapy is any more effective than traditional treatment of these problems.
Acute Ligament and Muscle Injuries
Much of the publicity PRP therapy has received has been about the treatment of acute sports injuries, such as ligament and muscle injuries. PRP has been used to treat professional athletes with common sports injuries like pulled hamstring muscles in the thigh and knee sprains. There is no definitive scientific evidence, however, that PRP therapy actually improves the healing process in these types of injuries.
More recently, PRP has been used during certain types of surgery to help tissues heal. It was first thought to be beneficial in shoulder surgery to repair torn rotator cuff tendons. However, the results so far show little or no benefit when PRP is used in these types of surgical procedures.
Surgery to repair torn knee ligaments, especially the anterior cruciate ligament (ACL) is another area where PRP has been applied. At this time, there appears to be little or no benefit from using PRP in this instance.
Some initial research is being done to evaluate the effectiveness of PRP in the treatment of the arthritic knee. It is still too soon to determine if this form of treatment will be any more effective than current treatment methods.
Treatment with PRP could hold promise, however, current research studies to back up the claims in the media are lacking. Although PRP does appear to be effective in the treatment of chronic tendon injuries about the elbow, the medical community needs more scientific evidence before it can determine whether PRP therapy is truly effective in other conditions.
Even though the success of PRP therapy is still questionable, the risks associated with it are minimal: There may be increased pain at the injection site, but the incidence of other problems — infection, tissue damage, nerve injuries — appears to be no different from that associated with cortisone injections.
If you are considering treatment with PRP, be sure to check your eligibility with your health insurance carrier. Few insurance plans, including workers' compensation plans, provide even partial reimbursement.
BONE MARROW ASPIRATE CONCENTRATE (BMAC):
BMAC is a regenerative therapy approved by US Food and FDA-approved method for delivering mesnechymal stem cells. The procedure that uses cells from a patient’s bone marrow to initiate healing for a number of orthopedic conditions, including osteoarthritis and cartilage injuries.
Chronically painful areas often have inadequate blood supply, healing potential and regenerative cells to repair damage. BMAC can provide a rich supply of regenerative cells with the ability to replicate into various types of tissue. It has tremendous potential for patients with moderate to severe orthopedic conditions or injuries and is most often used to treat severe arthritis in the shoulder, knee and hip.
Recently, in vitro studies and clinical trials have reported the benefits of BMAC for the treatment of knee pathologies. When delivered into an injured site, it assists on cartilage regeneration and preservation by inducing the production of several cell types within the knee which promoting growth and healing. All these factors strengthen the healing process as they reduce local inflammation.
Although the ideal number for the applications, volume, and timing of BMAC injections have not been well defined, these studies have shown that the intra-articular guided BMAC applications do not induce adverse events besides temporary joint swelling. Despite promising results, the number of clinical trials evaluating the efficacy and safety of BMAC for knee OA is considerably small and, for that reason, more studies with extensive follow-up periods are needed.
What you should know about Bone Marrow Aspirate Concentrate
BMAC is obtained during an outpatient procedure in which a small amount of the patient’s bone marrow is extracted from the back of the pelvis, using local anesthesia to minimize any discomfort. The marrow is then processed in a centrifuge to produce a concentration of stem cells which will then be injected into the patient’s damaged tissue to promote healing.
The procedure involves minimal down time and patients typically feel sore for two or three days at the site of the injection. As with all regenerative procedures, anti-inflammatory medications such as ibuprofen, naproxen and aspirin should be avoided for at least two weeks following the procedure, as they may interrupt the healing process.
Patients should follow up with a short period of physical therapy to accelerate recovery. The full benefit of the procedure should be felt within six to eight weeks of the procedure.
Articular cartilage is the smooth, white tissue that covers the ends of bones where they come together to form joints. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction. Articular cartilage can be damaged by injury or normal wear and tear. Restoring articular cartilage can relieve pain and allow better function. Most importantly, it can delay or prevent the onset of arthritis.
Cartilage defects in the knee are being diagnosed with increased frequency and are treated with a variety of techniques. The aim of any cartilage repair procedure is to generate the highest tissue quality, which might correlate with improved clinical outcomes, return-to-sport, and long-term durability.
The main component of the joint surface is a special tissue called hyaline cartilage.When it is damaged, the joint surface may no longer be smooth. Moving bones along a tough, damaged joint surface is difficult and causes pain. Damaged cartilage can also lead to arthritis in the joint. The goal of cartilage restoration procedures is to stimulate new hyaline cartilage growth.
Identifying Cartilage Damage
In many cases, patients who have joint injuries, such as meniscal or ligament tears, will also have cartilage damage. This damage may be hard to diagnose because hyaline cartilage does not contain calcium and cannot be seen on an X-ray.
Most candidates for articular cartilage restoration are young adults with a single injury, or lesion. Older patients, or those with many lesions in one joint, are less likely to benefit from the surgery. The knee is the most common area for cartilage restoration. Ankle and shoulder problems may also be treated.
OSTEOCHONDRAL AUTOGRAFT TRANSPLANT (OATS):
In an Autograft procedure, healthy cartilage and bone is taken from an area of the knee that does not bear weight. It is done for smaller defects generally less than 1 cm because the healthy graft tissue can only be taken from a limited area of the same joint. It can be done with an arthroscope in a minimally invasive approach.
The harvested autograft of healthy cartilage and bone is then moved the deficient area normally in a weight bearing portion of the knee. This procedure reliably improves function and relieves pain.
If a cartilage defect is too large for an autograft, an allograft may be considered. An allograft is a tissue graft taken from a cadaver donor. Like an autograft, it is a block of cartilage and bone. In the laboratory it is sterilized and prepared. It is tested for any possible disease transmission.
An allograft is typically larger than an autograft. It can be shaped to fit the exact contour of the defect and then press fit into place. Allografts are typically done through an open incision.
After surgery, the joint surface must be protected while the cartilage heals. If the procedure was done on your knee or ankle, you may not be able to put weight on the affected leg. You will need to use crutches to move around for the first few weeks after surgery. Physical Therapy will start quickly after surgery and will typically last 2-3 months.
Return to sport after OATS:
Long term survival OATS:
Autograft vs Allograft:
AUTOCART: MINCED CARTILAGE IMPLANTATION:
Autocart is a procedure where healthy cartilage is taken from an area of the knee and minced into smaller pieces. This is typically mixed with a regenerative agent such as BMAC and placed into small to medium size defects within the knee. The diffence between this and OATS is there is less damage to the native joint during the harvest since no bone is taken along with the graft. For small to medium size defects with healthy underlying (subchondral) bone this is an easy and effective option.
Minced cartilage implantation (MCI) is a relatively simple and cost-effective technique to transplant autologous cartilage fragments in a single-step procedure. Minced cartilage has a strong biologic potential since autologous, activated non-dedifferentiated chondrocytes are utilized. It can be used both for small and large cartilage lesions, as well as for osteochondral lesions. As it is purely an autologous and homologous approach, it lacks a significant regulatory oversight process and can be clinically adopted without such limitations.
DENOVO® NT GRAFT:
DeNovo works under a similar principle as Autocart but the cartilage cells are acquired from a donor source with high potential for growth and incorporation. There is no harvest of the patients own cells in this procedure therefore there is no risk to other areas of the knee. The cartilage cells come packaged from a lab ready to use. It is a particulated juvenile cartilage implant used for the repair of articular cartilage damage. It is intended to provide surgeons with an early-intervention option for articular cartilage repair and cartilage restoration.
Advantages of using DeNovo NT Graft include:
Juvenile tissue has 10x greater chondrocyte density than adult tissue and does not elicit an allogeneic immune response
The graft is implanted in a single stage procedure with fibrin fixation
No need to harvest a periosteal flap
No need to harvest tissue or cells from areas of undamaged cartilage
Minced Cartilage Implantation
MRI before and after Autocart procedure