Platelet-Rich Plasma (PRP) Therapy

Transcription

1 Platelet-Rich Plasma (PRP) Therapy SCBM302-Regenerative neurobiology Somphong Narkpinit, M.D. Department of Pathobiology, Faculty of Science, Mahidol University

2 Introduction Platelet Rich Plasma Therapy (PRP) is defined as a sample of autologous blood with concentrations of platelet is a given volume of plasma this is above the concentration found in whole blood (Arnoczky et al, JAAOS 2010)

3 Introduction First induced in the 1980s for the treatment of cutaneous ulcers (Margolis et al, Diabetes Care 2001) Use expanded in the 1990s in the maxillofacial and plastic surgery fields (Marx, J Oral Maxillofac Surg 2004)

4 Blood components Blood components : - 93% RBCs - 6% Platelets - 1% WBCs - Plasma (liquid component)

5 PRP Preparation Optimal quantity of platelet and growth factor is debated Thought that ideally, PRP should have at least four times the normal platelet concentration in blood (Marx, J Oral Maxillofac Surg 2004)

6 PRP Components PRP contain not only a high concentration of platelet, but also the full component of clotting factor and secretory proteins

7 Platelet Biology Hematology Slide

8 Platelets Platelet are derived from megakaryocytes Important in hemostasis clotting Platelet are normally activated during the inflammatory phase to begin healing

9 Platelets Role in the normal healing response via the secretion of local growth factor Growth factor released by the platelets recruit reparative cell and augment soft-tissue repair (Eppley et al, Plast Reconstr Surg 2004)

10 Platelets Platelets contain two unique types of granules 1. -granules : contain variety of - Hemostatic proteins (coagulation) - Growth factors - Cytokines - Chemokines (pro-inflammation) - Adhesion proteins Three important adhesion molecules & seven growth factor 2. Dense-granules : Contain factor that promote platelet aggregation

11 Platelets Granule

12 Hesham EI-Sharkwy, et al. Measured - Platelet derived growth factor (PDGF)-AB - PDGF-BB - Transforming growth factor-b1 - Insulin-like growth factor-i - Fibroblast growth factor-basic (FGF-b) - Epidermal growth factor (EGF) - Vascular endothelial growth factor - Interleukin-12 (p40/70) Measured - Normal T-cell expressed & Secreted (RANTES) levels > by enzyme-linked immunosorbent assay Analyzed - Cytokines - Chemokines - LXA4 level - Monocyte chemotactic migration PRP led to significantly increased level of growth factors - Significantly suppressed inflammation by promoting secretion LXA4 Hesham EI-Sharkwy, et al. Platelet Rich Plasma and pro inflammatory properties. J Poriodontol. 2007;78:

13 Growth factor in Platelet Rich Plasma Growth factor Growth factor Source Function Platelet derived growth factor Platelets Stimulate cell replication, angiogenesis, mitogen for fibroblast Vascular endothelial growth factor Platelets Angiogenesis Transforming growth factor-ß1 Platelets Key regulatory in balance between fibrosis and myocyte regeneration Fibroblast growth factor Platelets Stimulates proliferative of myoblasts, angiogenesis Epidermal growth factor Platelets Proliferation of mesenchymal and epithelial cells, potentiation of other growth factor Hepatocyte growth factor Plasma Angiogenesis, mitogen for endothelial cells, antifibrotic Insulin like growth factor-1 Plasma Stimulate myoblasts and fibroblasts, mediated growth and repair of skeleton muscle Creany & Hamilton, Br J Sport Med 2008

14 Platelet Rich Plasma Biology Growth factor increase linearly with platelet concentration

15 PRP & Proteins PRP is more than just platelet concentrate Also contains 3 proteins in blood - Fibrin - Fibronectin - Vitronectin Know to act as - Cell adhesion molecules for osteoconduction - Matrix for > Bone > Connective tissue > Epithelial migration

16 Growth Factor yields Per Device

17 White Blood Cell in PRP White blood cells are a source of vascular endothelial growth factor (VEGF) VEGF is a potent stimulator of angiogenesis

18 Leukocytes Leukocytes May result in secondary tissue damage in setting of muscle injuries Recent studies have suggested Importance of keeping leukocytes in PRP concentrate

19 Leukocytes Leukocytes May provide anti-infectious environment Promote vascular endothelial growth factor Regulate immunity Show to release oxygen-free radicals Leukocytes use in PRP Decreased wound infection rate Did not affect outcome of PRP use in joint surgery Able to promote regenerating & remodeling process in tendons

20 Platelets activation Platelets are stimulated to release these growth factors and cytokines by exposure either to collagen or to thrombin and calcium

21 Platelets activation If fibrin levels are to high Or platelet activation occurs prior to collagen binding - Graft is inhibited Other functions of platelet activation and subsequent cascade of events that occur include Cytokines Chemokines release Mitogenesis

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24 PRP Preparation Withdrawal of patient peripheral blood Centrifugation Red layer White layer Yellow layer Erythrocytes Leukocytes and inflammatory cytokines Plasma platelet growth factor Inject at site of injury Lopez-Vidriero et al, Arthroscopy 2010

25 Technique Autologous Blood Collection Pre Centrifuge Post Centrifuge Withdraw PRP into procedure syringe

26 Technique Venipuncture Collection of around 34 ml (8.5 ml each x 4 tubes) of whole blood (WB) in anticoagulated vacutainer tubes First Spin Transfer of the upper layer with buffy coat to empty sterile tubes Collection of platelet pellets with few RBCs at bottom of the tubes Platelet pellets Second Spin Homogenize platelet pellets by thoroughly mixing into lower 1/3 rd volume of plasma, discarding upper 2/3 rd Ready to use 5 ml of homogenized PRP

27 Centrifuge Methods Different types of centrifuge methods Gravitational platelet sequestration technique Centrifuge system May differ in ability to separate RBCs from platelets Separating leukocytes from platelets Shearing platelets during centrifugation process - Leading to premature platelet activation and degranulation

28 Centrifugation Separate whole blood into three layers RBCs - Bottom layer - Specific gravity = 1.09 Platelet-poor plasma - Top layer - Specific gravity = 1.03

29 Segmentation of Blood

30 Factors affecting PRP count Centrifuge system used Hematocrit products Hydration status Inflammatory status Lipemia diet increase platelets Testosterone level

31 Research Concentration of platelets well above baseline levels - Not only increases attraction of undifferentiated cell to wound site - Increases proliferation of those cells Enhanced cellular proliferation resulting from high platelet concentrations - Can allow for reduction in autograft requirements - Can accelerate bone & soft-tissue healing - Direct impact on bioactive proteins available to accelerate wound healing process

32 PRP subtypes WBC rich PRP WBC poor PRP Activated PRP Non- activated PRP RBC rich PRP RBC poor PRP

33 What is PRP Therapy? PRP is Non-surgical healing treatment Used in many fields Sports medicine Orthopedics Cosmetic hair growth PRP is injected into affected region Stimulate & enhance healing

34 Common diagnoses treated with PRP Shoulder Rotator cuff tendinitis or tear Rotator cuff impingement syndrome or bursitis Bicipital tendinitis Arthritis Instability Elbow / Wrist / Hand Tennis elbow Golfer s elbow DeQuervaine s Tenosynovitis Trigger finger Arthritis

35 Common diagnoses treated with PRP Knee Patellar tendinitis Partially torn or strained major ligaments of knee ACL LCL MCL Meniscus tears Chondromalacia Arthritis Instability Ankle Achilles tendinitis Peroneal tendinitis

36 PRP used to treat Musculoskeletal injuries Over 100 million office visits yearly Sanchez M, et al Application of autologous GFs on skeletal muscle healing Mishra A, et al treatment of chronic severe elbow tendinosis with PRP Mild to moderate OA also treated with PRP in joint and body hip Stronger bones Regenerate muscle & tendon Increase vascularity Anti-inflammatory effect of PRP PRP-increased hyaluronic acid Distance runners 52% suffer injury to Achilles tendon during lifetime

37 Effective of PRP American Journal of Sports Medicine (2006) Reviewed effectiveness of PRP 15 patients with chronic elbow pain 60% improvement at 8 weeks 80% improvement at 6 months 93% improvement at final fellow-up (12-28 months) No side effects or complications reported

38 Everts On reviewing 21 human studies Positive outcome Found seven showed either no benefit or negative effects of PRP Several had platelet portion that had been activated prior to use via differing mean No side effects or complications reported Everts PAM, Knape JTA, Weibrich G,Schonberger JPAM, Hoffmann JJHL, Overdevest EP, Box HAM, and van Zundert A. Platelet-Rich Plasma and Platelet Gel : A Review. JECT.2006;38;

39 Standardizing the nomenclature for PRP PRP syndromes Platelets leukocyte gel Platelet rich plasma gel Platelet concentrate Blood plasma therapy Therapeutic effectiveness factors for success Concentrations of platelets Nucleated cells Growth factors Fibrin Platelets activation at the site Everts PAM, Knape JTA, Weibrich G,Schonberger JPAM, Hoffmann JJHL, Overdevest EP, Box HAM, and van Zundert A. Platelet-Rich Plasma and Platelet Gel : A Review. JECT.2006;38;

40 Delivery of PRP Delivery of PRP without exogenous activator Commonly performed Evidence demonstrating platelets can be slowly activated - Exposure to tendon-derived collagen alone Mishra A, Pavelko T : Treatment of chronic elbow tendinosis with buffering platelet rich plasma. Am J Sports Med 2006;34:

41 Surgical applications For surgical applications PRP commonly treated with Calcium chloride or Gluconate Thrombin - Allowing formation of putty or gel-like clot - Applied or sutured at surgical site Gamradt SC, Rodeo SA, Warren RF : Platelet rich plasma in rotator cuff repair, Tech Orthop Surg 2007;22:26-33.

42 How does PRP work to heal? Growth factor are released from large quantities of activated platelets at site of injury Induced inflammatory reaction - Initiates powerful effective healing cascade Growth factor Stimulate blood flow Promote matrix formation - Groundwork of all soft-tissue Restore tendon & ligamentous proteins Toughen up cartilage - More firm & resilient

43 Is PRP Painful? Patients tolerate procedure well - Post-injection soreness is expected - PRP induced inflammatory response > up to 10 days

44 Wound Healing Once tissue injury occurs Hematoma forms at site of tissue damage Platelets adhere to exposed collagen - Create clot - Inflammatory phase begins with activation of platelets resulting in release of > Growth factor > Bioactive factors > Hemostatic factors

45 Necessary Stages of Healing If an stages are incomplete Tissue homeostasis is lost Pain & loss of function may result Most reviews focus on growth factors contained within alpha granule of platelet Released upon platelet activation

46 Inflammatory Phase During inflammatory phase, functions of activated platelets include - Anti-microbial - Adhesion - Clot retraction - Pro-coagulation - Cytokine signaling - Chemokine release - Growth factor release

47 Proliferative Phase Within a few days of injury Proliferative phase begins - Characterized by > Angiogenesis > Collagen deposition > Granulation tissue formation > Epithelialization > Wound contraction

48 Proliferative Phase Following initial inflammatory phase - Typically lasts for two to three days - Fibroblasts enter site and begin proliferative phase Proliferative phase - Low ph & low oxygen levels > Stimulate fibroblast proliferation in the injury site

49 Proliferative Phase Fibroblasts become most abundant cell - By seventh day Fibroblasts - Responsible for deposition of collagen & ground substance Proliferative phase - Lasts from to two four weeks - Mandatory for tissue repair

50 Proliferative Phase Proliferative Phase - Peaking from day 5 to 15 - Can last for weeks Fibroblasts differentiate into myofibroblasts - Actin contracts to make wound smaller Low ph & hypoxemia - Stimulates neovascularization

51 Proliferative Phase Neovessels begin to form - Approximately days Process proceeds until neovessels disappear > Near completion of remodeling phase

52 Remodeling Phase Tissue repair starts when production & break down of collagen equalizes Remodeling phase - Can last over one year - Type III collagen is replaced - Reorganization occurs - Blood neovessels disappear

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54 Cell Proliferation Triangle PRP grafts function via triad of interaction Cell proliferation triangle - Each element of this triangle must be present for > Effective tissue repair > Pain relief

55 In vivo Study : Skin Healing Single-blind pilot study 80 full-thickness skin punch wounds - PRP applied topically On day 17 - Percentage of closure was > 81.1% for PRP treated sites > 57.2% for control sites PRP wound closure velocities significantly faster

56 In vivo Study : Diabetic Foot Ulcers Study examining PRP gel for diabetic foot ulcers 13 of 19 patients in study group had complete healing > Compared with only 9 of 21 of control group

57 Forehead Wrinkle Treatment

58 Burn Scar Treatment

59 Alopecia Treatment

60 Hair Restoration PRP Procedure - Mix thrombin Bovine origin 5000 IU with 5 cc Calcium Chloride 10% 13.6 meq Ca / 10 ml - Draw 5 ml of mixture, injected over affected area by nappage technique (multiple small injections in a linear pattern one-cm apart) & apply after injections within 4x4 gauze

61 Hair Restoration PRP Procedure - Inject 1/5 1/4 cc of PRP intradermal - Use micro-roller over scalp after injection - Massage mixture on site of treatment area with blood & PRP to stimulate hair growth - Apply PRP after micro-roller to penetrate on site - Leave the PRP on treatment sit eovernight - Shampoo in the morning

62 Skin rejuvenation Micro needling & Injecting Platelet Rich Plasma Micro needling Increase remolding of skin - Creating thousands of microscopic channels in skin > Increase formation of new tissue by activating body s healing cascade Micro needling Platelet Rich Plasma (PRP) into dermis Intensify natural wound cascade - High concentration of patients own growth factors

63 New collagen & Elastin Formation Before After

64 Patients received three treatments at two week intervals 18 control, 18 IPL, 18 MN Micro needling demonstrated More skin thickness than IPL or control Histology more collagen fiber than IPL or control Higher collagen qualitative analysis than IPL or control

65 Fibroblast & Collagen Among cells activated by TGF-beta When activated Under goes cell division Produces collagen Collagen is responsible for Plumping the skin Reversing visible signs of aging

66 TGF-beta & PDGF TGF-beta Extremely important Affects most aspects of tissue wound repair PDGF Improves dermal regeneration Acts locally to promote protein & collagen synthesis Causes endothelial migration or angiogenesis Induces expression of TGF-beta

67 PRP Gel Wounds treated with PRP gel Exhibited enhances wound repair - Compare to controls Possess more organized collagen than control tissues - Without excessive disposition of connective tissue or scar formation

68 Safety No studies have documented any cases of hyperplasia, carcinogenesis, or tumor growth Some system use purified bovine thrombin to activate the platelets, which may produce coagulopathies Most now have converted to human recombinant thrombin Mei-Dan et al, Phys Sports Med 2011

69 PRP : Contraindications Thrombocytopenia Anticoagulation therapy or NSAIDs Active infection Tumor Metastatic disease Allergy to bovine products if bovine thrombus is to be used

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