Platelet Rich Plasma

Basic Science and Clinical Applications

 Introduction.
Biological therapies for tissue Regeneration
are increasingly used currently, so it is
essential to expand our knowledge.

Platelet rich plasma is one of them.

Rationale for Biologic Treatment
Pool of bioactive anabolic and anti-catabolic
molecules to modify the healing process

Tendons and Muscles

Cartilage
Synovium
Subchondral bone

GFs as therapeutic proteins...”Combination therapy”

PRP as delivery method for multiple GFs
Biological
Therapy
 What is PRP??

 How it works?

 What are the different formulations

 What are the different preparations?

 What is Activation?

 Clinical Indication?

 Potential Adverse Reactions?

 Barriers and Future of PRP?

 Does PRP work?
pub Med article search:6,047

Significant difference No difference

 Peerbooms.AJSM,2010
Kon,KSSTA,2010
Silva,KSSTA,2009
Filardo,KSSTA,2010
De Vos,JAMA,2010
Radice,Arthroscopy,20
Vogrin,ESR,2010
10
Creaney,BJSM,2011
Wang-
De Jonge,AJSM,2011
Saegusa,AOTS,2011
Schepull,AJSM,2011
Thanasas,AJSM,2011
Gosens,AJSM,2011

50% 50%
 What is PRP?
 Technical Definition of Platelet – Rich – Plasma:
 Platelet Concentration above physiologic levels
 1, 000, 000 platelets/microliter
(5 x baseline)
• Mixed Opinions on whether the PRP should
contain WBCs or not
• All PRPs are not same (mainly due to differences
in platelet activation)
 Platelets
• Platelets are small granulated bodies (2 – 4 µm
in diameter)
• Average of 300, 000 platelets/µl of circulating
blood
• T1/2 of 7 days
• Produced in bone marrow and stored in spleen
• Involved in initial phase of wound healing
• Contains Ca++, K+, Clotting Factors, Serotonin,
ADP, Prostaglandins and Growth Factor
 Platelets

Dense Granules: Bioactive Factors

Adenosine: Important rule in energy transfer
Serotonin: Chemo-attractant for fibroblasts and
macrophages
Histamine: Local vasodilator
Calcium: Required for epidermal cell migration
and regenaration
 Plasma
• Fluid Portion of the Blood
• Contains Proteins, Anti – Bodies, Clotting
Factors and Ions
• ≈ 5% of the body weight (≈ 3500ml in a
person of 70kg body weight)
• Plasma clots on standing
• Hence, an Anti – Coagulant must be added
to the whole blood to harvest plasma
Platelet Rich Plasma Biology

White Blood Cells/PRP

Many bioactive substances within WBCs
Lysozyme
Cytokines: IL-1, TNF, FGF
Surface Receptors
 How does PRP work?
Proliferatio Chemotaxi
n s

Platelet – Rich
– Plasma

Angiogenesi Anti –
s Apoptosis
 Tissue Healing Response
Inflammation (Releasing Growth factors,
Cytokines from platelets
and
leucocytes)

Cell migration (Chemotaxis)

Cell Proliferation (mitosis)
Angiogenesis

• Remodelling
Growth Factors in Platelet-rich Plasma
Growth Factor Source Function
Platelet derived growth Platelets Stimulates cell replication,
factor angiogenesis, mitogen for
fibroblastas

Vascular endothelial growth Platelets Angiogenesis

factor

Transforming growth factor- Platelets Key regulator in balance

β1 between fibrosis and
myocyte regenration

Fibroblast growth factor Platelets Stimulates proliferation of

myoblasts, angiogenesis

Epidermal growth factor Platelets Proliferation of

mesenchymal and epithelial
cells, potentiation of other
growth factors
Via Cytokines within the platelets and
WBC granules
Initiates an Intra – Cellular Signaling
which results in Protein Expression
 PRP Not Created Equal
Platelet Concentration:
A= 5*Baseline or higher
B= Less than 5*Baseline

Type White Blood Cells Activation

Type 1: Increased WBCs Inactivated

Type 2: Increased WBCs Activated

Type 3: Few/None WBCs Inactivated

Type 4: Few/None WBCs Activated

PRP growth factor concentrations differ
by system
Preparation
Collection

Centrifugation

Fractionization

Application
Office Injection of PRP
- The Protocol
 PRP Application Technique
 Remove PPP
 Shake vigorously for 30 seconds

Platelet Poor Plasma

(PPP)

Platelet Rich Plasma

(PRP)

Packed Red Blood Cells

 Platelet Rich Fibrin Matrix
Production of a highly cross – linked fibrin
matrix by simultaneous centrifugation and
coagulation.
Addition of CaCl2 and a 2nd round of
Centrifugation initiates the fibrin clotting
cascade utilizing autogenous thrombin
(minimizes platelet activation)
Inactivated platelets get trapped in this matrix
Clinical Indications.
Chronic Tendinopathy

Muscles and Ligaments

Cartilage

Menisci
 How does PRP work in Tendons?
PRP influences the three over – lapping phases
of Tendon healing
Re – modeling:
 PRP enhances the gene expression of Type 1
Collagen
 PRP recruits bone – marrow derived cells to
an area of injection
Adverse Reaction…

Coagulopathy

Transmission of Diseases

Anti Doping regulations (WADA 2012

Regulation)
 Future of PRP

Growth factors antagonistic, mitigating effects of

PRP
Future Methods to Improve Efficacy

1. Formulation specific to indication

2. Concentrate Blood components other than
PLTs
3. Exclude unwanted growth factors
4. Add cell source for improved
induction/signaling
 Components of PRP
Platelets Choose flexible
Growth factors system
WBCs Can produce multiple
RBCs
formulations
Low/high WBCs, RBCs,
PLT
Intra-articular use
Low WBCs, RBCs
Extra-articular use
Include WBCs
Intra-Articular Injections of PRP
Laboratory results agree with recent
RCTs
Inclusion of WBCs may hamper results
Is this due to inflammation?
RBCs not tolerated well
Hemophilia
Trauma/ACL tear
Microfracture?
 Results- Inflammatory Mediators

LR-PRP causes significant increases in pro-inflammatory

mediators
LR-PRP causes significant increases in anti-inflammatory
mediators
Results: Synoviocyte Viability
RCT: Intra-articular LP-PRP Injections
 2nd Generation Formulations
Subtraction method Isolation method
Delete unwanted factors Filter out specific proteins
Eliminate antagonism Must be large molecules
 2nd Generation Formulation
Combination method

Add MSCs or ADSCs to PRP

Increase cellularity
2nd Generation PRP
 Summary.
Potentially it is the Ideal Biological Tool
Safe and Simple to use
Inexpensive compared to the
Surgery Costs.
Available at the point of Care
Effective??????
THANK YOU