The efficacy of autologous platelet gel in pain control and blood loss in total knee arthroplasty. An analysis of the haemoglobin, narcotic requirement and range of motion

Platelet-rich plasma prevents blood loss and pain and enhances early functional outcome after total knee arthroplasty: a prospective randomised controlled study

PURPOSE

The purpose of this study was to determine whether platelet-rich plasma (PRP) might prevent blood loss and postoperative pain and expedite wound healing following total knee arthroplasty (TKA).

METHODS

Forty consecutive patients with knee arthritis who were matched for age, sex and body mass index (BMI) were randomly allocated to either receive or not receive PRP application over the wound, including capsule, medial and lateral recesses, during TKA. Postoperative haemoglobin, blood loss, blood transfusion, visual analogue scale (VAS) score, wound score, Knee Society Score (KSS) and Western Ontario and McMaster Osteoarthritis Index (WOMAC) score were recorded and evaluated.

RESULTS

The platelet-rich plasma and control groups comprised 17 and 23 patients, respectively. The PRP group recorded significantly less reduction in haemoglobin and need for blood transfusion (p = 0.00 and p = 0.001, respectively), experienced less pain (p = 0.00) and required fewer narcotics than the control (p = 0.00). There was significant difference in range of motion (ROM) at three months (p = 0.01), no significant difference in wound scores (p = 0.311) and significant difference in KSS and WOMAC scores at 12 weeks (p = 0.00, 0.00). However no significant difference was found at six months.

CONCLUSIONS

PRP has significant effect in preventing blood loss, postoperative pain and need for narcotics after TKA and has a positive effect on short-term clinical outcome.

Application of Platelet-Rich Plasma to Disorders of the Knee Joint

IMPORTANCE

The promising therapeutic potential and regenerative properties of platelet-rich plasma (PRP) have rapidly led to its widespread clinical use in musculoskeletal injury and disease. Although the basic scientific rationale surrounding PRP products is compelling, the clinical application has outpaced the research.

OBJECTIVE

The purpose of this article is to examine the current concepts around the basic science of PRP application, different preparation systems, and clinical application of PRP in disorders in the knee.

EVIDENCE ACQUISITION

A systematic search of PubMed for studies that evaluated the basic science, preparation and clinical application of platelet concentrates was performed. The search used terms, including platelet-rich plasma or PRP preparation, activation, use in the knee, cartilage, ligament, and meniscus. Studies found in the initial search and related studies were reviewed.

RESULTS

A comprehensive review of the literature supports the potential use of PRP both nonoperatively and intraoperatively, but highlights the absence of large clinical studies and the lack of standardization between method, product, and clinical efficacy. Conclusions and Relevance. In addition to the call for more randomized, controlled clinical studies to assess the clinical effect of PRP, at this point, it is necessary to investigate PRP product composition and eventually have the ability to tailor the therapeutic product for specific indications.

Addition of platelet concentrate to dermo-epidermal skin graft in deep burn trauma reduces scarring and need for revision surgeries

BACKGROUND

[corrected] Deep skin burn injuries, especially those on the face, hands, feet, genitalia and perineum represent significant therapeutic challenges. Autologous dermo-epidermal skin grafts (DESG) have become standard of care for treating deep burns. Additionally, human autologous thrombin activated autologous platelet concentrate (APC) has gained acceptance in the setting of wounds. While each of these interventions has been independently shown to accelerate healing, the combination of the two has never been evaluated. We hypothesized that the addition of platelets (source of growth factors and inhibitors necessary for tissue repair) to the DESG (source of progenitor cells and of tissue proteases necessary for spatial and temporal control of growth regulators released from platelets) would create the optimal environment for the reciprocal interaction of cells within the healing tissues.

METHODS

We used clinical examination (digital photography), standardised scales for evaluating pain and scarring, in combination with blood perfusion (laser Doppler imaging), as well as molecular and laboratory analyses.

RESULTS

We show for the first time that the combination of APC and DESG leads to earlier relief of pain, and decreased use of analgesics, antipruritics and orthotic devices. Most importantly, this treatment is associated with earlier discharges from hospital and significant cost savings.

CONCLUSIONS

Our findings indicate that DESG engraftment is facilitated by the local addition of platelets and by systemic thrombocytosis. This local interaction leads to the physiological revascularization at 1-3 months. We observed significant elevation of circulating platelets in early stages of engraftment (1-7 days), which normalized over the subsequent 7 and 90 days.

Augmenting tendon and ligament repair with platelet-rich plasma (PRP)

Tendon and ligament injuries (TLI) commonly occur in athletes and non-athletes alike, and remarkably debilitate patients' athletic and personal abilities. Current clinical treatments, such as reconstruction surgeries, do not adequately heal these injuries and often result in the formation of scar tissue that is prone to re-injury. Platelet-rich plasma (PRP) is a widely used alternative option that is also safe because of its autologous nature. PRP contains a number of growth factors that are responsible for its potential to heal TLIs effectively. In this review, we provide a comprehensive report on PRP. While basic science studies in general indicate the potential of PRP to treat TLIs effectively, a review of existing literature on the clinical use of PRP for the treatment of TLIs indicates a lack of consensus due to varied treatment outcomes. This suggests that current PRP treatment protocols for TLIs may not be optimal, and that not all TLIs may be effectively treated with PRP. Certainly, additional basic science studies are needed to develop optimal treatment protocols and determine those TLI conditions that can be treated effectively.

Platelet rich plasma use in allograft ACL reconstructions: two-year clinical results of a MOON cohort study

BACKGROUND

Platelet rich plasma has been promoted as a biologic agent to enhance tissue healing. As a concentration of autologous growth factors, it has gained increased use in musculoskeletal applications.

METHODS

The purpose of this study was to evaluate the effect of intra-operative PRP on patient-reported outcomes 2 years after ACL reconstruction with tibialis anterior allograft. Fifty patients who underwent allograft ACL reconstruction with intra-operative application of PRP to the graft were matched with 50 allograft ACL -reconstructions without PRP use. The same surgeon performed all procedures with identical technique. Two year patient-reported outcomes including KOOS, IKDC, and Marx activity scores were obtained. Effusions in the immediate post-operative period, post-operative complications, and any subsequent procedures were also recorded.

RESULTS

There was no difference between the groups with respect to additional surgeries or complications in the first 2 years after reconstruction. Decreased effusions at 10±4 days were noted in the PRP group, but this difference disappeared by 8±4 weeks. No differences in patient-reported outcomes were noted in the 58 patients with two-year outcome data.

CONCLUSION

The study demonstrated that although PRP application in tibialis allograft ACL reconstructions appeared safe; clinical benefit was minor and short-term. No differences in patient-reported outcomes or number of additional surgeries at 2 years were noted.

LEVEL OF EVIDENCE

Level III - retrospective comparative study.

Intraoperative platelet rich plasma usage in total knee arthroplasty: does it help?

Autologous platelet rich plasma preparations, commonly referred to as platelet gel, have been reported to have benefits when used in total knee replacement of less blood loss and better motion, with few reported complications. This retrospective review of 268 consecutive primary total knee arthroplasty cases compares postsurgical range of motion at 2, 8, and 12 weeks, knee manipulation rates, change in hemoglobin, and complications between one group receiving a platelet gel preparation (135 cases), and an equivalent group receiving no platelet gel preparation (133 control cases). No difference was found between groups in manipulation rates, knee range of motion, or changes in hemoglobin (P > 0.05). The use of platelet gel in this study did not have a significant effect on hemoglobin at 72 hours postoperatively, knee range of motion, or manipulation rates up to 3 months post-op in this patient cohort.

Sensory neuropathy associated with aggressive cauterization using a bipolar radiofrequency device in primary TKA

Because significant postoperative blood loss can result in many complications, hemostasis remains a critical part of successful joint replacement outcomes. Advanced techniques, such as electrocautery use after optimally timed tourniquet release, focus on desired patient blood loss outcomes. The purposes of this study were to report the incidence of nerve injury, identify associated risk factors following the use of bipolar electrocautery for hemostasis in the posterior knee during primary total knee arthroplasty, and compare that rate with the rate seen using a standard electrocautery device. Clinical and operative data were retrospectively reviewed for an association with postoperative nerve injury in 241 consecutive patients when using bipolar electrocautery between July 2007 and October 2008. A comparison group of 192 demographically similar consecutive patients between November 2008 and October 2009 was also evaluated to establish a surgeon-specific benchmark when using standard electrocautery. Seven (2.9%) of 241 patients in the bipolar electrocautery group reported documented neuropathies compared with 1 (0.52%) of 192 patients using standard electrocautery. In addition, female sex and rheumatoid arthritis were associated with postoperative nerve injury following bipolar electrocautery. Although the bipolar radiofrequency device is effective in achieving hemostasis, the authors recommend judicious use of this procedure in women or patients with rheumatoid arthritis and cautious, nonaggressive use of posterior compartment bipolar radiofrequency ablation in the remaining patient populations.

DEVELOPMENT AND TEST OF A DECISION SUPPORT TOOL FOR HOSPITAL HEALTH TECHNOLOGY ASSESSMENT

Objective: To develop and test a decision-support tool for prioritizing new competing Health Technologies (HTs) after their assessment using the mini-HTA approach.

Methods:A two layer value/risk tool was developed based on the mini-HTA. The first layer included 12 mini-HTA variables classified in two dimensions, namely value (safety, clinical benefit, patient impact, cost-effectiveness, quality of the evidence, innovativeness) and risk (staff, space and process of care impacts, incremental costs, net cost, investment effort). Weights given to these variables were obtained from a survey among decision-makers (at National/Regional level and hospital settings). A second layer included results from mini-HTA (scored as higher, equal or lower), which compares the performance of the new HT (in terms of the abovementioned 12 variables) with the available comparator. An algorithm combining the first (weights) and second (scores) layers was developed to obtain an overall score for each HT, which was then plotted in a value/risk matrix. The tool was tested using results from the mini-HTAs for three new HTs (Surgical Robot, Platelet Rich Plasma, Deep Brain Stimulation).

Results: No significant differences among decision-makers were observed as regards the weights given to the 12 variables, therefore, the median aggregate weights from decision-makers were introduced in the first layer. The dot plot resulting from the mini-HTA presented good power to visually discriminate between the assessed HTs.

Conclusion: The decision-support tool developed here makes possible a robust and straightforward comparison of different competing HTs. This facilitates hospital decision-makers deliberations on the prioritization of competing investments under fixed budgets.

Effect on blood loss and cost-effectiveness of pain cocktails, platelet-rich plasma, or fibrin sealant after total knee arthroplasty

This study evaluated the effect of periarticular pain cocktail, platelet-rich plasma, or fibrin sealant injections on blood loss, transfusion rate, and hospital costs after total knee arthroplasty. A retrospective review of 400 patients undergoing primary total knee arthroplasty with one of the different periarticular treatments as stated above was performed. Postoperative blood loss, hemoglobin levels, allogenic blood transfusion rates, and per-case hospital injection cost were reported. Although platelet-rich plasma and fibrin sealant decreased blood loss compared with the control group (P < .001), there was no significant difference in blood loss in the pain-cocktail group or in postoperative hemoglobin levels or transfusion rates between all groups. Significant efficacy and cost-effectiveness for these modalities could not be identified and have, therefore, been discontinued at our practice.

LEVEL OF EVIDENCE

level III.

Platelet-rich plasma therapy - future or trend?

Chronic complex musculoskeletal injuries that are slow to heal pose challenges to physicians and researchers alike. Orthobiologics is a relatively newer science that involves application of naturally found materials from biological sources (for example, cell-based therapies), and offers exciting new possibilities to promote and accelerate bone and soft tissue healing. Platelet-rich plasma (PRP) is an orthobiologic that has recently gained popularity as an adjuvant treatment for musculoskeletal injuries. It is a volume of fractionated plasma from the patient's own blood that contains platelet concentrate. The platelets contain alpha granules that are rich in several growth factors, such as platelet-derived growth factor, transforming growth factor-β, insulin-like growth factor, vascular endothelial growth factor and epidermal growth factor, which play key roles in tissue repair mechanisms. PRP has found application in diverse surgical fields to enhance bone and soft-tissue healing by placing supra-physiological concentrations of autologous platelets at the site of tissue damage. The relative ease of preparation, applicability in the clinical setting, favorable safety profile and possible beneficial outcome make PRP a promising therapeutic approach for future regenerative treatments. However, there is a large knowledge gap in our understanding of PRPs mechanism of action, which has raised skepticism regarding its potential efficacy and use. Thus, the aim of this review is to describe the various factors proposed to contribute to the biological activity of PRP, and the published pre-clinical and clinical evidence to support it. Additionally, we describe the current techniques and technology for PRP preparation, and review the present shortcomings of this therapy that will need to be overcome if it is to gain broad acceptance.

Fibrin sealants in orthopaedic surgery: practical experiences derived from use of QUIXIL® in total knee arthroplasty

BACKGROUND

Total knee arthroplasty is associated with a significant postoperative blood loss even without any form of perioperative anticoagulation.

METHODS

The potential role of QUIXIL(®), a fibrin sealant used in orthopaedic surgery to control blood loss and avoid blood transfusions in patients undergoing total knee arthroplasty was evaluated in a prospective randomized trial with twenty-four patients diagnosed with primary osteoarthritis of the knee.

RESULTS

Results showed that application of 2 ml QUIXIL(®) adds costs to treatment without reducing the number of transfused red blood cell counts and postoperative haemoglobin loss. However, significant lower levels of postoperative fluid loss (P = 0.026) was detected in QUIXIL(®) treated patients.

CONCLUSION

Regarding cost effectiveness and benefit no indication for the use of 2 ml QUIXIL(®) fibrin sealant in standard knee arthroplasty could be proofed statistically.

Patellar tendon healing with platelet-rich plasma: a prospective randomized controlled trial

BACKGROUND

The patellar tendon has limited ability to heal after harvesting its central third. Platelet-rich plasma (PRP) could improve patellar tendon healing.

HYPOTHESIS

Adding PRP to the patellar tendon harvest site would improve donor site healing and improve clinical outcome at 6 months after anterior cruciate ligament (ACL) reconstruction with a patellar tendon graft.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Twenty-seven patients were randomly divided to receive (n = 12) or not receive (n = 15) PRP in the patellar tendon harvest site during ACL reconstruction. The primary outcome was magnetic resonance imaging (MRI) assessment of patellar tendon healing (gap area) after 6 months. Secondary outcomes were questionnaires and isokinetic testing of ACL reconstruction with a patellar tendon graft comparing both groups.

RESULTS

Patellar tendon gap area was significantly smaller in the PRP group (4.9 ± 5.3 mm(2); 95% confidence interval [CI], 1.1-8.8) than in the control group (9.4 ± 4.4 mm(2); 95% CI, 6.6-12.2; P = .046). Visual analog scale score for pain was lower in the PRP group immediately postoperatively (3.8 ± 1.0; 95% CI, 3.18-4.49) than in the control group (5.1 ± 1.4; 95% CI, 4.24-5.90; P = .02). There were no differences after 6 months in questionnaire and isokinetic testing results comparing both groups.

CONCLUSION

We showed that PRP had a positive effect on patellar tendon harvest site healing on MRI after 6 months and also reduced pain in the immediate postoperative period. Questionnaire and isokinetic testing results were not different between the groups at 6 months.

Comparison of hemostatic matrix and standard hemostasis in patients undergoing primary TKA

Bleeding after total knee arthroplasty increases the risk of pain, delayed rehabilitation, blood transfusion, and transfusion-associated complications. The authors compared pre- and postoperative decreases in hemoglobin as a surrogate for blood loss in consecutive patients treated at a single institution by the same surgeon (J.L.C.) using conventional hemostatic methods (electrocautery, suturing, or manual compression) or a gelatin and thrombin-based hemostatic matrix during total knee arthroplasty. Data were collected retrospectively by chart review. The population comprised 165 controls and 184 patients treated with hemostatic matrix. Median age was 66 years (range, 28-89 years); 66% were women. The arithmetic mean ± SD for the maximal postoperative decrease in hemoglobin was 3.18 ± 0.94 g/dL for controls and 2.19 ± 0.83 g/dL for the hemostatic matrix group. Least squares means estimates of the group difference (controls-hemostatic matrix) in the maximal decrease in hemoglobin was 0.96 g/dL (95% confidence interval, 0.77-1.14 mg/dL; P<.0001). Statistically significant covariate effects were observed for preoperative hemoglobin level (P<.0001) and body mass index (P=.0029). Transfusions were infrequent in both groups. The frequency of acceptable range of motion was high (control, 88%; hemostatic matrix, 84%). In both groups, overall mean tourniquet time was approximately 1 hour, and the most common length of stay was 3 to 5 days. No serious complications related to the hemostatic agent were observed. These data demonstrate that the use of a flowable hemostatic matrix results in less reduction in hemoglobin than the use of conventional hemostatic methods in patient undergoing total knee arthroplasty.

Proliferation and differentiation of human tenocytes in response to platelet rich plasma: an in vitro and in vivo study

Platelet rich plasma (PRP) is the autologous plasma fraction with a platelet-rich cellular component which is enriched with a number of growth factors. Due to its availability and low cost, PRP has become an increasingly popular clinical tool as an alternative source of growth factors for various applications, for example, tendon regeneration but with limited success in clinical trials. The main objective of the current study was to determine whether activated PRP [i.e., platelet rich plasma-clot release (PRCR)] could be used to induce the proliferation and collagen synthesis in human tenocyte in vitro. The advantage of using PRCR is that the platelet-derived bioactive factors are more concentrated and could initiate a more rapid and accelerated healing response than PRP. Our results demonstrated that 10% PRCR treatment accelerated the extent of cell proliferation and collagen production by human tenocytes in vitro. The expression of specific tenocyte markers were similar to conventional fetal bovine serum (FBS)-treated tenocytes implanted in mice within 14 days of implantation in diffusion chambers. Moreover, relatively more collagen fibrils were evident in PRCR-treated tenocytes in vivo as compared to 10% FBS-treated cells. Overall, our feasibility study has indicated that PRCR can induce human tenocyte proliferation and collagen synthesis which could be implemented for future tendon regeneration in reconstructive surgeries.

The effect of platelet-rich plasma on normal soft tissues in the rabbit

BACKGROUND

Platelet-rich plasma is reported to contain multiple growth factors, and has been utilized in orthopaedic surgery to aid healing in multiple tissues. To date, the use of autologous platelet-rich plasma has not been studied for its effects on normal soft tissue.

METHODS

Eighteen adult New Zealand White rabbits were injected with 0.5 mL of autologous platelet-rich plasma in the right or left quadriceps muscle, Achilles tendon, medial collateral ligament, subcutaneous tissue, tibial periosteum, and ankle joint. Saline solution was injected on the contralateral side as a control. The soft tissues were examined histologically at two weeks (six rabbits) and six weeks (six rabbits), and soft tissues from six rabbits that had been reinjected at six weeks were examined at twelve weeks.

RESULTS

Inflammatory skin lesions were visible at forty-eight hours at superficial platelet-rich plasma sites. All lesions resolved by six days. Compared with findings in control specimens, histological analysis of platelet-rich plasma injection sites at two weeks showed a marked inflammatory infiltrate with lymphocytic and monocytic predominance. Intra-articular injection showed villous synovial hyperplasia and chronic synovitis. Tendon and ligament sites showed new collagen deposition. Intramuscular injection sites showed thrombosis, necrosis, and calcium deposition. Subcutaneous sites also showed calcium deposition without necrosis as well as collagen nodules representing early scar tissue. Histological examination of platelet-rich plasma injection sites at six and twelve weeks demonstrated a persistent but diminished inflammatory infiltrate. Focal areas of scar tissue were seen with fibroblasts, collagen formation, and neovascularity. All saline solution sites at all times were nonreactive.

CONCLUSIONS

Platelet-rich plasma can initiate an inflammatory response in the absence of an inciting injury in normal soft tissue in rabbits.

Prospective randomized evaluation of a collagen/thrombin and autologous platelet hemostatic agent during total knee arthroplasty

The purpose of this study was to evaluate the effectiveness of a collagen/thrombin and autologous platelet hemostatic agent in preventing blood loss during primary total knee arthroplasty. This prospective, double-blinded, randomized study was designed to enroll a total of 100 patients. Patients were randomized 1:1 to either the treatment arm (standard hemostasis plus study product) or the control arm (standard hemostasis alone). Transfusion requirements, as determined by a blinded investigator using standardized criteria, were significantly lower in the treatment group (no blood transfusions) compared with the control group (5 transfusions; P = .007). These data support the addition of the study product to prevent blood transfusions after primary total knee arthroplasty.

Platelet gel in oral and maxillofacial surgery: a single-centre experience

BACKGROUND

Platelet gel is a blood product intended for non-transfusion, therapeutic purposes; it is produced by combining platelet concentrate with cryoprecipitate. Platelet gel stimulates tissue growth and is a key player in tissue regeneration. As an allogeneic product, platelet gel is obtained from the blood of a common type O blood donor, with a platelet count >200×10(3)/μL. Most of the beneficial effects of this product are due to the numerous growth factors (PDGF, TGF-β, IGF-1 and IGF-2, EGF, VEGF and FGF) contained in the alpha-granules of platelets. The aim of this study was to confirm that platelet gel is a valuable aid for the surgical repair of alveolar bone loss.

MATERIALS AND METHODS

Our study was carried out on 87 patients with inflammatory or dysembryoplastic osteolytic lesions >2 cm in diameter in jaw bones. For most patients the platelet gel was collected into a 450 mL bag and kept frozen at -40 °C until, whereas for a small group of patients the gel was prepared and activated in the sterile field of the operating theatre.

RESULTS

All of our patients reported a decrease in painful symptoms immediately after surgery. Follow-up showed considerable acceleration of the healing processes in soft tissues and faster bone regeneration.

CONCLUSION

Multicentre studies are needed in order to standardise the methods for producing platelet gel and the clinical use of this product. Furthermore, for research purposes in vitro studies are needed to increase knowledge on the functional network and platelet growth factors and also to investigate the biochemical and molecular mechanisms involved.

Platelet-rich plasma does not reduce blood loss or pain or improve range of motion after TKA

BACKGROUND

Numerous reports suggest the application of platelet-rich plasma (PRP) during TKA may decrease postoperative bleeding. Because excessive bleeding can increase postoperative pain and inflammation, use of PRP also reportedly decreases the need for narcotics and increases speed of recovery after TKA. Because previous investigations of PRP and TKA reflect a weak level of medical evidence, we sought to confirm these findings.

QUESTIONS/PURPOSES

We asked whether an intraoperative application of PRP gel to the deep wound reduced postoperative bleeding after TKA.

METHODS

We retrospectively reviewed the charts of all 134 patients who received an intraoperative application of PRP during TKA from November 2009 to April 2010 and all 139 patients undergoing TKA who did not receive PRP between September 2009 to November 2009. Patients' charts were reviewed to identify detailed data, including hemoglobin level, ROM, postoperative narcotic use, and length of hospital stay. Blood loss was determined by the hemoglobin drop on postoperative Day 2.

RESULTS

The blood loss between study groups was similar (3.6 g/dL [study] versus 3.8 g/dL [controls]). Differences in passive ROM (88° versus 88°), narcotic requirement (27 versus 32 morphine equivalent), and length of stay (2.4 versus 2.6 days) were also similar.

CONCLUSION

We found no clinically important differences in patients who received an intraoperative application of PRP compared with patients who did not receive PRP and therefore could not confirm the findings of previous studies.

Use of platelet rich plasma gel on wound healing: a systematic review and meta-analysis

OBJECTIVE

Autologous platelet rich plasma is an advanced wound therapy used in hard-to-heal acute and chronic wounds. To better understand the use and clinical outcomes of the therapy, a systematic review of the published literature in cutaneous wounds was performed.

METHODS

Electronic and hand searches for randomized controlled trials and comparative group studies using platelet rich plasma therapy in cutaneous wounds and published over the last 10 years was conducted. Eligible studies compared the treatment to standard care or other interventions. All citations were screened and eligible studies were assessed for validity, quality, and bias using accepted scoring methods. The primary outcomes were effect of platelet rich plasma and control wound care on wound healing and related healing measurements. Secondary outcomes related to healing such as infection, pain, exudate, adverse events, and quality of life were also considered. The meta-analysis utilized appropriate statistical methods to determine the overall treatment effect on chronic and acute wound healing and infection.

RESULTS

The search terms resulted in 8577 citations and after removing duplicates and screening for protocol eligibility, a total of 24 papers were used. The meta-analysis of chronic wound studies revealed platelet rich plasma therapy is significantly favored for complete healing. The meta-analysis of acute wounds with primary closure studies demonstrated that presence of infection was reduced in platelet rich plasma treated wounds.

CONCLUSIONS

This systematic review and meta-analysis of platelet rich plasma therapy in cutaneous wounds showed complete and partial wound healing was improved compared to control wound care.

Injection of platelet-rich plasma in patients with primary and secondary knee osteoarthritis: a pilot study

OBJECTIVE

To evaluate the clinical effects of intraarticular platelet-rich plasma (PRP) injections in a small group of patients with primary and secondary osteoarthritis. Most of the current treatments for osteoarthritis are palliative and attack the symptoms rather than influencing the biochemical environment of the joint. Autologous platelet-rich plasma has emerged as a treatment option for tendinopathies and chronic wounds. In addition to release of growth factors, platelet-rich plasma also promotes concentrated anti-inflammatory signals including interleukin-1ra, which has been a focus of emerging treatments for osteoarthritis.

DESIGN

In this single-center, uncontrolled, prospective preliminary study, 14 patients with primary and secondary knee osteoarthritis who met the study criteria received three platelet-rich plasma injections in the affected knee at ∼4-wk intervals. Outcome measures included the Brittberg-Peterson Visual Pain (Visual Analog Scale [VAS]), Activities, and Expectations score and the Knee Injury and Osteoarthritis Outcome Scores at preinjection visit at 2-, 5-, 11-, 18-, and 52-wk follow-up visits. Musculoskeletal ultrasound was used to measure cartilage thickness.

RESULTS

There were no adverse events reported. The study demonstrated significant and almost linear improvements in Knee Injury and Osteoarthritis Outcome Scores, including pain and symptom relief. Brittberg-Peterson VAS showed many improvements including reduced pain after knee movement and at rest. Cartilage assessment was limited because of the small sample size. The majority of the patients expressed a favorable outcome at 12 mos after treatment.

CONCLUSIONS

The positive trends and safety profile demonstrated could potentially be used to inspire a larger, blinded, and randomized clinical trial to determine whether platelet-rich plasma is safe and effective for the treatment of knee osteoarthritis.

Platelet-rich plasma (PRP) to treat sports injuries: evidence to support its use

Tissue repair in musculoskeletal lesions is often a slow and sometimes incomplete process. In sports patients or professional athletes, the impact of musculoskeletal lesions on life and work is great, and the fast recovery of full efficiency and return to competition is of primary importance. The clinical improvement offered by available treatments is not always sufficient for highly demanding patients to return to their previous level of activity. The search for a minimally invasive solution to improve the status of the chondral surface of the injured joint is therefore highly desirable, especially in these patients. Platelet-rich plasma (PRP) is a procedure that allows to obtain a natural concentration of autologous growth factors. The attractive possibility to use the patients' own growth factors to enhance reparative process in tissues with low healing potential, the promising preliminary clinical findings and the safety of these methods, explain the wide application of this biological approach. The aim of this review is to analyse the existing published studies to look for scientific evidence in preclinical studies or in the results obtained through PRP application in humans that supports the efficacy of PRP and its use for the treatment of tendinous, ligamentous, cartilaginous and muscular injuries. The analysis of the literature shows promising preclinical results but contradictory clinical findings for the treatment of sport injuries. High-quality studies are required to confirm these preliminary results and provide scientific evidence to support its use.

Platelet concentrate vs. saline in a rat patellar tendon healing model

PURPOSE

To evaluate single centrifuge platelet concentrate as additive for improved tendon healing. Platelet-rich plasma has been reported to improve tendon healing. Single centrifuge platelet concentration may increase platelet concentration enough to positively affect tendon healing. A single centrifuge process will lead to a blood product with increased platelet concentrations which, when added to a surgically created tendon injury, will improve tendon healing when compared with a saline control.

METHODS

Lewis rats had a surgical transection of the patellar tendon that was subsequently stabilized with a cerclage suture. Prior to skin closure, the tendon was saturated with either a concentrated platelet solution or saline. At 14 days, all animals were killed, and the extensor mechanism was isolated for testing. Biomechanical testing outputs included ultimate tensile load, stiffness, and energy absorbed.

RESULTS

Comparisons between the control group and the concentrated platelet group revealed no differences. A subgroup of the concentrated platelet group consisting of specimens in whom the concentration process was most successful showed significantly higher ultimate tensile load (P < 0.05) and energy absorbed to failure (P < 0.05) when compared to the control group.

CONCLUSION

When successful, single centrifuge platelet concentration yields a solution that improves tendon healing when compared with a saline control. Single-spin platelet concentration may yield a biologically active additive that may improve tendon healing, but more studies must be undertaken to ensure that adequate platelet concentration is possible.

Avaliação da perda sanguínea na artroplastia total do joelho com e sem soltura do torniquete

OBJETIVO: Avaliar a perda sanguínea em pacientes submetidos à artroplastia total cimentada do joelho com e sem soltura trans-operatória do torniquete pneumático para a hemostasia. MÉTODOS: Foram estudados 72 pacientes submetidos à artroplastia total, num total de 80 joelhos, divididos em dois grupos: Grupo 1 onde se manteve o torniquete pneumático até a sutura e curativo da ferida operatória, e Grupo 2 onde foi realizada a soltura do torniquete pneumático após a cimentação da prótese, com realização de hemostasia direta, antes da sutura e curativo. Os pacientes foram avaliados quanto ao sangramento pelo dreno de sucção e à contagem de hemoglobina e hematócrito, considerando os intervalos de duas, 24 e 48 horas de pós-operatório. RESULTADOS: Não houve diferença significante entre os dois grupos quanto ao sangramento pós-operatório e decréscimo dos parâmetros hematimétricos. Somente um paciente do Grupo 2 necessitou transfusão de concentrado de hemáceas no pós-operatório. CONCLUSÃO: O sangramento pós-operatório na ATJ mostrou-se igual com e sem a soltura do torniquete pneumático para a realização da hemostasia.

Autologous platelet gel in total knee arthroplasty: a prospective randomized study

PURPOSE

Total knee arthroplasty (TKA) is often associated with major postoperative blood loss, postoperative pain, and impaired wound healing. The application of autologous platelet gel (APG), prepared from the buffy coat of a unit of autologous blood, has been advocated to improve haemostasis after surgery, to decrease perioperative blood loss, diminish postoperative pain and to enhance the wound healing process. This randomized controlled pilot study was developed to assess the effects of APG after total knee arthroplasty on blood loss, wound healing, pain, range of motion, and hospital stay.

METHOD

A prospective, randomized observer blind controlled trial was performed. Forty patients with only osteoarthritis of the knee were scheduled to have a TKA, and they were randomized into two groups. Patients in the treatment group were all treated with the application of autologous platelet gel after the prosthesis was implanted. Patients in the control group were treated with the same protocol but no APG was used.

RESULTS

Preoperative and postoperative Hb levels showed no significant difference and allogenic blood transfusions were not given in either group. Haematomas were significantly larger in the control group than in the platelet gel group (P = 0.03). The pain score at rest was higher in the control group on the 3rd day (P = 0.04). Wound healing disturbances were seen in four patients in the control group and in no patients in the APG group (n.s.). Range of motion of the knee was similar postoperatively. Hospital stay was 6.2 days in the APG and 7.5 days in the control group (n.s.).

CONCLUSION

In this prospective randomized pilot study on APG in total knee arthroplasty, differences in favour of the use of platelet gel were found, but these were subjective evaluations, marginal in effect, or did not reach statistical significance. The use of drains might have decreased the concentration of delivered platelets and may have diminished the effect. However, in this study, a statistically significant clinically important effect in favour of platelet gel application was not found. Further studies with larger numbers of patients, and without the use of drains, are warranted to investigate the possible benefits of autologous platelet gel in total knee arthroplasty.

The use of fibrin glue in surgery of the knee

Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.

Magnetic resonance imaging evaluation of the integration and maturation of semitendinosus-gracilis graft in anterior cruciate ligament reconstruction using autologous platelet concentrate

PURPOSE

To evaluate integration and maturation of semitendinosus-gracilis (STG) grafts in anterior cruciate ligament (ACL) reconstruction with magnetic resonance imaging (MRI) in patients who underwent ACL reconstruction with STG with and without autologous platelet concentrate (APC).

METHODS

A randomized single-blinded evaluator prospective study was performed in 2 consecutive series of patients who underwent reconstruction over a 14-month period: 30 with APC use (group A) and 20 as control subjects (group B). At 6 months, an MRI evaluation was performed, with observation of the graft's maturation and presence or absence of synovial fluid at the tunnel-graft interface. To facilitate interpretation, a scoring scale was designed to evaluate graft integration and maturation.

RESULTS

Regarding the presence of synovial fluid at the bone-graft interface, the test was negative in 86.84% of patients in group A and 94.74% in group B. A disorganized autograft signal pattern was found in 2.63% in group A and 5.26% in group B. Signal intensity was considered hypointense in 63.16% in group A and 42.11% in group B, isointense in 34.21% in group A and 52.63% in group B, and hyperintense in 0% in both groups. The final mean score was 4.45 points in group A and 4.2 points in group B (P ≥ .05). Poor integration was found in 2.63% in group A and 5.26% in group B (P = .214). Good integration was found in 97.37% in group A and 94.74% in group B (P = .784).

CONCLUSIONS

In our consecutive series of patients who underwent ACL reconstruction with STG grafts, 1 group with intraoperative APC use versus a control group, followed up by MRI at 6 months after reconstruction, we did not find any statistically significant benefit in the APC group in terms of integration assessment and graft maturation (ligamentization).

LEVEL OF EVIDENCE

Level III, case-control study.

Platelet rich plasma injection grafts for musculoskeletal injuries: a review

In Europe and the United States, there is an increasing prevalence of the use of autologous blood products to facilitate healing in a variety of applications. Recently, we have learned more about specific growth factors, which play a crucial role in the healing process. With that knowledge there is abundant enthusiasm in the application of concentrated platelets, which release a supra-maximal quantity of these growth factors to stimulate recovery in non-healing injuries. For 20 years, the application of autologous PRP has been safely used and documented in many fields including; orthopedics, sports medicine, dentistry, ENT, neurosurgery, ophthalmology, urology, wound healing, cosmetic, cardiothoracic, and maxillofacial surgery. This article introduces the reader to PRP therapy and reviews the current literature on this emerging treatment modality. In summary, PRP provides a promising alternative to surgery by promoting safe and natural healing. However, there are few controlled trials, and mostly anecdotal or case reports. Additionally the sample sizes are frequently small, limiting the generalization of the findings. Recently, there is emerging literature on the beneficial effects of PRP for chronic non-healing tendon injuries including lateral epicondylitis and plantar fasciitis and cartilage degeneration (Mishra and Pavelko, The American Journal of Sports Medicine 10(10):1–5, 2006; Barrett and Erredge, Podiatry Today 17:37–42, 2004). However, as clinical use increases, more controlled studies are needed to further understand this treatment.

Dutch orthopedic blood management surveys 2002 and 2007: an increasing use of blood-saving measures

BACKGROUND

Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. The surveys were developed to assess the use of blood-saving measures in orthopedic surgery in the Netherlands in 2002 and 2007.

STUDY DESIGN AND METHODS

In 2002 and 2007, a questionnaire on blood management measures after several orthopedic procedures was sent to all Dutch orthopedic departments (110 and 96, respectively).

RESULTS

The response was 79% in 2002 and 84% in 2007. The use of preoperative autologous blood donation remained virtually unchanged in 2002 versus 2007 for both hip (10.9 and 10.5%) and knee (5.7 and 8.2%) arthroplasty. In 2007, there was a substantial increase in departments using erythropoietine for hip (31.6–66.1%) as well as knee (24.0–55.5%) arthroplasty. There was an increase of the use of autologous retransfusion of intraoperatively suctioned washed blood in hip (20.3–28.4%) as well as knee arthroplasty (8.9–16.1%) over the 5-year period, but it was predominantly used in revision hip arthroplasty (54.3%). The use of postoperative autologous retransfusion of filtered drained wound blood increased dramatically in 5 years time in hip (11.5–51.0%) and knee arthroplasty (15.9–59.3%).

CONCLUSION

There is an evident increase in the preoperative use of erythropoietin and the postoperative use of autologous retransfusion of drained blood among Dutch orthopedic departments. There appears to be an increasing awareness and positive attitude among Dutch orthopedic surgeons to implement perioperative blood-saving measures.

The role of fibrin sealants in orthopaedic surgery

Blood conservation, specifically the avoidance of allogeneic blood transfusion, is becoming an important aspect of preoperative planning and intraoperative decision making in orthopaedic surgery. Knee and hip arthroplasty, as well as certain spine procedures, place patients at risk of significant blood loss. Fibrin sealants are topically applied hemostatic agents that reduce the time required to achieve hemostasis as well as the volume of blood loss. Fibrin sealants may provide additional benefits beyond hemostasis, such as improvements in wound healing and postoperative range of motion as well as lower rates of wound infections.

Buffered platelet-rich plasma enhances mesenchymal stem cell proliferation and chondrogenic differentiation

The success of tissue engineering applications can potentially be dramatically improved with the addition of adjuncts that increase the proliferation and differentiation of progenitor or stem cells. Platelet-rich plasma (PRP) has recently emerged as a potential biologic tool to treat acute and chronic tendon disorders. The regenerative potential of PRP is based on the release of growth factors that occurs with platelet rupture. Its autologous nature gives it a significant advantage in tissue engineering applications. To test whether PRP may be useful specifically for cartilage regeneration, a cell culture experiment was devised in which mesenchymal stem cells (MSCs) were grown in control media or media enhanced with inactivated, buffered PRP. Proliferation 7 days after PRP treatment was increased: 1.041 versus 0.199 for the control media cells ( p<0.001). The messenger RNA (mRNA) level of the osteogenic marker RUNX2 was 52.84 versus 26.88 for the control group ( p<0.005). Likewise the mRNA level of the chondrogenic markers Sox-9 and aggrecan was 29.74 versus 2.29 for the control group ( p<0.001) and 21.04 versus 1.93 ( p<0.001), respectively. These results confirm that PRP enhances MSC proliferation and suggest that PRP causes chondrogenic differentiation of MSC in vitro.

Platelet-rich plasma: from basic science to clinical applications

Platelet-rich plasma (PRP) has been utilized in surgery for 2 decades; there has been a recent interest in the use of PRP for the treatment of sports-related injuries. PRP contains growth factors and bioactive proteins that influence the healing of tendon, ligament, muscle, and bone. This article examines the basic science of PRP, and it describes the current clinical applications in sports medicine. This study reviews and evaluates the human studies that have been published in the orthopaedic surgery and sports medicine literature. The use of PRP in amateur and professional sports is reviewed, and the regulation of PRP by antidoping agencies is discussed.

No positive effect of autologous platelet gel after total knee arthroplasty

BACKGROUND AND PURPOSE

Activated platelets release a cocktail of growth factors, some of which are thought to stimulate repair. We investigated whether the use of autologous platelet gel (PG) in total knee arthroplasty (TKA) would improve wound healing and knee function, and reduce blood loss and the use of analgesics.

PATIENTS AND METHODS

102 patients undergoing TKA were randomly assigned to a PG group (n = 50) or to a control (C) group (n = 52). The primary analysis was based on 73 participants (PG: 32; C: 41) with comparison of postoperative wound scores, VAS, WOMAC, knee function, use of analgesics, and the pre- and postoperative hemoglobin values after a follow-up of 3 months. 29 participants were excluded due to insufficient data.

RESULTS

The characteristics of the protocol-compliant patients were similar to those of the patients who were excluded. Analysis was per protocol and focused on the remaining 73 patients. At baseline and after 3 months of follow-up, there were no statistically significant differences between both groups regarding age, height, weight, sex, side of operation, platelet count, hemoglobin values, severity of complaints (WOMAC), and level of pain.

INTERPRETATION

In our patients undergoing TKA, application of PG to the wound site did not promote wound healing. Also, we found that PG had no effect on pain, knee function, or hemoglobin values.

The biology of platelet-rich plasma and its application in trauma and orthopaedic surgery: a review of the literature

Although mechanical stabilisation has been a hallmark of orthopaedic surgical management, orthobiologics are now playing an increasing role. Platelet-rich plasma (PRP) is a volume of plasma fraction of autologous blood having platelet concentrations above baseline. The platelet alpha granules are rich in growth factors that play an essential role in tissue healing, such as transforming growth factor-beta, vascular endothelial growth factor, and platelet-derived growth factor. PRP is used in various surgical fields to enhance bone and soft-tissue healing by placing supraphysiological concentrations of autologous platelets at the site of tissue damage. The easily obtainable PRP and its possible beneficial outcome hold promise for new regenerative treatment approaches. The aim of this literature review was to describe the bioactivities of PRP, to elucidate the different techniques for PRP preparation, to review animal and human studies, to evaluate the evidence regarding the use of PRP in trauma and orthopaedic surgery, to clarify risks, and to provide guidance for future research.

Platelet rich concentrate: basic science and current clinical applications

Improvements in resuscitation, dissemination of ATLS protocols, and growth of regional and local trauma centers has increased the survivability after severe traumatic injuries. Furthermore, advances in medical management have increased life expectancy and also patients with orthopaedic injuries. While mechanical stabilization has been a hallmark of orthopaedic fracture care, orthobiologics are playing an increasing role in the management of these patients with complex injuries. Platelet-rich concentrate is an autologous concentration of platelets and growth factors, including transforming growth factor-beta (TGF-beta), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF). The enhancement of bone and soft tissue healing by the placement of supraphysiologic concentration of autologous platelets at the site of tissue injury or surgery is supported by basic science and clinical studies. Due to the increased concentration and release of these factors, platelet-rich plasma can potentially enhance the recruitment and proliferation of tenocytes, stem cells, and endothelial cells. A better understanding of platelet function and appropriate clinical use is essential in achieving the desired outcomes of platelet-rich concentrate in orthopaedic clinical applications.

Antimicrobial activity of platelet-leukocyte gel against Staphylococcus aureus

Platelet-leukocyte gel (PLG) contains high concentrations of platelets and leukocytes. As leukocytes play an important role in the innate host-defense, we hypothesized that PLG might have antimicrobial properties. This study investigated the antimicrobial activity of PLG against Staphylococcus aureus and the contribution of myeloperoxidase (MPO), present in leukocytes, in this process. Platelet-rich plasma (PRP) and platelet-poor plasma (PPP) were obtained from whole blood of six donors. PLG was prepared by mixing PRP with autologous (PLG-AT) or bovine thrombin (PLG-BT). Antimicrobial activity of PLG-AT, PLG-BT, PRP, and PPP was determined in a bacterial kill assay. MPO release was measured by ELISA and activity was measured using a MPO activity assay. Cultures showed a rapid decrease in the number of bacteria for both PLG-AT and PLG-BT, which was maximal between 4 and 8 h, to approximately 1% of the bacteria in controls. The effect of PLG-AT was largest and significantly different compared to PRP (p = 0.004) and PPP (p < 0.001), however not compared to PLG-BT (p = 0.093). PLG-AT, PLG-BT, and PRP showed a comparable, gradually increasing MPO release. MPO activity was comparable for all groups and remained stable. No correlation between MPO release, activity, and bacterial kill could be found. PLG appears to have potent antimicrobial capacity, but the role of MPO in this activity is questionable. PLG might represent a useful strategy against postoperative infections. However, additional research should elucidate its exact antimicrobial activity.

Autologous platelet gel and fibrin sealant enhance the efficacy of total knee arthroplasty: improved range of motion, decreased length of stay and a reduced incidence of arthrofibrosis

In this study we describe the potential role of autologous platelet gel and fibrin sealant in unilateral total knee arthroplasty to improve the postoperative range of motion and to reduce the incidence of arthrofibrosis. Total knee arthroplasty is often associated with a considerable amount of post-operative blood loss. Persistent limited motion directly after surgery may ultimately result in arthrofibrosis. To counteract these effects we investigated whether the use of autologous derived platelet gel and fibrin sealant would reduce postoperative blood loss, decrease the impaired range of motion and the incidence of arthrofibrosis. All patients were consecutively operated and assigned to the study or control groups. Study group patients (n = 85) were treated with the application of autologous platelet gel and fibrin sealant at the end of surgery. Eighty patients were operated without the use of platelet gel and fibrin sealant, and served as the control group. The postoperative hemoglobin decrease, range of motion and length of hospitalization were recorded. During a 5-month postoperative period patients were followed to observe the incidence of arthrofibrosis. In patients in the treatment group the hemoglobin concentration in blood decreased significantly less when compared to the control group. They also showed a superior postoperative range of motion when compared to those of the control group (P < 0.001). The incidence of arthrofibrosis and subsequent forced manipulation was significantly less (P < 0.001) in patients managed with platelet gel and fibrin sealant. We conclude that peri-operatively applied platelet gel and fibrin sealant may improve the range of motion after total knee arthroplasty, decreases the length of stay and may reduce the incidence of arthrofibrosis.

Autologous platelet gel in coronary artery bypass grafting: effects on surgical wound healing

Stimulating the body's natural healing at the cellular level can be achieved through the application of growth factors located within platelets. Once combined with a mixture of calcium and thrombin, this substance, now referred to as autologous platelet gel (APG), can be applied to surgical wound sites for patients undergoing cardiac surgery. The purpose of this study was to examine the effects of APG on surgical site infection, post-operative pain, blood loss, and bruising. After 30 mL platelet-rich plasma (PRP) was processed, 10 mL PRP was distributed on the sternum after re-approximation and 7 mL PRP before skin closure. Ten milliliters PRP was used on the endoscopic leg harvest (EVH) site. The remaining 3 mL was sent to the laboratory for hematologic testing. Both the control (CTR) and treatment (TRT) groups were well matched, with the exception of ejection fraction and pre-operative platelet count, which was significantly higher in the TRT group. Average platelet count yield was 4.2 +/- 0.5 x 103/mcL, white blood count (WBC) yielded 1.9 +/- 0.7 x 103/mcL, and fibrinogen yielded 1.2 +/- 0.2 mg/dL above baseline. There were no deep or superficial sternal infections. However, one patient from each group did experience a leg infection at the EVH site, which occurred after hospital discharge. More patients in the TRT group experienced less pain on postoperative day (POD) 1 and at the post-operative office follow-up. Blood loss and bruising was less in the TRT group on POD 2; however, there was no statistical significance. The application of APG seems to confer beneficial effects on pain, blood loss, and bruising. However, further studies with a greater sample size are needed to power significant differences.