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therapeutic efficacy of PRP: analysis of its cellular composition and literature review

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Therapeutic efficacy of autologous conditioned plasma (ACP TM): analysis of its cellular composition and literature review

Y. Bohu, Klouche S., N. Lefevre, S. Herman, P. Hardy  

summary

Introduction. - The injection of platelet concentrates, platelet rich plasma, or PRP, in the injured tissue has become widespread in recent years, especially in sports traumatic pathology. There is no consensus on the optimal concentration but a value between 200,000 and 1,000,000 ? L appears have a therapeutic effect. The autologous conditioned plasma (ACP TM) is a fast PRP to prepare but its average concentration of platelets is significantly lower compared to other PRP. The main purpose of the study was to analyze the platelet concentration of the ACP TM in a group of patients and compare it to that of whole blood in the same subjects. The secondary objective was to take stock of the interests of the ACPTM through a literature review.  

Patients and methods. - A prospective study conducted in 2011 included a consecutive series of patients with chronic tendinopathy resistant to standard treatments and for which an injection was scheduled ACP TM. Three samples of venous blood, with a volume of 9? L each were performed in each patient: one for analysis of blood count, the second and third for the preparation of two doses of ACP TM, one was injected into the patient and the other subjected to analysis biological. The parameters analyzed were, in whole blood, the level of hematocrit and platelet concentration, and in the ACP TM, Platelet concentration, the number of red blood cells and white blood cells. A literature search was conducted in PubMed using autologous conditioned plasma keywords. All studies, both experimental and clinical, in English or Translation, have been included.

Results. - The series included 14patients mean age 39 ┬▒ 14 years, all male. The mean platelet concentration in the whole blood was 230 ┬▒ 538.5 23 663 ? L (min: 192 000 max: 267 000). The mean platelet concentration in the ACP TM was 377 ┬▒ 69 153.8 169.9 ? L (min: 291 000, max: 511 000). The platelet concentration in the ACP TM was significantly higher than that of whole blood, (p= 0.00015). The average ratio "platelet concentration ACP TM / platelet concentration whole blood" was 1.64 ┬▒ 0.30. The number of red blood cells and white blood cells was below the detection threshold. The systematic review identified eight studies: three in animals, five humans.

Discussion. - The literature review conducted showed that in the present state of knowledge, it was not possible to conclude on the clinical relevance of the CPATM.

Conclusion. - The preparation technique of the ACP TM was quick and easy to use, both in consultation block. The CPA TM had a significantly higher platelet concentration than that of whole blood and contained no white blood cells, or red blood cells. The literature review has not concluded on the therapeutic effectiveness of CPATM. Randomized clinical comparative studies versus placebo are needed.

 

Abstract

Purpose. - To analyze the platelet counts of autologous conditioned plasma (ACP TM) In a group of patients Compared To That of whole blood and to determine the value of ACP TM based on a literature review. Methods. - In 2011, prospective study Was Performed in a continuous series of patients presenting with chronic tendinopathy. Three 9 ? The venous blood samples Were therefor obtained from Each patient: the first to perform a full blood count and the second and third to prepare two doses of ACP TM, One qui Was injected into the patient and l'autre qui underwent biological testing. A bibliographic search Was Performed on PubMed with the key words "autologous conditioned plasma". All studies Both clinical and experimental, in English and in French, Were included.

Results. - The series included 14 male patients mean age 39 ┬▒ 14 years. The mean platelet count Was 230,538.5 ┬▒ 23.663 ? L in whole blood and 377,153.8 69,169.9 ┬▒? L in ACP TM, P = 0.00015. The mean "ACP TM platelet count / whole blood platelet count" Was ratio 1.64 ┬▒ 0.30. The number of red and white blood cells below the detection Was Thresholds. The systematic review APPROBATION eight studies: three in five animals and in human clinical studies of two qui.

Conclusion. - The technical preparation for ACP TM Was rapid and easy to use. ACP TM Had a platelet count That Was Significantly Higher Than That of whole blood and Did not contenir Any red or white blood cells. The review of the literature Clearly Did not confirm the therapeutic efficacy of ACP TM. Randomized clinical studies Comparing ACP TM to placebo are needed.

Level of evidence. - IV.

 

1. Introduction

The role of platelets is crucial during the early inflammatory phase of healing. Their primary role is mechanical as they can limit the bleeding through the formation of a lesion hematoma. Once activated, platelets release, in situ, several active molecules including growth factors (PDGF, insulinlike growth factor-1[IGF-1], TGF ????, vascular endothelial growth factor [VEGF], basic fibroblast growth factor [bFGF]. . .) Contained in ???? granules and which cause proliferation of fibroblasts secondarily promoting tissue healing [1].

The injection of platelet concentrates, platelet rich plasma, or PRP, in the injured tissue has become widespread in recent years, especially in sports traumatic pathology. PRP is a generic term for all autologous plasma samples having platelet concentrations than whole blood. There is no consensus on the optimal concentration but a value between 200 000 and 1 000 000? L seems to have a therapeutic effect. [2]

Several studies have shown that the composition of PRP differed on one hand, according to the methods of manufacture and, second, from one subject to another and in the same subject as the days [3-5] . Kaux et al. [6] compared five technologies platelet concentrations: one used by the biological hematology department of the University Hospital of Li├Ęge (Belgium), PRP Kit ┬« Curasan(Germany), that of Plateltex ┬« (Slovakia), GPS ┬« II Biomet ┬« system (Warsaw, Indiana) and the technique described by RegenLab ┬«(Swiss). This study concluded that the superiority of Plateltex ┬« technique for obtaining the highest platelet concentration in the lowest volume available with a number of red blood cells (RBC) and white blood cells (GB) significantly lower than the whole blood.

The PRP is made ??from autologous anticoagulated collected in a heparinized tube, with added citrate. Usually a first centrifugation is performed to isolate the plasma supernatant, also called platelet-poor plasma (PPP) by analogy with the label PRP. A second centrifugation is performed to concentrate and to isolate the PRI PPP [1]. The average preparation time is 45 minutes. Arthrex (Naples, USA) has developed a simple technique of direct manual aspiration after a single centrifugation, inexpensive and quick, to obtain the autologous conditioned plasma(ACP TM). However, several studies [3-5] showed that the average concentration of platelets in the ACP TM was significantly lower compared to other PRP. Furthermore, a recent study [7] prospective, comparative, evaluated in 49 patients undergoing repair of the rotator cuff of the shoulder, with or without an injection of ACP TMin situ, the healing rates at six months tendon on MR arthrography. No significant differences were noted between the two groups.

Two questions arise: qu'injecte are we really to patients? What is to be inferred on the therapeutic efficacy of ACP TM? The main purpose of the study was to analyze the platelet concentration of the ACP TMin a group of patients and compare it to that of whole blood in the same subjects. The secondary objective was to take stock of the interests of the ACP TM through a literature review.

2. Patients and methods

A prospective study conducted in 2011, included a continuous series of patients with chronic tendinopathy resistant to standard treatments and for which an injection ACPTM had been scheduled. The patients were informed and gave their consent.

2.1. Preparation technique of the ACP TM

All operations were conducted under stringent aseptic conditions approved by the hospital's health committee. The preparation of the ACPTM has required 9 ? The blood withdrawn from the patient's arm and placed in the double Arthrex syringe containing 1 ? L of dextrose citrate anticoagulant (ACD-A). The double syringe was capped and placed in the centrifuge. She underwent centrifugation for five minutes at 1500 rpm. The plasma supernatant was then visible and drawn into the second syringe.

2.2. bioassays

They were carried out in the same laboratory on an auto analyzer. Three samples of venous blood with a volume of 9 ? L each were taken from each patient: one for analysis of blood count, the second and third for the preparation of two doses of ACPTM, one was injected into the patient and the other subjected to biological analysis. The parameters analyzed were, in whole blood, the hematocrit level and platelet concentration and in the ACP TM, platelet concentration, the number of GR and GB.

2.3. Literature paper

A literature search was conducted in PubMed using autologous conditioned plasma keywords. The last search was effected on 25 March 2013. In addition, in each article, references were checked and potentially includable items in the analysis were searched manually. All the studies, both experimental and clinical, published in English and Translation were included.

2.4. statistical Analyses

Considering the sample size, non-parametric test paired Wilcoxon was used. The significance level was set at 0.05.

3. Results

3.1. Cellular composition of the ACP TM

The series included 14patients mean age 39 ┬▒ 14 years, all male. Five patients had patellar tendinopathy, four calcaneal tendinopathy, three of tennis elbow, and two of a partial rupture of the Achilles tendon. The ACP ProtocolTM was performed in nine cases and in consultation with the block in five patients.

The total time of preparation of the ACP TM varied between ten and 15 minutes. The amount of plasma collected was between 3 and 4.5 cm 3. The mean hematocrit was 45.3 ┬▒ 1.5%. The mean platelet concentration in the whole blood was 230 ┬▒ 538.5 23 663 ? L (min: 192 000 max: 267 000). The mean platelet concentration in the ACP TM was 377 ┬▒ 69 153.8 169.9 ?/ L (min: 291 000, max: 511 000). The platelet concentration in the ACP TM was significantly higher than that of whole blood, p = 0.00015. The average ratio "platelet concentration ACP TM / platelet concentration whole blood" was 1.64 ┬▒ 0.30. The number of GR and GB was below the detection threshold.

3.2. Literature paper

The systematic review identified eight studies: three in animals [8-10] and five humans whose cell study [11], two analytical studies of the cellular composition of the ACP TM [3.4 ] and two clinical studies [12,13].

3.2.1. Animal studies

A veterinary study published in 2010 presented the clinical results in seven riding horses treated for severe tendinopathy by two injections of ACPTM made ??two weeks apart [8]. Platelet concentrations ranged between 115 000 and 173 000 / ? The whole blood and 160 000-197 000 / ? L in ACPTM. The primary endpoint was a questionnaire filled out by the trainer or veterinarian who noted a return to the same level for all the horses to a decline of ten to 13 months.

Stief et al. [9] analyzed in a first group of ten healthy dogs, the composition of the ACP TM prepared according to the same protocol as recommended by the manufacturer in humans, then in a second group of ten dogs by changing the speed and the centrifugation time (700tours / minute for 15 minutes). No difference was found between platelet concentrations of whole blood and CPATM in both groups. However, the ACP TM contained no GR or GB.

The third study was conducted in sheep [10]. A cartilage defect was created on the medial femoral condyle of 30 animals. This defect was then treated with microfracture, either alone or associated with intra-articular five weekly injections of ACPTM. The quality of tissue repair was assessed a macroscopic view that the score International Cartilage Repair Society (ICRS) histological score changed according to O'Driscoll and biomechanics with an electromechanical tester (ARTScan 200). The group that received treatment with ACP TM had significantly better results for all criteria at three, six and 12 months postoperatively.

3.2.2. Human Studies

A study in ten healthy athletes [11] sought an increased systemic levels of various growth factors by test Elisa half an hour, three hours and 24 hours after intramuscular injection of ACP TM. Only a significant increase in TGF-? 2 factor was noted.

Sundman et al. [3] analyzed in 11 healthy volunteers composition PRP obtained by two methods: the ACP TM Arthrex and GPS ® ILT Mini Platelet Concentrate System (PCS) Biomet ®. CPATM had a higher concentration of platelets 1,99fois to that of whole blood versus 4.69 for Biomet ® GB and a rate 0.13 times that of whole blood versus 4.26 for Biomet ®. The WBC count was significantly lower in the ACP TM. PRP Biomet ® was the one with the highest concentration significantly in growth factors. The concentrations of the mediators catabolism (MPP-9 and IL-1 ? ) Were positively correlated to the numbers of neutrophils and monocytes.

Mazzocca et al. [4] analyzed in eight healthy volunteers composition PRP obtained in three ways: CPATM Arthrex, GPS ® ILT PCS Biomet ® (Warsaw, Indiana) and a method of double centrifugation. The mean platelet concentration was significantly lower in the ACP TM378 300 ± 58 640 ± versus 447 700 183 700 for the double centrifugation and 873 800 ± 207 820 for the GPS ® ILT PCS. In this study also, the PRI Biomet ® was the one with the highest concentration significantly in growth factors.

The study of Deans et al. [12] reported the results of a prospective series of 26patients treated with an injection of ACPTM for chronic calcaneal tendinopathy, followed by standard therapy for six weeks. The primary endpoint was the Foot and Ankle Outcome Score (score FAOS) at six weeks of decline. The improvement was significant for all items (pain, other symptoms, daily activities, sports activities and quality of life).

For the second clinical study [13], 120 patients with knee osteoarthritis were randomized into two groups. The treat ment administered consisted of four weekly injections of either ACPTM, or hyaluronic acid. The primary endpoint was the WOMAC score before infiltration, then four, 12 and 24 weeks after the first injection. The clinical results were significantly better in the ACP TM group.

4. Discussion

This study showed that the platelet concentration of the ACPTM was significantly higher than that of whole blood with an average ratio of 1.64. The literature review showed that at present, the ACP TM was insufficiently evaluated.

In this work, the cellular composition of the ACP TMwas comparable to those already published. According to the literature, this concentration remains lower than that of other PRP but studies suggest that hyper-concentrated solutions have a catabolic effect on cartilage [14] or induce healing, certainly accelerated, but fibrotic treated muscle tissue [11,15].

The study also showed that the ACP TM injected contained no GB. Neutrophils are likely to release toxic agents such as my├ęlop├ęroxidases and matrix metalloproteinases (MMP-9), responsible for the degradation of collagen in the extracellular matrix, or cause pathological inflammation by releasing pro-inflammatory cytokines (IL -1b├ęta), which may prevent or delay healing [16-18]. Sundman et al. [3] found that the number of neutrophils PRP was strongly correlated with MMP-9 and IL-1beta and that the ACPTM was the one which contained the least.

The literature review conducted showed that in the present state of knowledge, it was not possible to conclude on the clinical relevance of the ACP TM. Clinical efficacy studies, randomized, comparative, placebo are needed. A search of the international repertoire of clinical studies (www.clinicaltrials.gov) shows that five studies on the ACP TM are currently underway: three randomized placebo compared to the rotator cuff tear (NCT01414764, NCT01170312 and NCT01266226), a prospective observational evaluating the association of an injection ACP TM tendon repair with a patch in the ruptures of the rotator cuff (NCT01586351), and a comparative randomized versus corticosteroid injection in chronic plantar fasciitis (NCT01614223).

This lack of scientific evidence does not concern the ACP TM. The latest meta-analysis published by Shet et al. [19] on randomized 33├ętudes and ten observational prospective studies, and evaluating the effectiveness of PRP in orthopedics, could not bring irrefutable arguments justifying their increasing use. This work pointed to the lack of standardization of manufacturing processes and evaluation criteria used in clinical trials.

The ban intramuscular injections of PRP enacted in 2010 by the WADA (World Anti Doping Agency, or WADA) was lifted in 2011, "since current studies do not show the performance improvement potential beyond a therapeutic effect, "but the use of growth factors purified remains prohibited (http://www.wada-ama.org). However, Wasterlain et al. [20] have shown that athletes treated with PRP exhibited high systemic concentration in prohibited growth factors: VEGF, IGF-1 and bFGF. VEGF rate remained high at more than 88% of patients until 96an hour after the injection, which could, according to the authors make a biomarker to identify treated sports PRP.

The main limitation of this study was the lack of determination of platelet growth factors. However, immunohistochemical analysis in animal models has shown that these factors have a different level of expression according to tendon healing phase [21]. Intakes of platelet growth factors would thus to modulate in time. This line of research is promising and perhaps will propose targeted biomolecular treatment in stages based on multiple growth factors.

5. Conclusion

The preparation technique of the ACP TM was quick and easy to use both in the block that consultation. The ACP TM had significantly higher platelet concentration than that of whole blood and contained neither GB or GR. The literature review has not concluded on the therapeutic effectiveness of CPATM. Randomized clinical comparative studies versus placebo are needed.

References

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  • [2] Marx RE. Platelet-Rich Plasma (PRP) PRP what is and what is not PRP? Implant Dent 2001; 10: 225-8.

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  • [4] Mazzocca AD, McCarthy MB, DM Chowaniec, Cote MP, Romeo AA, Bradley JP, et al. Plasma platelet-rich differs selon preparation method and human variability. J Bone Joint Surg Am 2012; 94: 308-16.

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  • [8] Georg R, Maria C, Gisela A, Bianca C. Autologous conditioned plasma as therapy of tendon and ligament lesions in seven horses. J Vet Sci 2010; 11: 173-5.

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  • [16] Faurschou M, Borregaard N. Neutrophil granules and secretory vesicles in inflammation. Microbes Infect 2003; 5: 1317-1327.

  • [17] Lenzlinger PM, Morganti-Kossmann MC, Laurer HL, McIntosh TK. The duality of the inflammatory response to traumatic brain injury. Mol Neurobiol 2001; 24: 169-81.

  • [18] WateletJB, DemetterP, ClaeysC, VanCauwenbergeP, CuvelierC, Bachert C. Neutrophil-derived metalloproteinase-9predicts healing quality after-sinus surgery. Laryngoscope 2005; 115: 56-61.

  • [19] Sheth U, N Simunovic, Klein G, Fu F, Einhorn TA, Schemitsch E, et al. Efficacy of autologous platelet-rich plasma use for orthopedic indications: a meta-analysis. J Bone Joint Surg Am 2012; 94: 298-307.

  • [20] Wasterlain AS, HJ Braun, AH Harris, Kim HJ, Dragoo JL. The systemic effects of platelet-rich plasma injection. Am J Sports Med 2013; 41: 186-93.

  • [21] Heisterbach PE, Todorov A, R Fl├╝ckiger, CH Evans, Mr. Majewski Effect of BMP-12, TGF-????1and autologous conditioned serum on growth factor expression in Achilles tendon healing. Knee Surg Sports Traumatol Arthrosc 2012; 20: 1907-1914.

 

 

 

 

Doctor Yoann BOHU, Doctor Shahnaz KLOUCHE , Doctor Nicolas LEFEVRE, Doctor Serge HERMAN, Doctor Antoine GEROMETTA. - 20 septembre 2015.

Conflicts of interest: the author or authors have no conflicts of interest concerning the data published in this article.

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