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PRP - platelet concentrates
By Dr. Yves Guglielmetti
Clinical Sports Paris V
36, Bd Saint Marcel
75005 paris 5
History platelet concentrates
PRP platelet concentrates are causing blood derivatives used in hematology for the prevention and treatment of bleeding due to severe thrombocytopenia of central origin.
Platelet concentrates used as surgical aids in trauma and sports were arbitrarily called PRP as standard platelet concentrates transfusion hematology.
According to equipment manufacturers and authors, different terms are used to define these platelet concentrates: PRP (Platelet Rich Plasma or Platelet Rich Plasma) cPRP(Concentrated PRP) PRGF (Plasma Rich in Growth factors rich plasma growth factors), autologous blood. We will see that these concentrates are variable in composition, in terms of concentration of growth factors, fibrinogen, platelet view by the presence of leukocytes or granulocytes, or the use of an activator.
The first uses of autologous platelet concentrates, the PRF(Platelet Rich Fibrin, whole blood without anticoagulant) back to the 1970s in the indications of maxillofacial surgery Matras H. (2), to the 1980s for the treatment of skin ulcers in diabetic patients. The use of this method has been widely developed in the 90s in North America, Asia and Europe, as a surgical adjuvant (3,4,5), to take an important place in sports traumatology past ten years.
The indications are numerous, first as a surgical aid in tendon repair, bone and ligament and tendon in medical, ligament or muscle injuries and traumatic or degenerative chondropathies.
The Executive Committee of WADA (World Anti Doping Agency) met on 18 September 2010 in Montreal has withdrawn from the 2011 list of prohibited substances and methods the use of platelet-derived preparations (PRP).
Scientific basic principle - action mechanism
The natural mechanisms of healing of a body in the event of vascular injury are: activation and platelet aggregation, fibrin stabilization allowing the formation of a thrombus (clot) and release of growth factors, stimulating cell proliferation and thus healing.
The principle of treatment with PRP is to reproduce these mechanisms of healing and tissue regeneration by injection into the autologous blood plasma injured tissue concentrated platelets. This fabric can be a tendon, ligament, muscle, bone or joint. The use is purely medical or surgical procedure accompanies a.
The preparation of PRP requires a blood sample, which is centrifuged to separate the platelet-poor plasma (PPP, 5%) on the surface, rich plasma platelet and fibrinogen (PRP, 40%) in the middle, granulocytes and leukocytes the bottom of the tube (55%). The cell separator makes it possible to increase the concentration of platelets and growth factors contained in their alpha granules of 200 to 600%. Depending on the material used and the single or double centrifugation, thePRP has composition can vary in terms of concentration of platelets and growth factors; it must be free of granulocytes or leukocytes and should not be coagulated.
Some use an activator (bovine thrombin or calcium chloride) permitting gelation of the platelet concentrate by the polymerization of fibrinogen, which constitute a weft fibrin hemostatic and adhesive properties particularly useful in surgical indications. Furthermore theactivation would allow a slower release and prolonged growth factors. Bovine thrombin has been abandoned because of the risk of coagulopathy autoimmune causes it.
Using a local anesthetic before the injection of PRP is not recommended by most authors, it would change the local pH outside the PRP is pH-dependent.
The concentrated platelet plasma is then reinjected into the pathological zone. These platelets release growth factors in large numbers, allowing the healing of injured tissues by stimulating local stem cells, and reduce inflammation and bleeding. Thepathophysiological hypothesis is that these are TGF ? (transforming growth factor ?) and bFGF (basic fibroblast growth factor) that act as humoral mediators to trigger the cascade of healing (1). Other factors are involved in the proliferation, differentiation and cell migration or in angiogenesis, such as PDGF (platelet-derived growth factor), the ECGF (endothelial cell growth factor), the PD-EGF (platelet-derived epithelial growth factor), IGF-I, II (insulin-like growth factor), VEGF (vascular endothelial growth factor) and ECGF (endothelial cell growth factor). The alpha granules of platelets also contain organic active molecules such as serotonin, histamine, dopamine, the adenosine, calcium, catecholamines, which play a fundamental biological role in all three phases of the repair (inflammation, proliferation, remodeling ). Of these properties resulted from a large number of therapeutic indications that better suitsassess.
Platelet concentrates have bacteriostatic properties, highlighted the Staphylococcus epidermidis and Staphylococcus aureus on, reducing the risk of contamination microbiale the treated area (Endoret of Biotechnology Institute).
NSAIDs should not be used 10 days before and two weeks after the injection of PRP, they may inhibit the action of prostaglandins and thus the stimulatory effects of PRP. We also avoid the anti-inflammatory local care including cold bag application. In case of pain, we will resort to paracetamol.
Graziani (20) studied the in vitro action of platelet concentrates on osteoblasts and fibroblasts. He highlighted the PRI stimulatory role on cell proliferation, particularly clear in 72 hours, maximum for a platelet concentration of 2.5 times the plasma concentration, higher concentrations reduce this proliferation. This study is a response element in the choice of the platelet concentration to be used in therapeutic protocols. He joinsin that other authors especially Weibrich (24).
Gerben van Buul (22) studied the effect of platelet concentrates (6x) on cultures of human chondrocytes from osteoarthritic knees. Many studies have shown the anabolic effects of PRP on the healthy chondrocytes. The whole point of this study is to analyze the effect of PRP on the degenerative cartilage. The demonstration of an inhibition of the inflammatory processencourages its use in osteoarthritis.
E. Anitua (23) observed the effect of PRGF (platelet concentrate 2 to 3x) on chondrocytes derived from osteoarthritic joints. It showed a stimulatory role in the hyaluronic acid secretion and angiogenesis.
The main clinical studies in sports traumatology.
This is in maxillofacial surgery as the bibliography is the richest on the healing effect of PRP, with the first publication of H. Matras (2) in 1985 and for many publications Marx RE (5) and J. Choukroun in France (15).
The studies are numerous in sports traumatology, seeking to demonstrate the effectiveness of PRP injections into muscle injury, chronic tendinopathy and in many surgical indications.
Tendinopathy epicondylar was the subject of several studies. Mr. Bouvard and B. Eichene (34 and 35), caught in the literature 3 studies high level of evidence (40, 41, 42) carried on the ├ępicondylien tendon (single injection, versus corticosteroids). 2 of 3 studies showed a superiority of PRP, especially long-term.
Calcaneal tendinopathy is often found in sports pathology, with frequent failure of conservative treatment, 25 and 45% according to studies, offering the PRP a promising alternative to surgical treatment. She includes several entities, the corporeal tendinopathy, and the ent├ęsopathie peritendinitis sometimes associated. Corporeal tendinopathy is generated by repetitive microtrauma on a hypovascularis├ęe area, sometimes leading to rupture. The assumption is that the PRI could allow revascularization and improve tendon healing. One RJ de Vos study (10) caught my attention, randomized, double-blind, with one treatment group (27 patients) and control group (27 patients treated with saline), with equivalent results in the group treated and control group. Two criticisms can be made ??on the treatment protocol, the use of a local anesthetic that disrupt the effectiveness of PRP and PRP a single treatment while recommendations from histological analyzes, recommend 3 injections a week apart . Miquel Sanchez released a small series in 2007 (9), using PRP as a surgical adjuvant in the rupture of the Achilles tendon.
Plantar fasciitis has been the subject of numerous publications. 2 High-level studies of evidence, Monto RR (37) and Kim E and JH Lee (38) confirm the efficacy of PRP in the treatment of plantar fasciitis, superior to steroids.
Chronic patellar tendinopathy or jumper's knee is a sometimes debilitating pathology sport for athletes. Less invasive and with short suites, PRP may present an attractive alternative to surgery in these rebel tendon, resistant to adequate medical treatment including physiotherapy, deep transverse massage, NSAIDs and dynamic eccentric work.
3 high-level evidence studies (37, 38, 39) on the patellar tendon, confirm the effectiveness of PRP (2 versus 3 injections shockwaves 2 studies, 1 ultrasound guided injection versus blind screening for the third) . Superiority of PRP
the ODC was noted, especially in the long term.
Traumatic muscle injuries are very common in sports medicine (26, 27), second cause of consultation after the sprain. The severity assessment and treatment are difficult for the therapist with frequent recurrences, estimated between 12 and 36% (25,36). The quality of healing connective tissue determines the functional outcome. The main objectives of PRP are to achieve rapid pain relief, improved wound healing and thus limiting the risk of recidivism.
Mr. Bouvard (36) of biology and sports medicine center Pau injected with PRP 50 athletes suffering from muscle injury grade 2 to 4 according to the classification and Durey Rodineau. He estimated the number of relapses and time to return to competition. He concluded that this treatment appears to be effective at the time of return to sport and recidivism, provided that this treatment made ??no later than the 9th day after the accident. The author acknowledges that his study has some weaknesses particularly on the number of patients included and insufficient hindsight, 4 months to 2 years. Bubnov Rostyslav in a study high level of evidence (39) in the treatment of acute muscle injury has encouraging results especially in the relief of pain and physical recovery, in terms of time as quality.
What makes a good indication in bad natural prognosis lesions (myo myo fascial tendon lesions).
Publications in osteoarthritis
The use of platelet concentrates in osteoarthritis and chondropathies interested many authors, seeking to clarify the mode of action and compare their effectiveness compared to injections of hyaluronic acid or placebo.
Sanchez et al (19) studied prospectively the effectiveness of PRGF intra articular injection in knee osteoarthritis patients over 30, compared to a control group of 30 patients treated with intra-articular injection of hyaluronic acid at a rate of 3 injections one week apart. They conclude that 33.4% of positive results on the pain to 5 weeksthe PRGF group and 10% in the group hyaluronic acid. The beneficial effects at 6 and 12 months have not been analyzed, relativize the importance of this study.
Elizaveta Kon (21) analyzed the effectiveness of a treatmentPRP versus hyaluronic acid in the affected knee osteoarthritis or degenerative chondral. The analysis covers 3 homogeneous groups of 50 patients treated with either a low molecular weight HA (AHBP) or by a high molecular weight HA (AHHP) or PRP. The selected protocol consisted in the injection of 5 ml of platelet concentrate (6x anticoagulated and enabled), 3 times at 14 day intervals. Patients were assessed by the IKDC score before treatment, 2 months and 6 months. The results show a greater and more prolonged effectiveness of PRP therapy in most patients and assets with less advanced lesions. The results at 6 months of treatment with PRP or AH are comparable in older subjects. The authors opted for a significantly higher platelet concentration in the in vitro study of Graziani. The ideal concentration of platelets may not be the same depending on the therapeutic indications and injection sites.
Mr. Bouvard and B. Eichene(34 and 35) made ??an excellent review of the literature on the subject, they selected six high-level evidence studies on chondropathy, 5 against AH (28, 29, 30, 31, 32) and 1 against placebo (33). The effectiveness of PRP is greater than the HA or placebo, especially in patients with mild chondropathy.
The use of PRP has spread widely in sports traumatology last ten years, as an alternative to surgery or as a surgical adjuvant. Successful, high-profile among top athletes and the removal from the list of substances and methods prohibited by WADA late 2010 have literally flaming appeal for this technique.
In the present state of our knowledge, the effectiveness of PRP therapy is well established in the treatment of cartilage lesions.
Efficiency is generally good on the patellar tendon, the ├ępicondylien tendon and plantar fascia.
The effectiveness is difficult to assesson the Achilles tendon and the rotator cuff as studies are scarce and of poor quality.
The ultrasound guidance of PRP injection is essential in tendon and muscle damage.
Good pain management is essential (analgesics, nitrous oxide).
The absence of side effects and excellent tolerability, make the injection of PRP, performed under rigorous conditions, a technique of great safety.
It is essential to better understand the composition of different platelet concentrates, compare their effectiveness, to define the therapeutic protocols and to better define the indications.
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