By Mary Ann Porucznik
An international group of orthopaedic surgeons, clinician scientists, and researchers agreed that, for many orthopaedic conditions, administration of platelet-rich plasma (PRP) may be an option, but its efficacy is unproven. The participants of the 2011 PRP Forum also endorsed the development of standards in the manufacture of PRP, noted that PRP may be contraindicated in some conditions, and called for the establishment of a study group to follow up on the other recommendations resulting from the session.
Attendees discussed the applicability of PRP in the following areas:
- treatment of acute soft-tissue injuries, such as Achilles tendon rupture and rotator cuff repair
- chronic tendinopathies such as plantar fasciitis or medial/lateral epicondylitis
- augmentation of soft tissue or bone such as in spinal fusion
- treatment of cartilage defects such as those resulting from osteochondral lesions or osteoarthritis.
The 2011 PRP Forum was staged by AAOS Now, and cochaired by AAOS Now Editor-in-Chief S. Terry Canale, MD, and AAOS Now editorial board member Frank B. Kelly, MD. It brought together approximately 50 of the most knowledgeable and experienced clinicians and researchers in the field of PRP therapy, including Steven P. Arnoczky, DVM; Freddie H. Fu, MD; Wellington Hsu, MD; Elizaveta Kon, MD; Allan K. Mishra, MD; Nicola Maffulli, MD, PhD; Pietro Randelli, MD; and Scott A. Rodeo, MD. It combined a series of presentations, followed by break-out group discussions, resulting in a series of recommendations for future study of PRP.
All PRPs are not the same
In opening the forum, Dr. Arnoc-zky noted that “All PRPs are not the same, and we have to be aware of what we are putting in the patient.” Although PRP is a concentrated, autologous preparation developed from the patient’s own blood, some concentrations may contain double the number of platelets while others may contain five or ten times the number of platelets. The proportion of white blood cells, growth factors, and other compounds such as thrombin can also affect the compound.
The problem, however, is that “we don’t know how PRP works,” admitted Dr. Arnoczky. Most of the published literature on the efficacy of PRP in treating orthopaedic conditions that range from acute rotator cuff tears to chronic Achilles tendinitis have not specified the formulation used. The variation in composition does not enable scientists to compare results… “we’re talking apples and oranges and bananas,” said Ramon B. Cugat, MD.
Dr. Mishra presented a potential classification system for PRP, based on the presence or absence of white blood cells, the concentration of platelets, and the activation status. He noted that much current use of PRP in orthopaedics is patient-driven and based on reports of its use in elite athletes such as Tiger Woods and Cliff Lee.
Most major league sports governing bodies (National Football League, Major League Baseball, and National Basketball Association) have approved the use of PRP on athletes, and the World Anti-Doping Association recently removed platelet-derived preparations from its list of prohibited substances and methods, based on the lack of current evidence concerning the use of PRP for performance enhancement.
At the end of the day, an informal survey of participants found most in agreement that PRP would be an option, particularly if conservative treatments have failed and the next step would be surgery.
“PRP is a simple concept,” concluded Dr. Mishra, “but it is surrounded by a complex set of questions that are still unanswered.”
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