OrthoBiologics and Platelet Rich Plasma

Courtesy: Sandeep Patel, Asst Professor, PGIMER, Chandigarh

Introduction to Orthobiologics

• Orthobiologics are substances used by orthopaedic surgeons to enhance and accelerate the natural healing process.

• These substances are derived from materials naturally found in the human body.

• They are used in conditions involving:

  • Fracture healing

  • Muscle injuries

  • Tendon and ligament injuries

  • Degenerative joint conditions

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Platelet-Rich Plasma

Definition

• Platelet-rich plasma is the plasma fraction of autologous blood with a platelet concentration higher than baseline levels.

• A platelet concentration of approximately 4 to 5 times the baseline value qualifies a product as platelet-rich plasma.

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Synonyms of Platelet-Rich Plasma

• Platelet-enriched plasma

• Platelet-rich concentrate

• Platelet-rich fibrin

• Platelet-leukocyte gel

• Autologous platelet gel

• Preparation rich in growth factors

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Use of Platelet-Rich Plasma in Orthopaedics

Platelet-rich plasma has been used in the management of conditions involving:

• Shoulder

• Spine

• Wrist and hand

• Elbow

• Hip

• Knee

• Foot and ankle

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Evolution of Platelet-Rich Plasma Use

• The concept gained popularity in the early 21st century with significant enthusiasm.

• Until approximately 2010, evidence supporting its use was limited despite widespread discussion.

• Over the past 10 years, scientific evidence has increased substantially.

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Rationale for Platelet-Rich Plasma Use

• Platelet-rich plasma contains a complex mixture of bioactive proteins essential for tissue repair.

• Healing requires a combination of growth factors rather than isolated individual factors.

• Platelet-rich plasma provides a physiological pool of these growth factors.

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Learning Objectives

• Understanding the mechanism of action of platelet-rich plasma in knee osteoarthritis

• Evaluating the clinical benefits of platelet-rich plasma

• Determining the appropriate type and number of platelet-rich plasma injections

• Identifying ideal patient profiles for platelet-rich plasma therapy

• Reviewing the biological effects of platelet-rich plasma in osteoarthritis

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Experimental Research on Platelet-Rich Plasma in Knee Osteoarthritis

• Experimental studies conducted at PGIMER demonstrated:

  • Reduced levels of chondrocyte apoptosis due to complex intra-articular interactions of platelet-rich plasma

  • Downregulation of programmed cell death 5 expression mediated by insulin-like growth factor 1 present in platelet-rich plasma

  • Significant increase in aggrecan levels in the platelet-rich plasma group compared with saline controls

• Immunohistochemical analysis suggested a role of platelet-rich plasma in extracellular matrix production

• Multiple doses of platelet-rich plasma demonstrated anti-apoptotic effects at 3 months, persisting up to 6 months

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Materials and Methods of Platelet-Rich Plasma Preparation

• 100 milliliters of whole blood collected in a CPD-A1 blood bag

• Transfer of whole blood into sterile 50 milliliter plastic tubes within a biosafety cabinet

• Centrifugation using a soft spin protocol at 1500 revolutions per minute at 22 degrees Celsius for 15 minutes

• Filtration of platelet-rich plasma through a leukocyte filter

• Final preparation dispensed as:

  • Platelet-rich plasma 8 milliliters

  • Calcium chloride 2 milliliters

• Injection administered at the supralateral pole of the patella

• Post-injection immobilization for 5 minutes

• Observation period of 2 to 3 hours

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Outcome Evaluation

• Follow-up assessments performed at 6 weeks, 3 months, and 6 months by an independent observer

• Evaluation parameters included:

  • Western Ontario and McMaster Universities Osteoarthritis Index score

  • Visual analogue scale for pain

  • Adverse effects

  • Overall patient satisfaction

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Safety Profile

• Platelet-rich plasma is considered safe.

• Supported by extensive scientific literature, including:

  • At least 17 randomized controlled trials

  • 7 meta-analyses

  • More than 25 clinical studies

• A 2017 meta-analysis showed no significant difference in adverse reaction rates between platelet-rich plasma and hyaluronic acid injections

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Platelet-Rich Plasma Versus Normal Saline

• An Food and Drug Administration-approved study published in the American Journal of Sports Medicine demonstrated:

  • 78 percent improvement in Western Ontario and McMaster Universities Osteoarthritis Index scores in the platelet-rich plasma group

  • 7 percent improvement in the placebo group at 12 weeks

• Platelet-rich plasma showed significantly better outcomes compared with normal saline

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Platelet-Rich Plasma Versus Hyaluronic Acid

• Comparative studies consistently favored platelet-rich plasma over hyaluronic acid

• Platelet-rich plasma resulted in superior pain reduction at 3, 6, and 12 months

• Platelet-rich plasma provides advantages in conservative management of knee osteoarthritis

• Long-term pain reduction and functional improvement observed without increased risk

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Classification of Platelet-Rich Plasma

1. Pure platelet-rich plasma or leukocyte-poor platelet-rich plasma

2. Leukocyte-rich platelet-rich plasma

3. Pure platelet-rich fibrin or leukocyte-poor platelet-rich fibrin

4. Leukocyte-rich platelet-rich fibrin

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Selection of Platelet-Rich Plasma for Knee Osteoarthritis

• Comparison between leukocyte-rich and leukocyte-poor platelet-rich plasma

• Leukocytes contain matrix metalloproteinases that may be detrimental

• Leukocyte-rich preparations are associated with:

  • Increased inflammatory response

  • Higher incidence of adverse effects

• In vitro studies have shown increased chondrocyte proliferation with leukocyte-rich preparations

• Clinical outcomes generally favor leukocyte-poor platelet-rich plasma for knee osteoarthritis

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Magnetic Resonance Imaging Findings After Platelet-Rich Plasma

• Significant changes observed in:

  • Patellofemoral cartilage volume

  • Synovitis

• Platelet-rich fibrin demonstrated no significant effect

• Leukocyte-poor platelet-rich plasma showed superior outcomes compared with leukocyte-rich preparations

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Consensus Statements and Evidence-Based Applications

Rotator Cuff Tears

• IBOSCON 2018 consensus reported:

  • Injectable platelet-rich plasma is preferable

  • Leukocyte-poor platelet-rich plasma is superior

  • Reduction in pain scores at 30 days

  • Lower retear rates compared with controls

  • Improved functional outcomes

  • Favorable safety profile

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Achilles Tendinopathy

• Platelet-rich plasma demonstrated outcomes similar to placebo or sham injections

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Plantar Fasciitis

• Studies from PGIMER showed positive outcomes in more than 60 cases

• Evidence for long-term superiority over corticosteroid injections remains limited

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Other Sports-Related Injuries

• Conditions include:

  • Hamstring injuries

  • Rectus femoris tears

  • Patellar tendinopathies

• Results suggest faster recovery and earlier return to sport

• Current evidence remains limited and further studies are required

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Lateral Epicondylitis

• Multiple studies demonstrate:

  • Superior pain relief in intermediate and long-term follow-up

  • Functional improvement at 12 weeks, 6 months, and 1 year

• Platelet-rich plasma is recommended as a preferred treatment option

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Summary of Evidence

Strong Evidence

• Early knee osteoarthritis

• Medial and lateral epicondylitis

• Plantar fasciitis

• Augmentation in rotator cuff repair

Weak Evidence

• Full-thickness rotator cuff tears

• Achilles tendinosis

• Patellar tendinosis

• Hamstring muscle tears