Platelet-rich-plasma or PRP is a form of regenerative medicine that has been used to treat professional athletes for years - over time, the procedure has become more accessible to the general public. PRP is most simply defined as a volume of plasma with a platelet count above baseline blood levels. It is autologous (from the patient) and can be injected into damaged areas to deliver platelet derived growth factors, promote a healing environment, and provide a growth delivery vehicle, as well as assist in modulating inflammation.
How is it harvested?
It is harvested by taking 60-180cc (depending on treatment area) of blood from the patient and spinning it in a centrifuge to get 2-12 cc (depending on patient) of PRP product.
Is all PRP created the same?
Not all PRP is the same or the same for each treatment area.
Leukocyte (white blood cell)poor PRP (LP PRP)
Has little or no leukocytes in it and a lower platelet count.
Leukocyte (white blood cell)rich PRP (LR PRP)
Has a larger concentration of leukocytes in it and higher platelet count.
Is it safe?
Platelet-rich plasma (PRP) is a concentrate of platelets and plasma proteins derived from whole blood, which is centrifuged to remove red blood cells. Platelets contain hundreds of growth factors that have a role in tissue repair and healing. Although we are still learning about PRP, laboratory studies have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process (Source: AAOS).
Surgeons have also seen success using PRP in the treatment of certain fractures and in some knee and hip surgeries.
What is the recovery like?
When tendons, ligaments, and meniscus are treated, patients are sorer with increased pain for about 2 weeks. Then the pain waxes and wanes for about 2-6 weeks, with some decreased pain days intermixed with days where it is very painful. It takes about 6 weeks for tendons to heal and remodel on repeat imaging. Anecdotally, most patients are not pain free until 6-12 weeks after treatment, but this can vary from patient to patient. The recovery is different for different tendons and ligaments and can vary from patient to patient. This will be reviewed at the time of consultation.
When joints are treated, initially it is sorer for the first 2-3 days, then the pain subsides, and some patients already start feeling improvement. It takes about 4-6 weeks on average for patients to see the full effects of the treatment.
What to consider when choosing PRP
The risks of any procedure involving a break in the skin include, infection, neurovascular or tendinous soft tissue injury and failure to provide relief. Ultrasound makes risk of iatrogenic injury to neurovascular structures and anatomic variants lower as the anatomic is viewed throughout the procedure. Transiently increased pain at the site of the procedure (varies based on site and tissue treated) and pain at venipuncture site are the most common complaints.
Is it FDA approved?
It is not FDA approved but FDA compliant if “minimally manipulated”. This means that it must be harvested and immediately reinjected. We do not store it or modify the product collected in anyway.
As with all procedures, patients are encouraged to gather information on the treatment option before pursuing it.
Bone marrow aspirate concentrate (BMAC):
Bone marrow aspirate concentrate (BMAC) is harvested from a patient’s pelvic to get mesenchymal stromal cells (MCSs) an orthobiologic.
How is it harvested?
In this clinic it is harvested from the posterior hip (posterior superior iliac spine). This is the same procedure that has been done for over 60 years in hematology offices to look for cancer, we are harvesting the bone marrow for the goal of obtaining mesenchymal stromal cells (MSCs).(176) This has been shown to be a safe way to harvest bone marrow in the office with the high yield of multi potent MSCs.177
The procedure is done under local anesthetic in the office. Most patients describe the process as uncomfortable but not painful. Most patients will say the feel the pulling sensation in the pelvis as the bone marrow is harvested.
The literature suggests that multiple small (10cc) syringes and multiple different depths increases the MSC yield. (176,178) After harvesting 120 cc (60cc from each side of pelvis), the BMAC is placed in a centrifuge and spun down to collect the MSCs, because these are taken out of a large volume of BMAC, the MSCs are concentrated.
Following this the patient’s blood is drawn (120 cc) and the blood is spun down to harvest the platelets, creating platelet-rich plasma, or a platelet count above normal. The MSCs are then injected under ultrasound guidance followed by PRP.
The entire harvest and injection procedures takes on average 60-90 minutes to complete and is done in one visit.
What conditions have been treated with it?
BMAC studies have recently shown encouraging results for improved pain and function for patients with chronic tendinopathy (Multiple different tendons), osteochondral defects, avascular necrosis, meniscal tears, and osteoarthritis. (179-195)
How does it work?
Mesenchymal stromal cells are one of many cells in BMAC. They have been shown in animal models to have the ability to home to the site of injury. They have “paracrine effects”. This means that these secrete bioactive proteins and mRNA, like “mini-drugstores”.The cells have anti-apoptotic (anti- cell death), Anti-scarring, Angiogenic(cell growth/blood vessel growth), miotic (promoting cell division), and antimicrobial properties. (172,196-198)
So far there are mostly case series looking at MSC therapy for osteoarthritis. There is evidence that it can stimulate a healing response in tendons with improved post-procedure imaging, functional outcomes, and pain. There are studies suggesting disease modification, meaning potentially slowing down arthritic loss. The main effect is not likely regrowth of cartilage. (199-204) I.e. currently we do not think it regrows cartilage or reverses arthritic loss. The effects seem to be mainly tied to the paracrine effects.
How long does it last?
BMAC studies have recently shown encouraging results for improved pain and function at 12 months with decreased biomarkers for inflammation, in treating tendons and joint conditions such as osteoarthritis. (179-195,205)
Is it safe/what are potential complications?
Several groups have demonstrated that BMAC is safe for patient use and has potential to improve pain and activity level, with minimal reported side effects. (179-195) The most common side effect reported in musculoskeletal use is that of increased pain for up to 7-10 days on average following the injection. Bone marrow harvest is a safe procedure, with a great safety record and low complication rate when performed in the office. (181,183,189,190,200,205)
Is it FDA approved?
It is not FDA approved but FDA compliant if “minimally manipulated”. The FDA considers this experimental. This means that it must be harvested and immediately reinjected. We do not store it, culture expand it in a lab, or modify the product collected in anyway. As with all procedures, patients are encouraged to gather information on the treatment option before pursuing it.
Watch Dr.Pourcho's talk on regenerative therapies on 'New Day Northwest'