PRP (PLATELET RICH PLASMA) IMPLEMENTATIONS FOR THE HAND, WRIST AND ELBOW (UPPER EXTERMITY) PROBLEMS
Injecting some materials with needle to the area with severe pain is a method known for many years for the tendinitis treatment. The materials applied with this injection method are:
2-Botox (botulinum toxine)
3-The blood of the same person
4-PRP (platelet rich plasma)
There are several publications indicating that all of the aforementioned injection materials have been beneficial for the patient and based on the methods called empirical. However, no mechanism of action has been clearly proved up to now.
PRP has been used by the orthopedicians for many years in the treatment of muscle-skeleton system especially with chronic pain. The two main problems are that the mechanism of actions has not been proved and whether this pain relieving affect is permanent is not clear yet.
Platelet is one of the three cell types in the blood. Its main purpose is to thrombose in order to stop bleeding in case of an injury. To provide this, they include growth factors and cytokines which can be called as the intensively regenerative proteins within the cells. The preparate acquired by drawing the patient’s own blood, subjecting it to the mechanic implementations and increasing the density of the platelet is called as PRP. By this concentration which is highly above the physiologic levels, the area is intensively applied proteins called growth factor and cyutokine. It is already known that the regenerative cells of these proteins have the alarm mission on the injured area. It is assumed that with this implementation, the area with pain due to tendon pathology shall be repaired first and the pain will be relieved accordingly. THE AFFECT OF THE SAID MECHANISM ON THE TENDON INJURY HAS BEEN PROVED IN THE EXPERIMENTAL STUDIES (IN VITRO). Besides, it is not clearly known which growth factors are released at what rate after the implementation with PATIENTS (IN VIVO), their action mechanism and period and the reaction of the normal tissues to this implementation.
To summarize the published diseases which have been applied PRP treatment at least to relieve the pain within the last 10 years:
- Osteoarthrosis on the knee joint
- Acceleration and strengthening of the bone union
- Strengthening of the shoulder rotator cuff repair
- Strengthening of the anterior cruciate ligament repair of the knee
- Patellar tendinitis
- Plantar fasciitis
- Achilles tendinitis
- Tennis elbow (lateral epicondylitis).
Most of the studies are empirical and subjective. Although a well-being condition is observed, its action mechanism cannot be proved and it is not clear how much time will this well-being long. Besides, well-designed objective studies called “outcome studies” RECOMMEND PRP treatment in the lateral epicondylitis.
PREPERATION AND CLASSIFICATION OF PRP
Now, 16 different types of PRP preparation system are sold in the USA. Basically, an amount of blood is drawn from the patient’s vein system and erythrocyte (red blood cell) is separated by centrifuge. The acquired liquid (plasma) is processed again and platelet rich plasma (PRP) is separated from platelet poor plasma. In accordance with the differences among the systems on sale, the density rate of platelet can be 1.6 to 12 times more than normal blood. Besides, the amount of leucocyte in the PRP acquired in each system can vary. Another variable factor is that whether any chemical material called activator is added to the prepared PRP or not. The general opinion is that it would be better if no activator is added. These chemicals called activator are simply calcium and thrombin. In some implementations, they have been observed to create clot (within the injector) at the very early stage. It is stated that the PRP without any activators makes the growth factors swing as it contacts the protein called collagen which is already existing in the tendon.
In summary, the PRP solutions applied to the patients are not monotype. Thus, it is not possible to analyze the publications as a whole (meta analysis). There are 3 important factors differentiating each PRP preparates:
1-Platelet concentration / total acquired amount (volume)
3-Whether activator is used.
Since the person’s own tissue (blood) is used, PRP is an implementation of which safety concern is classified as “minimum” in the USA. Local reaction is rarely presented. Pain and a little swelling after the injection are expected outcomes.
In a laboratory research, PRP is found out to have antimicrobial effect against bacteria like S. Aureus and E. Coli. That’s why, the infection (inflammation) risk is almost nonexisting.
In summary, against every positive feedback, it should be taken into consideration that the outcomes of the controlled, random, prospective standardized studies may vary. Another important issue is the financial outcomes. A lot of health insurance institution still accepts the PRP treatment at the research stage. It means the financial responsibility of the treatment belongs to the patient.
This letter is almost exact translation of the relevant compilation on the March 2012 issue of the American Hand Surgery Magazine.
Platelet-rich plasma. Saucedo JM, Yaffe MA, Berschback JC, Hsu WK, Kalainov DM.
J Hand Surg Am. 2012 Mar;37(3):587-9; . No abstract available.