PRP Literature

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DiponEd BioIntelligence LLP

PLATELET RICH PLASMA (PRP) BENEFICIAL EFFECTS FOR VARIOUS

INDICATIONS

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PLATELET RICH PLASMA (PRP) Platelet-rich plasma (PRP) is blood plasma that has been enriched with platelets. As a concentrated source of autologous platelets, PRP contains (and releases through degranulation) several different growth factors and other cytokines that stimulate healing of bone and soft tissue. The growth factors and other cytokines present in PRP include

platelet-derived growth factor transforming growth factor beta fibroblast growth factor insulin-like growth factor 1 insulin-like growth factor 2 vascular endothelial growth factor epidermal growth factor Interleukin 8 keratinocyte growth factor connective tissue growth factor

PRP has been investigated and used as clinical tool for several types of medical treatments,

including Nerve injury Tendinitis Osteoarthritis Cardiac muscle injury Bone repair and regeneration Facial plastic surgery Oral surgery Chronic wounds Non-healing diabetic ulcers Chronic diabetic foot ulcers Refractory skin lesion Traumatic scars Hair growth Soft tissue augmentation & reconstruction Survival of fat grafts Lower extremity ulcers Breast contouring Chronic pressure ulcer Osteochondral defects Knee injuries Arthroscopic rotator cuff repairs

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REFERENCES

1. Aimetti M, Romano F, Dellavia C, De Paoli S (2008). "Sinus grafting using autogenous bone and platelet-rich plasma: histologic outcomes in humans". The International Journal of Periodontics & Restorative Dentistry 28 (6): 585–91. PMID 19146054.

2. Alan Schwarz (2009-02-16). "A Promising Treatment for Athletes, in Blood". New York Times (New York).

3. Andia I, Sanchez M, Maffulli N (2012). "joint pathology and platelet-rich plasma therapies". Expert Opinion in Biological Therapies 12 (1): 7–22. doi:10.1517/14712598.2012.632765. PMID 22171664.

4. Borrione P, Gianfrancesco AD, Pereira MT, Pigozzi F (2010). "Platelet-rich plasma in muscle healing". Am J Phys Med Rehabil 89(10): 854–61. doi:10.1097/PHM.0b013e3181f1c1c7. PMID 20855985

5. Carina Storrs (2009-12-18). "Is Platelet-Rich Plasma an Effective Healing Therapy?". Scientific American.

6. Gina Kolata (2010-01-12). "Popular Blood Therapy May Not Work". New York Times. 7. Gretchen Reynolds (2011-01-26). "Phys Ed: Does Platelet-Rich Plasma Therapy Really

Work?". New York Times. 8. Griffin XL, Smith CM, Costa ML (2009). "The clinical use of platelet-rich plasma in the

promotion of bone healing: a systematic review".Injury 40 (2): 158–62. doi:10.1016/j.injury.2008.06.025. PMID 19084836.

9. Marx RE, Garg AK (1999). "Bone Graft Physiology with Use of Platelet-Rich Plasma and Hyperbaric Oxygen". In Jensen OT. The Sinus Bone Graft. Chicago: Quintessence. pp. 183–9. ISBN 0-86715-343-1.

10. Mishra A, Pavelko T (2006). "Treatment of chronic elbow tendinosis with buffered platelet-rich plasma". The American Journal of Sports Medicine 34 (11): 1774–8. doi:10.1177/0363546506288850. PMID 16735582.

11. Mishra A, Velotta J, Brinton TJ, et al. (2010). "RevaTen platelet-rich plasma improves cardiac function after myocardial injury".Cardiovasc Revasc Med 12 (3): 158–63. doi:10.1016/j.carrev.2010.08.005. PMID 21122486.

12. Mishra A, Woodall J, Vieira A (2009). "Treatment of tendon and muscle using platelet-rich plasma". Clinics in Sports Medicine 28 (1): 113–25. doi:10.1016/j.csm.2008.08.007. PMID 19064169.

13. Por YC, Shi L, Samuel M, Song C, Yeow VK (2009). "Use of tissue sealants in face-lifts: a metaanalysis". Aesthetic Plastic Surgery 33(3): 336–9. doi:10.1007/s00266-008-9280-1. PMID 19089492.

14. Yu W, Wang J, Yin J (2011). "Platelet-Rich Plasma: A Promising Product for Treatment of Peripheral Nerve Regeneration After Nerve Injury". Int J Neurosci 121 (4): 176–180. doi:10.3109/00207454.2010.544432. PMID 21244302

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PLATELET ALPHA-GRANULES. Platelets contain a vast number of biologically active molecules within cytoplasmic granules which are classified according to their respective distinct ultrastructures, densities and content. The alpha-granule is a unique secretory organelle in that it exhibits further compartmentalization and acquires its protein content via two distinct mechanisms: (1) biosynthesis predominantly at the megakaryocyte (MK) level (with some vestigial platelet synthesis) (e.g. platelet factor 4) and (2) endocytosis and pinocytosis at both the MK and circulating platelet levels (e.g. fibrinogen (Fg) and IgG). The currently known list of alpha-granular proteins continues to enlarge and includes many adhesive proteins (e.g. Fg, von Willebrand factor (vWf) and thrombospodin (TSP)), plasma proteins (e.g. IgG and albumin), cellular mitogens (e.g. platelet derived growth factor and TGF beta), coagulation factors (e.g. factor V) and protease inhibitors (e.g. alpha 2-macroglobulin and alpha 2-antiplasmin). More recently the inner lining of the alpha-granule unit membrane has been demonstrated to contain a number of physiologically important receptors including glycoprotein IIb/IIIa (alpha IIb beta 3) and P-selectin. The alpha-granules originate from small precursor granules which can be observed budding from the trans-Golgi network within the platelet precursor cell the MK. During MK maturation the alpha-granules become very prominent and are ultimately packaged into platelets during thrombopoiesis. The alpha-granular contents are destined for release during platelet activation at sites of vessel wall injury and thus play an important role in haemostasis, inflammation, ultimate wound repair and in the pathogenesis of atherosclerosis.( Harrison P, Cramer EM. 1993)

REFERENCES

Harrison P, Cramer EM. Platelet alpha-granules. Blood Rev. 1993 Mar;7(1):52-62.

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PRP EFFECTS ON DIABETIC FOOT ULCERS

The use of platelet-rich plasma (PRP) to enhance wound healing has increased dramatically over the last decade.Non healing diabetic foot ulcers and the resulting potential amputations present significant costs to the health care system and reduce patient quality of life. The goal of diabetic foot ulcer treatment is to obtain wound closure as expeditiously as possible. study investigated the efficiency of platelet releasate on the healing of chronic diabetic ulcers in comparison with platelet-poorplasma (PPP) study in 24 patients with chronic diabetic ulcers. They were systematically randomised into two groups: PRP group (n = 12) and PPP group (n = 12). The results showed that healing in PRP group was significantly faster (P < 0·005). PRP enhances healing of chronic diabetic foot ulcers.(Saad Setta H et al., 2011) A cost-effectiveness analysis compared the potential economic benefit of an autologous, platelet-rich plasma (PRP) gel to alternative therapies in treating nonhealing diabetic foot ulcers.The average 5-year direct wound care cost per modality and QALYs were PRP gel, $15,159 (2.87); saline gel, $33,214 (2.70); standard of care, $40,073 (2.65); noncontact kilohertz ultrasound therapy, $32,659 (2.73); human fibroblast-derived dermal substitute, $40,569 (2.65); allogenic bilayered culture skin substitute, $24,374 (2.79); bilayered cellular matrix, $37,340 (2.71); negative pressure wound therapy, $20,964 (2.81); and recombinant human platelet-derived growth factor BB, $47,252 (2.69). Dougherty shows that use of PRP gel resulted in improved quality of life and lower cost of care over a 5-year period than other treatment modalities for nonhealing diabetic foot ulcers. Although actual treatment outcomes may differ from those modeled, PRP gel represents a potentially attractive treatment alternative for insurers and health care providers to address the cost burden and health effects of nonhealing diabetic foot ulcers.(Dougherty EJ.2008)

Zhongguo Xiu et al., compared the platelet enrichment ratio of platelet-rich plasma (PRP) prepared by different centrifuge methods and to compare the concentration of growth factors released from autologous platelet-rich gel (APG) with the whole blood.Thirteen diabetic patients with refractory skin lesions were enrolled in APG treatment. (1) Three kinds of centrifuge methods were selected for PRP by 11 diabetic patients: A (n = 6): 529 x g for 4 minutes in the first centrifuge and 854 x g for 6 minutes in the second centrifuge; B (n = 5): 313 x g for 4 minutes in the first centrifuge and 1,252 x g for 6 minutes in the second centrifuge; C (n = 5): 176 x g for 5 minutes in the first centrifuge and 1,252 x g for 5 minutes in the second centrifuge. Platelet counted on the whole blood and PRP was determined. The APG, produced by combining the PRP with thrombin and calcium gluconate (10:1) was used by patients. (2) PDGF-BB, TGF-beta1, VEGF, EGF, and IGF-1 were measured in the APG and the whole blood using the enzyme-linked immunosorbent assay method.(1) The average platelet concentration was higher in group B [(1,363.80 +/- 919.74) x 10(9)/L] than in groups A [(779.67 +/- 352.39) x 10(9)/L)] and C [(765.00 +/- 278.78) x 10(9)/L] and the platelet recovery rate was 75.2% +/- 21.0% in group B. (2) The concentration of growth factors all increased with the increasing platelet number. On average, for the wholeblood as compared with APG, the PDGF-BB concentration increased from (145.94 +/- 133.24) pg/mL to (503.81 +/- 197.86) pg/mL (P < 0.05); TGF-beta1 concentration increased from (3.31 +/- 2.27) ng/mL to (5.67 +/- 4.80) ng/mL (P < 0.05); IGF-1 concentration increased from (14.54 +/- 35.34) ng/mL to (110.56 +/- 84.36) ng/mL (P < 0.05); and EGF concentration increased from (160.73 +/- 71.10) pg/mL to (265.95

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+/- 138.43) pg/mL (P < 0.05). No increase was found for VEGF (P > 0.05). (3) There was positive correlation between the platelet concentration and PDGF-BB and TGF-beta1 (r = 0.627, r = 0.437, P < 0.05). (4) Thirteen diabetic repractory dermal ulcers received APG treatment for 18 times, 9 ulcers (69.2%) and 10 sinuses (88.3%) were cured at the end of 12-week treatment. There is positive correlation between the platelet concentration and PDGF-BB and TGF-beta(Yuan N et al. 2008) Hong JP et al studied the healing effect of recombinant human epidermal growth factor (EGF) on chronic diabetic foot ulcers. A total of 89 patients enrolled for the prospective, open-label trial, crossover study. Predetermined criteria were used for diagnosis and classification of ulcer. The average duration of ulcer was 6 months (range from 3 to 27 months) prior to study. Upon study, the ulcers were debrided and treated with hydrocolloid or composite dressing depending on the condition of the wound. If treatment effect was minimal using advanced dressing for 3 weeks, patients were crossed over to twice-a-day treatment with 0.005% EGF and advanced dressing. Among the patients, 21 patients showed improvement using hydrocolloid or composite dressing alone and 68 patients were crossed over to treatment with EGF and advanced dressing. In the EGF-treated patients, complete healing was noted in 52 patients within an average of 46 days (range from 2 to 14 weeks). Recurrence was not noted during the 6-month observation. But 5 patients showed new lesions different from the prior site. Sixteen patients required further interventions. Results suggests that topical treatment with EGF combined with advanced dressing may have positive effects in promoting healing of chronic diabetic foot wounds. (Hong JP et al., 2008) Recombinant human epidermal growth factor (REGEN-D 150), which was cloned and over expressed in E. coli, has shown enhanced healing of chronic diabetic foot ulcers (DFU) by significantly reducing the duration of healing in addition to providing excellent quality of wound healing and reepithelization. Post-marketing surveillance (PMS) study of REGEN-D 150 in 135 patients of DFU in India was compared with Phase III clinical trial data of REGEN-D 150 in India. Statistical analysis of study data determined that the empirical survival probability distribution, in terms of non-healing of ulcers, was lowest in the case of PMS study, better than that for Phase III; more DFU patients were healed in PMS study. Percentage of patients cured in any given week (e.g., in week 10) is above 90% in PMS study, as compared to 69% in Phase III clinical trial; this percentage was around 18% for the control group with placebo in the Phase III trial. The average wound healing time was significantly lower in PMS study, 4.8 weeks, while it was 9 weeks in Phase III clinical trials while the average wound healing with REGEN-D 150 was found to be 86% in this study. REGEN-D 150 has been found to result in healthy granulation and stimulate epithelization, thus leading to final wound closure. The PMS study has established the efficacy of REGEN-D 150 in fasterhealing of diabetic foot ulcers. (Mohan VK 2007)

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REFERENCES

1. Dougherty EJ An evidence-based model comparing the cost-effectiveness of platelet-

rich plasma gel to alternative therapies for patients with nonhealing diabetic foot ulcers. Adv Skin Wound Care. 2008 Dec;21(12):568-75.

2. Hong JP, Jung HD, Kim YW Recombinant human epidermal growth factor (EGF) to

enhance healing fordiabetic foot ulcers. Ann Plast Surg. 2006 Apr;56(4):394-8; discussion 399-400.

3. Mohan VK Recombinant human epidermal growth factor (REGEN-D 150): effect

on healing ofdiabetic foot ulcers. Diabetes Res Clin Pract. 2007 Dec;78(3):405-11. Epub 2007 Jul 25.

4. Saad Setta H, Elshahat A, Elsherbiny K, Massoud K, Safe I Platelet-rich plasma versus platelet-poor plasma in the management of chronic diabetic foot ulcers: a comparative study. Int Wound J. 2011 Jun;8(3):307-12. doi: 10.1111/j.1742- 81X.2011.00797.x. Epub 2011 Apr 7.

5. Yuan N, Wang C, Wang Y, Yu T, Long Y, Zhang X, Ran X

Preparation of autologous plateletrich gel for diabetic refractory dermal ulcer andgrowth factors analysis from it. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2008 Apr;22(4):468-71

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PRP AND FAT GRAFT COMBINED EFFECTS IN VARIOUS WOUND ULCERS PLATELET-RICH PLASMA (PRP) PROMOTES SURVIVAL OF FAT-GRAFTS IN RATS Nakamura et al., evaluated the effects of platelet-rich plasma (PRP) on resorption and adipocyte survival in autologous fat-graft of rats prepared with isogenous PRP. Fat grafts prepared without PRP (control group) became united to the tissue adjacent to the implantation site and were significantly resorbed from 30 days. On the other hand, fat grafts prepared with PRP (PRP group) demonstrated little resorption from 30 to 120 days and appeared pink, had a soft, supple feel, and were easily compressible. Histologic sections of grafts in the control and PRP groups at 10 days exhibited similar consolidation of the grafted tissue, which contained morphologically normal adipocytes with different degrees of granulation and capillary formation. From 20 days normal adipocytes were obviously decreased in the control group, while the PRP group demonstrated increased granulation tissue and capillary formation and good maintenance of normal adipocytes for at least 120 days.( Nakamura S et al., 2010 )

PLATELET-RICH PLASMA (PRP) UTILIZED TO PROMOTE GREATER GRAFT VOLUME RETENTION IN AUTOLOGOUS FAT GRAFTING

Autologous fat theoretically provides one of the most ideal mediums for soft-tissue augmentation and reconstruction, although its clinical applications have been marked with skepticism because of its documented unreliable survival. Over the years, numerous unsuccessful efforts have set forth to elucidate modifications in the application process of autologous fat grafts to allow the medium greater clinical predictability. Kevin et al., investigated the effects of platelet-rich plasma (PRP) on autologous fat grafts when used in conjunction with each other in soft tissue augmen- tation and reconstruction.study is Retrospective review, over a 30-month period, of consecutive patients with results greater than 6 months in duration.based on clinical experiences representing 2033 grafts in 448 consecutive patients using PRP additives and in the previous 132 patients who had syringe harvest without use of PRP. All PRP isolates were harvested via the Smart Prep system. Results were based on clinical observations and patient satisfaction. Of the 580 patients in the experimental group, essentially all showed greater graft volume retention over extended time intervals compared with control subjects (nongraft areas). Patients in the PRP-added experimental group displayed less postoperative ecchymosis and edema, which also led to greater patient satisfaction in this group. Adding PRP to autologous fat aids in graft volume retention and survival when used clinically for soft- tissue augmentation and reconstruction (Kevin S et al., 2006)

INCREASED SURVIVAL OF FREE FAT GRAFTS WITH PLATELET-RICH PLASMA IN RABBITS. Numerous applications of autogenous platelet-rich plasma (PRP) have been studied so far; however, its property of enhancing the survival of free fat grafts has not been defined yet Pires fraga et al investigated PRP its effect in free fat grafts' survival in a rabbit model. A total of 30 New Zealand male rabbits aged 6 months received 0.8 g fat tissue (harvested by scissors

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dissection from the scapular area of the own animal) in the ears and were randomised into two groups. Group 1 (PRP group) was given the combination of 0.8 g of free fat graft and 1 ml of PRP. Group 2 (control group) received 0.8 g of free fat graft and 1 ml of saline solution. The rabbits were followed up for a period of 6 months after the procedure and then euthanised. The grafted tissue was stained with haematoxylin-eosin and submitted to microscopical evaluation. Graft histopathology was investigated for adipocyte viability, number of blood vessels and the presence of necrosis and fibrosis. All data were statistically analysed by the differences between the study groups.Three major effects of the addition of PRP in the free fat graft were observed. Group 1 showed a significantly higher fat survival weight as compared with the control group (P<0.05). Histopathological investigations revealed that the number of viable adipocytes and blood vessels was higher in group 1, and still, a larger number of necrotic areas and fibrosis were detected between group 2 (P<0.05). Application of autogenous PRP can enhance free fat graft survival in rabbits.( Pires Fraga MF et al., 2010) ACTIVATED PLATELET-RICH PLASMA IMPROVES FAT GRAFT SURVIVAL IN NUDE MICE: A PILOT STUDY. Numerous processing methods have been proposed to enhance the survival of fat grafts, but no definitive treatment protocol is available. Platelet-rich plasma (PRP) contains a high concentration of platelets with neovascularization properties and has the potential to promote fat graft survival.Oh Ds et al., evaluated the effect of activated PRP on human graft quality and survival.Using the scalp model, nude mice received fat mixed with PRP followed by injection of thrombin and calcium chloride to activate the PRP (PRP group) or fat mixed with saline (control group). After 10 weeks, mice were killed, the volume and weight of the fat graft were determined, and graft sections were examined using light microscopy. Results showed that Fat graft volume and weight were significantly higher in the PRP group than in the control group, and histologic evaluation revealed greater vascularity, fewer cysts and vacuoles, and less fibrosis in the PRP group than in the control group. The cellular integrity and inflammation were not statistically different between the two groups.PRP treatment improved the survival and quality of fat grafts. Safer methods of PRP activation and preparation should be further investigated for potential application in humans. (Oh DS et al.,2011 ) APPLICATION OF ENHANCED STROMAL VASCULAR FRACTION AND FAT GRAFTING MIXED WITH PRP IN POST-TRAUMATIC LOWER EXTREMITY ULCERS. Cervelli V et al., presented their experience in regenerative surgery of post-traumatic lower extremity ulcers, evaluating the effects related to the use of Enhanced Stromal Vascular Fraction (e-SVF) and Fat Grafting with Platelet rich Plasma (PRP) and compared the results of two control groups. Analysed 20 patients aged between 23 to 62 years affected by post-traumatic lower extremity ulcers. 10 patients managed with e-SVF and 10 patients managed with Fat grafting+PRP. Patients in the first control group (n=10), were treated only with curettage and application of hyaluronic acid in the bed of ulcers. Patients in the second control group (n=10), were treated only with PRP.Results showed that wounds treated with e-SVF healed better than those treated with hyaluronic acid. In fact, after 9.7 weeks, patients treated with e-SVF underwent 97.9% ± 1.5% reepithelialisation compared to 87.8% ± 4.4% of the first control group (only hyaluronic acid; p<0.05). Patients treated with PRP and fat grafting also

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showed an improvement in reepithelialisation; in fact after 9.7 weeks, they underwent a 97.8% ± 1.5% reepithelialisation compared to 89.1% ± 3.8% of the second control group (only PRP; p<0.05). As reported e-SVF and PRP mixed with fat grafting were the two treatments evidencing improvement in the healing of patients post-traumatic extremity ulcers.(Cervelli Vet al,.2011) TREATMENT OF TRAUMATIC SCARS USING FAT GRAFTS MIXED WITH PLATELET-RICH PLASMA, AND RESURFACING OF SKIN WITH THE 1540 NM NONABLATIVE LASER. Many treatments have been proposed for cosmetic or functional improvement of scars. It is known that fatgrafts and laser treatment can have beneficial effects on remodelling of scar tissue, and platelet-rich plasma (PRP) can be effective during the wound-healing process. Cervelli V et al.,hypothesized that these combined treatments would be effective in improving traumatic scars, with minimal recovery time and few side-effects. Study among 60 patients affected by traumatic scars involving different body parts. All patients were randomly allocated to one of three groups (20 patients per group) and underwent one of three different procedures. Group A was treated with fat grafts mixed with PRP, group B was treated with nonablative laser, and group C was treated with both procedures.Comparison of the groups showed that PRP produced a significant difference in these treatments. The most effective scar treatment was the combination of fat grafts mixed with PRP plus nonablative laser resurfacing (group C). This treatment resulted in group C having an increase of 22% in wound healing compared with group A, and an increase of 11% compared with group B.The data confirm the efficacy of all three treatments, with the most effective scar treatment being the fatgrafts mixed with PRP, followed by skin resurfacing with nonablative laser. This combined treatment appeared to be safe and effective for scar treatment. Further studies are needed to explore the potential use of this combined treatment.( Cervelli V et al., ) PLATELET-RICH PLASMA OFFERS VAST FAT GRAFT BENEFITS Platelet rich plasma (PRP) appears to be a useful adjunct for enhancing outcomes of autologous fat transplantation, Results of in vitro studies show that the incorporation of PRP during preparation of autologous fat for transplantation both increases cellular survival and proliferative potential. That finding is consistent with the clinical observation of higher retention volume in transplantations performed with PRP-enriched fat relative to conventional fat grafts. In addition, clinical experience indicates the addition of PRP is associated with other advantages, including acceleration of the healing processes, and, in large volume transfers, reduction of spherical calcifications and lipid cyst formation. This observation has been confirmed by radiographic and ultrasonic visualization. Autologous fat meets many of the criteria of an ideal material for use in tissue augmentation procedures and stem cell investigations. current studies suggest improved cellular take rates as a result of addition of PRP, does improve the predictability fat grafting procedures. The benefits and uses of this safe and readily available tissue resource would be greatly enhanced" . the effects of addition of PRP to autologous fat since the late 1990s, based on the principle that PRP, as a material rich in growth factors and cytokines, would have the potential of improved fat cell viability, as well as accelerate the wound-healing cascade. "The platelet-derived chemical mediators found in PRP would be expected to contribute to survival and increased metabolic activity of the fat cells, while also enhancing healing and revascularization at the surgical site. Consequently, there would be an increase in transplant cell survival and lipogenesis potential, as well as reduction of liponecrosis, resulting in calcification

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and microcyst formation. Theoretically, if PRP reduces the time needed for the grafted cells to be accepted in its recipient site, there will be less loss of graft cells to prolonged inflammation and necrosis, and improved clinical efficacy,". In the last few years, development of an affordable and convenient method of isolating PRP has made its uses in outpatient surgeries much more enriching all processed fat with PRP, regardless of the volume of grafts and whether the material will be used for immediate transfer, or frozen for delayed grafting. Currently, he uses "plain" PRP (not activated with the addition of calcium chloride and thrombin) isolated with technology able to spin down a useful volume of platelet concentrate from a reasonably small sample of blood. A 16- to 18- cc blood specimen yields about 3 cc of PRP, while 10 cc of PRP is obtained from 54 cc of blood. (Cheryl Guttman 2004) USE OF FAT GRAFTING COMBINED WITH PLATELET-RICH PLASMA FOR CHRONIC LOWER-EXTREMITY ULCERS V.Cervelli et al presented their experience with reconstructive surgery of the lower extremity for chronic ulcers, evaluating the effects related to the use of a plateletrich plasma combined with fat tissue. A total of 20 patients, 25 to 50 years of age (median age, 40 years), have been managed with platelet.The patients were affected by both lower-extremity chronic ulcers and vascular disease.Results suggested that 16 of 20 chronic lowerextremity ulcers reepithelialized during an average of 9.7 weeks, with platelet releasate suspended on a collagen base (platelet-derived wound-healing factor), compared with 2 of 10 similar wounds treated with medication based on hyaluronic acid and collagen. Collectively, these data provide evidence for the clinical use of platelet technology in the healing of both soft and hard tissue wounds.Currently, plastic surgery with autogenous fat grafts can be performed for stabilization of chronic lower-extremity ulcers. The objective of this study was, through the presentation of clinical cases, to suggest a therapeutic plan formed by two sequential treatments: acquisition of platelet gel from a small volume of blood (9– 18 ml) followed by the Coleman technique for reconstructing the three-dimensional projection and superficial density of tissues. The results proved the efficacy of combining these two treatments, and the satisfaction of the patients confirmed the quality of the results.( V. Cervelli et al., 2009 ) BREAST CONTOURING WITH "GELLED" AUTOLOGOUS FAT

The method of autologous fat transfer to the breast has been improved by addition of a platelet gel. The fat is obtained during tumescent liposuction using the syringe method. This resulted in a pleasing augmentation in 65 cases studied over a ten year period. The average retention of the transplant was 73%. The majority of these patients have been pleased with their augmentation and there have been no incidents of diffuse firmness of the breasts. Complications have included small areas of ecchymosis and the development of striae. This technique has become a useful addition to the breast augmentation armamentarium and is the procedure of choice for patients who prefer not to have silicone implants.( JAMES E. FULTON)

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REFERENCES

1. Cervelli V, Gentile P, De Angelis B, Calabrese C, Di Stefani A, Scioli MG, Curcio BC, Felici M, Orlandi AApplication of enhanced stromal vascular fraction and fat grafting mixed with PRP in post-traumatic lower extremity ulcers. Stem Cell Res. 2011 Mar;6(2):103-11. Epub 2010 Nov 30.

2. Cervelli V, Nicoli F, Spallone D, Verardi S, Sorge R, Nicoli M, Balzani A Treatment of traumatic scars using fat grafts mixed with platelet-rich plasma, and resurfacing of skin with the 1540 nm nonablative laser.

3. Cheryl Guttman Platelet-rich plasma offers vast fat graft benefits PRP-enrichment increases cellular survival and proliferative potential Cosmetic Surgery Times, 2004.

4. JAMES E. FULTON, M.D., PH.D. Breast contouring with "gelled" autologous fat

5. Kevin S. Sadati, DO; Anthony C. Corrado, DO; Robert W. Alexander, MD, DMD: Platelet-Rich Plasma (PRP) Utilized To Promote Greater Graft Volume Retention in Autologous Fat Grafting 2006

6. Nakamura S, Ishihara M, Takikawa M, Murakami K, Kishimoto S, Nakamura S, Yanagibayashi S, Kubo S, Yamamoto N, Kiyosawa TPlatelet-rich plasma (PRP) promotes survival of fat-grafts in rats. Ann Plast Surg. 2010 Jul;65(1):101-6.

7. Oh DS, Cheon YW, Jeon YR, Lew DH Activated platelet-rich plasma improves fat graft survival in nude mice: a pilot study. Dermatol Surg. 2011 May;37(5):619-25. doi: 10.1111/j.1524-4725.2011.01953.x. Epub 2011 Apr 14.

8. Pires Fraga MF, Nishio RT, Ishikawa RS, Perin LF, Helene A Jr, Malheiros

CAIncreased survival of free fat grafts with platelet-rich plasma in rabbits. J Plast Reconstr Aesthet Surg. 2010 Dec;63(12):e818-22. Epub 2010 Aug 13.

9. Ulcers V. Cervelli Æ P. Gentile Æ M. Regenerative Surgery: Use of Fat Grafting Combined with Platelet-Rich Plasma for Chronic Lower-Extremity Grimaldi Aesth Plast Surg (2009) 33:340–345.

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PRP ROLE IN HAIR GROWTH

Recently, autologous platelet-rich plasma (PRP) has attracted attention in various medical fields, including plastic and orthopedic surgery and dermatology, for its ability to promote wound healing. PRP has been tested during facelift and hair transplantation to reduce swelling and pain and to increase hair density.PRP was prepared using the double-spin method and applied to dermal papilla (DP) cells. The proliferative effect of activated PRP on DP cells was measured. To understand the mechanisms of activated PRP on hair growth, we evaluated signaling pathways. In an in vivo study, mice received subcutaneous injections of activated PRP, and their results were compared with control mice, Results suggest that Activated PRP increased the proliferation of DP cells and stimulated extracellular signal-regulated kinase (ERK) and Akt signaling. Fibroblast growth factor 7 (FGF-7) and beta-catenin, which are potent stimuli for hair growth, were upregulated in DP cells. The injection of mice with activated PRP induced faster telogen-to-anagen transition than was seen on control mice this research provides support for possible clinical application of autologous PRP and its secretory factors for promotion of hair growth(Li ZJ et al., 2012) Treatments for alopecia are in high demand, but not all are safe and reliable. Dalteparin and protamine microparticles (D/P MPs) can effectively carry growth factors (GFs) in platelet-rich plasma (PRP). Takikawa M et al., analyzed the effects of PRP-containing D/P MPs (PRP&D/P MPs) on hair growth.with 26 volunteers Participants with thin hair who received five local treatments of 3 mL of PRP&D/P MPs (13 participants) or PRP and saline (control,13 participants) at 2- to 3-week intervals and were evaluated for 12 weeks. Injected areas comprised frontal or parietal sites with lanugo-like hair. Experimental and control areas were photographed. Consenting participants underwent biopsies for histologic examination. Results suggest that D/P MPs bind to various GFs contained in PRP. Significant differences were seen in hair cross-section but not in hair numbers in PRP and PRP&D/P MP injections. The addition of D/P MPs to PRP resulted in significant stimulation in hair cross-section. Microscopic findings showed thickened epithelium, proliferation of collagen fibers and fibroblasts, and increased vessels around follicles. PRP&D/P MPs and PRP facilitated hair growth but D/P MPs provided additional hair growth. The authors have indicated no significant interest with commercial supporters.( Takikawa M et al., 2011 )

ACell (Matristem) attracts Adult Stem Cells to the site of injury (in this case Hair Transplantation) and converts them into active progenitor cells which is what becomes missing during hair miniatuization. It also sets up a non crosslinked temporary scaffolding for the tissue reconstruction mimicking the surrounding healthy but damaged tissue. This scaffolding contains and slowly releases growth factors (VEGF etc.). The Acell also contains an abundance of necessary materials for remodeling including Collagen IV.This process has resulted in increased hair counts in the grafts in the recipient area (increased hair density) plus remarkable healing in the donor area. Much has been written as of late in the use of PRP (Platelet Rich Plasma) Injections to slow down or stop balding as well as to re-grow miniaturizing scalp hairs. A lot of the early reported variable successes have been attributed to the fact that there are significant vital proteins (Collagen IV etc.) as well as multiple growth factors (ie: VGRF) that are vital to terminal hairs along with hair survival and enhancement in general. It has been postulated that

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the addition of ECM (Extracellular matrix) may significantly improve the results.( Greco, J, 2009)

REFERENCES

1. Greco, J, Brandt, R. The effects of autologous platelet rich plasma and various growth factors on non-transplanted miniaturized hair. Hair Transplant Forum Int’l, Vol 19:2, 49-50, March /April 2009

2. Li ZJ, Choi HI, Choi DK, Sohn KC, Im M, Seo YJ, Lee YH, Lee JH, Lee Y Autologous Platelet-Rich Plasma: A Potential Therapeutic Tool for Promoting Hair Growth. Dermatol Surg. 2012 Mar 27. doi: 10.1111/j.1524-4725.2012.02394.x

3. Takikawa M, Nakamura S, Nakamura S, Ishirara M, Kishimoto S, Sasaki K, Yanagibayashi S, Azuma R, Yamamoto N, Kiyosawa T: Enhanced effect of platelet-rich plasma containing a new carrier on hair growth. Dermatol Surg. 2011 ,1524-4725.2011.02123.x. Epub 2011 Aug 24.

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PRP BENEFICAL EFECTS IN PLASTIC SURGERY APPLICATION OF PLATELET-RICH PLASMA IN PLASTIC SURGERY: CLINICAL AND IN VITRO EVALUATION. The clinical use of platelet-rich plasma (PRP) for a wide variety of application has been reportedly employed most prevalently in problematic wounds, maxillofacial and hemi-facial atrophy, Romberg Syndrome, and diabetic foot ulcers. To our knowledge, PRP has never been described in the enhancement of fat grafting during tissue-engineering application in vivo. The authors describe the preparation of PRP and its use in a series of 43 patients who underwent plastic, reconstructive, and maxillofacial surgery for chronic lower extremity ulcers (n = 18) and multiple facial applications (n = 25). PRP mixed with fat grafting was used in 76% patients affected by multiple facial diseases and in 88.9% patients affected by lower extremity ulcers. PRP injection alone was used in the remaining patients. The authors observed that after a 7.1-week and 9.7-week (average) course of twice-daily wound treatment with PRP suspended on a collagen base, 61.1% and 88.9% of chronic lower extremity ulcers underwent to 100% reepithelization compared with 40% and 60% of controls (n = 10) treated with hyaluronic acid and collagen medication. In patients treated with reconstructing three-dimensional projection of face by fat grafting and PRP, we observed a 70% maintenance of contour restoring and three-dimensional volume after 1 year compared to only 31% of controls (n = 10) treated with fat grafting alone. In vitro, PRP induced a significant increase in the number of adipose-tissue-derived stem cells compared to control cultures. These results documented that PRP accelerates chronic skin ulcer reepithelization and improves maintenance and function of fat graft in patients who underwent plastic reconstructive surgery, possibly by stimulating adipose-tissue-derived stem cell proliferation.( Cervelli Vet al., 2009 ) CURRENT APPLICATIONS OF PLATELET GELS IN FACIAL PLASTIC SURGERY. The response of living tissue to injury is a central component in the planning of all surgical procedures. The wound-healing process is typically divided into three phases (inflammatory, proliferative, and remodeling) and is a complex process in which a multitude of cellular and humoral components interact to restore a wound defect. Platelets and their released cytokines and growth factors are pivotal in the modulation of this entire process. Although several techniques may be used to achieve hemostasis after initial injury, few initiate and actually accelerate tissue regeneration. Both platelet gel and fibrin glue are effective hemostatic agents. Platelet gels, unlike fibrin glue, have a high concentration of platelets that release the bioactive proteins and growth factors necessary to initiate and accelerate tissue repair and regeneration. In particular, two growth factors that play a major role in platelet gels are platelet-derived growth factor, a powerful chemoattractant, and transforming growth factor beta, which significantly increases and stimulates the deposition of extracellular matrix. In creating a platelet gel, autologous blood is centrifuged to produce a concentrate high in both platelets and plasma. This concentrate can be applied to wounds, providing hemostasis, adhesion, and enhanced wound healing. Recent techniques for the autologous concentrating process have been streamlined, and now platelet gels are clinically accessible to most physicians. Platelet gels have global applications in surgery and are especially useful for the soft tissue and bony reconstructions encountered in facial plastic and reconstructive surgery. In these applications, their use has been associated with a decrease in operative time, necessity for drains and pressure dressings, and incidence of complications. When applied to bony reconstruction it provides adhesion for the consolidation of cancellous bone and comminuted fracture segments.( Bhanot S, Alex JC 2002)

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PLATELET GELS AND HEMOSTASIS IN FACIAL PLASTIC SURGERY. The availability of autologous and homogenous platelet-rich and fibrin-rich gels has increased. Due to their more widespread availability and the potential benefits of improved hemostasis and wound healing, their use during facialplastic and reconstructive surgery procedures has also grown. These gels, when applied topically, attract inflammatory cells and fibroblasts and stimulate collagen deposition. Various studies have investigated the potential surgical applications and benefits of these gels. (Farrior E, Ladner K. 2011) PLATELET-RICH FIBRIN MATRIX FOR FACIAL PLASTIC SURGERY. Platelets are known primarily for their role in hemostasis, but there is increasing interest in the effect of platelets on wound healing. Platelet isolates such as platelet-rich plasma have been advocated to enhance and accelerate wound healing. describes the use of a novel preparation, platelet-rich fibrin matrix (PRFM), for facial plastic surgery applications such as volume augmentation, fat transfer supplementation, and as an adjunct to open surgical procedures.( Sclafani AP, Saman M. 2012 ) L-PRP/L-PRF IN ESTHETIC PLASTIC SURGERY, REGENERATIVE MEDICINE OF THE SKIN AND CHRONIC WOUNDS. The use of platelet concentrates for topical use is of particular interest for the promotion of skin wound healing. Fibrin-based surgical adjuvants are indeed widely used in plastic surgery since many years in order to improve scar healing and wound closure. However, the addition of platelets and their associated growth factors opened a new range of possibilities, particularly for the treatment of chronic skin ulcers and other applications of regenerative medicine on the covering tissues. In the 4 families of platelet concentrates available, 2 families were particularly used and tested in this clinical field: L-PRP (Leukocyte- and Platelet-rich Plasma) and L-PRF (Leukocyte- and Platelet-Rich Fibrin). These 2 families have in common the presence of significant concentrations of leukocytes, and these cells are important in the local cleaning and immune regulation of the wound healing process. The main difference between them is the fibrin architecture, and this parameter considerably influences the healing potential and the therapeutical protocol associated to each platelet concentrate technology. we describe the historical evolutions of these techniques from the fibrin glues to the current L-PRP and L-PRF, and discuss the important functions of the platelet growth factors, the leukocyte content and the fibrin architecture in order to optimize the numerous potential applications of these products in regenerative medicine of the skin. Many outstanding perspectives are appearing in this field and require further research.( Cieslik-Bielecka A,2011 )

REFERENCES

1. Cervelli V, Gentile P, Scioli MG, Grimaldi M, Casciani CU, Spagnoli LG, Orlandi A.

Application of platelet-rich plasma in plastic surgery: clinical and in vitro evaluation. Tissue Eng Part C Methods. 2009 Dec;15(4):625-34

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2. Cieslik-Bielecka A, Choukroun J, Odin G, Dohan Ehrenfest DM L-PRP/L-PRF in Esthetic Plastic Surgery, Regenerative Medicine of the Skin and Chronic Wounds. Curr Pharm Biotechnol. 2011 Jul 8.

3. Farrior E, Ladner K Platelet gels and hemostasis in facial plastic surgery.. Facial Plast

Surg. 2011 Aug;27(4):308-14. Epub 2011 Jul 26.

4. Sclafani AP, Saman M. Platelet-rich fibrin matrix for facial plastic surgery. Facial Plast Surg Clin North Am. 2012 May;20(2):177-86

5. Bhanot S, Alex JC Current applications of platelet gels in facial plastic surgery. Facial Plast Surg. 2002 Feb;18(1):27-33

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PRP ROLE IN CHRONIC WOUND AND ULCER

AUTOLOGOUS PLATELET-RICH PLASMA ENHANCES HEALING OF CHRONIC WOUNDS Chronic wounds are a frequent problem in developing countries, are often difficult to heal because they lack the necessary growth factors to maintain the healing process, and are frequently complicated by superinfection. Conventional therapies such as dressings, surgical debridement, and even skin grafting cannot provide satisfactory healing since these treatments are not able to provide enough necessary growth factors to modulate the healing process. Platelet-rich plasma (PRP), as a concentrate of platelets, releases a high concentration of multiple growth factors that can modulate healing processes. Furthermore, PRP also contains a high level of leukocytes, which can inhibit infection. PRP has been widely used in many clinical applications. Three patients with large chronic wounds were treated with PRP and achieved good clinical outcomes.(Ting Yuan et al., 2009)

A CASE REPORT ON THE USE OF SUSTAINED RELEASE PLATELET-RICH PLASMA FOR THE TREATMENT OF CHRONIC PRESSURE ULCERS Chronic pressure ulcers affect patient health, emotional state, and quality of life, causing considerable morbidity and mortality in addition to contributing to significant health care costs from lengthy hospitalizations to advanced home care and surgical care costs. The conventional treatment of these wounds can be slow due to their chronic inflammatory state and the senescence of local reparative cells. Platelet-rich plasma (PRP) therapy has been growing as a viable treatment alternative for a number of clinical applications and has potential benefit for use in chronic wounds. The sustained release of large quantities of autologous growth factors, cytokines, and other mediators found in PRP plus the favorable mononuclear cell profile of PRP may help us to stimulate wound healing and resolve chronic inflammation. Three veterans with spinal cord injury (SCI), presenting with chronic stage IV pressure ulcers, were treated with a sustained release PRP therapy to stimulate wound healing. Results suggest that PRP treatment consistently resulted in the formation of granulation tissue and improved vascularity for each of the three patients treated, while reducing the overall ulcer area and volume. The controlled release of growth factors from PRP demonstrated a positive stimulatory effect on the

healing rate of chronic pressure ulcers in individuals with SCI.( Scott A. Sell et al., 2011)

REFERENCES 1. Scott A. Sell1,2, Jeffery J. Ericksen1,3, Timothy W. Reis1,3, Linda R. Droste4,

Mohammed B. A. Bhuiyan4, David R. Gater3,4: A case report on the use of sustained release platelet-rich plasma for the treatment of chronic pressure ulcers The Journal of Spinal Cord Medicine 2011 VOL. 34 NO. 1.

2. Ting Yuan, MD; Chang-Qing Zhang, MD; Ming-Jie Tang, MD; Shang-Chun Guo, MD;

Bing-Fang Zeng, MD Autologous Platelet-rich Plasma Enhances Healing of Chronic WoundsWOUNDS 2009;21(10):280–285.

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THE USE OF AUTOLOGOUS PLATELET-RICH PLASMA (PLATELET GEL) AND AUTOLOGOUS PLATELET-POOR PLASMA (FIBRIN GLUE) IN COSMETIC SURGERY Daniel man et el evaluated a new technique of harvesting and preparing autologous platelet gel and autologous fibrin glue (body glue) and to evaluate their effectiveness in stopping capillary bleeding in the surgical flaps of patients undergoing cosmetic surgery. A convenience sample of 20 patients ranging from 25 to 76 years of age undergoing cosmetic surgery involving the creation of a surgical flap were included in the study. The types of surgical procedures included face lifts, breast augmentations, breast reductions, and neck lifts. Plateletpoor and platelet-rich plasma were prepared during the procedure from autologous blood using a compact, tabletop, automated autologous platelet concentrate system (SmartPReP, Harvest Autologous Hemobiologics, Norwell, Mass.). The platelet-poor and platelet-rich plasma were combined with a thrombin-calcium chloride solution to produce autologous fibrin glue and autologous platelet gel, respectively. Capillary bed bleeding was present in all cases and effectively sealed within 3 minutes following the application of platelet gel and fibrin glue. The technique for making the solution and for evaluating its effectiveness in achieving and maintaining hemostasis during cosmetic surgical procedures is described. Autologous platelet gel and fibrin glue prepared by the automated concentrate system are compared with autotransfusor-prepared platelet gel and Tisseel (Baxter Healthcare Corp.), a commercially prepared fibrin sealant preparation. This new technique for the harvesting of autologous fibrin glue and autologous platelet gel, with their promise of decreased bleeding and improved wound healing combined with ease of use, moderate cost, and patient safety should pique the interest of plastic surgeons and help this technique spread to encompass a large number and variety of plastic surgical procedures. The risks are small and the potential benefits large. The technique offers immediate theoretical and practical benefits. It opens a new emerging field of “wound pharmacology”and offers the exciting prospect of a revolutionary advance in plastic surgical ther-apeutics. This study has demonstrated that the use of autologous fibrin glue as a hemostatic agent and platelet gel as a tissue repair and regeneration agent has resulted in improved surgical outcomes( Daniel Man et al ., 2001)

REFERENCES

Daniel Man, M.D., Harvey Plosker, M.D., and Jill E. Winland-Brown, Ed.D., M.S.N., F.N.P.-C. THE USE OF AUTOLOGOUS PLATELET-RICH PLASMA (PLATELET GEL) AND AUTOLOGOUS PLATELET-POOR PLASMA (FIBRIN GLUE) IN COSMETIC SURGERY Plast. Reconstr Surg. 107: 229, 2001.

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USE OF PLATELET RICH PLASMA GEL ONWOUND HEALING: A SYSTEMATIC REVIEW AND META-ANALYSIS Autologous platelet rich plasma is an advanced wound therapy used in hardto-heal acute and chronic wounds. To better understand the use and clinical outcomes of the therapy, a systematic review of the published literature in cutaneous wounds was performed. Electronic and hand searches for randomized controlled trials and comparative group studies using platelet rich plasma therapy in cutaneous wounds and published over the last 10 years was conducted. Eligible studies compared the treatment to standard care or other interventions. All citations were screened and eligible studies were assessed for validity, quality, and bias using accepted scoring methods. The primary outcomes were effect of platelet rich plasma and control wound care on wound healing and related healing measurements. Secondary outcomes related to healing such as infection, pain, exudate, adverse events, and quality of life were also considered. The meta-analysis utilized appropriate statistical methods to determine the overall treatment effect on chronic and acute wound healing and infection.Results suggest that The search terms resulted in 8577 citations and after removing duplicates and screening for protocol eligibility, a total of 24 papers were used. The meta-analysis of chronic wound studies revealed platelet rich plasma therapy is significantly favored for complete healing. The meta-analysis of acute wounds with primary closure studies demonstrated that presence of infection was reduced in platelet rich plasma treated wounds. This systematic review and meta-analysis of platelet rich plasma therapy in cutaneous wounds showed complete and partial wound healing was improved compared to control wound care.( Marissa J. Carter et al ., 2011)

REFERENCES 1. Marissa J. Carter, PhD, MA,a Carelyn P. Fylling, MSN, RN, CWS, CLNC,b

and Laura K. S. Parnell, MSc Use of Platelet Rich Plasma Gel onWound Healing: A Systematic Review and Meta-Analysis, CWS 2011

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THE REGENERATIVE EFFECT OF PLATELET-RICH PLASMA ON HEALING IN LARGE OSTEOCHONDRAL DEFECTS Platelet-rich plasma (PRP), a platelet concentrate made of autogenous blood, has been used to improve bone and soft tissue defect healing in recent years. The aim of this study was to assess the effect of PRP on articular cartilage defects in a rabbit model. Forty-eight osteochondral defects created in the femoropatellar groove were (a)left untreated, (b) treated with autogenous PRP in a polylactic- glycolic acid (PLGA), or (c) with PLGA alone. Platelets were enriched 5.12-fold compared to normal blood in the PRP. After four and 12 weeks, the explanted tissue specimens were assessed by macroscopic examination,micro-computed tomography, and histological evaluation. Macroscopic examination, micro-computed tomography and histology of the newly formed cartilage and bone in the defect differ significantly between the PRPtreated and the untreated groups, and stimulatory effect of PRP on osteochondral formation was observed. In conclusion, PRP in PLGA improves osteochondral healing in a rabbit model.( Y. Sun et al., 2009) PLATELET RICH PLASMA IN ARTHROSCOPIC ROTATOR CUFF REPAIR: A PROSPECTIVE RCT STUDY, 2-YEAR FOLLOW-UP. Local application of autologous platelet rich plasma (PRP) improves tendon healing in patients undergoing arthroscopic rotator cuff repair. Prospective, randomized, controlled, double blind study; considering an alpha level of 5%, a power of 80%, 22 patients for group are needed. Fifty-three patients who underwent shoulder arthroscopy for the repair of a complete rotator cuff tear were randomly divided into 2 groups, using a block randomization procedure. A treatment group (N = 26) consisted of those who received an intraoperative application of PRP in combination with an autologous thrombin component. A control group (N = 27) consisted of those who did not receive that treatment. Patients were evaluated with validated outcome scores. A magnetic resonance image (MRI) was performed in all cases at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol.Results shows that The 2 groups were homogeneous. The pain score in the treatment group was lower than the control group at 3, 7, 14, and 30 days after surgery (P < .05). On the Simple Shoulder Test (SST), University of California (UCLA), and Constant scores, strength in external rotation, as measured by a dynamometer, were significantly higher in the treatment group than the control group at 3 months after surgery (strength in external rotation [SER]: 3 ± 1.6 vs 2.1 ± 1.3 kg; SST: 8.9 ± 2.2 vs 7.1 ± 2.7; UCLA: 26.9 ± 3 vs 24.2 ± 4.9; Constant: 65 ± 9 vs 57.8 ± 11; P < .05). There was no difference between the 2 groups after 6, 12, and 24 months. The follow-up MRI showed no significant difference in the healing rate of the rotator cuff tear. In the subgroup of grade 1 and 2 tears, with less retraction, SER in the PRP group was significant higher at 3, 6, 12, and 24 months postoperative (P < .05).The results showed autologous PRP reduced pain in the first postoperative months. The long-term results of subgroups of grade 1 and 2 tears suggest that PRP positively affected cuff rotator healing.( Randelli P et al., 2011)

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PLATELET-RICH PLASMA IN KNEE INJURIES

Injuries affecting the knee occur at a relatively high incidence, in athletes and causes instability and reduced function, besides being extremely painful, especially the acute phase. Surgical treatment is widely accepted as the therapy of choice and is recommended especially for young athletes in need of immediate return to their activities.

In recent years the use of growth factors has been used to speed healing, with the idea of a faster return to activity without restriction . The platelet-rich plasma (PRP) is defined as a volume fraction of blood plasma with an autologous platelet concentration above baseline. Platelets contain a large number of growth factors and cytokines that have a role in bone regeneration and soft tissue maturation . The rationale for use of the PRP is the reverse relationship of red blood cells that are less useful in the healing process and increase the recovery of platelets to . Since the use of PRP is increasing to improve the treatment of various orthopedic pathologies, held review in order to elucidate the efficacy of PRP in patients with knee injuries.( Romulo Soares Paris et al.,)

REFERENCES

1. Randelli P, Arrigoni P, Ragone V, Aliprandi A, Cabitza PPlatelet rich plasma in

arthroscopic rotator cuff repair: a prospective RCT study, 2-year follow-up. J Shoulder Elbow Surg. 2011 Jun;20(4):518-28.

2. Romulo Soares Paris I , Toyama Aires Felipe I ; Wanderley Marques Bernardo Platelet-rich plasma in knee injuries

3. Y. Sun & Y. Feng & C. Q. Zhang & S. B. Chen & X. G. Cheng; The regenerative effect of platelet-rich plasma on healing in large osteochondral defects International Orthopaedics (SICOT) (2010) 34:589–597

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