Can Platelet-Rich Plasma Therapy Help Surgery Patients Heal Faster?

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1 Can Platelet-Rich Plasma Therapy Help Surgery Patients Heal Faster? Sari Murray and Stacey Twisdale, Master of Surgical Assisting Students, Class of 2016, Eastern Virginia Medical School, Norfolk, VA Nervous, worried, anxious, and scared describe many surgical patients coming through the swinging doors of the OR. Regardless of whether the patient s surgery is a voluntary rhinoplasty or an emergency appendectomy, the average patient usually expresses some apprehension not only about the procedure, but more often about the recovery time following the surgery. Healing time is a major concern for many patients because it requires them to take time off work, alter their lifestyles, and worry about secondary problems resulting from the surgery that may result in future health issues. As practicing health care professionals, we always want the best for the patients. If there is a way we can help alleviate their worries, fears, pain or post-operative stress, we want to take the necessary measures to do so. One of the top questions surgical patients ask is when can I return to my normal activities? Of course, the answer depends on the type of surgery and the general health of the individual, but what if there were a treatment we could implement in the OR that would get the patient back on his/her feet more quickly? This is the concept behind platelet-rich plasma (PRP) therapy a treatment designed to use the patient s concentrated platelets to augment the body s natural healing process. What is PRP? Biologic therapy use has grown exponentially in the last few years, and the field of sports medicine has produced encouraging studies on the beneficial effects of PRP in the treatment of various ligament, cartilage, and tendon disorders. On the surgical front, PRP has been used to augment repairs in orthopedics, dentistry, and plastic surgery. PRP is a concentration of platelets in a small amount of plasma produced from the patient s own centrifuged blood. Normally, blood has a concentration of 150, ,000 platelets/µl, while PRP contains at least 1,000,000 platelets/µl. These highly concentrated platelets contain a variety of growth factors (including insulinlike growth factor 1 (IGF-1), transforming growth factor beta 1 (TGF- β1), plateletderived growth factor (PDGF), fibroblast growth factor (FGF), and vascular endothelial growth factor (VEGF) all of which have an anabolic effect on tissue. These growth factors are released once the platelets are activated. The principle behind PRP therapy is that by injecting a high concentration of platelets into damaged tissues, it will imitate and accelerate the body s natural

2 healing process. Furthermore, it has been shown that a four- or five-fold increase in platelets causes the proliferation of mesenchymal stem cells. These cells differentiate to regenerate various types of tissue, including bone, tendon, and cartilage. An increase in platelets can also stimulate the formulation of type I collagen to assist in tendon repair and to stimulate the proliferation of fibroblasts, which initiate repair at the molecular level and are essential to provide strength in connective tissue. According to the Perfusion Management Group, PRP accelerates endothelial, epithelial, and epidermal regeneration, stimulates angiogenesis, enhances collagen synthesis, promotes soft tissue healing, decreases dermal scarring, enhances the hemostatic response to injury, and reverses the inhibition of wound healing caused by glucocorticoids. With its tissue-sealing and hemostatic properties, PRP acts as a fibrin tissue adhesive similar to fibrin glue. However, PRP differs from fibrin glue due to its high concentration of platelets that promote wound healing and enhance osteogenesis properties that are not found with other platelet-poor tissue adhesives. By increasing the rate of hemostasis and tissue regeneration, PRP injections after surgery can potentially decrease the recovery time of a patient, and get him/her back into a daily routine more quickly. How Does It Work? Creating PRP starts by drawing blood from the patient. The amount of blood needed depends on the size of the area to be treated and the desired concentration of platelets. Next, the blood is placed into a centrifuge to separate out the three layers of blood red and white blood cells, the PRP layer, and the plasma portion. After mixing a small amount of the plasma with the PRP, a mixture of powdered bovine thrombin and calcium chloride are combined to activate the PRP and form a gel. The gel is inserted into the patient as needed, and its viscosity allows it to remain in place. To render a PRP preparation effective, it must be activated. Activation refers to the degranulation of platelets and the subsequent release of growth factors, and the cleavage of fibrinogen, which initiates the formation of the matrix. PRP may be activated either before or after it is injected into the tissue. Pre-injection activation methods (mentioned earlier) require the addition of thrombin and calcium chloride, while post-injection activation requires the inactivated PRP to be injected into the patient and allows it to become activated naturally after contacting collagen inside the tissue. The post-injection activation method is the preferred method for clinical applications for two reasons: it allows some growth factors to be released at a slower, more constant rate than the pre-injection method and, since the clotting takes place inside the tissue, the PRP can be introduced into the tissue using a smaller-gauge needle thus reducing the trauma to the patient s tissue.

3 What Are the Uses of PRP in Surgery? PRP is used in a wide variety of clinical applications including guided bone regeneration and dental implants in periodontal surgery, stenotomies and graft conduit sites in cardiothoracic surgery, full- and split-thickness skin grafts for both donor and recipient sites, skin flaps and aesthetic surgeries, mandibular and facial reconstructions, total knee and hip replacements, and even to help heal dura tears during laminectomies. Studies show that PRP decreases the frequency of bleeding in both donor and recipient sites both intra- and post-operatively. Additionally, PRP injected after surgery can promote and accelerate soft-tissue healing, support and stabilize the tissue at the graft site, and promote vascularization of the graft and surrounding tissue by delivering growth factors to the area. One of the growth factors found in PRP is Bone Morphogenic Protein (BMP). Research shows that when this protein combines with bone grafting material, it assists in the initiation of new bone growth. Many oral and maxillofacial surgeons found PRP to greatly accelerate healing time and bone growth in procedures such as sinus lifts, cleft lip and palate repairs, jaw reconstructions, and ridge expansions. In a cosmetic surgery study, researchers applied a combination of PRP and plateletpoor plasma (PPP) to patients undergoing procedures including face lifts, breast augmentations, breast reductions, and neck lifts. Due to the higher amounts of fibrinogen found in the PPP, the combination stopped the bleeding capillaries within three minutes. The surgical team noted this rapid coagulation could decrease the use of the electrocautery, and minimize the risk of damaging adjacent nerves. A 2005 study of over 1,300 cardiac surgery patients showed that PRP reduced the incidence of sternal infections following cardiac surgery. No deep sternal wound infections were found in the test group, compared to 1.5% of the patients in the control group. The number of superficial infections was markedly lower in the treatment group with only 0.3% reporting an infection compared to 1.8% in the control group. The utilization of PRP in ascending and transverse aortic arch repair using profound hypothermic circuit arrest (PHCA) surgery patients markedly decreased the need for blood transfusions and reduced early postoperative morbidity. Strategies to conserve the patient s blood and reduce transfusions have been ongoing, as coagulopathy is a common complication during this procedure. PRP use in orthopedic surgeries is showing great promise. Orthopedic doctors across the nation have been using PRP increasingly over the past few years to treat tendon tears in athletes some of whom believe it completely healed them. In February 2013, a study by researchers at the Hospital for Special Surgery (HSS) in New York found that PRP holds promise for treating patients with knee

4 osteoarthritis. Previous studies evaluated patients using subjective scores, but this study included MRIs of the patients knees before and one year after the PRP injection. Radiologists reading the MRIs were not told which images were taken before or after. Previous studies showed patients had an average loss of five percent of knee cartilage each year, but HSS researchers determined that 73% of their test subjects did not show any cartilage loss in the year following the PRP injection. Investigators also found the PRP treatment to be useful in improving pain, stiffness, and daily function. One researcher attributes the patients improvements to the PRP activating growth factors and stem cells that repair the tissue, calm osteoarthritic symptoms, and decrease inflammation. What Does the Future Hold? With its autologous supply of growth factors and demonstrated improvement of wound healing, PRP shows promise as an extremely beneficial tool in the operating room. There is a great deal of research showcasing the safety and efficacy of PRPs in dental, orthopedic, cardiothoracic, and plastic surgery. However, more clinical trials with concrete study designs, control groups, and parameters need to be performed to solidify these conclusions. If future studies continue to uphold the existing results, PRP could become a regular modality incorporated into intraoperative care to help patients make faster recoveries. Takeaways: The Advantages of PRP Safety The availability and autologous nature of PRP eliminate the risks associated with allogenic products used in surgery, so it does not carry the risks of transmitting infectious disease or tissue rejection. Promotes Healing The saturation of platelets in PRP not only mimics the last step in the clotting cascade to form a fibrin clot and promote homeostasis, but it also releases growth factors to precipitate tissue synthesis and regeneration. This significantly shortens healing time in both bone and soft tissue by up to 50%. Convenient Blood is taken from the patient s body and centrifuged either before or during the surgery, so there is no need for an additional trip to a blood bank or hospital. Multiple Growth Factors Once activated, PRP contains multiple growth factors and differentiation factors. The morphologic and molecular configuration of PRP shows that it is a fibrin framework over platelets with the potential to support a regenerative matrix. Easy to Use The gel-like consistency of pre-activated PRP makes it easy to inject into a specific site, and its viscosity ensures it will stay in place.

5 References: Halpern, Brian, MD, Salma Chaudhury, MD, Catherine Hayter, MBBS, Eric Bogner, MD, Joseph Nguyen, MPH, and Scott Rodeo, MD. "Platelet-rich Plasma (PRP) Treatment Shows Potential for Knee Osteoarthritis." Hospital for Special Surgery. Hospital for Special Surgery, 12 Feb Web. 29 Mar Ma, Richard, Michael Schaer, Macalus Hogan, Marco Demange, Scott A. Rodeo. "Orthobiologics: Clinical Application of Platelet-Rich Plasma and Stem Cell Therapy." DeLee and Drez s Orthopaedic Sports Medicine: Principles and Practice. 4th ed. Elsevier, Sánchez, Mikel, Diego Delgado, Pello Sanchez, Nicolas Fiz, Juan Azofra, Gorka Orive, Eduardo Anitua, Sabino Padilla. "Platelet Rich Plasma and Knee Surgery." BioMed Research International, 2 Sep Web. 30 Nov mid: Smith, Rick G., B.S., C.C.P., Craig J. Gassmann, C.C.P., and Mark S. Campbell, B.A., C.C.P. Platelet-Rich Plasma: Properties and Clinical Applications. The Journal of Lancaster General Hospital. Summer "Surgical Technique." EmCyte Corporation. Web. 17 Jan Wasterlain, Amy S., Hillary J. Braun, and Jason L. Dragoo. "Contents and Formulations of Platelet-Rich Plasma." Operative Techniques in Orthopaedics. Elsevier, Zhou, Shao-Feng, MD, Anthony L. Estrera, MD, Charles C. Miller, III, PhD, Craig Ignacio, MD, Sreelatha Panthayi, MD, Paul Loubser, MD, Dean L. Sagun, BA, Roy Sheinbaum, MD, and Hazim J. Safi, MD. "Analysis of Autologous Platelet- Rich Plasma During Ascending and Transverse Aortic Arch Surgery." The Annals of Thoracic Surgery 95.5 (2013): The Annals of Thoracic Surgery. The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association, Web. 20 Mar