Evolution of Platelet-Rich-Plasma in orthopaedics: an update for upper limb conditions

Jul 13, 2021

Platelet-rich plasma (PRP) is increasing recognised in the community as a treatment of Regenerative Medicine. Whilst the cosmetic applications have been quickly adopted, there is still mixed messaging in the scientific literature on the effectiveness of PRP for musculoskeletal conditions. Below is an update from the point of view of a Shoulder & Elbow Sub-Specialist.

What is it? 

Autologous PRP is the processed liquid fraction of autologous peripheral blood with a platelet concentration above the baseline. The goal of PRP therapy is to harness the individual patient's own healing system to accelerate the repair of tendons, ligaments, muscles, and joints. 

The science behind PRP 

The underlying scientific rationale is the initiation of tissue repair via the release of numerous biologically active factors (growth factors, cytokines, lysosomes) and adhesion proteins that are responsible for initiating the haemostatic cascade, synthesis of new connective tissue, and revascularization. 

How is PRP performed? 

A set volume of blood is drawn from the patient and placed into a sterile container which is then placed into a centrifuge. This spinning process separates whole blood into layers of PRP, platelet-poor plasma (PPP) and red blood cells. The patient can be given a local anaesthetic and the prepared PRP volume is injected into the area to be treated, sometimes under ultrasound guidance. The discomfort at the injection site relates to the volume injected, however, most patients can return to normal activity with no significant down time. 

The Evidence for Lateral/medial epicondylitis (tennis/golfer’s elbow) 

Traditional treatment for epicondylitis has traditionally involved peri- or intra-tendinous corticosteroid injections. The benefit is often short lived and repeated dosages contributes to a catabolic effect and prolonged healing. Systematic reviews and meta-analyses have concluded that PRP is superior to corticosteroids in the medium to long term for pain relief and earlier return to activities. There is early evidence to suggest a clinical benefit over placebo with reduced need for anti-inflammatories or opioids.  

The Evidence for Rotator cuff tendinopathy / tear 

There is early moderate evidence to suggest that severe refractory tendinopathy of the rotator cuff may benefit from intra-tendinous PRP therapy. The role of PRP in augmenting rotator cuff repair healing, intrasubstance or partial tears is still inconclusive. 

The Evidence for shoulder or elbow osteoarthritis 

Beyond low level evidence of medium-term symptom and functional improvements, there is no large RCTs to date that demonstrates a similar effectiveness of PRP as for knee osteoarthritis. 

Why doesn’t it work every time?

Although PRP has been increasingly utilised in the treatment of a variety of sports-related injuries, improvements in healing and clinical outcomes have not been universally reported. With every different commercial PRP preparation device, the variations in the volume of whole blood taken, the platelet recovery efficacy, the final volume of plasma in which the platelets are suspended, and the presence or absence of white blood cells, and the addition of exogenous thrombin to activate the platelets or calcium chloride to induce fibrin formation, can all affect the character and potential efficacy of the final PRP product. Furthermore, the lack of consensus on standardization of PRP preparation protocols, with adequate reporting on bioformulations in clinical applications, contributes to inconsistencies in reported outcomes. 

Truths and Myths 

Key points to remember:

• Basic science studies show that PRP treatment improves healing in many tissues.
  
• Since PRP is created from a patient's own blood, it is a relatively low-risk treatment with the potential to improve or speed healing.
  
• Anti-inflammatory medicines should be stopped before and after PRP treatment is given.
  
• With early promising results, more studies are needed to research the best ways to standardize the treatment's preparation.

Where to for the future? 

The full potential of PRP applications has yet to be determined. Technological advances in PRP devices and preparation methodologies show promising patient outcome results. The lack of a consensus in PRP preparation methods and validation continues to contribute to inconsistencies in PRP therapies, with enormous differences in PRP formulation, specimen quality, and, thus, clinical outcomes. Standardisation and further research should inform future treatment algorithm. In the meantime, PRP treatment for tennis or golfer’s elbow is an accepted mainstream treatment option for the upper limb, with case-by-case management of other conditions. 

Dr Rui Niu 

Orthopaedic Surgeon (Shoulder & Elbow)

Harbour to Highlands Orthopaedics
Level 7, Suite 701
Wollongong Private Hospital
360-364 Crown Street Wollongong
P: 02 9053 6757
F: 02 8088 6263
E: office@hhortho.com.au