REGENERATIVE THERAPIES

Yes. Much research has gone into the development of PRP based procedures.  WHAT LINKS TO PUBLICATIONS SHOULD GO HERE?

PRP does not offer quick pain relief. Pain gradually subsides as the injured tissue repairs and pain relieving factors activate. This can take weeks or months, but when successful, the effect is lasting.  If relief is not sufficient at 3 months, a second injection may be performed. Maximum effects are usually seen at 6-9 months.  Some knee joints may require 2 injections in closer succession.

Most patients are able to return to work the day following the procedure unless they are 1 in 10 that has a post-injection flare.  In that situation, the patient may need an extra day off work. Return to athletic activity depends on the type and site of injury. Most chronic tendon injuries that have failed to respond to any other type of treatment will generally take quite a number of weeks to heal. Injections into joints and acute muscle injuries respond a bit sooner.

No serious complications have been reported related to PRP.  Like any injection, there is a risk of infection, or damage to a nerve or blood vessel.  However, there is not a risk of adverse reaction to the platelets the way there is to a medication (ex. corticosteroids)

Cortisone injections have been widely used over many years to treat sports injuries and arthritis.  Unlike PRP injections cortisone injections allow only inflammation and pain to settle down and they do not induce healing. Hence, in many conditions the pain will recur due to lack of healing. Also steroid injections have potential complications such as skin atrophy, discoloration, weakening and rupture of the tendon where injection is given, joint deterioration and infection, among others.

If the injection is in your right knee or ankle tendons, you should bring a driver. If the injection is located in any other body part, you may drive yourself home after the injection.

Yes, Dr. Lehman will want to see you back in clinic to check your progress. You will be asked to make a follow up appointment 6 weeks following the injection.

Do not take anti-inflammatory medication such as Advil, Aleve, Motrin, Ibuprofen, Mobic, Naproxen, Nabumetone, or Diclofenac for 7 days prior to the injection and several weeks after the last injection. Pain medication will be prescribed the day of the procedure to be taken as needed. A regular aspirin regimen (81mg/day) is ok.  Tylenol/Acetaminophen is allowed.

Research and clinical experience suggest that PRP can successfully treat pain from chronic degeneration and tears of tissue tendons, and pain from mild-moderate joint articular cartilage degeneration. It is important to understand that PRP isn’t a miracle cure. The Hospital for Special Surgery in NYC estimates that their success rate for the platelet-rich plasma treatment, or PRP, is between 60 and 75 percent. (success=>50% relief of pain)

The Mayo clinic claims an 80% success rate. However, for a minimally invasive procedure in injuries/conditions that are notoriously hard to heal, that’s pretty impressive.

Ultrasound guidance is essential to accuracy of placement and enhancing efficacy of the injection. For more information, see our Ultrasound section.

Then bone marrow stem cell therapy or surgical treatment might be the next step.

PRP therapy seems to show its greatest potential when used for chronic tendinopathy conditions, such as epicondylitis. Mishra and Pavelko¹ prospectively evaluated recalcitrant cohort cases of medial and lateral epicondylitis after injection of buffy coat PRP or bupivacaine. They noted greater clinical improvement in the PRP group by 8 weeks postinjection, with continued improvement at just over 2 years.

Sampson and colleagues⁶ injected osteoarthritic knees with PRP 3 separate times at 4-week intervals. Their findings demonstrated significant resolution of pain and restoration of function compared with baseline for up to 1 year after treatment in a majority of patients.

In 2009, Kon and coworkers⁷ injected PRP into 115 arthritic knees 3 times at 21-day intervals. Statistically significant objective and subjective improvements were noted at the end of treatment and at 6- and 12-month follow-up compared with pretreatment.

Giannini et al.⁸ published similar results in their study of 46 patients. The conclusion of this study was that intra-articular injections of PRP showed a reduction of pain and recover function of the knee joint in patients affected by severe chondropathies of the knee.

Reports out of Hospital for Special Surgery in New York City suggest good improvement in over 300 people treated with PRP for knee arthritis. http://hss.edu/onthemove/does-platelet-rich-plasma-prp-really-work/#.UPQ4lY5qqRo

Gobbi et. al. studied 50 active patients with knee OA to evaluate outcomes in patients with and without previous surgical treatment of articular lesions. Two intra-articular injections of PRP (2.5 fold above baseline concentration without activation) were given to the two groups (operated on, and nonoperated), one month apart. They were followed at 6 months and 12 months. All patients, whether operated or not, showed significant improvement in pain and function scores as well as return to previous activities.

A double blind, randomized control trial with level 1 evidence was performed by Patel et. al.¹⁴ that demonstrated that a single injection of PRP at a concentration 10 times normal limit was as effective as 2 injections 3 weeks apart (platelet concentration 3x) for alleviating symptoms of early knee OA, and both significantly superior to saline. These results, however, seemed to deteriorate after 6 months, which may suggest that repeated treatments may be necessary.

In a more recent prospective, comparative study conducted by Kon and associates,⁹ PRP was pitted against low- and high-molecular-weight hyaluronic acid viscosupplementation in 115 knees that exhibited degenerative lesions, early OA, and severe OA. Improvement was noted in all treatment groups, but PRP was more effective than viscosupplemention in improving clinical and functional outcomes at 6 months postinjection in patients aged 50 years or younger. In patients older than 50 years, PRP and low-molecular-weight viscosupplementation produced equivalent beneficial results and high-molecular-weight viscosupplementation produced the worst results. The authors concluded that PRP may be a safe, viable alternative to hyaluronic acid injections.

The study by Sanchez et al.¹⁰ presented the preliminary results of the effectiveness of intra-articular injections of PRP in retrospective cohort study of 30 patients treated with PRP and 30 patients treated with HA. They suggested that knee OA treated with the application of PRP could present new and safe possibilities for enhanced outcomes.

A prospective, cohort study with a control group comparing PRP and hyaluronic acid was done by Spakova, et. al.¹¹. They studied 120 patients with a history of chronic pain of the knee lasting at least 12 mos and the radiologic signs of knee OA Grade 1, 2, and 3 according to Kellgren and Lawrence classification. All patients had previously been treated conservatively using analgesics and nonsteroidal anti-inflammatory drugs without success for at least 6 mos. One group was treated with three weekly injections of a medium molecular weight hyaluronic acid (Erectus) and the other with three weekly injections of PRP. No severe adverse events were observed. Platelet concentration was 4.5 fold above baseline and were inactivated. (compared to use of calcium chloride in other studies) The leukocyte concentration was 3.6 fold above baseline. (This has not been standardized at all.) Statistically significant improvement in pain and function at 3 and 6 month followup in the PRP group.

1. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006;34:1774-1778.

2. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38:255-262.

3. Taco Gosens,*”1″ MD, PhD, Joost C. Peerbooms,* MD, Wilbert van Laar,* and Brenda L, den Oudsten,1″ PhD. Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-year Follow-up. Am J Sports Med. 2011; 39:1200-1208.

4. Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper???knee. Injury. 2009;40:598-603.

5. van Buul GM, Koevoet WL, Kops N, et al. Platelet-rich plasma releasate inhibits inflammatory processes in osteoarthritic chondrocytes. Am J Sports Med. 2011;39:2362-2370.

6. Sampson S, Reed M, Silvers H, et al. Injection of platelet-rich plasma in patients with primary and secondary knee osteoarthritis: a pilot study. Am J Phys Med Rehabil. 2010;89:961-969.

7. Kon E, Buda R, Filardo G, et al. Platelet-rich plasma: intra-articular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc. 2010;18:472-479.

8. Giannini S, Vannini F, Timoncini A, et al: The treatment of severe chondropaties of the knee with autologous platelet rich plasma injections: Prelimi- nary results. Osteoarthr Cartilage 2008;16:126Y7

9. Kon E, Mandelbaum B, Buda R, et al. Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: from early degeneration to osteoarthritis. Arthroscopy. 2011;27:1490-1501.

10. Sanchez M, Anitua E, Azora J, et al: Intra-articular injection of an autologous preparation rich in growth factors for the treatment of knee OA: retrospective kohort study. Clin Exp Rheumatol 2008;26:910Y3

11. Frizziero, Giannotti, Ferraro, Masiero?Platelet rich plasma intra-articular injections: a new therapeutic strategy for the treatment of knee osteoarthritis in sport rehabilitation. A systematic review. Sport Sci Health (2012) 8:15?22

12. Spakova, et. al. “Treatment of Knee Joint Osteoarthritis with Autologous Platelet-Rich Plasma in Comparison with Hyaluronic Acid” American Journal of Physical Medicine & Rehabilitation 2012; 91:5:411-417.

13. G Filardo, E Kon, A Di Martin. Platelet-rich plasma vs hyaluronic acid to treat knee degenerative pathology: study design and preliminary results of a randomized controlled trial. BMC Musculoskeletal Disorders 2012, 13:229

http://www.biomedcentral.com/1471-2474/13/229/

14. S Patel, MS Dhillon, S Aggarwal. Treatment With Platelet-Rich Plasma Is More Effective Than Placebo for Knee Osteoarthritis A Prospective, Double-Blind, Randomized Trial. Am J Sports Medicine. 2013

http://ajs.sagepub.com/content/early/2013/01/07/0363546512471299.abstract

15. Alberto Gobbi, MD, Georgios Karnatzikos, MD, Vivek Mahajan, MD, and Somanna Malchira, MD “Platelet-Rich Plasma Treatment in Symptomatic Patients With Knee Osteoarthritis: Preliminary Results in a Group of Active Patients” Sports Health: A Multidisciplinary Approach 2012 4: 162 originally published online 20 January 2012

Bone marrow is the source of stem cells that Dr. Lehman uses. She harvests the bone marrow stem cells (called BMAC) from the posterior iliac crest (the back of the hip). Sometimes she will also mix PRP with BMAC.

The cost of this treatment will ultimately be determined by what particular injections are being done. The cost can vary but is estimated at $3,500-$4000 (for one joint). Stem Cell therapy is typically not covered by your insurance company. This is an out of pocket expense.

There is some limited data suggesting an ability to regenerate cartilage in joints, but it also appears that whether or not the cartilage regenerates has little correlation with relief of pain. If there is significant spurring and significant loss of the joint space, there is little chance of cartilage regeneration.

Most patients will have significant relief of pain around 1-2 months post injection. This will often continue to improve for the first 3-6 months after the stem cell procedure. There are patients who will not get any improvement at all from this procedure, probably around 10-20%. This is still an experimental treatment, and there have not been a lot of long term outcomes studies done so far so we are still figuring out who is an ideal candidate to have this done.

Typically one stem cell injection followed up 6 weeks later with a platelet rich plasma injection in the office. The protocol is continually evolving, so this is ultimately decided on a case-by-case basis.

If you are flying (and you are not the pilot), you may fly home the same day, but there will be increased pain/discomfort after the procedure. If you are driving, you should have a driver, as there can be some mild to moderate discomfort in the first few hours following the procedure.

Because of the potential for infection within the bone, this procedure is done in a complete sterile surgical environment at the Monticello Community Surgery Center in Charlottesville, Virginia.

Schedule a consultation with Dr. Lehman for an appointment to review your radiology films (x-rays), conduct a physical exam, and determine if you are a good candidate or not.