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PRP Injections

By: Dr. Brent Mollon

On behalf of Simcoe-Muskoka Orthopaedics 

 

A new series of so-called ‘regenerative’ treatments are evolving in an attempt to stimulate the body’s natural healing process. Although we are frequently asked about ‘stem-cell’ therapies, most treatments designed to inject stem cells (bone marrow aspiration or adipose tissue harvest) remain clinically unproven and thus not recommended by our department.

In contrast, Platelet Rich Plasma (PRP) is a biologically active substance with increasing clinical evidence to support its use for several diseases of the musculoskeletal system.

 

What is PRP?

PRP is harvested from a patient’s own blood just prior to an injection. Through commercially available technology, blood is spun in a centrifuge to isolate the platelet layer. Platelets are a liquid substance found within the blood that contain many substances and growth factors required for healing of injury.1 Once isolated, the biologically active platelet layer is injected into the site of arthritis or injury to incite or augment a healing response.

 

Is PRP Treatment Effective?

 The rationale behind PRP injections is supported by basic science research on cellular regeneration following injury.1,2  High quality clinical evidence continues to emerge to help determine which orthopaedic conditions may benefit from PRP. To date, available evidence suggests PRP injections may be beneficial in patients with mild to moderate osteoarthritis of the knee, as well as lateral epicondylitis of the elbow.3 PRP appears to be more effective than hyaluronic acid injections for osteoarthritis of the knee.4,5 Although PRP has been tried in muscular injuries, medial epicondylitis, ACL reconstructions, Achilles tendon injuries and rotator cuff injuries, available data does not support the use of these injections in these diseases.3

 

Treatment Considerations?

  1. Every Patient is Different: We see many patients seeking PRP therapy for diseases in which these injections have not been proven to work, or for cases with the arthritis is too severe to have any chance of success. Simply because someone you know benefited from these injections does not necessarily mean they will be helpful for you.
  2. Hydration: Prior to any injection, it is important that you are adequately hydrate and avoid excessive caffeine use so the maximal amount of blood (and thus PRP) can be extracted.
  3. Anti-Inflammatory Medications: some experts believe that anti-inflammatory medications will negatively impact the healing response. We believe the data behind this notion is poor, but still recommend that our patients avoid anti-inflammatory medications as a precaution.
  4. WADA: PRP is not prohibited by the World Anti-Doping Agency, as it is designed to return an athlete to their prior level of sport. However, the addition of substances to PRP that may be considered to produce ‘performance-enhancing’ benefits would be prohibited. Athletes considering PRP should consult with their team physician or coach prior to treatment.

 

Cost?

 As a newer therapy, PRP treatments are not covered by the Ontario Health Insurance Plan (OHIP) and are often not covered by independent insurance plans. The cost of most PRP injections ranges from $500-800 per injection depending on location and treating provider. As best available evidence suggests 2 or 3 injections (performed once a week) may be more effective than a single injection,5 this should be factored into treatment cost. As an example, we are able to provide PRP injections at $500 per injection to our patients, and recommend two injections separated by 7-10 days for a total treatment cost of $1000. As a patient, it is important that you are informed of total cost and your available insurance benefits when considering the investment in this treatment, should it be offered to you.

 

Anything Else I Should Know?

 Although PRP injections are safe, any injection comes with it a small risk of infection. It is possible that the additional fluid injected into your knee joint or soft tissues causes local irritation, so an increase in pain may be anticipated for a few days following any injection. Redness, warmth, heat, and/or excessive swelling is not normal and should prompt a call to your doctor and/or a trip to the emergency room.

 

The field of regenerative injections or ‘orthobiologics’ will continue to expand at a fast pace. Often newer treatments are made available when high-quality clinical data is lacking. It is important that you are as informed as possible about any proposed treatment.  Ask questions! Seek clarification if you do not understand! Being as involved as possible in the decision-making processes will go far in ensuring you get the best result possible – regardless of what ails you and what treatment is decided.

 

  1. Mollon B, Kandel R, Chahal J, Theodoropoulos J. The clinical status of cartilage tissue regeneration in humans. Osteoarthritis Cartilage. 2013;21(12):1824-1833.
  2. Sheth U, Simunovic N, Klein G, et al. Efficacy of autologous platelet-rich plasma use for orthopaedic indications: a meta-analysis. J Bone Joint Surg Am. 2012;94(4):298-307.
  3. Hussain N, Johal H, Bhandari M. An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature. SICOT J. 2017;3:57.
  4. Laudy AB, Bakker EW, Rekers M, Moen MH. Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: a systematic review and meta-analysis. Br J Sports Med. 2015;49(10):657-672.
  5. Gormeli G, Gormeli CA, Ataoglu B, Colak C, Aslanturk O, Ertem K. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017;25(3):958-965.

 

Smoking

Let us start by saying – this article will not be a lecture from atop a high horse. People still smoke for a variety of reasons, and the choice is theirs. We commend those that have tried and successfully quit, regardless of why they chose to do so. We respect how difficult it is to quit, and recognize many people try multiple times to do so. We acknowledge that some people don’t want to quit smoking, and we are not here to twist their arm.

There are many health reasons to quit smoking. Grab a pamphlet at any doctor’s office and it will tell you how quitting will prevent heart attacks, or strokes, or emphysema, or cancer. All those are great, but we not experts in any of those things. The reason busy orthopedic surgeons are writing about smoking cessation is that it makes a difference to your bones, joints and muscles. It makes a difference If we are managing your fractures, or talking to you about a surgery. It makes a difference in your outcomes of the treatments we recommend or the surgeries we perform on you.

Here are the only statistics we will put in this article:

  • Smokers are 30% more likely to have any post-operative infection and six times more likely to have a wound infection when compared to non-smokers.
  • Smokers have a 40% chance of having a breathing problem after surgery, compared to 11% in those that do not smoke.
  • Smoking inhibits bone growth and is the major preventable cause of bone non-union (inability of a fracture to heal).
  • Smoking negatively impacts success of bone fusion procedures (common in the foot and ankle).
  • Smoking predicts negative results in those undergoing knee ligament repair, rotator cuff repair, total knee arthroplasty, total hip arthroplasty, and fracture surgery.
  • Smokers are 38% more likely to die after surgery than patients who have never smoked.

Stats are all done.  If you skimmed over them the following sentence applies to nearly every orthopaedic surgery or injury: Smoking impedes healing, delays return to function, increases infection and complication risk, and may predict failure of surgery.

We will never make life choices for you, but we would be doing you a disservice by not stating the above. In some cases, such as fusion surgery of the foot and ankle, we may delay surgery because the results are so poor in smokers. Beyond that, we can only be there to help if surgery does not go as planned. But if you are so inclined, you can help increase the chance that surgery does go well – by quitting. You can speak to your family physician. You can seek information from trusted websites (www.stopsmokingforsafersurgery.ca or www.smokershelpline.ca to name a few). You can ask the help of family and friends to keep you honest and give you support. You can ask us, and we will provide whatever help we can.

Many people joke that it is only a matter of time before you will be sitting in the clinic of an Orthopaedic surgeon.  As surgeons, we want the best outcomes for our patients. There are many things in our control which we use to give a patient the best shot – following treatment guidelines, meticulous surgical technique, multi-modal and multi-disciplinary care, and asking for the help of colleagues when needed. It is humbling to know that smoking may have as great an impact as any one of those factors, and it is completely out of our control. The best we can do is get the word out, and thank those who take the time to listen – regardless of what they decide.

 

Yours in Health

Drs. Brent Mollon, Jerry Xing & Raaj Vora