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Plasma rich platelet protein injections normally referred to as PRP, is becoming a widely accepted treatment alternative for managing chronic tendinopathy and also degenerative joint disease.
Platelets are the cells of healing and repair. They contain over 1100 proteins contained in the alpha granules that are involved in various aspects of tissue repair.
PRPP solutions aim to harness this ‘healing potential’ of blood to stimulate a regenerative process in tendons and potentially articular cartilage.
The pathogenesis of tendon problems is not universally understood. It involves overload in a degenerative structure followed by an aberrant microvascular response known as angiofibroblastic hyperplasia.
Tendon conditions are well described to heal slowly, often taking 12—18 months to improve. This may be attributable to poor blood supply failing to stimulate the process of tissue repair. These prolonged timeframes are not always acceptable to an athlete or manual worker.
Standard treatment of tendinopathy usually involves relative rest, anti-inflammatory measures, physiotherapy with a rehabilitation program and consideration of a local cortisone injection.
While this approach is successful in many patients, a small proportion do not improve and require further treatment. Historically this has involved surgery, which is not universally helpful.
Biologic therapies have been available in other fields of medicine for a number of years, and have stimulated a lot of interest in filling the gap between standard conservative and surgical treatment.
Initial methods involved the injection of whole blood around tendons with a view to stimulating a healing response. In one study, 22/26 patients with tennis elbow improved after a single autologous blood injection.
The logical next step involved concentrating the active component of the blood, the platelets, while removing the parts that were not directly useful for healing, mainly the red blood cells and excess plasma. Injection of this platelet-rich plasma should theoretically enhance tissue healing in chronic tendon conditions.
An anticoagulant such as citrate-dextrose should be added to the whole blood to prevent activation of the platelets and subsequent clotting until they are delivered into the required area.
Where possible the PRPP should be delivered to the affected area with imaging guidance, such as ultrasound, to maximise the accuracy of delivery.
On the whole, PRPP injection is a safe procedure. The use of the patient’s own blood does make this a true ‘natural therapy’. The main side effect is with local pain around the injection site. The severity and duration is variable, but generally lasts for a few days (coinciding with a period of acute inflammation) and will often require stronger painkillers.
Some patients do develop pain for a few weeks. Ice is initially helpful. Pain is generally worse in tight tissue spaces such as the common extensor origin. Other side effects could include local infection, which is uncommon.
The PRPP injection usually takes 2—3 weeks to take effect, but it will often take a good six weeks before pain will improve. There is a role for repeating the injection at around the 6- to 8-week mark if initial improvement has occurred. Uncommonly a third injection can be required.
PRPP injections are not universally beneficial. The success rate for various tendon conditions in papers of variable quality is around the 70% mark. One higher quality randomised double-blind study looking at PRPP injection versus cortisone injection for chronic tennis elbow found a 75% improvement rate in the PRPP group at 12 months compared to a 49% improvement in the cortisone group.
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