People are always looking for the latest miracle cure for their ailments. Not a week goes by when someone doesn’t ask me “What’s new in Orthopedics?”
The conversation usually gravitates to the issue of PRP and Stem cells. Platelet Rich Plasma (PRP) and Stem cells are the latest treatments that have moved on from the secret world of rich athletes and celebrities to your neighborhood doctor. The proof of the effectiveness of these treatments is still lacking but the availability is not – if you can afford the price (insurance does not cover these treatments).
Scott A. Rodeo, M.D., of the world famous Hospital for Special Surgery in New York, spoke on this subject at this year’s American Academy of Orthopaedic Surgeons Annual Meeting in New Orleans, a meeting I attended. Rodeo gave six reasons for the increased interest in these new treatments:
- Consumer demand, with patients frequently asking about and requesting these approaches
- Aggressive marketing, contributing to the demand
- A low regulatory bar for many of these agents
- The autologous nature that makes many approaches largely safe
- Some early, positive data demonstrating symptom modification (but few data for structure modification)
- A lack of effective therapeutic alternatives for many soft-tissue injuries
“There is little regulation and some early positive data, and we don’t have great solutions as clinicians for some of our patients’ problems. This creates a perfect storm that leads patients to seek these various treatments,” Dr. Rodeo said.
There is wide variability in the formulations used to treat patients. Among the formulations used for treatment under the PRP umbrella are pure platelet-rich plasma, platelet-leukocyte rich plasma, pure platelet-rich fibrin, and leukocyte-and-platelet-rich fibrin. Other blood derivatives, including autologous conditioned serum and autologous protein solution (APS) also have therapeutic potential. With all these various formulations being used, it is difficult to get meaningful conclusions from comparison of outcomes.
While these preparations have potential, there is a lot of work yet to be done to identify the goals of treatment and the most effective formulation for each condition. The wrong formulation for the right condition being treated is destined to failure. The right formulation for the wrong condition will be equally ineffective.
This “trial and error” approach is inefficient, wasteful, and expensive. Successful treatment becomes more luck than science. Terry Stanton, reporting for AAOS Now, tells us what we do know as of 2018:
- Tendinopathy: A positive effect is seen for leukocyte-rich PRP systems compared to leukocyte-poor PRP.
- Rotator cuff repair: A positive effect is seen in some studies using leukocyte-poor PRP; leukocyte-rich PRP and platelet-rich fibrin matrix are not effective.
- Anterior cruciate ligament surgery: PRP does not affect graft-tunnel healing; PRP may accelerate graft maturation; there is no effect on clinical outcomes.
- Knee osteoarthritis : Leukocyte-poor PRP has a positive effect on symptoms, not structure.
- Meniscus : Arthroscopic repair with platelet-rich fibrin matrix has no effect at two years; in open repair of horizontal tear, the PRP group was better for Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales for pain and sports.
- Hamstring injury: One of three randomized clinical trials showed beneficial effect of PRP over control for full recovery significantly earlier than physiotherapy alone; no other study found any significant difference between PRP and autologous blood, placebo injection, or platelet-poor plasma.
There is much potential in these biologic treatments, but until the science is better understood and clinical trials have produced better data, these treatments will remain an “expensive shot in the dark.”