Platelet-Rich Plasma (PRP)

During the past several years, much has been written about a preparation called platelet-rich plasma (PRP) and its potential effectiveness in the treatment of injuries.

Many famous athletes — golfer Tiger Woods, tennis star Rafael Nadal, and several others — have received PRP for various problems, such as sprained knees and chronic tendon injuries. These types of conditions have typically been treated with medications, physical therapy, or even surgery. Some athletes have credited PRP with their being able to return more quickly to competition.

Even though PRP has received extensive publicity, there are still lingering questions about it, such as:

• What exactly is platelet-rich plasma?
• How does it work?
• What conditions are being treated with PRP?
• Is PRP treatment effective?
• What Is Platelet-rich Plasma (PRP)?

Although blood is mainly a liquid (called plasma), it also contains small solid components (red cells, white cells, and platelets). The platelets are best known for their importance in clotting blood. However, platelets also contain hundreds of proteins called growth factors that are very important in the healing of injuries.

PRP is plasma with many more platelets than what is typically found in blood. The concentration of platelets — and, thereby, the concentration of growth factors — can be 5 to 10 times greater (or richer) than usual.

To develop a PRP preparation, blood must first be drawn from a patient. The platelets are separated from other blood cells and their concentration is increased during a process called centrifugation. These platelets are then injected into the injured site.

How Does PRP Work?

Although it is not exactly clear how PRP works, laboratory studies have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process.

To speed healing, the injury site is treated with the PRP preparation. This can be done in one of two ways:

PRP can be carefully injected into the injured area. For example, in Achilles tendinitis, a condition commonly seen in runners and tennis players, the heel cord can become swollen, inflamed, and painful. A mixture of PRP and local anesthetic can be injected directly into this inflamed tissue. Afterwards, the pain at the area of injection may actually increase for the first week or two, and it may be several weeks before the patient feels a beneficial effect.

PRP may also be used to improve healing after surgery for some injuries. For example, an athlete with a completely torn heel cord may require surgery to repair the tendon. Healing of the torn tendon can possibly be improved by treating the injured area with PRP during surgery. This is done by preparing the PRP in a special way that allows it to actually be stitched into torn tissues.

What Conditions are Treated with PRP? Is It Effective?

Research studies are currently being conducted to evaluate the effectiveness of PRP treatment. Recent research has shown that certain tendon problems can have improved outcomes with PRP injections. Additionally, more and more literature is showing the significant effectiveness of PRP in the treatment of mild to moderate knee osteoarthritis. Factors that can influence the effectiveness of PRP treatment include:

• The area of the body being treated
• The overall health of the patient
• Whether the injury is acute (such as from a fall) or chronic (an injury developing over time)
• The preparation of the PRP, including the cellular makeup of the material that is injected

Chronic Tendon Injuries

According to the research studies currently reported, PRP is effective in the treatment of chronic tendon injuries, especially tennis elbow, a very common injury of the tendons on the outside of the elbow.

The use of PRP for other chronic tendon injuries — such as chronic Achilles tendinitis or inflammation of the patellar tendon at the knee (jumper's knee) is promising. However, it is difficult to say at this time that PRP therapy is any more effective than traditional treatment of these problems.

Acute Ligament and Muscle Injuries

Much of the publicity PRP therapy has received has been about the treatment of acute sports injuries, such as ligament and muscle injuries. PRP has been used to treat professional athletes with common sports injuries like pulled hamstring muscles in the thigh and knee sprains. 

Surgery

More recently, PRP has been used during certain types of surgery to help tissues heal. It was first thought to be beneficial in shoulder surgery to repair torn rotator cuff tendons. However, the results so far show little or no benefit when PRP is used in these types of surgical procedures. Recent research has been dedicated to the benefit of PRP in meniscus healing after meniscus repair; however, these studies are only in their infancy.

Surgery to repair torn knee ligaments, especially the anterior cruciate ligament (ACL) is another area where PRP has been applied. At this time, there appears to be little or no benefit from using PRP in this instance.

Knee Arthritis

More and more literature is showing the effectiveness of low-leukocyte PRP in treating low- to moderate-grade knee osteoarthritis. Some studies have shown that these results can last up to two years.

Fractures

PRP has been used in a very limited way to speed the healing of broken bones. So far, it has shown no significant benefit.

Conclusion

Treatment with PRP could hold promise, however, current research studies to back up the claims in the media are lacking. Although PRP does appear to be effective in the treatment of certain chronic tendon injuries and low- to moderate-grade knee osteoarthritis, the medical community needs more scientific evidence before it can determine whether PRP therapy is truly effective in other conditions

Even though the success of PRP therapy is still questionable, the risks associated with it are minimal: There may be increased pain at the injection site, but the incidence of other problems — infection, tissue damage, nerve injuries — appears to be no different from that associated with cortisone injections.

If you are considering treatment with PRP, be sure to check your eligibility with your health insurance carrier. Few insurance plans, including workers' compensation plans, provide even partial reimbursement.

Regenerative Cell Injections

What are Regenerative Cells?

Regenerative cells are specialized cells that can replicate themselves and transform into various tissue forming cells. These cells can form bone, muscle, cartilage, and other u0003connective soft tissues.

Types of Regenerative Cells

There are two primary types of regenerative cell

• Adult u0003
• Embryonic.

Embryonic regenerative cells are obtained from an embryo during the every early stages of embryonic development. Their use is quite controversial due to concerns about their safety and ethics of use. Your Physician does NOT use u0003Embryonic cells.

Adult regenerative cells are your own cells. These adult u0003regenerative cells reside in reservoirs throughout your body. Your body uses these stored cells for tissue repair and u0003regeneration - they are the reason our bodies can heal. The regenerative cells your physician will be injecting are simply u0003a concentrated supply of your own cells! Adult regenerative cell use is not controversial because of their safety and u0003renewable nature.

Where are Regenerative Cell found

Adult regenerative cells are found throughout your body. They orchestrate the formation of tissue such as bone, u0003cartilage, fat, muscle, heart tissues, blood vessels, and nerves. The richest source for these cells are your bone marrow and fat. Bone marrow is found inside your bones. Using a small needle, your Physician will aspirate a small amount of your adult regenerative cell rich marrow to obtain the cells needed for your injection procedure.

Regenerative Cell use

Adult regenerative cells have been shown to transform into site specific tissue. As we age, some of these regenerative cells decrease in number. Your Physician uses a specialized device to concentrate your own cells to harness and enrich your body’s own ability to heal injured tissues. In other words, this procedure allows us to mimic the healing power of your younger self.

Conditions treated by Regenerative Cell Injections

• Regenerative Disc Disease in the Spine
• Mild to Moderate Osteoarthritis in any Joint
• Partial Tears of any Tendon, Ligament, or Meniscus
• Chronic Muscle Strain or Sprain
• Avascular Necrosis

Procedure

• Duration of Procedure: 30 to 45 minutes
• Positioning During Procedure: Laying down
• Volume of Marrow Aspirated: 1 to 4 ounces
• Pain Management: At least local anesthetic; consult with your Physician regarding additional options
• Procedure Recovery Time: 30 to 60 minutes

What to expect during the procedure

• Certified staff will monitor your vital signs before, during, and/or after the procedure
• Staff will take extra care to make sure that you feel comfortable and safe during the procedure
• You are encouraged to communicate your needs during the procedure
• The Doctor will identify the safest and easiest way to harvest the stem cells
• Your skin will be cleansed with a cold soap at the aspiration and injection sites
• Ultrasound or x-ray will be used in the procedure
• Your bone marrow will be expertly processed to identify and isolate your regenerative cells
• You will be assisted to change positions during the procedure for the injection
• Your concentrated adult regenerative cells will be injected into your injury site to aide healing
• You will be assisted to a private area to rest

Frequently Asked Questions

Is the procedure painful?

Many patients report mild to moderate discomfort lasting less than 5 minutes during the aspiration portion of the procedure. Discomfort at the aspiration site subsides as soon as the aspiration procedure is complete. Most patients report mild discomfort at their injection site consistent with what they would feel after any routine shot or injection. Specific procedures, such as injections into the disc in the spine can cause intermittent increased discomfort that patients report as moderate and is well treated with an ice pack and/or oral pain medications. This discomfort typically lasts less than 3 days.

When should I expect to see improvement?

Most patients report some initial improvements in their pain within a few days of the procedure. Studies show that most patients experience a significant decrease in their pain, and improvements in their disability, within the first couple weeks and months following treatment. These improvements should continue through the 6 month mark. Improvements in pain and disability happen as your Adult Regenerative Cells begin to influence tissue healing at your injury site. Improvements are typically cumulative in nature. Improvements may be visible on MRI around the 1 year mark.

How much will the procedure cost?

Procedure costs vary depending on what is being treated. Insurance may cover this type of treatment under some very specific circumstances. In most cases, this procedure is not yet covered by insurance. Please work with your Physician regarding options for payment for this treatment.

Viscosupplementation Injections

What are viscosupplementation injections

Viscosupplementation injections are specialized injections that reduce inflammation and pain in your knee joints. These injections are made of hyaluronic acid, a natural protein that lubricates your joints. Your body naturally produces hyaluronic acid, but the amount present in the joints often drops off with age.

Benefits

Viscosupplementation injections offer several benefits, including:

• Better viscosity of joint fluids
• Improved joint mobilization
• Reduced inflammation
• Diminished knee pain
• Reduced need for knee surgery

Injections reduce the knee discomfort caused by arthritis, other degenerative diseases, and physical trauma. Knee injections are far less invasive than knee surgery.

Are viscosupplementation injections right for me?

To find out if you’re a candidate for viscosupplementation injections at the Orthopaedic Institute of Henderson, your provider reviews your medical history and symptoms. They complete a physical exam and often suggest you undergo blood tests, X-rays, CT scans, MRIs, or other imaging procedures.

Procedure

The process of getting viscosupplementation injections is an outpatient procedure. Your orthopedist examines your knee joint for fluid retention and swelling. If needed, they drain off excess fluids from the joint before giving you the injections. Each injection takes just minutes to complete.

Outcomes

After undergoing viscosupplementation injections, take it easy on your joints for a while. You could notice temporary swelling or soreness at the injection site. Avoid long periods of standing and heavy lifting until your doctor gives you the OK. Ice the treatment area as needed.

Dr. Bellapianta might recommend that you receive additional injections once weekly for 3-5 weeks. You might notice results right away or over several weeks or months. Results vary from patient to patient.

In some cases, Dr. B may recommend more than one type of knee pain treatment to ensure the best possible, long-lasting results.

Steroid injections

Steroid injections are commonly used to treat a variety of inflammatory conditions of the upper extremity. Examples of these include trigger fingers (stenosing tenosynovitis), De Quervain's tendonitis, carpal tunnel syndrome, arthritis, tennis elbow, (lateral apicondylitis), and rotator cuff tendonitis. 

What is in a steroid injection

Steroid injections contain a mixture of a synthetic cortisone and a local anesthetic such as lidocaine or bupivacaine. Cortisone is a steroid normally produced by the adernal gland and is a powerful anti-inflammatory. There are several available synthetic preparations such as triamcinolone, betamethasone, and dexamethasone, and they are also commonly referred to by their trade names. They all have similar mechanisms although they vary in strength and duration of action (short versus long-acting). No single preparation has been found to be superior to others so the choice of medication is left up to the individual provider. These anti-inflammatory steroids are distinctly different from the anabolic steroids that have been abused by some athletes for body-building and performances enhancement. The local anesthetic dissolves the steroid and anesthetizes the area of the injection, diminishing discomfort during the procedure. 

How injections work

Steroid injections work by decreasing inflammation. Once the inflammation subsides, the associated pain usually improves as well.

Frequently Asked Questions

How is the procedure performed?

The area to be injected is first cleansed with an antiseptic such as an iodine preparation, alcohol, or other skin disinfectant. The injection is then given with a small needle. Typically, only a small amount of steroid and local anesthetic is injected. Afterwards, the area is covered with gauze or an adhesive bandage. 

When does it take effect and how long does it last?

The injection should take effect within a few days and the benefits can last for many weeks. The exact timing, however, varies from patient to patient. For some conditions, one injection can be sufficient to completely get rid of the inflammation and pain while for more severe cases, several injections may be required. Most patients respond well to injections although a small subset may not experience any relief of symptoms. 

How many injections can one get?

There is no set rule as to how many injections a person can get. Many providers use three injections as a rule of thumb, although, in some cases, more frequent injections may be helpful. Your response to the first injection is very important in determining whether to proceed with re-injection: If the first injection doesn't work or wears off quickly it may not be worthwhile repeating. Many providers limit the number of injections because repeated cortisone may cause damage to tendons and/or cartilage. 

What are common side effects?

The most common side effect is known as cortisone flare. This is thought to happen when the steroid crystallizes after being injected. In patients who experience a flare, a brief episode of pain lasting one or two days follows the injection. This pain can be worse than the initial discomfort for which the injection was given. Cortisone flares resolve spontaneously over a few days and can be treated with ice and immobilization. 

Another common side effect, especially in patients with darker skin, involves skin discoloration at the injection site. The skin becomes locally lighter in color and sometimes thinner. Although this can improve, the whitening of the skin can sometimes be permanent. 

One of the more serious complications from steroid injections is an infection, especially if the injection was given into a joint. Fortunately infections are rare and can usually be prevented by carefully cleansing the skin before performing the injection. Very rarely, some patients may experience allergic reactions to the steroid or local anesthetic in the injection. 

Concerns in diabetic patients

Patients with diabetes will often notice a transient increase in their blood glucose in the days following a steroid injection.

When should you call your healthcare provider

If you have received a steroid injection and the area is bright red, warm to the touch, or your temperature is greater than 101 orally, you should call your provider to check for an infection.