ORANGE COUNTY PLATELET RICH PLASMA (PRP) AND ADULT STEM CELLS
By Steve A. Mora, MD
Platelet Rich Plasma and Stem Cell Treatment for Knee Arthritis
So what do you do if you are under 50 and have had steroid injections and maybe some hyaluronic acid for your arthritic knee pain? Perhaps you had a car accident or ligament rupture as a young person and now you have post traumatic arthritis. What do you do if you are a high level athlete with a meniscus tear or pain due to sports related injuries and you need to compete in a month or two? Do you live with the pain and maybe have surgery some day in the future when it is really bad?
Over the last 5 years there has been a surge of information regarding the use of non-operative therapies which harness the body’s own healing capacity to relieve or heal from injuries. Some of these treatment have been called blood therapies because they utilize some component of a patient’s own blood. These treatments include Platelet-Rich Plasma, Mesenchymal Stem Cell injections, amniotic tissue, Hyaluronic Acid injections, and Orthokine. As a whole these therapies are being called Autologous Regenerative Therapies. A whole new sector in the treatment of pain is emerging called “Orthobiologics”.
It’s quite possible that we are entering the era where the solution to arthritic pain or injury is no longer found by way of the scalpel but instead within our cells that have the capacity to heal.
Platelet Rich Plasma (PRP) is by far the most common regenerative treatment. The media attention on celebrities and superstar athletes has helped boost the popularity and awareness of these agents. The reality is that star athletes are not just getting PRP. There are other novel biological therapies available.
Why has there been such a surge in popularity of these treatments? There are numerous factors including the fact that surgical procedures are not as effective as we once thought, recovery after a surgery can be lengthy and patient are more educated about cutting edge medical advances. Also in general I think people, especially athletes, do not want surgery. Patients are more interested in biological treatments and prevention. There have been advances in molecular research which as advanced our knowledge of the stages of injury, cell death, chondral degeneration and the onset of post traumatic arthritis. There is also a financial issue. Treatments such as PRP and Adult Stem Cell injections are not covered by insurance.
The goal of this article is to touch on the more common Autologous Regenerative Therapies such as PRP and stem cell treatment. My goal is to answer the questions I frequently get asked in my own practice.
PLATELET RICH PLASMA
Platelet Rich Plasma (PRP) therapy appears to be a promising solution to accelerate healing of tendon injuries. Blood is made of RBC (Red Blood Cells), WBC (White Blood Cells), Plasma, Water, Clotting Factors, Antibodies and of course Platelets. Platelets were initially known to be responsible only for blood clotting however it was become clear that they do more than help create a blood clot. Cumulatively platelets and their growth factors may accelerate tissue and wound healing capacity.
The procedure is done in my office and involves the following. Your blood is drawn and put into a test tube. The blood is then put through a series of centrifuge spins which separates and increases the concentration of your platelets. The layer with the platelets is isolated and pulled into a sterile syringe. This part of the procedure takes about 30 minutes. The second part of the procedure involves injecting the PRP into the desired area. In the case of a arthritic knee I will use a portable ultrasound to accurately inject the platelets into the joint. I often recommend injecting Hyaluronic Acid (Orthovisc) along with the PRP. I usually recommend a series of 3 injections 2 weeks apart. One of the theories behind PRP is that it will ignite or initiate the healing response and decrease a pathological inflammatory response. It has been shown to be effective for the treatment of mild to moderate arthritis of the knee. Pain improvement is usually not immediate. It can take up to 3-4 weeks to feel better.
In some cases of knee arthritis patients will present with degenerative meniscus tears, loose debris and large knee effusions. In some of these cases I will recommend a simple knee scope first to shave or trim degenerative loose tissue. I will start the PRP treatments after the surgery. Patients who have suffered an acute meniscus tear, in contrast to a arthritic related meniscus tear might also benefit from PRP treatment.
Viscosupplementation, a.k.a. Hyaluronic acid (HA) injections, is a treatment option that is FDA approved for arthritis of the knee. Common brands of HA include Synvisc, Orthovisc, Supartz, and Euflexxa. Due to its success, some physicians have been using it “off label” (not FDA approved) for the treatment of arthritis of other joints such as the hip, elbow and ankle. Hyaluronic acid injections are recognized by most insurance carriers. The treatment involves injecting a gel like substance into the joint space. In order to improve accuracy the injection is sometimes performed using ultra-sound or fluoroscopy x-ray guidance. Once in the joint the gel-like fluid mimics natural components of the joint and cartilage called “hyaluronic acid”. The fluid provides an initial lubricant and or “cushion” effect resulting in pain or grinding reduction. In time it will get absorbed into the joint surface potentially generating a more durable cartilage. It is therefore more effective for joints which still have some cartilage remaining. Due to its anti-inflammatory effect, HA may even play a role in diminishing the risk of post traumatic arthritis after articular fractures. Visco- supplementation injections are usually performed once a week for 3 consecutive weeks. In some cases we can do a large of Synvisc however not all knees can accommodate so much fluid. Some patients tend to do better with one brand versus another. For this reason we sometimes switch the brand if the first series of injections did not help much. It can be repeated every 6 months or less. There really is no down side to injecting HA in a joint. For the treatment of mild or moderate arthritis I have been injecting a cocktail containing PRP and HA. Studies have shown that this combination of treatments is more effective than injecting HA alone.
MESENCHYMAL STEM CELLS DERIVED FROM YOUR BONE MARROW
Mesenchymal stem cells (MSC) can be readily obtained from the pelvis and from your own adipose tissue (fat) around your belly and waist. The benefit of Adipose Tissue MSC versus Bone Marrow MSCs is not certain. Doctors tend to use the one which they feel comfortable harvesting. I perform Bone Marrow (BM) derived Mesenchymal cells which I perform in my office. Mesenchymal stem cells have potent anti-inflammatory effects and growth factors. Mesenchymal stem cells are different than embryonic stem cells because of their ability to only form particular tissue such as cartilage, muscle, and tendons. These adult mesenchymal stem cells help to maintain our body’s continuous cycle of repair and healing of injuries. As we get older the concentrating of MSC is thought to diminish and as a consequence it becomes harder for us to recover from injury and/or damaged joints. Mesenchymal stem cell injections are being used to accelerate healing, and decrease pain in moderate to severe osteoarthritis and for acute injuries. The theoretical benefit of MSC over PRP is that you are getting a much higher concentration of growth factors and more anti-inflammatory potential. It is not recommended that patients who have been diagnosed with metastatic cancer or blood related cancers have bone marrow adult stem cell treatment. Patients who are on anticoagulants should be off
The process of obtaining these powerful regenerative cells requires 2 steps. I do the procedure in my office. It will take approximately 1 hr to complete. I first aspirate your BM from your left pelvis bone. This bone is easy to palpate and easy to completely anesthetize. Special equipment is required to gently and nearly painlessly into your pelvis. The Bone Marrow is them put through a series of centrifuge spins which separates the desired cellular components and produces the desired MSC. Part 2 involves injecting the acquired MSC into the desired area. In order to optimize the healing and pain reduction potential, I always combine the MSC with PRP. Although the MSC has some platelets, a PRP preparation from a simple blood draw will increase the total number of platelets being injected. Patients go home the same day. They are instructed to limit activity over the next 1-2 days and ice the joint and the pelvis area. . A PRP booster can be given 6-8 weeks after the MSC injection. Some doctors are doing Bone Marrow Concentrate immediately after a lavage and debridement surgery for patients with severe OA of the knee. There has been a surge in interest and in research on this topic however there is still minimal evidence that it is better than HA injections or steroid injections alone. There is growing amounts of empirical evidence (basically patient and doctor testimonials) showing that it helps. Compared to PRP this treatment is more involved, takes more time, requires more equipment and therefore is more expensive. Patients who have had bone marrow conditions such as cancer or bleeding disorders are not candidates for bone marrow harvesting.
To summarize there is a huge void in the treatments available for patients who have pain due to degenerative arthritis or cartilage injuries. The problem is especially difficult when I treat patients with moderate to severe arthritis but who are too young for joint replacement. I have found that the above “orthobiological” treatments can help however it is important to completely understand what is causing the pain and address it from various directions. Often times patients come in to see me for PRP or Stem Cells because they have been told that nothing else can be done. I have found that although these are challenging patients they are also especially gratifying to treat. I address the problem comprehensively and often times incorporate physical therapy, active release therapy, nutrition, endocrine, bracing, patient specific surgery and of course orthobiological treatments.
The orthobiological options such as PRP and adult mesenchymal stem cells for the treatment of injuries and arthritis are very exciting and hold great promise. We just might be a step closer to the Holy Grail of treatments, i.e. a treatment that can help heal, regenerate and prevent future degeneration.
Recent Patient Testimonial
I live in China. I had two knee operations on my left knee. After the second one, my knee never felt normal. It felt like there was still something wrong. I went to see Dr. Mora
He examined me and listen to what my goals were for my life style physical activity. He talked to me about the various options available. He recommended a Stem Cell shot.
I read all the material he provided and decided to get the stem cell shot. Afterwards, the first week my knee felt tight. When it went away, my knee felt better than the past 20
years. It now feels normal like before the first operation.
I highly recommend DR. Mora as he cares about the patient’s life style and will try to do everything to make it a reality. So if you need an Orthopedic Surgeon, do your research,
get the various opinions and lastly go see Dr. Mora. He will tell you what you need and not what is the easiest solution for someone else.
Review Articles regarding PRP:
Pourcho AM, Smith J, Wisniewski SJ, Sellon JL
Intraarticular Platelet-Rich Plasma Injection in the Treatment of Knee Osteoarthritis: Review and Recommendations.
American Journal of Physical Medicine and Rehabilitation, May 29, 2014
Platelet-rich Plasma Therapy: What You Should Know.
Michael Scarpone, DO; David Rabago, MD; Edward Snell, MD; Patrick DeMeo, MD; Kristine Ruppert, Dr PH; Perry Pritchard, PT, ATC; Gennie Arbogast, ATC; John Wilson, MD, MS; John F. Balzano, MD
Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective Open-label Study
Global Adv Health Med. ;0(ja):2-2
Vora A, Borg-Stein J, Nguyen RT.
Regenerative injection therapy for osteoarthritis: fundamental concepts and evidence-based review
American Academy of Physical Medicine and Rehabilitation. PM R. 2012 May;4(5 Suppl):S104-9
Kenneth Mautner, Gerard Malanga & Ricardo Colberg
Optimization of ingredients, procedures and rehabilitation for platelet-rich plasma
injections for chronic tendinopathy
Future Medicine, 2011
J. Alsousou, A. Ali, K. Willett et al.
The role of platelet-rich plasma in tissue regeneration
Informa Healthcare May 30, 2012
Boswell SG, Cole BJ, Sundman EA, Karas V, Fortier LA
Platelet-Rich Plasma: A Milieu of Bioactive Factors
Arthroscopy 2012 Jan 25.
Platelet-Rich Plasma: A Milieu of Bioactive Factors
Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2012
Rosalyn T Nguyen MD, Joanne Borg-Stein MD, Kelly McInnis DO.
Applications of Platelet-Rich Plasma in Musculoskeletal and Sports Medicine: An Evidence-Based Approach
PM&R; 2011 Mar; 3(3): 226-250.
Kenneth S Lee, John J Wilson, David P Rabago, Geoffrey S Baer, Jon A Jacobson, Camilo G Borrero.
Musculoskeletal Applications of Platelet-Rich Plasma: Fad or Future?
AJR Am J Roentgenol. 2011 Mar;196(3):628-36.
Sampson S, Gerhardt M, Mandelbaum B.
Platelet rich plasma injection grafts for musculoskeletal injuries: a review
Curr Rev Musculoskelet Med. 2008 Dec;1(3-4):165-74.
Tate K MD, Crane D.
Platelet Rich Plasma Grafts in Musculoskeletal Medicine
Journal of Prolotherapy. 2010 May; 2(2): 371-376.
Crane D, Everts P.
Platelet Rich Plasma (PRP) Matrix Grafts. Practical Pain Management
Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA.
Platelet-rich plasma: current concepts and application in sports medicine
J Am Acad Orthop Surg. 2009 Oct;17(10):602-8.
Sánchez M, Anitua E, Orive G, Mujika I, Andia I.
Platelet-rich therapies in the treatment of orthopaedic sport injuries
Sports Med. 2009;39(5):345-54.
Molloy T, Wang Y, Murrell G. 2003.
The Roles of Growth Factors in Tendon and Ligament Healing
Sports Med. 33(5):381-394
De Almeida AM, Demange MK, Sobrado MF, Rodrigues MB, Pedrinelli A, Hernandez AJ.
Platelet-Rich Plasma Added to the Patellar Tendon Harvest Site During Anterior Cruciate Ligament Reconstruction Enhanced Healing
Am J Sports Med. 2012 Jun;40(6):1282-8.
Podesta L, Crow SA, Volkmer D, Bert T, Yocum LA.
Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow With Platelet-Rich Plasma.
Am J Sports Med. 2013 May 10
Halpern B, Chaudhury S, Rodeo SA, Hayter C, Bogner E, Potter HG, Nguyen J.
Clinical and MRI Outcomes After Platelet-Rich Plasma Treatment for Knee Osteoarthritis.
Clin J Sport Med. 2012 Dec 12.
Giuseppe Filardo, Elizaveta Kon, Stefano Della Villa, Ferruccio Vincentelli, Pier Maria Fornasari and Maurilio Marcacci
Use of platelet-rich plasma for the treatment of refractory jumper’s knee
International Orthopaedics; 31 July 2009; Vol 24, No 6; 909-915
Elizaveta Kon, Giuseppe Filardo, Marco Delcogliano, Mirco Lo Presti, Alessandro Russo, Alice Bondi, Alessandro Di Martino, Annarita Cenacchi, Pier Maria Fornasari, Maurilio Marcacci
Platelet-rich plasma: New clinical application: A pilot study for treatment of jumper’s knee
International Journal of the Care of the Injured; 2009 June; 40(6): 509-603
Kelly L. Scollon-Grieve, MD, Gerard A. Malanga, MD
Platelet-Rich Plasma Injection for Partial Patellar Tendon Tear in a High School Athlete: A Case Presentation
American Academy of Physical Medicine and Rehabilitation, Vol. 3, 391-395, April 2011.
About Steve A. Mora MD:
Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He completed his training at the UC Irvine where he earned top of his class honors with his induction into the Alpha Omega Alapha Medical Society honors. He completed his Orthopedic Surgery training USC. He then completed a Sports Medicine, Cartilage, Shoulder, and Knee Fellowship at Santa Monica Orthopaedic and Sports Medical Group. He is currently practicing Orthopedic Surgery in Orange County. Dr. Mora’s practice focus on sports related trauma, knee ligament and cartilage repair, shoulder rotator cuff and instability, hip arthroscopy and partial knee replacement and ACL reconsctruction. He sees athletes of all levels including professional soccer and UFC/MMA. He is team doctor for the Anaheim Bolts pro indoor soccer team and Foothill High School. Some of the procedures he performs include Cartilage transplantation (Genzyme), partial custom knee replacement, OATS, tibial osteotomies, meniscus transplant, knee ligament reconstruction, shoulder reconstruction, elbow arthroscopy, hip arthroscopy, platelet rich plasma (PRP) and adult stem cell injections. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.
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