Plate Lysate/Platelet Releasate vs PRP Plate Lysate/Platelet Releasate vs PRP in Regenerative Medicine “Blood-in Regenerative Medicine “Blood-

derived Growth Factor Concentrates” derived Growth Factor Concentrates” EBM updateEBM update

Paul S. Lieber, M.D.Paul S. Lieber, M.D.

AAOM Annual Conference & Scientific Seminar 2018AAOM Annual Conference & Scientific Seminar 2018

Clearwater Beach, FLClearwater Beach, FL

Try to simplify to make Try to simplify to make things teachable and things teachable and understandableunderstandable

You are only going to You are only going to learn a few things from learn a few things from each lecture each lecture

Make it count!Make it count!

KISS PRINCIPLE

20 Minute Lecture20 Minute Lecture

Simple TopicSimple Topic

500 slides500 slides

2 minute lecture 2 minute lecture

18 minutes for Q&A18 minutes for Q&A

Done on timeDone on time

No Problem!No Problem!

PRP HistoryPRP History

Late 90s, use in implant Late 90s, use in implant dentistrydentistryMid 2000s-the beginning Mid 2000s-the beginning of orthopedic useof orthopedic useLate 2000s more wide-Late 2000s more wide-spread adoption as an spread adoption as an orthobiologicorthobiologic

Platelets live in whole blood…Platelets live in whole blood…

The good stuff lives in granules...The good stuff lives in granules...

Types of granules…Types of granules…

Alpha-GFs, clotting Alpha-GFs, clotting factors, fibrin factors, fibrin stabilizing factorsstabilizing factors

Dense-ATP, ADP, Dense-ATP, ADP, Ca2+, serotonninCa2+, serotonnin

TGF-B

TGF-BTGF-B

TGF-B

PDGF

PDGF

PDGF

PDGF

PDGF

VEGF

VEGF

VEGF VEGF

VEGF

VEGF

Platelets have growth Platelets have growth factors inside them…factors inside them…

How platelets augment healing…How platelets augment healing…

Using PRPUsing PRP

Activation?Activation?

Thrombin and CaCl2 will activate Thrombin and CaCl2 will activate plateletsplatelets

Platelets will also be activated by Platelets will also be activated by injecting them into an OA joint or tendoninjecting them into an OA joint or tendon

Hence, it’s unlikely that manual Hence, it’s unlikely that manual activation carries a benefitactivation carries a benefit

Different Preps and Techniques?Different Preps and Techniques?

PreparationPreparation

ClassificationClassification

ActivationActivation

WBCs?WBCs?

RBCs?RBCs?

ConcentrationConcentration

WBCs?WBCs?

No evidence yet for clinical differences in No evidence yet for clinical differences in knee knee OA between LR and LP-OA between LR and LP-Arthroscopy.Arthroscopy. 2016  2016 Mar;32(3):495-505Mar;32(3):495-505Antibacterial effects not related to WBCs (likely Antibacterial effects not related to WBCs (likely cytokines)-cytokines)-BMC Microbiol.BMC Microbiol. 2015 Jul 30;15:149. 2015 Jul 30;15:149.Adverse reactions in knee OA joint injections Adverse reactions in knee OA joint injections directly related to WBC concentration- directly related to WBC concentration- Am J Sports Med.Am J Sports Med. 2016 Mar;44(3):792-800. 2016 Mar;44(3):792-800.LR PRP stimulates a pro-inflammatory LR PRP stimulates a pro-inflammatory environment in fibrin scaffolds that hurt environment in fibrin scaffolds that hurt fibroblast and osteoblast proliferation. fibroblast and osteoblast proliferation. PLoS One.PLoS One. 2015 Mar 30;10(3):e0121713. 2015 Mar 30;10(3):e0121713.

LR vs. LP PRP (Leukocyte Rich vs. LR vs. LP PRP (Leukocyte Rich vs. Poor)-KneePoor)-Knee

LR resulted in significant synovial cell LR resulted in significant synovial cell death and pro-inflammatory mediators death and pro-inflammatory mediators in-vitro, whereas LP did not. in-vitro, whereas LP did not. Am J Sports Med.Am J Sports Med. 2014  2014 May;42(5):1204-10.May;42(5):1204-10.LP caused better chondrocyte LP caused better chondrocyte proliferation in-vitro. LP caused anabolic proliferation in-vitro. LP caused anabolic ECM production, LR caused catabolism-ECM production, LR caused catabolism-J Bone Joint Surg Am.J Bone Joint Surg Am. 2014 Mar  2014 Mar 5;96(5):423-95;96(5):423-9Knee OA-LP outperformed LR on Knee OA-LP outperformed LR on functional scores-functional scores-Am J Sports Med.Am J Sports Med. 2016 Mar;44(3):792-800. 2016 Mar;44(3):792-800.

LP caused less tendon LP caused less tendon inflammation, but similar inflammation, but similar celluarity-animal model-celluarity-animal model-Am J Sports Med.Am J Sports Med. 2012  2012 Jun;40(6):1274-81Jun;40(6):1274-81More on this once we More on this once we review concentrationreview concentration

LR vs. LP PRP (Leukocyte Rich vs. Poor)-TendonLR vs. LP PRP (Leukocyte Rich vs. Poor)-Tendon

MSC Responses MSC Responses to LR vs. LP PRPto LR vs. LP PRP

This information protected by copyright 2016-Regenerative Sciences LLC

RBC-, PRP

No growing MSCsNo growing MSCs

MSCMSCColoniesColonies(CFUs)(CFUs)

MSCMSCColoniesColonies(CFUs)(CFUs)

Representative MSC colonies for CFU counts (inversion microscopy).

RBC+, PRP

RBC-, PL

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The best concentration for tendons?The best concentration for tendons?

Invivo studiesInvivo studies

Animal model of tendon healing-increasing Animal model of tendon healing-increasing platelet concentrations from 2X to 5-7X to 15-platelet concentrations from 2X to 5-7X to 15-20X, with and without WBCs20X, with and without WBCsEven 2X showed good tendon healingEven 2X showed good tendon healingIt was more important to eliminate WBCs than It was more important to eliminate WBCs than to hyper-concentrate tendons (i.e. maximizing to hyper-concentrate tendons (i.e. maximizing platelet to leukocyte ratio was better)platelet to leukocyte ratio was better)There may be a threshold of concentration There may be a threshold of concentration beyond which going higher could reduce beyond which going higher could reduce expression of certain collagen typesexpression of certain collagen typesBoswell, et al-Boswell, et al-Am J Sports Med.Am J Sports Med. 2014  2014 Jan;42(1):42-9.Jan;42(1):42-9.

Tendon concentration/WBC Tendon concentration/WBC summary?summary?

Many animal models performed in young tissuesMany animal models performed in young tissues

There is likely a plateau effectThere is likely a plateau effect

Our own data has shown that in-vitro work with high platelet Our own data has shown that in-vitro work with high platelet concentrations can negatively impact culture conditions due concentrations can negatively impact culture conditions due to mitochondrial waste productsto mitochondrial waste products

Is there a negative effect of going higher?Is there a negative effect of going higher?

A PRP count of 2B is approximately 7XA PRP count of 2B is approximately 7X

Recommendation-For young tendons, you likely don’t need Recommendation-For young tendons, you likely don’t need more than 2-3X, for older tendons go as high as 5-7X. more than 2-3X, for older tendons go as high as 5-7X. Either way, best to avoid RBCs!Either way, best to avoid RBCs!

Knee OA (meta-analysis)Knee OA (meta-analysis)

Arthroscopy.Arthroscopy. 2016 Mar;32(3):495-505 2016 Mar;32(3):495-505

6 studies reviewed (n=739, 817 knees, 39% 6 studies reviewed (n=739, 817 knees, 39% males, mean age of 59.9 years, with 38 weeks males, mean age of 59.9 years, with 38 weeks average follow-up)average follow-up)

PRP injection results in significant clinical PRP injection results in significant clinical improvements up to 12 months postinjection. improvements up to 12 months postinjection.

Clinical outcomes and WOMAC scores are Clinical outcomes and WOMAC scores are significantly better after PRP versus HA at 3 to significantly better after PRP versus HA at 3 to 12 months postinjection. 12 months postinjection.

Knee OAKnee OA

In general, PRP works better In general, PRP works better in less severe OAin less severe OASweet spot seems to be Kl Sweet spot seems to be Kl grade 1-2 (mild to moderate grade 1-2 (mild to moderate OA)OA)Less likely to work in severe Less likely to work in severe OAOA

Hip OAHip OA

N=111 RCT, 3 weekly US guided N=111 RCT, 3 weekly US guided injections of PRP vs. PRP+HA vs. injections of PRP vs. PRP+HA vs. HAHA

LP-PRP-concentrations not listedLP-PRP-concentrations not listed

PRP superior to the other two PRP superior to the other two tested treatmentstested treatments

Am J Sports Med.Am J Sports Med. 2016  2016 Mar;44(3):664-71Mar;44(3):664-71

Best Achilles tendon study to date:Best Achilles tendon study to date:

20 Achilles tendon ruptures treated with PRP 20 Achilles tendon ruptures treated with PRP vs. salinevs. saline

They took samples of the tendonThey took samples of the tendon

PRP treated tendons with better collagen 1, PRP treated tendons with better collagen 1, better cellularity, less vascularity, better better cellularity, less vascularity, better GAGsGAGs

PRP outperformed saline control on PRP outperformed saline control on pain/functionpain/function

Lancet.Lancet. 2015 Feb 26;385 Suppl 1:S19 2015 Feb 26;385 Suppl 1:S19

Best Tendonitis Study to date Best Tendonitis Study to date (lateral epicondylitis):(lateral epicondylitis):

DB multi-center RCTDB multi-center RCT

N=230N=230

LR-PRPLR-PRP

No significant differences were found at No significant differences were found at 12 weeks in this study. At 24 weeks, 12 weeks in this study. At 24 weeks, however, clinically meaningful however, clinically meaningful improvements were found in patients improvements were found in patients treated with leukocyte-enriched PRP treated with leukocyte-enriched PRP compared with an active control group.compared with an active control group.

Am J Sports Med.Am J Sports Med. 2014 Feb;42(2):463- 2014 Feb;42(2):463-71.71.

Lysate vs releasate-what’s the Lysate vs releasate-what’s the diference?diference?

Platelet LysatePlatelet Lysate

Lyse platelets by freezingLyse platelets by freezing

GF Immediately availableGF Immediately available

More advanced techniques leave fewer platelets More advanced techniques leave fewer platelets hanging aroundhanging around

Anti-inflammatoryAnti-inflammatory

Creates Neovasculogenesis around nervesCreates Neovasculogenesis around nerves

A releasate is a growth factor (gf) poor A releasate is a growth factor (gf) poor product…product…

A releasate is created by A releasate is created by overwhelming PRP with CaCl2 or overwhelming PRP with CaCl2 or thrombin to create a clot and thrombin to create a clot and prompt a GF releaseprompt a GF release

Platelets naturally release GFs Platelets naturally release GFs over 7-10 daysover 7-10 days

Hence prompting early release Hence prompting early release only allows a fraction of the total only allows a fraction of the total GF payload to be degranulatedGF payload to be degranulated

perfect for epidural useperfect for epidural use

PL injected epidural using PL injected epidural using fluoroacopically guided fluoroacopically guided transforaminal route or caudaltransforaminal route or caudalSame patient population who Same patient population who would normally benefit from ESI-would normally benefit from ESI-radiculopathy secondary to disc radiculopathy secondary to disc protrusion, extrusion, protrusion, extrusion, sequestration, or stenosissequestration, or stenosis

• Prospective registry data of epidural steroid patients versus platelet lysate epidurals

• Validated Functional Rating Index (FRI) used before and after at 3 and 6 months

• Patient population was lumbar radiculopathy due to HNP, bulge, or stenosis (mixed group)

• Injections were fluoro guided transforaminal and caudal (>90% TF)

• 11 patients crossed over from the ESI to the PL group

• Better FRI scores at 3 and 6 months for the Pl group vs. ESI (p<0.05)

• Cases chosen based on no missing registry data

n 3 month n 6 month

ESI 24 2.41 19 0.58

PL/Dex 60 9.65 48 7.62

SummarySummaryPRP seems to workPRP seems to work

WBCs/RBCs are likely an issue (red WBCs/RBCs are likely an issue (red PRP)PRP)

Going higher on concentration in Going higher on concentration in joints to stimulate local MSCs may joints to stimulate local MSCs may be helpfulbe helpful

Going lower on concentration in Going lower on concentration in tendons may be a good ideatendons may be a good idea

PL is anti-inflammatory and works PL is anti-inflammatory and works for epidurals and hydrodissection of for epidurals and hydrodissection of nervesnerves