Platelet rich plasma injections for meniscus tears

Platelet rich plasma injections for meniscus tears

Ross Hauser, MD and Katherine L. Worsnick, MPAS, PA-C

In this article we will explore research on Platelet Rich Plasma therapy for meniscus injury. This article is for people exploring the possibility of meniscus arthroscopic surgery, meniscus arthroscopic surgery with PRP augmentation, or PRP injections for meniscus tears as an option.

Patients will contact our office with questions about their meniscus injury and ask what our recommendations are for treatment. Of course the best recommendations are made after we perform a physical examination and check for range of motion, popping and clicking sounds, and catching and other issues of knee instability.

The patient may already have an MRI showing a meniscus tear, a recommendation for arthroscopic meniscus surgery, or a history of physical therapy and other conservative care treatments including anti-inflammatories and/or a recommendation from a surgeon that they really need to wait until their knee is worse before an operation can be performed.

One of the treatment options the patient may have researched is platelet rich plasma therapy or commonly referred to as PRP. PRP is an injection treatment which re-introduces your own concentrated blood platelets into areas of chronic joint and spine deterioration.

The video below will help you understand the treatment process

The reason patients are seeking out alternatives to conservative care or surgical intervention for meniscus injury is that these treatments have come under intense scrutiny in the medical community for failing to help patients achieve long-term knee repair. The most serious of the long-term consequences is an acceleration of joint degeneration.

In brief, in the research, surgeons warn each other that they face the difficult decision of removing or retaining the meniscus during an arthroscopic procedure. If the decision is made to retain the meniscus, the surgeons must address the difficulties of post-operative meniscal healing.

One option is to introduce Platelet Rich Plasma into the surgery. For some of our patients this is in fact where they heard about PRP the first time, when a doctor discussed with them surgical possibilities and the use of PRP for accelerated surgical healing.

PRP for meniscus repair, best during surgery or in office injection?

Doctors at Department of Orthopaedics, Xiangya Hospital, Central South University in China published their research in the journal Medical science monitor.

In this research they discuss the meniscus white-white tears which they describe as “a meniscus lesion completely in the avascular zone (which) are without blood supply and theoretically cannot heal.”

They hypothesize that doctors need to get blood to this meniscal zone for healing to occur but face the task that the problem of promoting meniscal healing in the avascular area has not yet been resolved. The possible answer? Platelet-rich plasma (PRP). The Chinese team supports the idea that the application of platelet-rich plasma for white-white meniscal tears will be a simple and novel technique of high utility in knee surgery.

Platelet-rich plasma (PRP) can be the answer for some surgical patients during the surgery to address the healing challenges of the “white-on-white” meniscus tear.(1)

So the idea is to bring PRP in during the surgery, apply it to areas where normal blood supply is limited and this should accelerate healing. In theory should work great. But it does not.

Meniscal Surgery: a poor option that PRP intervention at the time of surgery may not help

There is no question that cartilage heals slowly and poorly this includes the meniscus. Recommendations for surgeries involving shaving or removing the torn portion of the tear using arthroscopic surgery, or sewing the tear together is flawed because it does not repair the deteriorated meniscus.

By failing to heal the damaged meniscal cartilage, surgery does not alleviate the chronic pain that people with this condition experience.

Here is research from the University of Virginia Health System. Here doctors focused on the problem of increased contact stresses in the knee after meniscectomy.(2)

They note that since Platelet-rich plasma has received attention as a promising strategy to help induce healing, the doctors then sought to:

In this study, the experiment was to remove meniscus tissue and see if PRP treatment made a significant impact in the surgical outcome. Before we go on, a quick citation is needed to help with understanding of dilution of PRP during surgery.

So theoretically, during surgery, a weakened PRP treatment is asked to heal the surgical and meniscal damage

Returning to the University of Virginia Health System research, its conclusion should then not be surprising:

“Patients who sustain meniscus injuries should be counseled at the time of injury about the outcomes after meniscus repair. With our limited study group, outcomes after meniscus repair with and without PRP appear similar in terms of reoperation rate.”2

In the two above studies, researchers sought to improve the surgical outcomes in meniscal surgery by applying a PRP solution to the torn meniscus during the procedure. PRP could not be confirmed as effective – the culprit for non-conclusive results was not the PRP but the surgical procedure.

Medical reviews of PRP meniscus injections

Research has shown that the damaged meniscus lacks growth factors to heal. Research has found that injections of PRP bring the healing components to the site of the injury.

These components are:

Animal studies with these same growth factors have confirmed that meniscal tears and degeneration can be stimulated to repair with various growth factors or solutions that stimulate growth factor production.

In order to understand how growth factors affect the treatment of meniscus injuries, it is first important to understand the role that they play in the natural process of healing.

Each platelet is made up of an alpha granule and a dense granule. For lack of a better term these are “vessels” which contain a number of proteins and growth factors which are “poured” out onto the wound or injury. The growth factors contained in the alpha-granule are an especially important component to healing. When activated by an injury, the platelets will change shape and develop branches to spread over injured tissue to help stop the bleeding in a process called aggregation, and then release growth factors, primarily from the alpha granules.

At this point, the healing process then proceeds in three simple stages: inflammatory, fibroblastic (formation of new connective tissue), and maturation (completion of healing process).

In the case of the injured meniscus, it is clear that the damaged tissue can not repair itself. Healing in the meniscus depends on the having enough of a blood supply and/or growth factors at the site of the injury. Since less than 20% of the meniscus is vascularized by the time a person reaches the age of 40 years, meniscal healing is generally incomplete.

In a recent study, German and Swiss doctors publishing in the Muscles, ligaments and tendons journal. The doctors sought to demonstrate that Platelet Rich Plasma injections have the ability to regenerate tissue; as already shown in several experimental studies.

In this study:

Recently doctors at a military hospital in Pakistan treated patients with PRP and published the results: In their paper they evaluated the clinical effects, adverse reactions and patient satisfaction after intraarticular injection of platelet rich plasma in a small group of patients with internal derangements of knee. (Torn cartilage and Meniscus)

They concluded Intraarticular PRP injection is safe and effective method in the conservative treatment of internal knee derangements.(5)

In our experience, using dextrose Prolotherapy with PRP together enhances the effectiveness of meniscal repair. When treating a meniscal tear with PRP Prolotherapy, the concentrated platelets (PRP) are placed at the site of the tear. Growth factors are released which will stimulate healing of the tear. The growth factors in the PRP will cause a proliferation and regeneration of the injured tissue. This boosts fibroblastic events involved in tissue healing causing these tears to heal.

Five PRP Prolotherapy cases studies presented in the medical literature

In 2010, our Caring Medical and Rehabilitation Services research team published our clinical observations on Platelet Rich Plasma Prolotherapy as first-line treatment for meniscal pathology in the medical journal Practical Pain Management.(6)

In our paper, our goal was to not only show the effectiveness of PRP for meniscal tears, but also provide evidence that treating the whole knee for instability by utilizing Prolotherapy, would lead to better PRP results.

Case Report #1
A 21-year-old runner athlete sustained a medial meniscal tear during wrestling. MRI revealed an oblique tear of the posterior horn of the medial meniscus. Because the patient failed physiotherapy and other conservative care the orthopedic surgeon recommended a partial meniscectomy. The patient’s parents were prolotherapy patients and hoped that prolotherapy would offer a non-surgical option for their son as well.

The patient received one session of 3.5cc of platelet rich plasma prolotherapy to the inside of the knee. The anterior cruciate ligament and medial collateral ligament were treated with Hackett-Hemwall prolotherapy using a 15% dextrose, 10% Sarapin and 0.2% procaine solution as previously described.

Case Report #2
A 39-year-old squash player sustained a right knee injury while playing squash about one year prior to the visit. An MRI revealed a horizontal flap tear in the body of the lateral meniscus and the patient had a trial of physiotherapy without success. The patient did not want to get an arthroscopy which was suggested but instead sought out prolotherapy after an internet search.

Case Report #3
A 50-year-old chiropractor sustained medial and lateral meniscal tears after falling in a bicycling accident two years prior. He had tried previous conservative therapy without success in relieving his severe left knee pain. He was completely disabled as far as his previous activities of running and cycling. He did not want to get arthroscopy because of a poor response to an arthroscopy on his right knee several years before.

Case Report #4
A 52-year-old athlete presented after sustaining an MRI-documented horizontal tear of the posterior horn of the lateral meniscus and oblique tear involving the postern horn of the medial meniscus after falling during running. He had a past history of partial lateral meniscectomy 20 years prior. His symptoms included diffuse knee pain and a feeling of his knee giving way. He also had occasional locking of the knee.

Case Report #5
A 46-year-old male with a history of three right knee surgeries and two on the left including partial meniscectomies on both knees presented for a prolotherapy evaluation because of presumed recurrent meniscal tears on both knees. The patient’s main sport is soccer, but had a recent skiing injury causing bilateral knee swelling and pain for one month prior to the first visit. The patient saw an orthopedist who ordered an MRI which showed the medial meniscal tears.

The patient was adamant about not wanting another knee surgery. He was on nonsteroidal anti-inflammatory medication, which was stopped once PRPP was begun. The complaints in both knees (the right was worse than the left) were swelling, popping and snapping and inability to run at all without significant pain. He felt both knees were unstable. The patient was completely disabled in regard to sports because of the injuries.

We have found PRP Prolotherapy to be a dependable and reliable treatment for meniscus tears.

If you have questions about your meniscus injury, email us for help and information

1. Wei LC, Gao SG, Xu M, Jiang W, Tian J, Lei GH. A novel hypothesis: the application of platelet-rich plasma can promote the clinical healing of white-white meniscal tears. Medical science monitor: international medical journal of experimental and clinical research. 2012;18(8):HY47. [Google Scholar]

2. Griffin JW, Hadeed MM, Werner BC, Diduch DR, Carson EW, Miller MD. Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes?. Clinical Orthopaedics and Related Research. 2015 May 1;473(5):1665-72 [Google Scholar]

3. Stopka SS, Wilson GL, Pearsall AW. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. J Surg Orthop Adv. 2015 Winter;24(4):209-12. [Google Scholar]

4. Blanke F, Vavken P, Haenle M, von Wehren L, Pagenstert G, Majewski M. Percutaneous injections of platelet rich plasma for treatment of intrasubstance meniscal lesions. Muscles, ligaments and tendons journal. 2015 Jul;5(3):162. [Google Scholar]

5. Razaq S, Ejaz A, Rao SE, Yasmeen R, Arshad MA. The Role of Intraarticular Platelet Rich Plasma (PRP) Injection in Patients with Internal Knee Derangements. Journal of the College of Physicians and Surgeons Pakistan. 2015 Sep 1;25(9):699-701. [Google Scholar]

6. Hauser RA, Phillips HJ, Maddela H. Platelet rich plasma Prolotherapy as first-line treatment for meniscal pathology. Pract Pain Manag. 2010 Jul;10(6):53-64.Pract Pain Manag. 2010 Jul;10(6):53-64. [Google Scholar]

 

 

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