XIII JORNADAS SOBRE MEDICINA Y DEPORTE DE ALTO NIVEL

COE, MADRID 23 Y 24 DE SEPTIEMBRE DE 2011

PLASMA RICO EN PLAQUETAS:

PRP
Revisin de la literatura: evidencia
cientfica de la eficacia y efectos
secundarios

David Lpez Capap

Especialista Ciruga Ortopdica y Traumatologa

INTRODUCCIN

Tema de controversia en toda la comunidad

internacional.
Uso clnico paralelo, no previo, a estudios de
laboratorio y en animales.
Tema atractivo especialmente en el deporte.
Importancia y responsabilidad de los medios de
comunicacin.
Gran complejidad y dificultad para sacar conclusiones.

INTRODUCCIN

Orthopaedics today Europe,

March/April 2011:
Platelet-rich plasma: Yet to be
proven, but studies are on
their way

INTRODUCCIN

INTRODUCCIN

INTRODUCCIN

Autologous platelets
have no effect on
the
healing
of
human
achilles
tendon ruptures: a
randomized singleblind study. Am J
Sports Med 2011
Jan.

DEFINICIN
PLASMA RICO EN PLAQUETAS (PRP)
Muestra de sangre autloga con una concentracin de
plaquetas por encima de los valores normales
OTRAS DENOMINACIONES
Plasma rico en factores de crecimiento
Plasma enriquecido con plaquetas
Preparacin rica en factores de crecimiento
Concentrado plaquetas
Fibrina rica en plaquetas

TERAPIA CON PRP

Inyeccin o aplicacin de la preparacin de
sangre autloga con alta concentracin de
plaquetas en un tejido lesionado, con el objetivo
de favorecer o mejorar el proceso de curacin o
cicatrizacin del mismo
Ms de 20 aos de experiencia clnica, en
diferentes especialidades mdicas, pero poca
literatura que evidencie su eficacia

FASES DE LA CURACIN

FACTORES DE CRECIMIENTO
GRNULOS ALFA:
PROTENAS
PDGF, VEGF, TGF-B1
FGF, EGF, PLATELET FACTOR 4
TROMBOSPONDINA 1
ANGIOPOIETINAS, ENDOSTATINAS
HGF
IGF-1

FACTORES DE CRECIMIENTO

MITOGENESIS
ESTIMULACIN DE CLULAS MESENQUIMALES
ESTIMULACIN DE LA PROLIFERACIN CELULAR
ANGIOGNESIS
SNTESIS DE COLGENO
SNTESIS DE MATRZ EXTRACELULAR
EFECTO ANTIINFLAMATORIO
EFECTO QUIMIOTCTICO
ETC

PLAQUETAS
GRNULOS DENSOS
ADENOSINA
SEROTONINA
HISTAMINA
CALCIO

Mishra A, Woodall J Jr, Vieira V A: Treatment of

Tendon and Muscle Using Platelet-Rich Plasma. Clin
Sports Med 2009, 28: 113-125

PREPARACIN PRP

Extraccin de entre 10 y 60 ml
Centrifugacin
Separacin fracciones
PPP
L-PRP
Hemates
Activacin:
Trombina, Calcio, Colgeno

PREPARACIN PRP
Falta de estandarizacin del proceso:
Cantidad de sangre
Centrifugacin y separacin
Concentracin final de plaquetas
Presencia o no de leucocitos (P-PRP, L-PRP)
Forma de activacin
Varias preparaciones diferentes, por lo tanto
pueden tener eficacia diferente

PREPARACIN PRP

Laboratorios con campana flujo laminar

Autologous Conditioned Plasma, Arthrex
Cascade, Musculoskeletal Tissue Foundation
GPS III, Biomet
Smart PReP, Harvest Technologies
Palex
PRFG, BTI
FIBRINET

CONTRAINDICACIONES PRP

Trombopenia
Problemas de coagulacin
Terapia anticoagulante
Infeccin
Cncer
Embarazo

COSTE PRP

No est regulado
Desde menos de 100 a ms de 600 por
inyeccin (HASTA 1200 !!)
Normalmente excluido en seguros de salud
Tambin se utiliza en medicina pblica
Valorar coste/beneficio

SEGURIDAD

No se han comunicado efectos adversos

relevantes
Trombina bovina
La hiptesis de que pudiera aumentar la
incidencia de neoplasias no ha sido corroborada

COMPLICACIONES
Dolor, Infecciones
Problemas cutneos, Ndulos o abultamientos

PRP Y ANTI-DOPAJE

ESTUDIOS DE LABORATORIO

Aumento de la expresin de genes de colgeno en

tenocitos tratados con PRP
Movilizacin de clulas satlites y produccin de
colgeno tipo I
Mayor proliferacin celular y angiognesis
Estmulo de las clula madre mesenquimales

ESTUDIOS EN ANIMALES
Mejora de la reparacin de lesin aguda del tendn de
Aquiles en ratas (Aspenberg y Virchenko, Acta Orthop Scan
2004 y 2006)
IGF-1 y FGF mejora lesiones msculo esqueltico en
ratones (Menetry JBJS Br 2000)
Miogenesis mayor con PRP que con PPP en ratas
(Hammond, Am J Sports Med 2009)
Efectos positivos en la reconstruccin de defectos de
cartlago en conejos y corderos (Garca-lvarez F, Rev esp
cir ortop traumatol 2010)
Algunos otros resultados son contradictorios

ESTUDIOS CLNICOS

Pocos artculos se pueden considerar

controlados y randomizados (RCT)
Algunos artculos recogen series de
casos
Muchos artculos comunican un caso
clnico

REVISIN LITERATURA
PUBMED
PRP & sports injuries: 42
PRP & tendon: 73
PRP & muscle: 37
PRP & cartilage: 60
PRP & ligaments: 42

TENDINOPATIA CODO

TENDINOPATIA CODO
Creaney L. Growth factor-based therapies
provide
additional
benefit
beyond
physical therapy in resistant elbow
tendinopathy: a prospective, single-blind,
randomised trial of autologous blood
injection versus platelet-rich plasma
injections. Br J Sports Med 2011 Mar 28

TENDINOPATIA CODO
Coombes BK. Efficacy and safety of corticosteroid
injections and other injections for management of
tendinopathy: a systematic review of randomised
controlled trials. Lancet 2010 Nov 20; 376
(9754):1751-67.
Despite effectiveness of corticosteroid injections
non-corticosteroid
in
the
short-term,
injections might be of benefit for long-term
treatment of lateral epicondylalgia, response to
injections should not be generalised because of
variation in effect between sites of tendinopathy

TENDINOPATIA CODO
Mishra A, Pavelko T: Treatment of chronic
elbow tendinosis with buffered platelet rich
plasma. Am J Sports Med 2006; 34: 17741778
Peerbooms JC, Gosens T: Positive effect
of an autologous platelet concentrate in
lateral epicondylitis in a double-blind
randomized controlled trial: platelet-rich
plasma versus corticosteroid injection with a
1-year follow-up. Am J Sports Med 2010; 38:
255-262

TENDINOPATIA

AQUILEA

TENDINOPATIA

AQUILEA

De Vos RJ, et al. Platelet rich plasma injection for

chronic Achilles tendinopathy: a randomized
controlled trial. JAMA 2010; 303: 144-9
De Vos RJ, et al.: No effects on ultrasonographic
tendon structure and neovascularisation in
chronic midportion Achilles tendinopathy. Br J
S`ports Med 2011, 45: 387-392
De Jonge S, De Vos RJ: One-Year Follow-up of
Platelet-Rich Plasma Treatment in Chronic Achilles
Tendinopathy. A Double-Blind Randomized Placebo
Control-Trial. Am J Sports Med 2011, 39 (8)

TENDINOPATIA

AQUILEA

Tice JA. Platelet-rich plasma Injection for

Achilles Tendinopathy: A Technology Assessment.
Octubre 2010

TENDINOPATIA

ROTULIANA

Kon E, Filardo G: Platelet-rich plasma: New

clinical applications: a pilot study for the
treatment of jumpers knee. Injury 2009, 40:
598-603
Filardo G, Kon E: Use
of platelet-rich plasma
for the treatment of
refractory
jumpers
knee. Int Orthop 2009

TENDINOPATIA

CRNICA

De Vos RJ,Mafulli N: Autologous growth factor

injectons in chronic tendinopathy: a systematic
review. British Medical Bullletin 2010, 95: 63-77
there is limited evidence to support the use of
injections with PRP in the management of
chronic tendinopathy

TENDINOPATIA

HOMBRO

ROTURAS MANGUITO ROTADOR

Castricini R. Platelet-rich plasma augmentation for
arthroscopic rotator cuff repair: a randomized
controlled trial. Am J Sports Med 2011 Feb 39 (2): 25865.
Our study does not support the use of
autologous PRFM for augmentation of a doublerow repair

ROTURAS MANGUITO ROTADOR

Jo CH, Kim JE. Does Platelet-Rich Plasma
Accelerate Recovery After Rotator Cuff Repair? A
Prospective Cohort Study. Am J Sports Med 2011
Jul 7.
The results suggest that PRP application during
arthroscopic rotator cuff repair did not clearly
demonstrate accelerated recovery clinically or
anatomically except for an improvement of
internal rotation

ROTURAS TENDN DE AQUILES

Snchez M, Anitua E. Comparison of surgically
repaired Achilles tendon tears using plateletrich fibrin matrices. Am J Sports Med 2007; 35:
245-251
Schepull T. Autologous platelets have no effect on
the healing of human achilles tendon
ruptures: a randomized single-blind study. Am J
Sports Med 2011 Jan; 39 (1):38-47
The results suggest that PRP is not useful for
treatment of Achilles Tendon ruptures

LESIONES MUSCULARES
Anda I, Snchez M, Mafulli N. Platelet rich plasma
therapies for sports muscle injuries: any evidence
behind clinical practice? Expert Opin Biol Ther 2011
Apr 11 (4): 509-18

No PRP formulation
has yet displayed
proven evidence to
the
stimulation
of
healing and recovery
after sports muscle
injuries

LESIONES MUSCULARES
Hamilton BH, Best
TM;
Platelet
Enriched
Plasma
and Muscle Strain
Injuries: Challenges
Imposed
by
the
Burden of Proof.
Clin J Sport Med
2011 Jan, 21 (1) :316

There is no level 1,2 and 3

evidence for the use,
There remain a large
number of unanswered
questions

LESIONES MUSCULARES
Aspetar Consensus, Hamilton, B y cols. 2009:
La falta de consistencia en la preparacin, aplicacin
y dosificacin de factores de crecimiento, as como las
dudas acerca de qu preparado con o sin leucocitos
puede ser mejor, hace no aconsejar el uso de PRP en
lesiones musculares de forma rutinaria.
Recomiendan continuar con la investigacin en
estudios de alto nivel de evidencia

LESIONES LCA

LESIONES LCA
Snchez M, Anitua E, Lpez-Vidriero E, Anda I.
The
Future:
Optimizing
de
Healing
Environment in Anterior Cruciate Ligament
Reconstruction. Sports Med Arthrosc Rev 2010
Marc 18 (1): 48-53
PR preparationsprovide a potential advantage
for
better
and
more
predictable
ligamentization and enhanced bone-tendon
healingHowever poor standardization in the field
has hampered the evaluations of different plasma
products and the establishment of standard
beneficial application of this technology

LESIONES LCA
Cervellin M. Autologous platelet-rich plasma gel to
reduce donor-site morbidity after patellar tendon graft
harvesting for anterior cruciate ligament reconstruction:
a randomized, controlled clinical study. Knee Surg sports
Traumatol Arthrosc 2011 Jun 16
study
shows
the
usefulness of PRP in
reducing subjective
pain at the donorsite level after ACL
reconstruction
with
BPTB

LESIONES LCA
Vogrin M. Effects of a platelet gel on early graft
revascularization after anterior cruciate ligament
reconstruction: a prospective randomized, double-blind,
clinical trial. Eur Surg Res 2010; 45 (2): 77-85
Locally applied PG
enhanced
early
revascularization
of the graft in the
osteoligamentous
interface
zone
after
ACL
reconstruction

LESIONES LCA
Vogrin M. The effect of platelet-derived growth
factors on knee stability after anterior cruciate
ligament reconstruction: a prospective randomized
clinical study. Wien Klin Wochenschr 2010 May; 122
Suppl 2: 91-5
Platelet-leukocyte
gel, applied locally,
can improve knee
stability in surgery
for reconstruction of
the anterior cruciate
ligament

LESIONES LCA
Taylor DW. A systematic review of the use of
platelet-rich plasma in sports medicine as a
new treatment for tendon and ligament
injuries. Clin J Sports Med 2011 Jul 21 (4):
344-52
In 3 studies on the use of PRP in ACL
reconstruction, no statistically significant
differences were seen

LESIONES FIBROCARTLAGOS

LESIONES MENISCALES
Delos D, Rodeo SA. Enhancing meniscal repair
through biology: platelet-rich plasma as an
alternative strategy. Instr Course Lect 2011;
60:453-60
PRP is the latest technique to be evaluated
for augmenting meniscal healing

LESIONES LABRUM GLENOIDEO

Hirahara, AM: Enhancing SLAP Repairs with
Fibrin-PRP Clots. Presented at the 76th
Arthroscopy Association of North America, San
Diego, April 30 - May 3, 2009
fibrin-PRP clot enhances the healing of the labrum
to the glenoid. There were significantly fewer
failures, less pain, quicker time to discharge,
and faster functional recovery

LESIONES DEL CARTLAGO

LESIONES DEL CARTLAGO

Fortier L. The Role of Growth Factors in
Cartilage Repair. Clin Orthop Relat Res 2011
Mar 15
The application of growth factors in the treatment of
local cartilage defects as well as osteoarthritis
appears promising; however further reseach is
needed at both the basic science and clinical levels
before routine application

LESIONES DEL CARTLAGO

Gobbi A, Bodrini L, Espregueira-Mendes J. The use of
platelet rich plasma for cartilage repair. En
Cartilage Repair, Current Concepts. Editors: Mats
Brittberg, andreas Inhoff, Henning Madry , Bert
Mandelbaum. 2010 DJO Publications
Nmero creciente de aplicaciones terapeticas con
prometedores resultados en estudios preliminares. La
estandarizacin del proceso es necesaria en cuanto
a la forma de preparar el PRP, sus caractersticas, sus
indicaciones, la forma de administracin y los
protocolos terapeticos antes de que su uso sea
utilizado indiscriminadamente.

ARTROSIS

GONARTROSIS
Snchez M, Anitua E. Intra-articular injection of
an autologous preparation rich in growth
factors for the treatment of Knee OA: a
retrospective cohort stdy. Clin Exp Rheumatolo 2008;
26: 910-913
Kon E. Platelet-Rich Plasma Intra-Articular
Injection
Versus
Hyaluronic
Acid
Viscosupplementation as Treatments for Cartilage
Pathology:
From
Early
Degeneration
to
Osteoarthritis. Arthroscopy 2011, Aug 8.

ARTCULOS DE REVISIN
Hall MP. Platelet-rich Plasma:
Current
Concepts
and
Application in Sports Medicine,
J AM Acad Orthop Surg 2009;
17:602-608
clinical use should be
approached cautiously until
high level clinical evidence
supporting platelet-rich plasma
efficacy is available

ARTCULOS DE REVISIN

Engebretsen L, Steffen K, Alsousou J,

Anitua E: IOC consensus paper on
the use of platelet-rich plasma in
sports medicine, Br J Sports Med
2010, 44: 1072-1081

ARTCULOS DE REVISIN
Kon E, Filardo G, Marcacci M.
Platelet-rich plasma (PRP) to
treat sports injuries: evidence
to support its use. Knee Surg
Sports Traumatol Arthrosc
2011 Apr 19 (4): 516-27
the analysis of the literature
shows promising preclinical
results but contradictory
clinical findings for the
treatment of sports injuries

ARTCULOS DE REVISIN

Lpez-Vidriero E. The Use of

Platelet-rich
Plasma
in
Arthroscopy
and
Sports
Medicine:
Optimizing
the
Healing
Environment.
Arthroscopy 2010 Feb 26 (2): 269278.
Future directions of PRP include
improving the results of
arthroscopic
and
related
surgery,
in
addition
to
delineating correct dosage,
timing and quantification, as
well as ideal techniques of
PRP application

ARTCULOS DE REVISIN
Paoloni J, De Vos RJ. Plateletrich plasma treatment
for ligament and tendon injuries. Clin J Sports
Med 2011 Jan 21 (1): 37-45
the potential risks involved with PRP are fortunately
very low. However, benefits remain unproven to
date
Lee KS: Muskuloskeletal Applications of Platelet-Rich
Plasma: Fad or Future? AJR 2011; 196: 628-636.
muskuloskeletal injuries have long eluded the
use of standardized therapeutic protocols
regardless of cause

DISCUSIN
Extensin del uso rpida en esta dcada
Grandes expectativas puestas
Importante negocio
Publicidad en los medios
Alta demanda por los pacientes
Seguridad

DISCUSIN
Creaney L. Platelet-rich plasma and the biological
complexity of tissue regeneration. Br J Sports Med 2011,
45: 611
growth factors can produce varying effects depending of
their concentration, time of release, point in cell cycle and
recipient cell
PRP has variable and inconsistent content and
concentration
The succes in maxillofacial applications are perhaps
not analogous to sports medicine

DISCUSIN
A medida que vayamos conociendo mejor este
tratamiento se podr ir indicando correctamente
su utilizacin

Pueden tener un efecto reparador en

defectos del tejido conectivo
Parecen tener un efecto antiinflamatorio
significativo (artrosis)

CONCLUSIONES
Ninguna lesin deportiva sera susceptible de
curacin nicamente por el uso del PRP
En lesiones musculares y tendinosas por
sobrecarga el protocolo de readaptacin es lo
ms importante
En lesiones articulares y roturas tendinosas
tratadas
quirrgicamente
la
correcta
tcnica y la rehabilitacin siguiente son
fundamentales

CONCLUSIONES

La terapia con PRP puede mejorar los

resultados de los tratamientos convencionales
Debe continuarse investigando para conocer
sus posibilidades terapeticas reales
Estandarizar el proceso es bsico
En el momento actual no se puede
recomendar su uso en las lesiones
deportivas de forma rutinaria

MUCHAS GRACIAS