Sports Medicine Research: In the Lab & In the Field: Is PRP More Effective than PRF in Rotator Cuff Repair? (Sports Med Res)

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Monday, March 19, 2018

Is PRP More Effective than PRF in Rotator Cuff Repair?


The Efficacy of Platelet-Rich Plasma and Platelet-Rich Fibrin in Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials

Hurley ET, Lim Fat D, Moran CJ, Mullett H. Am J Sports Med. 2018 Feb 1:363546517751397. doi: 10.1177/0363546517751397. [Epub ahead of print]
Text Freely Available

Take Home Message: A platelet-rich plasma injection – but not a platelet-rich fibrin injection – during arthroscopic rotator cuff repair improves clinical and patient-reported outcomes compared to controls.

https://media.defense.gov/2017/Feb/07/2001695985/888/591/0/170131-F-JC454-055.JPG
Platelet-rich therapies (e.g., platelet-rich plasma [PRP] or platelet-rich fibrin [PRF]) in adjunct with arthroscopic rotator cuff repair surgeries are growing in popularity. PRP primarily mediates growth factors, which facilitate healing through connective tissue growth, restoring oxygen in vessels, and cell division. PRF is a newer technique, which contains less platelets and more fibrin clotting factors, thus expediting the clotting at the tendon repair site. However, we lack recommendations for using platelet-rich therapies during surgical interventions despite basic science studies that show their promise for tendon healing. Hence, the authors performed a meta-analysis of randomized trials to assess the efficacy of PRP or PRF in arthroscopic rotator cuff repair. Two reviewers identified 18 clinical trials with 1,147 participants. The authors extracted results on incomplete tendon healing in all size tears (small, medium, large), patient satisfaction, and visual analog scale for pain at 30 days and final follow up.  Overall, PRP improves pain, functional outcomes, and tendon healing rates (regardless of tear size). At one month post-surgery, participants with PRP typically reported a clinically meaningful reduction of pain on a visual analog scale of 1.4 points compared with control participants. Conversely, participants who received PRF therapy failed to experience any benefits, with one study reporting adverse effects.

The growing acceptance of platelet-rich therapies in surgical interventions is inspired by growing basic science evidence that platelet-rich therapies improve tendon healing rates. The ability of PRP therapies to benefit complete tissue healing could drastically shift the post-operative paradigm of rotator cuff repair rehabilitation. Complete tissue healing begets decreased pain levels, which in turn begets increased functional activity outcomes. While this routine therapy seems flawless, clinicians need to recognize several limitations to PRP. Preparation and deliverance of PRP and PRF vary considerably in overall composition of platelet count, leukocyte count, and concentrations of growth factors. Without a standardized dosage of PRP or PRF, a universal protocol for these therapies are far from being accepted. Additionally, PRP injections range in cost between $500 and $2000 and are still an out-of-pocket expense for the patient since the treatment lacks sufficient evidence for insurance to cover it. Furthermore, platelet-rich therapies can be delivered post-operatively via injection and those effects have yet to be intensively studied or compared to intra-operative use. Despite these limitations, the inclusion of a PRP treatment during arthroscopic rotator cuff repair may be advantageous for improving healing rates and patient-reported outcomes.

Questions for Discussion: Would you recommend your patients to seek platelet-rich therapies during arthroscopic rotator cuff repair? If your patient did receive PRP or PRF during surgery, did you notice a difference in recovery between a patient who did not?

Written by: Danielle M. Torp
Reviewed by: Jeffrey Driban

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4 comments:

Sarah said...

Danielle, thank you for sharing this article. I found it very interesting that the participants given platelet-rich plasma (PRP) experienced more benefits than the platelet-rich fibrin (PRF). It would seem that the growth factors that facilitate healing from the PFP benefit the participant more than the additional fibrin clotting factors from the PRF. However, I think that further research of the PRF needs to be explored before making any deductions, since it is a newer technique. I think there would be a few things to consider before recommending platelet-rich therapies during arthroscopic rotator cuff repair to my patients. The ability of my athlete to afford the cost of the platelet-rich therapy as well as the sport and position of my athlete would affect my decision. Overall, I think that platelet-rich therapy in surgical interventions is a great option for patients to have.

Danielle Torp said...

Hi Sarah,

Thank you for the response on this post. In regards to the PRF outcomes, there is speculation as to why there was not as great of an affect. First, the PRF clot must be sutured to the repair site and its proposed this causes a "space-occupying effect." After the PRF dissolves, this space is still present instead of being filled in with scar tissue as with typical healing. Secondly, they propose there is less growth factors in PRF injections, thus not providing sufficient results as PRP.

I also agree with you regarding the cost to the patients. More research in this area is warranted before insurance companies will pick up the cost and before physicians will begin to view it as common practice. I believe the basic science claims are evident, but we yet been able to perfect it enough in-vivo to make a claim. It would be interesting to compare these results with other surgical interventions like ACL reconstruction or Achilles tendon repair.

Anonymous said...

Thanks for the review!

Its hard to say whether or not I would platelet-rich therapies during surgery. I'm honestly not sure there is enough evidence right now for me give a definitive recommendation to my patients. I have worked with many over-head athletes that have received PRP injection (not intra-operatively) and while these athletes do improve, its hard to say whether or not it was really from the PRP injection.

There is some decent evidence showing that PRP does work (like in this post) however I think its important for us as clinicians to determine if these differences are clinically meaningful, which in this case they are. I think that it's also important to take the patients point of view into account as well. Is 1.4 points change on a VAS worth paying up to 2,000 dollars for? I think that really depends on the patient and what they decide.

Its important that we don't forget that, as you mentioned, the treatment lacks sufficient evidence for insurance to cover PRP injections. If something lacks sufficient evidence, then why is it used so often? I am fairly certain there have been very few studies that report any adverse effects of PRP, however we must not forget that we practice based on the best current evidence. If a doctor recommends a PRP injection for one of my patients, and my patient is okay with paying for it, then I'd say go ahead and get it. I just think that these injections are being used too often for the evidence that is currently out there.

Danielle Torp said...

Thank you for the comment, you have some very valid points.
I think it is difficult to compare intra-operative injections verse non-operative intra-tendinous injections, especially when considering delivery methods for non-operative injections. The use of clinical ultrasound guided injections have improved the accuracy of injection site, whereas the blind “peppering” method has its own set of challenges. Moreover, a PRP injection during surgery is followed by a significantly longer rest period than a non-operative injection, potentially allowing the PRP to be more effective. I agree, it is difficult to know if PRP was responsible for your athletes healing when they were not in a situation to need repair.
In every situation the cost and rewards should be weighed, especially when the cost is going to be completely the athletes’ responsibility. I also believe the clinician and patient should keep in mind long term goals of the athlete. This study did not touch upon long-term outcomes, but as PRP injections become more common practice longitudinal studies need to be done to determine possible long-term consequences. As we are seeing in other joint injuries, the rise of osteoarthritis from surgery and poor early management is beginning to change the overall treatment process for clinicians. I would be curious if PRP injections have the potential to reduce risk of early onset OA in the shoulder (or any joint).
The popularity of PRP injections stemmed from promising basic science research; however as you mentioned, it does not have sufficient evidence to clearly determine the cost-reward of using PRP injections. Evidence can only come from information collected from use, so these injections need to be used in order to be studied. They have already passed a major step in being considered safe to use, now the clinicians and researchers must determine their clinical meaningfulness.

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