THE ROLE OF AUTOLOGOUS PLATELET-RICH PLASMA IN THE TREATMENT OF SOME PAINFUL ORTHOPEDIC CONDITIONS : A BASRA EXPERIENCE STUDY

The role of platelet-rich plasma in the pain relief and treatment of many orthopedic problems had gained lot of studies & practice. Yet, it hadn’t been practiced in our locality. Thus, the study of its role in the treatment of certain enthsiopathies (plantar faciitis, achillis tendinitis and lateral epicondylitis) had been planned for. A total of 63 cases of the three diseases were chosen for a case control study. They were divided into two groups: the case group who had been treated with local injection of autologous platelets rich plasma (prepared by the Trima accel cell separating machine) and the control group who were treated by local steroid injections. Pre and three post-treatment follow up of cases were done to assess the pain perception level using the simple visual analog scale (VAS). Results had shown a statistically significant reduction in pain among cases compared to control. These results were comparable to many studies elsewhere in the world. This had led us to conclude the advice to encourage this type of therapy on a large scale of patients in the future with more detailed further studies about. Introduction latelet-rich plasma (PRP), the plasma fraction of blood having a platelet concentration above baseline, had been used in orthopedics since the last few decades. Thousands of patients have gained benefits from this relatively safe therapeutic modality in many different problems like osteoarthritis, musculoskeletal soft tissue injuries (ligament, muscle and tendon tears) and tendinopathies. It is used either as the principal treatment or as an augmentation procedure (application after surgical repair or reconstruction. The properties of PRP are based on the production, by the platelets, storage in both alpha and beta granules and release of multiple growth and differentiating factors that help in alleviating pain and modulating inflammatory reaction after activation, where, after the initial burst, more than 95% of the growth factors are secreted within one hour, and the continuum of their synthesis and secretion for the remaining several days of their life span. These growth factors have a combined and complex interacting action on tissues to activate different sets of signaling pathways with the end result of ameliorating local inflammatory response. Early success in using PRP to treat chronic refractory tendinopathy has led to consideration of its use in the management of recalcitrant cases of plantar fasciitis. Local infiltration of PRP in Achilles tendinitis and lateral epicondylitis, had shown an improvement in pain relief and movement limitation, with all patients having at least moderate improvement and 96% of patients reporting mostly to complete improvement. P


Introduction
latelet-rich plasma (PRP), the plasma fraction of blood having a platelet concentration above baseline 1 , had been used in orthopedics since the last few decades.Thousands of patients have gained benefits from this relatively safe therapeutic modality in many different problems like osteoarthritis, musculoskeletal soft tissue injuries (ligament, muscle and tendon tears) and tendinopathies.It is used either as the principal treatment or as an augmentation procedure (application after surgical repair or reconstruction [2][3][4] .The properties of PRP are based on the production, by the platelets, storage in both alpha and beta granules and release of multiple growth and differentiating factors that help in alleviating pain and modulating inflammatory reaction after activation, where, after the initial burst, more than 95% of the growth factors are secreted within one hour, and the continuum of their synthesis and secretion for the remaining several days of their life span 5 .These growth factors have a combined and complex interacting action on tissues to activate different sets of signaling pathways with the end result of ameliorating local inflammatory response 6,7 .Early success in using PRP to treat chronic refractory tendinopathy has led to consideration of its use in the management of recalcitrant cases of plantar fasciitis [8][9][10][11][12] .Local infiltration of PRP in Achilles tendinitis and lateral epicondylitis, had shown an improvement in pain relief and movement limitation, with all patients having at least moderate improvement and 96% of patients reporting mostly to complete improvement [13][14][15][16][17] .

P
This study was designed to clarify the efficacy of autologous platelet-rich plasma local therapy in the selected tendinopathies (lateral epicondylitis, achillis tendinitis & plantar fasciitis compared to the local steroid therapy and which is more beneficial among each of them.

Patients and methods
A prospective case control study had been conducted in Orthopedic Department of Basra General Hospital between August 2013 and November 2014, where 66 patients with planter fasciitis, Achilles tendonitis and elbow lateral epicondylitis were selected.Diagnosis of each was established on clinical and radiological characteristics.Cases were subdivided to two groups: autologous (to avoid the possibility of sensitization or acute graftversus host disease if allogeneic source was taken), platelet-rich plasma (PRP)treated group (41 patients) and steroidtreated (control) group (25 patients).All patients were not diabetic, hypertensive or not on life-long medication for a systemic illness.Autologous platelet-rich plasma was prepared using the Trima Accel version 6 continuous-flow centrifugal system (Terumo BCT), using a disposable, closed, strictly sterile tubing set (figure 1).Injection was accomplished in Orthopedic Wards, Basra General Hospital by mixing 0.5 mls of (2%) of lidocaine local anesthesia with 3, 2, 2 mls of PRP for planter fasciitis, Achilles tendinitis and lateral epicondylitis, respectively.The mixture was given intralesionally to the site of maximum tenderness.To generate thrombin which is important to activate platelets to secrete their growth factors, a peppering technique, by doing multiple short stabs in many directions to penetrate the periosteum with an audible and palpable gristly crunchy texture when touching it to make minor injuries using the injecting needle, was done before injecting PRP.Control cases were injected with a mixture of 0.5 mls (2%) of lidocaine local anesthesia and 1 ml (40 mg) of methyl prednisolone acetate intralesionally, too.After finishing injection, dressing with sterile gauze and bandaging was done and the patient was put on a prophylactic short course of antibiotics.Pre-and three post-injection intervals (2, 8 & 16 weeks) pain assessment, was achieved using the visual analog scale (VAS) (Figure 2), a tool used frequently to assess pain.It is a rigid white plastic ruler, 100 mm in length, where the left extreme end indicates "no pain" and the right one the "worst imaginable pain" 18.
Each patient was asked to move a vertical marker along the line to a position that best represents his current perception of pain between the labeled extremes.Though it is subjective, the VAS is a valid and reliable tool to measure of chronic pain intensity 19,20 and differences in pain perception over time 21,22 .Statistical analysis (both descriptive and analytical, using the ANOVA test, was done using the SPSS version 20 23 .

Results
Patients' age ranged between 20-80 years with a mean of (40.3±10.9)years.

Discussion
The significant pain reduction among Achillis tendinitis group who were treated with PRP, compared with the steroid therapy duting post injection follow up period was comparable to that found by Maffulli N et al 2004 24 who did a prospective study on different tendenopathies and found that the Achilles tendon group had the best response, with all patients having at least moderate improvement and 96% of patients reporting mostly to complete improvement with a reduction of VAS from (7.0±1.8) to (1.8±1.2) (P.=0.001).The increase in VAS in the steroid group was comparable to that reported by Fredberg U 25 et al who concluded that corticosteroid injection inside the tendon or near to tendon has a deleterious effect on the tendon tissue and may cause tendon rupture, thus should be unanimously condemned.It is also comparable to Dacruz D J et al 26 .Who reported that peritendonous injection of methyl prednisolone acetate is of no value in Achilles tendinopathy.In planter fasciitis, the significant reduction of VAS among PRP-treated group was comparable to that reported by Martinelli N et al 27 , who showed that VAS had decreased significantly among their patients from 7.1±1.1 before treatment to 1.9±1.5 at the last follow-up (p<0.01).However, though Akashin et al 28 , in their prospective non-randomized comparison of PRP and corticosteroid injection for plantar fasciitis, had found that the mean (VAS) dropped from (6.2) to (3.2) in the steroid group and (7.33) to (3.93) in the PRP group at 6-month follow up, and both treatments appeared effective in reducing the VAS, yet, they had concluded that PRP injection appeared to be the safer of the two.In this study, no complication with steroid injection had been faced.However, Acevedo and Beskin 29 reported that in a group of 765 patients with a clinical diagnosis of plantar fasciitis, 51 were diagnosed as having a plantar fascia rupture.Of these 51 ruptures, 44 (86%) were associated with corticosteroid injection.Sellman JR 30 observed in a series of 37 patients with plantar fascial rupture and previous heel pain diagnosed as plantar fasciitis treated with corticosteroid injection into the calcaneal origin of the fascia, that one-third of these patients were reported to have rupture of the plantar fascia, described as a sudden tearing episode in the heel, and the remainder described mild-to-moderate pain reaching a conclusion was that although corticosteroid injections may be helpful in the treatment of "plantar fasciitis" but steroid may predispose to plantar fascial rupture.For those with lateral epicondylitis (LE), the significant VAS reduction of the PRP treated group in the post-treatment follow up [from (5.11±0.60) to (2.71±1.50)(P.=0.005)], was comparable to that reported by Allan Mishra et al 31 who did (at a time ranging between 12-38 months) follow up the PRP-treated patients and reported a 93% reduction in pain (range, 0-3), and 93% of these patients were completely satisfied with treatment, while 7% were partially satisfied.Those 93% were essentially pain-free (1 or less of 10 on VAS).Overall, the patients reported engaging in a mean of (99%) of the activities of daily living, (94%) of work or sporting activities.It is also comparable to Taco Gosens et al 32 who compared the effect of PRP and steroid therapy on lateral epicondylitis and reported that the PRP-treated group was more often successfully treated than the corticosteroid-treated group (P.=0001), and steriods failed to maintain the early pain relief in which the VAS re-elevated after a range of 8 weeks and patient became complaining again (where success was defined as a reduction of ≥25% on VAS).

Conclusion
The PRP seems to be superior to steroid injection in both the early and the remote Bas J Surg, December, 22, 2016 post-treatment follow up in all the three diseases studied above.The PRP seems to be safer than the steoid local therapy as it is an auto-product of the body and has less chance to cause tendon rupture.The preparation of PRP using the Trima Accel Machine is much more expensive than steroid therapy, besides, some of patients had experienced some phopia from the pheresis session itself, a thing that can be reduced by assurance and proper explanation.

Recommendations
More profound studies on the effects of PRP on each of the pathological conditions taken, separately with a larger scale of patients and for a longer time of follow up are needed to a certain their therapeutic effect in those diseases.The encouragement of the supply of PRPproducing machines to make this pattern of treatment available to a larger number of patients in the future.The establishment of cost-benefit types of studies on the effects of PRP compared to other modalities of treatment.

Figure 1 :
Figure 1: a.The Trima Accel system machine, overview, b.Trima Accel system during work, c.A diagram of the disposable set and tubing system, d.The disposable set before being opened for use, e.The Trima Accel display showing the progress of run, f.A patient being connected to the machine.

Table III : The frequency of certain clinical factors among cases
TableIVshows that housewives and casual workers were the most affected than others (28.8 % and 24.2 %, respectively), followed by officers and teachers (19.7 % and 13.6 %).