Musculoskeletal Care of the Mature Patient
Platelet Rich Plasma (PRP)
On May 13 and 14, I attended an international symposium on PRP in Los Angeles. The faculty was made up of experts from around the world. The impact of PRP management on arthritis included the knee, shoulder and ankle. The most important message I took home was that following a PRP injection, don’t expect immediate improvement as you might experience from an intra-articular cortisone injection. What was emphasized is that a recipient of a single PRP injection into the joint will be better at six weeks than at one week; and again, better in 12 weeks than at six weeks. The improvement should be realized for up to a year. There is no need for more than one PRP injection per year. There is a school of thought where in better results are experienced when the PRP injection is preceded by visco-supplementation; but no consensus was reached on the latter alternative. The scientific explanation as to how PRP works is that the autologous concentration of your platelets in a small volume of plasma contains growth factors secreted by alpha granules of the platelets. Among those growth factors are PDGFaa, PDGFBB, PDGFaB, TGFB1, TGFB2, vascular endothelial growth factor, and epithelial growth factor. Now that I have clarified how PRP allegedly works, let me offer some of the uncertainties. There are very few scientific articles in the peer reviewed orthopedic literature concerning outcomes of patients treated with PRP. Most of the clinical evidence is anecdotal. Nevertheless, the little clinical evidence supports my offering PRP as a treatment for arthritis
Stem Cells (Adult, Autologous, Mesenchymal, Bone Marrow Derived)
While there is much interest in adipose derived stem cells, namely because of the wealth of stem cell concentrate contained in fat; for the time being, the orthopedic use of this stem cell rich resource will remain reserved for veterinary medicine as the FDA will only approve homologous application. In other words, no adipose derived stem cells may be used in a human joint.
I continue to explore the orthopedic opportunities for stem cell applications in arthritis and there are options for same day procedures wherein your autologous derived skeletal mesenchymal cells are re-injected within four hours after harvesting. While there is data to support the clinical use of cultured cells-cells expanded and manipulated for a minimum of three weeks after harvesting; there is no scientific outcomes data when the skeletally derived cells are not manipulated. Therein lies the difficulty. The adipose derived cells are very abundant in numbers but we clinicians are restricted from usage by the FDA. So too is it illegal to maximally manipulate skeletally derived stem cells. The conclusion, if you want to throw a baseball over 90 miles per hour again after age 40, you would have to leave the USA
Metal on Metal Hip Prostheses (MoM)
While the FDA and other governmental agencies have raised concerns about the potential adverse effects of metal ions that may be produced by the MoM hip prostheses, no consensus has been reached on how to follow or manage patients who have received said bearing and are pain free.