I am an active 65-year-old who does not want a knee replacement. Are PRP injections an option for me?

Dr. Waqas Al-Ra'i, MD
Consultant Pain Management
Expert in Regenerative Medicine 

This is a more typical email than you think. “I am 65 years old, I am still working and walk around 30 min a day but I have a lot of pain in my both knee. My orthopedic says I have advanced osteoarthritis, and I will need a knee replacement. My doctor told me there was nothing else to offer me except pain medications and pain management until I can no longer tolerate the pain or I become a fall risk. I can also wear a functional knee brace to help keep me stable. I do not know if there are alternatives for me, can you help?”

Why would the doctor say there was nothing else but knee replacement? Because according to that particular doctor, there is nothing else.

Treatments that are useless for the elderly patient with degenerative knee disease.

We know, 65-year-olds do not like to be spoken of as elderly, in the medical literature they are. Now, why would the doctor say there were no alternatives to patient mentioned above? Because for those who resist the knee replacement option, the only other treatment suggestions are to therapies that are noted for their ability to ONLY prolong or delay the need to have a knee replacement. Not help avoid it.

These treatments include nonsteroidal anti-inflammatory drugs(NSAIDs), corticosteroid injections, Hyaluronic Acid Injections.  Here is the big statement: These treatments are useless for the elderly patient. This is not just my opinion, it is the opinion of a team of researchers publishing in the medical journal American Health and Drug Benefits. 

https://www.youtube.com/watch?v=uV17Yy9Jqoo               

These researchers insist:

• That there is only one realistic option for elderly or older patients with knee osteoarthritis, knee replacement.
• Delaying or prolonging the inevitable knee replacement is a waste of time, a waste of money, and a waste of health industry resources.
• The only people who should not get knee replacement are those with other health issues.
• The need for blood thinners to prevent blood clotting and possible prolonged recovery stay in a nursing home. Should be considered.

The very active elderly patient in the nursing home

There are likely not many active 70 and 80-year-olds who are ready for a nursing home, but why would an active 70 or 80-year-old need to be in a nursing home after knee replacement? The causes are many.

June 2016, published in the journal Anesthesia & Analgesia: “Elderly patients are at risk of increased length of hospital stay, postoperative complications, readmission, and discharge to destinations other than home (nursing homes) after elective total hip replacement and total knee replacement.”

• “I had a knee replacement and it fractured my shin bone.”
  • Post-surgical/implant fractures after total knee replacement are an increasing problem and challenging to treat. (Published BioMed Central musculoskeletal disorders September 2018) 
• “I developed blood clots.”
  • Blood clots – Venous thromboembolism is an important complication to monitor following total knee replacement. (Published BioMed Central musculoskeletal disorders September 2018) 
• “I lost too much blood during the procedure”
  • Blood management after a joint replacement has become a serious problem. (Published in the journal Medicine September 2018) (5)

I did not mention infection or mal-positioning of the new knee or the many other complications a more mature patient may face because I cover this is my article Problems after knee replacement | Finding help for prolonged pain 

Research then has been somewhat shocking in its recommendations that aging or elderly patients proceed directly to total knee replacement. Why not find a non-surgical alternative especially now that the science of joint repair focuses on healing the elderly patient with Bio-Medicine, namely those components of stem cells, blood platelets (PRP Therapy), and comprehensive Prolotherapy

For those who did not trust that joint replacement was their only option, alternatives including PRP and stem cell therapy were explored.

What is Platelet Rich 

Plasma(PRP) Therapy?

Platelet Rich Plasma Therapy repairs degenerative joints using your own healing growth factors

In this article, we discuss new research on the clinical benefits of Platelet Rich Plasma Therapy (PRP). Sometimes PRP is referred to as PRP Therapy, PRP injection therapy, plasma replacement therapy, or simply PRP shots.

• PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
• Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
• The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically
  
  three to six visits are necessary per areaAlthough the application of Platelet Rich Plasma has been around for decades, the treatment has become a more recent option for doctor and patient.In 2012, researchers at the University of Rochester wrote  in the medical journal Arthritis research and therapy:“Chronic complex musculoskeletal injuries that are slow to heal pose challenges to physicians and researchers alike. Orthobiologics is a relatively newer science that involves application of naturally found materials from biological sources (blood platelets), and offers exciting new possibilities to promote and accelerate bone and soft tissue healing. Platelet-rich plasma (PRP) is an orthobiologic that has recently gained popularity as an adjuvant treatment for musculoskeletal injuries. . .  The relative ease of preparation, applicability in the clinical setting, favorable safety profile and possible beneficial outcome make PRP a promising therapeutic approach for future regenerative treatments.”

In the years since there have been hundreds of research papers published in medical journals around the world which describes benefits and sometimes shortcomings of PRP treatments. We are going to present some of that research here.

As PRP gains popularity and more research validates its usefulness and reliability to patients, it is important to remember that PRP is just one proliferant available for the regenerative injection therapy. At Caring Medical and Rehabilitation Services we use numerous regenerative treatments depending on the severity of the pain or injury. This includes dextrose Prolotherapy, PRP, and stem cell therapy which can provide effective and safe treatments, leading to permanent healing of chronic pain and sports injury and avoidance of elective surgery.

Growth and healing factors in PRP, what make PRP work

Doctors at the University of Florence published findings  in which they described the growth, healing, and repair factors found in platelet rich plasma. These are the healing factors and what they do:

• PDGF (Platelet-derived Growth Factor) initiates connective tissue healing through the promotion of collagen and protein synthesis.The primary effect of PDGF seems to be its mitogenic activity to mesoderm-derived cells such as fibroblasts (produces collagen a building block of new cartilage),
  • vascular muscle cells (new blood vessels to bring healing factors to the injury),
  • glial cells (protects nerves) and chondrocytes (the stuff cartilage is made of – see our article on Extracellular Matrix).
  • The most important specific activity of PDGF is the creation of cartilage.
• VEGF (Vascular Endothelial Growth Factor) is the major regulator of vasculogenesis and angiogenesis and playing an important role in tissue regeneration. It does so by creating new highways of blood vessels for the healing factors to get to the site of the injury.
• Transforming Growth Factor (TGF) including TGF-b1 stimulates chondrocyte (Cartilage growth) and decreases the catabolic activity (breakdown of cartilage). There is also research to suggests that TGF-bi stimulates stem cell activity in the injured area.
• The summary of a recent research article adequately sums up the suggested use these healing factors in Platelet Rich Plasma Therapy in repairing and regenerating cartilage. The University of Torino and the University of Milan doctors writing in the medical journal Biomed Research International say:

“The convincing background of the recent studies, investigating the different potentials of platelet-rich plasma, offers the clinician an appealing alternative for the treatment of cartilage lesions and osteoarthritis. Recent evidence in literature has shown that PRP may be helpful both as an adjuvant for the surgical treatment of cartilage defects and as a therapeutic tool by intra-articular injection in patients affected by osteoarthritis.”

Is PRP an anti-inflammatory? Do we want PRP to be an anti-inflammatory?

The above effects of Platelet Rich Plasma Therapy on rebuilding cartilage and soft tissue are in effect PRP awakening the inflammatory response to healing. This also causes a degree of confusion even among medical professionals. In essence, they say “Do we want PRP to be an anti-inflammatory?”

This is the basis of Orthokine, a PRP “product” that reduces inflammation and tried by world famous athletes. The treatment has limited appeal because it is only an anti-inflammatory and does not promote healing.

In recent research, doctors writing in the American Journal of Sports Medicine tested different types of PRP formulas and they found that they may reduce inflammation when inflammation was induced by Interleukin-1, the peptide responsible for cell signaling and opening the healing pathways. 

In this case, PRP formulas manipulated to act as anti-inflammatories are not helpful for long-term healing.

This is why you get conflicting evidence surrounding Platelet Rich Plasma Therapy

A patient will often explore non-surgical methods of joint repair after they have been to a doctor that is recommending surgery. When they return to that doctor with questions about PRP they may hear that PRP is unproven, doesn’t work, no research to support it.

This entire article shows you the research that is supportive. I will also show you research that is not-supportive and why.

PRP may not work if the doctor does not use standardized procedures

PRP treatments are easy to learn. They are after all injections. If your doctor is experienced in giving cortisone injections, they will be experienced in giving PRP injections. But is this true?

Cortisone is a single injection, PRP’s best chance to work to its maximum benefit is when it is offered as part of a comprehensive program of joint healing. That means more than one injection. At Caring Medical and Rehabilitation Services we off PRP treatment as part of a comprehensive Prolotherapy program that treats all of the knee. Ligaments, tendons, cartilage, the entire diseased and dying knee joint.

• The lack of standardization is discussed in the medical journal Odontology by researcher Tomoyuki Kawase of Niigata University in Japan.
  
  • Platelet Rich Plasma Therapy is very promising BUT calls for a standardization for doctors who want to use Platelet Rich Plasma Therapy (PRP) in the treatment of chronic joint pain.
  • This research and similar papers indirectly and clearly suggest that Platelet Rich Plasma Therapy results will vary depending on the level of experience and training the doctor has in utilizing PRP.

Dr. Kawase says this is clearly alluded to in the research:

• Platelet-rich plasma has been widely investigated and applied to regenerative medicine.
  • PRP use is supported by evidence that PRP contains high concentrations of platelet-related growth factors and normal concentrations of plasma-derived fibrinogen, both of which contribute to the regenerative process.
  • Additionally, its superior cost-efficacy versus conventional therapies is attractive to many clinicians.
  • However, the current disadvantages of PRP include a relatively complicated preparation procedure and doctor’s effectiveness in giving PRP  treatment.

The high degree in variability in treatment procedures among practitioners who use Platelet Rich Plasma

An article in Orthopedics Today  from the doctors at the Hospital of Special Surgery in New York also warns against the high degree in variability among practitioners who use Platelet Rich Plasma (PRP). The main concerns are again those cited above – lack of standardization in treatment regimes and formula concentrations. Also mentioned are the various brands, concentrations, doses, etc that make it hard to determine the best use of PRP.

Doctors in Italy at the Rizzoli Orthopedic Institute and the University of Bologna expressed concern over the lack of standardization among doctors using Platelet Rich Plasma Therapy in their study. The researchers do acknowledge that the role of PRP in bone, tendon, cartilage, and ligament tissue regeneration has been shown in numerous preclinical studies published within the last 10 years to have delivered very promising results but many key questions remain unanswered and controversial results have arisen.

Writing in the medical journal Biomed Research International they also call for  studies to define the dosing, timing, and frequency of PRP injections, different techniques for delivery and location of delivery, optimal physiologic conditions for injections, and the concomitant use of recombinant proteins, cytokines, additional growth factors, biological scaffolds, and combined use of PRP and stems cells to develop optimal treatment protocols that can effectively treat various musculoskeletal conditions.

BACK TO TREATING THE WHOLE KNEE WITH A COMPREHENSIVE PROGRAM:

See what these researchers are suggesting, optimal physiologic conditions for injections and concomitant use of other growth factors, this is what we do at Caring Medical Regenerative Medicine Clinics. Optimal physiologic conditions meaning that the patient:

• Has the ability to heal, and is given the best ability to heal by use of concomitant use of growth factors found in dextrose Prolotherapy, Bone marrow prolotherapy, and adipose fat cell therapy.
• For PRP to have its maximum healing benefits, in many cases it must be combined into a whole joint treatment.

In 2017, doctors writing in the medical journal Pain Physician wrote:

“It is incumbent upon anyone using a specific PRP product to understand its precise formulation and consistency as well as the rationale for the technique used in its production and application. The lack of standardization and quality
control in addition to the diverse applications of PRP and outcomes, make it difficult to generate convincing data.”

On Conclusion in my opinion Platelet Rich Plasma (PRP Therapy) is best non-surgical treatment for knee osteoarthritis and is alternate to knee replacement. I would say Don't Replace ; Regenerate 

for any further query fee free to ask 

Whatsapp no: 0322-8063067

email: waqas.alrai@gmail.com

clinic : center for Pain Management

1# University Lahore Teaching Hospital

1km Off Defense Raod Raiwind Road, Lahore

2# Life Line Hospital, Johar Town Lahore 

for free evaluation send Xrays Knee Ap Standing and Lateral on whatsapp no along with some history of disease.