plasma rico en plaquetas: prp - comité...
TRANSCRIPT
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Revisión de la literatura: evidencia científica de la eficacia y efectos secundarios
XIII JORNADAS SOBRE MEDICINA Y DEPORTE DE ALTO NIVELCOE, MADRID 23 Y 24 DE SEPTIEMBRE DE 2011
David López Capapé
Especialista Cirugía Ortopédica y Traumatología
PLASMA RICO EN PLAQUETAS:PRP
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INTRODUCCIÓN
Tema de controversia en toda la comunidadinternacional.Uso clínico paralelo, no previo, a estudios delaboratorio y en animales.Tema atractivo especialmente en el deporte.Importancia y responsabilidad de los medios decomunicación.Gran complejidad y dificultad para sacar conclusiones.
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Orthopaedics today Europe, March/April 2011:
Platelet-rich plasma: Yet to beproven, but studies are ontheir way
INTRODUCCIÓN
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INTRODUCCIÓN
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INTRODUCCIÓN
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Autologous plateletshave no effect onthe healing ofhuman achillestendon ruptures: arandomized single-blind study. Am JSports Med 2011Jan.
INTRODUCCIÓN
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PLASMA RICO EN PLAQUETAS (PRP)
Muestra de sangre autóloga con una concentración deplaquetas por encima de los valores normales
OTRAS DENOMINACIONESPlasma rico en factores de crecimiento
Plasma enriquecido con plaquetas
Preparación rica en factores de crecimiento
Concentrado plaquetas
Fibrina rica en plaquetas
DEFINICIÓN
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Inyección o aplicación de la preparación desangre autóloga con alta concentración deplaquetas en un tejido lesionado, con el objetivode favorecer o mejorar el proceso de curación ocicatrización del mismo
Más de 20 años de experiencia clínica, endiferentes especialidades médicas, pero pocaliteratura que evidencie su eficacia
TERAPIA CON PRP
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FASES DE LA CURACIÓN
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GRÁNULOS ALFA:
PROTEÍNAS
PDGF, VEGF, TGF-B1
FGF, EGF, PLATELET FACTOR 4
TROMBOSPONDINA 1
ANGIOPOIETINAS, ENDOSTATINAS
HGF
IGF-1
FACTORES DE CRECIMIENTO
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MITOGENESISESTIMULACIÓN DE CÉLULAS MESENQUIMALESESTIMULACIÓN DE LA PROLIFERACIÓN CELULARANGIOGÉNESISSÍNTESIS DE COLÁGENO SÍNTESIS DE MATRÍZ EXTRACELULAREFECTO ANTIINFLAMATORIOEFECTO QUIMIOTÁCTICOETC…
FACTORES DE CRECIMIENTO
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GRÁNULOS DENSOS
ADENOSINA
SEROTONINA
HISTAMINA
CALCIO
Mishra A, Woodall J Jr, Vieira V A: Treatment ofTendon and Muscle Using Platelet-Rich Plasma. ClinSports Med 2009, 28: 113-125
PLAQUETAS
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Extracción de entre 10 y 60 mlCentrifugación
Separación fraccionesPPP
L-PRP
Hematíes
Activación: Trombina, Calcio, Colágeno
PREPARACIÓN PRP
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Falta de estandarización del proceso:Cantidad de sangreCentrifugación y separaciónConcentración final de plaquetasPresencia o no de leucocitos (P-PRP, L-PRP)Forma de activación
Varias preparaciones diferentes, por lo tanto pueden tener eficacia diferente
PREPARACIÓN PRP
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Laboratorios con campana flujo laminarAutologous Conditioned Plasma, ArthrexCascade, Musculoskeletal Tissue FoundationGPS III, BiometSmart PReP, Harvest TechnologiesPalexPRFG, BTIFIBRINET
PREPARACIÓN PRP
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TrombopeniaProblemas de coagulaciónTerapia anticoagulanteInfecciónCáncerEmbarazo
CONTRAINDICACIONES PRP
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No está reguladoDesde menos de 100 a más de 600 € por inyección (HASTA 1200 €!!)Normalmente excluido en seguros de saludTambién se utiliza en medicina públicaValorar coste/beneficio
COSTE PRP
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No se han comunicado efectos adversos relevantesTrombina bovinaLa hipótesis de que pudiera aumentar la incidencia de neoplasias no ha sido corroborada
SEGURIDAD
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Dolor, InfeccionesProblemas cutáneos, Nódulos o abultamientos
COMPLICACIONES
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PRP Y ANTI-DOPAJE
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Aumento de la expresión de genes de colágeno en tenocitos tratados con PRPMovilización de células satélites y producción de colágeno tipo IMayor proliferación celular y angiogénesis
Estímulo de las célula madre mesenquimales
ESTUDIOS DE LABORATORIO
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Mejora de la reparación de lesión aguda del tendón deAquiles en ratas (Aspenberg y Virchenko, Acta Orthop Scan2004 y 2006)
IGF-1 y FGF mejora lesiones músculo esquelético enratones (Menetry JBJS Br 2000)
Miogenesis mayor con PRP que con PPP en ratas(Hammond, Am J Sports Med 2009)
Efectos positivos en la reconstrucción de defectos decartílago en conejos y corderos (García-Álvarez F, Rev espcir ortop traumatol 2010)
Algunos otros resultados son contradictorios
ESTUDIOS EN ANIMALES
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Pocos artículos se pueden considerarcontrolados y randomizados (RCT)Algunos artículos recogen series decasosMuchos artículos comunican un casoclínico
ESTUDIOS CLÍNICOS
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PUBMED
PRP & sports injuries: 42PRP & tendon: 73PRP & muscle: 37PRP & cartilage: 60PRP & ligaments: 42
REVISIÓN LITERATURA
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TENDINOPATIA CODO
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Creaney L. Growth factor-based therapiesprovide additional benefit beyondphysical therapy in resistant elbowtendinopathy: a prospective, single-blind,randomised trial of autologous bloodinjection versus platelet-rich plasmainjections. Br J Sports Med 2011 Mar 28
TENDINOPATIA CODO
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Coombes BK. Efficacy and safety of corticosteroidinjections and other injections for management oftendinopathy: a systematic review of randomisedcontrolled trials. Lancet 2010 Nov 20; 376(9754):1751-67.“Despite effectiveness of corticosteroid injectionsin the short-term, non-corticosteroidinjections might be of benefit for long-termtreatment of lateral epicondylalgia, response toinjections should not be generalised because ofvariation in effect between sites of tendinopathy”
TENDINOPATIA CODO
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Mishra A, Pavelko T: Treatment of chronicelbow tendinosis with buffered platelet richplasma. Am J Sports Med 2006; 34: 1774-1778
Peerbooms JC, … Gosens T: Positive effectof an autologous platelet concentrate inlateral epicondylitis in a double-blindrandomized controlled trial: platelet-richplasma versus corticosteroid injection with a1-year follow-up. Am J Sports Med 2010; 38:255-262
TENDINOPATIA CODO
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TENDINOPATIA AQUILEA
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De Vos RJ, et al. Platelet rich plasma injection forchronic Achilles tendinopathy: a randomizedcontrolled trial. JAMA 2010; 303: 144-9
De Vos RJ, et al.: No effects on ultrasonographictendon structure and neovascularisation inchronic midportion Achilles tendinopathy. Br JS`ports Med 2011, 45: 387-392
De Jonge S, De Vos RJ: One-Year Follow-up ofPlatelet-Rich Plasma Treatment in Chronic AchillesTendinopathy. A Double-Blind Randomized PlaceboControl-Trial. Am J Sports Med 2011, 39 (8)
TENDINOPATIA AQUILEA
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Tice JA. Platelet-rich plasma Injection forAchilles Tendinopathy: A Technology Assessment.Octubre 2010
TENDINOPATIA AQUILEA
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Kon E, Filardo G: Platelet-rich plasma: Newclinical applications: a pilot study for thetreatment of jumper´s knee. Injury 2009, 40:598-603
Filardo G, Kon E: Useof platelet-rich plasmafor the treatment ofrefractory jumper´sknee. Int Orthop 2009
TENDINOPATIA ROTULIANA
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De Vos RJ,…Mafulli N: Autologous growth factorinjectons in chronic tendinopathy: a systematicreview. British Medical Bullletin 2010, 95: 63-77
“there is limited evidence to support the use ofinjections with PRP in the management ofchronic tendinopathy”
TENDINOPATIA CRÓNICA
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TENDINOPATIA HOMBRO
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Castricini R. Platelet-rich plasma augmentation forarthroscopic rotator cuff repair: a randomizedcontrolled trial. Am J Sports Med 2011 Feb 39 (2): 258-65.
“Our study does not support the use ofautologous PRFM for augmentation of a double-row repair…”
ROTURAS MANGUITO ROTADOR
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Jo CH, Kim JE. Does Platelet-Rich PlasmaAccelerate Recovery After Rotator Cuff Repair? AProspective Cohort Study. Am J Sports Med 2011Jul 7.
“The results suggest that PRP application duringarthroscopic rotator cuff repair did not clearlydemonstrate accelerated recovery clinically oranatomically except for an improvement ofinternal rotation”
ROTURAS MANGUITO ROTADOR
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Sánchez M, Anitua E. Comparison of surgicallyrepaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med 2007; 35:245-251
Schepull T. Autologous platelets have no effect onthe healing of human achilles tendonruptures: a randomized single-blind study. Am JSports Med 2011 Jan; 39 (1):38-47“The results suggest that PRP is not useful fortreatment of Achilles Tendon ruptures”
ROTURAS TENDÓN DE AQUILES
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Andía I, Sánchez M, Mafulli N. Platelet rich plasmatherapies for sports muscle injuries: any evidencebehind clinical practice? Expert Opin Biol Ther 2011Apr 11 (4): 509-18
LESIONES MUSCULARES
“No PRP formulationhas yet displayedproven evidence tothe stimulation ofhealing and recoveryafter sports muscleinjuries”
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Hamilton BH, BestTM; PlateletEnriched Plasmaand Muscle StrainInjuries: ChallengesImposed by theBurden of Proof.Clin J Sport Med2011 Jan, 21 (1) :31-6
LESIONES MUSCULARES
“There is no level 1,2 and 3evidence for the use”,“There remain a largenumber of unansweredquestions”
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Aspetar Consensus, Hamilton, B y cols. 2009:
La falta de consistencia en la preparación, aplicacióny dosificación de factores de crecimiento, así como lasdudas acerca de qué preparado con o sin leucocitospuede ser mejor, hace no aconsejar el uso de PRP enlesiones musculares de forma rutinaria.
Recomiendan continuar con la investigación enestudios de alto nivel de evidencia
LESIONES MUSCULARES
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LESIONES LCA
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Sánchez M, Anitua E, López-Vidriero E, Andía I.The Future: Optimizing de HealingEnvironment in Anterior Cruciate LigamentReconstruction. Sports Med Arthrosc Rev 2010Marc 18 (1): 48-53
“PR preparations…provide a potential advantagefor better and more predictableligamentization and enhanced bone-tendonhealing…However poor standardization in the fieldhas hampered the evaluations of different plasmaproducts and the establishment of standardbeneficial application of this technology”
LESIONES LCA
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Cervellin M. Autologous platelet-rich plasma gel toreduce donor-site morbidity after patellar tendon graftharvesting for anterior cruciate ligament reconstruction:a randomized, controlled clinical study. Knee Surg sportsTraumatol Arthrosc 2011 Jun 16
“study shows theusefulness of PRP inreducing subjectivepain at the donor-site level after ACLreconstruction withBPTB”
LESIONES LCA
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Vogrin M. Effects of a platelet gel on early graftrevascularization after anterior cruciate ligamentreconstruction: a prospective randomized, double-blind,clinical trial. Eur Surg Res 2010; 45 (2): 77-85
“Locally applied PGenhanced earlyrevascularizationof the graft in theosteoligamentousinterface zoneafter ACLreconstruction”
LESIONES LCA
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Vogrin M. The effect of platelet-derived growthfactors on knee stability after anterior cruciateligament reconstruction: a prospective randomizedclinical study. Wien Klin Wochenschr 2010 May; 122Suppl 2: 91-5
“Platelet-leukocytegel, applied locally,can improve kneestability in surgeryfor reconstruction ofthe anterior cruciateligament
LESIONES LCA
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Taylor DW. A systematic review of the use ofplatelet-rich plasma in sports medicine as anew treatment for tendon and ligamentinjuries. Clin J Sports Med 2011 Jul 21 (4):344-52
“In 3 studies on the use of PRP in ACLreconstruction, no statistically significantdifferences were seen…”
LESIONES LCA
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LESIONES FIBROCARTÍLAGOS
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Delos D, Rodeo SA. Enhancing meniscal repairthrough biology: platelet-rich plasma as analternative strategy. Instr Course Lect 2011;60:453-60“PRP is the latest technique to be evaluatedfor augmenting meniscal healing”
LESIONES MENISCALES
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Hirahara, AM: Enhancing SLAP Repairs withFibrin-PRP Clots. Presented at the 76thArthroscopy Association of North America, SanDiego, 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 LABRUM GLENOIDEO
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LESIONES DEL CARTÍLAGO
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“The application of growth factors in the treatment oflocal cartilage defects as well as osteoarthritisappears promising; however further reseach isneeded at both the basic science and clinical levelsbefore routine application”
Fortier L. The Role of Growth Factors inCartilage Repair. Clin Orthop Relat Res 2011Mar 15
LESIONES DEL CARTÍLAGO
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Número creciente de aplicaciones terapeúticas conprometedores resultados en estudios preliminares. Laestandarización del proceso es necesaria en cuantoa la forma de preparar el PRP, sus características, susindicaciones, la forma de administración y losprotocolos terapeúticos antes de que su uso seautilizado indiscriminadamente.
Gobbi A, Bodrini L, Espregueira-Mendes J. The use ofplatelet rich plasma for cartilage repair. EnCartilage Repair, Current Concepts. Editors: MatsBrittberg, andreas Inhoff, Henning Madry , BertMandelbaum. 2010 DJO Publications
LESIONES DEL CARTÍLAGO
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ARTROSIS
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Sánchez M, Anitua E. Intra-articular injection ofan autologous preparation rich in growthfactors for the treatment of Knee OA: aretrospective cohort stdy. Clin Exp Rheumatolo 2008;26: 910-913
Kon E. Platelet-Rich Plasma Intra-ArticularInjection Versus Hyaluronic AcidViscosupplementation as Treatments for CartilagePathology: From Early Degeneration toOsteoarthritis. Arthroscopy 2011, Aug 8.
GONARTROSIS
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Hall MP. Platelet-rich Plasma:Current Concepts andApplication in Sports Medicine,J AM Acad Orthop Surg 2009;17:602-608“clinical use should beapproached cautiously untilhigh level clinical evidencesupporting platelet-rich plasmaefficacy is available”
ARTÍCULOS DE REVISIÓN
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Engebretsen L, Steffen K, Alsousou J,Anitua E: IOC consensus paper onthe use of platelet-rich plasma insports medicine, Br J Sports Med
2010, 44: 1072-1081
ARTÍCULOS DE REVISIÓN
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Kon E, Filardo G, Marcacci M.Platelet-rich plasma (PRP) totreat sports injuries: evidenceto support its use. Knee SurgSports Traumatol Arthrosc2011 Apr 19 (4): 516-27
“the analysis of the literatureshows promising preclinicalresults but contradictoryclinical findings for thetreatment of sports injuries”
ARTÍCULOS DE REVISIÓN
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López-Vidriero E. The Use ofPlatelet-rich Plasma inArthroscopy and SportsMedicine: Optimizing theHealing Environment.Arthroscopy 2010 Feb 26 (2): 269-278.“Future directions of PRP includeimproving the results ofarthroscopic and relatedsurgery, in addition todelineating correct dosage,timing and quantification, aswell as ideal techniques ofPRP application”
ARTÍCULOS DE REVISIÓN
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Paoloni J, De Vos RJ. Platelet–rich plasma treatmentfor ligament and tendon injuries. Clin J SportsMed 2011 Jan 21 (1): 37-45“the potential risks involved with PRP are fortunatelyvery low. However, benefits remain unproven todate”
Lee KS: Muskuloskeletal Applications of Platelet-RichPlasma: Fad or Future? AJR 2011; 196: 628-636.“muskuloskeletal injuries have long eluded theuse of standardized therapeutic protocolsregardless of cause”
ARTÍCULOS DE REVISIÓN
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Extensión del uso rápida en esta década
Grandes expectativas puestasImportante negocioPublicidad en los mediosAlta demanda por los pacientesSeguridad
DISCUSIÓN
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Creaney L. Platelet-rich plasma and the biologicalcomplexity of tissue regeneration. Br J Sports Med 2011,45: 611“growth factors can produce varying effects depending oftheir concentration, time of release, point in cell cycle andrecipient cell”“PRP has variable and inconsistent content andconcentration”“The succes in maxillofacial applications are perhapsnot analogous to sports medicine”
DISCUSIÓN
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A medida que vayamos conociendo mejor estetratamiento se podrá ir indicando correctamentesu utilización
Pueden tener un efecto reparador endefectos del tejido conectivoParecen tener un efecto antiinflamatoriosignificativo (artrosis)
DISCUSIÓN
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Ninguna lesión deportiva sería susceptible decuración únicamente por el uso del PRPEn lesiones musculares y tendinosas porsobrecarga el protocolo de readaptación es lomás importanteEn lesiones articulares y roturas tendinosastratadas quirúrgicamente la correctatécnica y la rehabilitación siguiente sonfundamentales
CONCLUSIONES
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La terapia con PRP puede mejorar losresultados de los tratamientos convencionalesDebe continuarse investigando para conocersus posibilidades terapeúticas realesEstandarizar el proceso es básicoEn el momento actual no se puederecomendar su uso en las lesionesdeportivas de forma rutinaria
CONCLUSIONES
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MUCHAS GRACIAS