Application of PRP after arthroscopic cuff repair yielded structural, clinical healing

Patients who received PRP had a lower retear rate, but only large tears had a significant retear difference.

Issue: October 2016

Patients with large rotator cuff tears had superior structural and clinical healing after arthroscopic repair with the application of moderately concentrated platelet-rich plasma, according to study results.

Perspective from Nikhil N. Verma, MD

“There seems to be a positive healing response after the arthroscopic repair of medium to large size rotator cuff tears by instilling [platelet-rich plasma] PRP over the repaired cuff, most likely by increasing the vascularity in and around the cuff,” Vivek Pandey, MS (Ortho), of Kasturba Medical College, told Orthopedics Today.

Use of PRP

Pandey and his colleagues randomly assigned 102 patients with medium-sized and large-degenerative posterosuperior cuff tears that underwent arthroscopic repair to the PRP injection group, who received 8 mL of PRP, or the control group. Researchers used clinical scores and ultrasound to assess retear and vascularity pattern of the cuff in all patients.

At 1 month, 3 months and 6 months, results showed significantly lower VAS scores in the PRP group compared with the control group, but not at time points after 6 months. Researchers also found the PRP group had significantly better Constant-Murley scores at 12 months and 24 months and significantly higher University of California-Los Angeles scores at 6 months and 12 months. According to results, both groups had comparable American Shoulder and Elbow Surgeons scores at all time points. The PRP group had a significantly lower retear rate at 24 months compared with the control group. However, only large tears had a significant retear difference. According to Doppler ultrasound examination, the PRP group had significant vascularity at the repair site at 3 months postoperatively and in the peribursal tissue until 12 months.

“The role of PRP in healing the cuff is debatable as many studies do not confirm the healing response of PRP over the healing pattern of the cuff,” Pandey said. “All the more, we had selected medium- to large-sized degenerative cuff tears and not the traumatic tears, with apparently ‘poor healing potential’ to be repaired by single row. A better healing response by using PRP after the repair of the large tear was a surprise, but was an encouraging finding.”

Clinical implications

Pandey noted the results of the present study “challenges the theory that only higher concentrates of PRP are required for tendon-bone” by showing a positive healing response of single centrifuge moderately concentrated institutionally prepared and standardized PRP after cuff repair. He also noted the positive response in the healing of large degenerative cuff tears suggests that PRP should be used in such cases to enhance the healing response.

“Even though we have not done ‘on paper’ cost analysis on usage of ‘institutionally prepared PRP’ vs. ‘commercially available kit PRP,’ the former is certainly cheaper to prepare and use in our setup,” Pandey said. “Once the beneficial effects of PRP are proven beyond doubt, a low cost PRP may be more beneficial in making health care delivery system more affordable.” – by Casey Tingle

Reference:
Pandey V, et al. J Shoulder Elbow Surg. 2016;doi:10.1016/j.jse.2016.01.036.

For more information:
Vivek Pandey, MS Ortho, can be reached at Kasturba Medical College, Manipal, Karnataka 576104, India; email: vivekortho@gmail.com.

Disclosure: Vivek reports no relevant financial disclosures.

Perspective

Nikhil N. Verma, MD

In the last decade, strategies to improve healing following arthroscopic rotator cuff repair have focused on mechanical constructs, including double-row and transosseous equivalent fixation. However, tendon healing remains a biologic problem. In this well-designed clinical trial, the authors provide support for the use of PRP in achieving both improved clinical outcomes and structural healing rates. However, alternate studies have reported conflicting results.

When evaluating biologic therapies, the science remains in its infancy. Multiple confounding variables exist, including cellular and growth factor concentrations that may vary by product, delivery method and timing, as well as host factors (such as tear size and comorbidities). Many studies are underpowered to use structural integrity as a primary endpoint. These variables make comparison between studies difficult. In addition, the added cost of these products remains a concern. However, given the findings of this study and others showing potential benefits of adjuvant biologic therapy during arthroscopic rotator cuff repair, with little to no additional morbidity, consideration should be given to its use particularly in patients at risk for failure.

Nikhil N. Verma, MD

Orthopedics Today Editorial Board member

Disclosures: Verma reports no relevant financial disclosures.