This article extracted from getprolo.com discusses PRP for Meniscus tears

Patients will contact Prolotherapists’ offices  with questions about their meniscus injury and ask what type of  recommendations are available for treatment.

The patient may already have an MRI showing a meniscus tear, a recommendation for arthroscopic meniscus surgery, or a history of physical therapy and other conservative care treatments including anti-inflammatories and/or a recommendation from a surgeon that they really need to wait until their knee is worse before an operation can be performed.

One of the treatment options the patient may have researched is platelet rich plasma therapy or commonly referred to as PRP. PRP is an injection treatment which re-introduces your own concentrated blood platelets into areas of chronic joint and spine deterioration.

The reason patients are seeking out alternatives to conservative care or surgical intervention for meniscus injury is that these treatments have come under intense scrutiny in the medical community for failing to help patients achieve long-term knee repair. The most serious of the long-term consequences is an acceleration of joint degeneration.

In brief, in the research surgeons warn each other that they face the difficult decision of removing or retaining the meniscus during an arthroscopic procedure. If the decision is made to retain the meniscus, the surgeons must address the difficulties of post-operative meniscal healing.

One option is to introduce Platelet Rich Plasma into the surgery. For some people this is in fact where they heard about PRP the first time, when a doctor discussed with them surgical possibilities and the use of PRP for accelerated surgical healing.

PRP for meniscus repair, surgery or in office injection?

Doctors at Department of Orthopaedics, Xiangya Hospital, Central South University in China published their research in the journal Medical science monitor.

In this research they discuss the meniscus white-white tears which they describe as “a meniscus lesion completely in the avascular zone (which) are without blood supply and theoretically cannot heal.”

They hypothesize that doctors need to get blood to this meniscal zone for healing to occur but face the task that the problem of promoting meniscal healing in the avascular area has not yet been resolved. The possible answer? Platelet-rich plasma (PRP). The Chinese team supports the idea that the application of platelet-rich plasma for white-white meniscal tears will be a simple and novel technique of high utility in knee surgery.

Platelet-rich plasma (PRP) can be the answer for some surgical patients during the surgery to address the healing challenges of the “white-on-white” meniscus tear.1

So the idea is to bring PRP in during the surgery, apply it to areas where normal blood supply is limited and this should accelerate healing. In theory should work great. But it does not.

Meniscal Surgery: a poor option that PRP intervention at the time of surgery may not help

There is no question that cartilage heals slowly and poorly this includes the meniscus. Recommendations for surgeries involving shaving or removing the torn portion of the tear using arthroscopic surgery, or sewing the tear together is flawed because it does not repair the deteriorated meniscus.

By failing to heal the damaged meniscal cartilage, surgery does not alleviate the chronic pain that people with this condition experience.

Here is research from the University of Virginia Health System. Here doctors focused on the problem of increased contact stresses in the knee after meniscectomy.2

They note that since Platelet-rich plasma has received attention as a promising strategy to help induce healing, the doctors then sought to:

• evaluate whether PRP augmentation at the time of (surgical) meniscal repair decreases the likelihood that subsequent meniscectomy will be performed; in other words could PRP prevent the need for a second meniscal surgery.
• determine if PRP augmentation in arthroscopic meniscus repair influenced functional outcome measures; and
• examine whether PRP augmentation altered clinical and patient-reported outcomes.

In this study, the experiment was to remove meniscus tissue and see if PRP treatment made a significant impact in the surgical outcome. Before we go on, a quick citation is needed to help with understanding of dilution of PRP during surgery.

• University of South Alabama College of Medicine published in the Journal of surgical orthopaedic advancees a troubling study with implications for healing after arthroscopic surgery. These researchers hypothesized that agents injected into the knee during and after knee arthroscopy will be significantly diluted by residual arthroscopic fluid by 27%. 3

So theoretically, during surgery, a weakened PRP treatment is asked to heal the surgical and meniscal damage

Returning to the University of Virginia Health System research, its conclusion should then not be surprising:

“Patients who sustain meniscus injuries should be counseled at the time of injury about the outcomes after meniscus repair. With our limited study group, outcomes after meniscus repair with and without PRP appear similar in terms of reoperation rate.”2

In the two above studies, researchers sought to improve the surgical outcomes in meniscal surgery by applying a PRP solution to the torn meniscus during the procedure. PRP could not be confirmed as effective – the culprit for non-conclusive results was not the PRP but the surgical procedure.

Medical reviews of PRP meniscus injections

Research has shown that the damaged meniscus lacks growth factors to heal. Research has found that injections of PRP bring the healing components to the site of the injury.

These components are:

• platelet derived growth factor (PDGF), (the components of Platelet Rich Plasma.
• transforming growth factor (TGF), proteins crucial for tissue regeneration, and others, augment meniscus cell growth and subsequent collagen formation. Collagen is a building block of soft tissue.

Animal studies with these same growth factors have confirmed that meniscal tears and degeneration can be stimulated to repair with various growth factors or solutions that stimulate growth factor production.

In order to understand how growth factors affect the treatment of meniscus injuries, it is first important to understand the role that they play in the natural process of healing.

• The preliminary steps of healing begin with the attraction of blood cells to the site of an injured tissue.
• When a tissue is injured, bleeding will naturally occur in that area.
• A specialized type of blood cells called platelets, rush to the area to cause coagulation, or the clotting of blood cells, to prevent excessive bleeding from an injury.
• In addition, platelets also release growth factors which are an integral part of the healing process.

Each platelet is made up of an alpha granule and a dense granule. For lack of a better term these are “vessels” which contain a number of proteins and growth factors which are “poured” out onto the wound or injury. The growth factors contained in the alpha-granule are an especially important component to healing. When activated by an injury, the platelets will change shape and develop branches to spread over injured tissue to help stop the bleeding in a process called aggregation, and then release growth factors, primarily from the alpha granules.

At this point, the healing process then proceeds in three simple stages: inflammatory, fibroblastic (formation of new connective tissue), and maturation (completion of healing process).

In the case of the injured meniscus, it is clear that the damaged tissue can not repair itself. Healing in the meniscus depends on the having enough of a blood supply and/or growth factors at the site of the injury. Since less than 20% of the meniscus is vascularized by the time a person reaches the age of 40 years, meniscal healing is generally incomplete.

In a recent study, German and Swiss doctors publishing in the Muscles, ligaments and tendons journal. The doctors sought to demonstrate that Platelet Rich Plasma injections have the ability to regenerate tissue; as already shown in several experimental studies.

In this study:

• Ten recreational athletes with grade II meniscus tears were treated PRP injections into the affected meniscal area.
• Three sequential injections in seven day intervals were performed in every patient.
• Four of ten patients (40%) showed decrease of meniscal lesion in follow up MRI after six months.
• Six of ten patients (60%) showed Improvement of NRS-Score at final follow up.
• Average NRS-Score (A numeric scoring system for pain on a 1-10 scale) improved significantly from 6.9 before injections to 4.5 six month after treatment.
• Six of ten patients (60%) reported increase of sports activity compared to the situation before injections.
• In four patients (40%) additional surgical treatment was necessary because of persistent knee pain or progression of meniscal lesion.5

Recently doctors at a military hospital in Pakistan treated patients with PRP and published the results: In their paper they evaluated the clinical effects, adverse reactions and patient satisfaction after intraarticular injection of platelet rich plasma in a small group of patients with internal derangements of knee. (Torn cartilage and Meniscus)

• 10 patients received two doses of 3 ml of platelet rich plasma as intraarticular knee injection at two weeks interval.
• All patients were evaluated at 0, 4 and 12 weeks after treatment using standard scoring systems
• There was significant improvement in all scores.

They concluded Intraarticular PRP injection is safe and effective method in the conservative treatment of internal knee derangements.6

In the experience of many Prolotherapists, using dextrose Prolotherapy with PRP together enhances the effectiveness of meniscal repair. When treating a meniscal tear with PRP Prolotherapy, the concentrated platelets (PRP) are placed at the site of the tear. Growth factors are released which will stimulate healing of the tear. The growth factors in the PRP will cause a proliferation and regeneration of the injured tissue. This boosts fibroblastic events involved in tissue healing causing these tears to heal.

1. Wei LC, Gao SG, Xu M, Jiang W, Tian J, Lei GH. A novel hypothesis: the application of platelet-rich plasma can promote the clinical healing of white-white meniscal tears. Medical science monitor: international medical journal of experimental and clinical research. 2012;18(8):HY47.

2. Griffin JW, Hadeed MM, Werner BC, Diduch DR, Carson EW, Miller MD. Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes?. Clinical Orthopaedics and Related Research. 2015 May 1;473(5):1665-72

3. Stopka SS, Wilson GL, Pearsall AW. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. J Surg Orthop Adv. 2015 Winter;24(4):209-12.

4. Hauser RA, Phillips HJ, Maddela H. Platelet rich plasma Prolotherapy as first-line treatment for meniscal pathology. Pract Pain Manag. 2010 Jul;10(6):53-64.Pract Pain Manag. 2010 Jul;10(6):53-64.

5. Blanke F, Vavken P, Haenle M, von Wehren L, Pagenstert G, Majewski M. Percutaneous injections of platelet rich plasma for treatment of intrasubstance meniscal lesions. Muscles, ligaments and tendons journal. 2015 Jul;5(3):162.

6. Razaq S, Ejaz A, Rao SE, Yasmeen R, Arshad MA. The Role of Intraarticular Platelet Rich Plasma (PRP) Injection in Patients with Internal Knee Derangements. Journal of the College of Physicians and Surgeons Pakistan. 2015 Sep 1;25(9):699-701.

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