Consensus Achieved on Platelet Rich Plasma (PRP) Treatments for Musculoskeletal Pathology: A Comprehensive Analysis

Overview

PURPOSE: The purpose of this study was to establish consensus statements on platelet-rich plasma (PRP) for the treatment of musculoskeletal pathologies. 

METHODS: A consensus process on the treatment of PRP utilizing a modified Delphi technique was conducted. Thirty-five orthopaedic surgeons and sports medicine physicians participated in these consensus statements on PRP. The participants were composed of representatives of the Biologics Association, representing nine international orthopedic and musculoskeletal professional societies invited due to their active interest in the study of orthobiologics. 

Consensus was defined as achieving 80-89% agreement, strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. 

RESULTS: There was consensus on 62% of statements about PRP. 

Understanding PRP

PRP is an autologous blood product containing a high concentration of platelets, growth factors, and cytokines. Its application varies widely across different pathologies, with numerous randomized controlled trials evaluating its efficacy.

The experts further proposed that PRP should be classified based on several parameters:

• Platelet count

• Leukocyte count

• Red blood cell count

• Activation method

• Type of plasma (pure-plasma vs. fibrin matrix)

These classifications aim to provide a more systematic approach to understanding and applying PRP in different clinical scenarios.

Clinical Applications of PRP

The experts achieved consensus on several aspects related to the clinical applications of PRP. They agreed that PRP's ideal dose is undetermined, and the minimum volume required may depend on the pathology being treated.

Regarding the administration of PRP, the experts recommended that it should be performed under image guidance, depending on the injection location. They also stated that anti-platelet agents are contraindicated in patients receiving PRP, both before and after the injection.

However, the experts did not reach consensus on whether PRP should be activated before use or if there is a preferred preparation method, including the centrifugation time and the number of spin cycles.

PRP for Knee Osteoarthritis

One of the most common clinical applications of PRP therapy is for the treatment of knee osteoarthritis. The experts achieved consensus on the use of PRP for Grade IV Knee OA, stating that PRP can be given for this stage of OA based on other relative indications.

However, for mild to moderate knee OA, the experts agreed that PRP alone is currently preferred. They noted that the evidence Hyaluronic Acid (HA) while promising, needs more research to establish effectiveness as a combination therapy.

Cost and Reimbursement of PRP

The cost and cost-effectiveness of PRP treatments remain controversial. The experts did not achieve consensus on the ideal out-of-pocket cost for a single PRP injection or the ideal physician reimbursement for a single PRP injection.

Conclusion

(1) PRP should be classified based on platelet count, leukocyte count, red blood count, activation method, and pure-plasma vs. fibrin matrix, 

(2) PRP characteristics for reporting in research studies are platelet count, leukocyte count, neutrophil count, red blood cell count, total volume, the volume of injection, delivery method, and the number of injections, 

(3) the prognostic factors for those undergoing PRP injections are age, BMI, severity/grade of pathology, chronicity of pathology, prior injections and response, primary diagnosis (primary vs. post-surgery vs. post-trauma vs. psoriatic), comorbidities, and smoking, 

(4) regarding age and BMI, there is no minimum or maximum, but clinical judgment should be used at extremes of either, 

(5) the ideal dose of PRP is undetermined, and 

(6) the minimal volume required is unclear and may depend on the pathology

While the experts achieved consensus on several aspects of PRP treatments, there are still areas that require further research, particularly in terms of the optimal dosage and timing, the effect of adjuvant therapies like HA, and the cost-effectiveness of the treatment vs standard of care.

The consensus statements generated through this process represent a significant step towards standardizing the use and understanding of PRP in the medical community. Further research is necessary to optimize the use of PRP in treating musculoskeletal pathologies. However, these consensus statements provide a crucial foundation for future studies and can help guide clinicians in their use of PRP treatments.

Summary Consensus Statements

STRONG CONSENSUS 90-99% (in decreasing order)

What is the ideal dose for PRP?

97% agreed with this answer: It is unclear what the ideal dose of PRP is, and it may differ based on the pathology treated.

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How should PRP be classified? 

94% agreed with this answer: PRP should be classified based on a) platelet count, b) leukocyte count, c) red blood count, d) activation method, and e) pure-plasma vs. fibrin 

___________________________________

What PRP characteristics should be standardized for reporting in research studies?

94% agreed with this answer: A: The following PRP characteristics should be standardized for reporting in research studies a) platelet count, b) leukocyte count, c) neutrophil count, d) red blood cell count, e) total volume, f) volume of injection, g) delivery method, and h) the number of injections.

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What are the positive and negative prognostic factors that should be considered in those undergoing PRP injections?

94% agreed with this answer: The prognostic factors that should be considered in those undergoing PRP injections are a) age, b) BMI, c) severity/grade of pathology, d) chronicity of pathology, e) prior injections and response, f) primary diagnosis (primary vs. post-surgery vs. post-trauma vs. psoriatic), g) comorbidities, and h) smoking.

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Is there a minimum or maximum age and/or BMI for PRP?

94% agreed with this answer: There is no minimum or maximum age and/or BMI for PRP, but clinical judgment should be used at extremes of either.

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Does the injection volume influence outcomes? Is there a minimum volume required?

94% agreed with this answer: Yes, the injection volume influences outcomes. However, the minimal volume required is unclear and may depend on the pathology.

CONSENSUS 80-89% (in decreasing order)

Is there a preferred preparation method, including centrifugation time and the number of spin cycles?

89% agreed with this answer: It is unclear if there is a preferred preparation method, including centrifugation time and the number of spin cycles.

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What are the indications for LP-PRP over LR-PRP? 

86% agreed with this answer: The indication for LP-PRP over LR-PRP is osteoarthritis.

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Should PRP be administered under image guidance?

86% agreed with this answer: PRP should be administered under image guidance depending on the injection location/clinician if indicated, as it would be for other injections.

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What are the potential complications of PRP administration, and how can they be minimized?

86% agreed with this answer: The potential complications of PRP administration are a) pain, b) inflammation, c) infection, and d) swelling. They can be minimized by a) aseptic technique, b) RICE, and c) anti-inflammatories.

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For mild-moderate knee OA, is PRP alone vs. PRP + additive agents, such as HA, preferred?

80% agreed with this answer: For mild-moderate knee OA, PRP alone is currently preferred. Although, the evidence is promising on additive agents such as HA.

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What are the indications for LR-PRP over LP-PRP? 

80% agreed with this answer: The indications for LR-PRP over LP-PRP are a) tendinopathy and b) lateral epicondylitis.

NO CONSENSUS 0-79% (in decreasing order)

What is the ideal physician reimbursement for PRP for a single injection?  

77% agreed with this answer: The ideal physician reimbursement for PRP for a single injection is at least $300.

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What is the leukocyte count that should be defined as leukocyte rich or poor PRP? 

74% agreed with this answer: Leukocyte rich or poor PRP should be defined as whether it is above or below the baseline leukocyte level  

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How should platelet-rich plasma (PRP) be defined?

71% agreed with this answer: PRP should be defined as a platelet concentration at least two times above baseline blood  

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Are anti-platelet agents contraindicated in those getting PRP (before, during, or after the injection)?

69% agreed with this answer: Yes, they are contraindicated both pre- and post-injection.

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Is there a preferred PRP administration protocol (including the number and timing of injections) for those with knee OA?

63% agreed with this answer: At least two injections may be required, but the optimal PRP administration protocol is unclear.

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Should PRP be activated prior to use?

60% agreed with this answer: No, PRP should not be activated prior to use.

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What is the ideal out-of-pocket cost for PRP for a single injection?

60% agreed with this answer: The ideal out-of-pocket cost for PRP for a single injection is $500-$750.

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Should a CBC be taken from all patients undergoing PRP treatment? And should PRP also routinely be analyzed?

57% agreed with this answer: Yes, a CBC should be taken from all patients undergoing PRP treatment, and PRP should also routinely be analyzed.

For more information on the EmCyte PRP system, please contact us at sales@plymouthmedical.com.

Citations

[1] Hurley ET, Sherman SL, Stokes DJ, Rodeo SA, Shapiro SA, Mautner K, Buford DA, Dragoo JL, Mandelbaum BR, Zaslav KR, Cole BJ, Frank RM; Members of the Biologics Association. Experts Achieve Consensus on a Majority of Statements Regarding Platelet-Rich Plasma Treatments for Treatment of Musculoskeletal Pathology. Arthroscopy. 2023 Aug 23:S0749-8063(23)00673-4. Doi: 10.1016/j.arthro.2023.08.020. Epub ahead of print. PMID: 37625660. https://pubmed.ncbi.nlm.nih.gov/37625660/

11/10/23