By Santos F. Martinez, MD
The use of biologics such as platelet-rich plasma (PRP), mesenchymal
stem cells, or growth factors in the orthopaedic office setting is
becoming more common, fueled, in part, by a growing body of research and
increasing market demand for alternative methods of nonsurgical
management of soft-tissue and musculoskeletal conditions.
The use of biologics has been facilitated by advances in imaging
technology such as musculoskeletal ultrasound. In addition, platelet
processing centrifuges are becoming more affordable. Practical
strategies for office use depend on the surgeon’s patient flow and
practice patterns.
Although additional research is required to optimize the following
recommendations, they may be helpful as limited guidelines for current
office use.
Equipment and methodology considerations
Several different manufacturers offer centrifuges, with different levels
of automation and platelet concentration techniques. All provide closed
systems with “single-use kits,” which ultimately result in additional
cost considerations.
Duration of centrifuge processing is usually 15 to 20 minutes. A
sterile barrier may be necessary, depending on automation and centrifuge
processing protocols.
Current recommendations are that the platelet concentration be raised
to 4 to 6 times above the baseline concentration. Further research is
required to optimize recommendations.
Bovine thrombin and/or calcium may be used as an activation agent, depending on procedure.
Musculoskeletal ultrasound may be used to guide needle placement.
Administrative considerations
The three most significant administration considerations are time commitment, insurance coverage, and informed consent.
Some surgeons incorporate image-guided injections into their regular
office practice, while others set specific hours for such procedures.
Nomenclature and recognized research vary among insurance carriers.
Few third-party carriers are currently reimbursing for PRP injections.
Recently, the American Medical Association introduced a new category III
(new technology) Current Procedural Terminology (CPT) code for the
performance of PRP injection procedures. The new code includes the
harvesting of the blood, spinning of the blood, and injection of the
remaining plasma and should be used only when PRP is performed during a
completely separate patient encounter from a surgical procedure.
The new code does not have an assigned Medicare value and is priced
by regional carriers. Physicians will need to estimate the work involved
in providing the service. At present, PRP injections should be
considered a direct cost to the patient.
As for any typical medical procedure, the PRP injection process
should be thoroughly discussed with the patient, who should sign a
consent form before the procedure.
Pre-injection guidelines
The patient should be aware of and compliant with the following guidelines:
- No corticosteroids for 2 to 3 weeks before the procedure.
- Discontinue nonsteroidal anti-inflammatory drugs (NSAIDs). Although no formal recommendations have been made in this area, our practice suggests that the patient discontinue taking NSAIDs a minimum of 1 week before the procedure.
- No anticoagulation use 5 days before the procedure.
- Increase fluid intake in the 24 hours preceding the procedure.
- Anti-anxiety medication may be required for certain patients.
Contraindications
The following conditions should be considered as contraindications for
PRP injection: hematologic blood dyscrasias with platelet dysfunction;
septicemia or fever; cutaneous infections in the area to be injected;
anemia (hemoglobin less than 10 deciliters; malignancy, particularly
with hematologic or bony involvement; allergy to bovine products if
bovine thrombus is to be used.
Procedure
The procedure is simple. With sterile technique, obtain appropriate
amount of venous blood and transfer it to the centrifuge. After
processing is completed, extract the PRP from the centrifuge according
to the manufacturer’s instructions.
Cleanse the patient’s skin around the injection site; if desired, use
towels or drapes to create an aseptic field. Administer a local
anesthetic if necessary. With real-time image guidance (computed
tomography, fluoroscopy, or ultrasound) and sterile technique, inject
the PRP into the appropriate area; apply dressing or bandage to protect
needle entry site.
Complications
Reported adverse effects are not different from those of normal
venipuncture or injections at the same body locations. PRP injections,
however, are frequently more painful than other injections due to the
viscosity of the solution.
Santos F. Martinez, MD, is affiliated with the Campbell Clinic. He can be reached at sfmartinez@campbellclinic.com
Editor’s note: Although neither the AAOS nor AAOS Now
advocate the use of platelet-rich plasma, these guidelines may be
helpful to those who are considering adding this therapy to their
treatment armamentarium.
AAOS Now
September 2010 Issue
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