Biologics

Platelet Rich Plasma (PRP)

PRP therapy is not stem cell therapy. However, it does involve using your own blood to help stimulate the healing process. It has become a nice option in conservative care before committing to a surgical procedure which may be associated with a lengthy recovery. We typically perform PRP treatments in the office during a normal office visit. A small amount of blood is drawn from the arm and then spun in a centrifuge. We use a special kit that has all the materials necessary for this process. The process of spinning the blood isolates the platelets and plasma which contain natural growth factors and healing proteins. After isolating the PRP, we inject the area of concern under ultrasound guidance for needle placement. This process may lead to healing of cartilage, tendon and ligaments given the high concentration of healing factors delivered to the area of injury.

We are currently using PRP to help with healing of degenerative problems in the foot and ankle. It has been useful in treating tendinosis of the Achilles tendon and in cases of plantar fasciitis as well as other conditions. We typically recommend treatment with PRP when other more traditional modalities have failed to produce a satisfactory improvement and a patient is contemplating surgery. This means physical therapy, stretching, strengthening, activity modification, shoe wear modifications and use of anti-inflammatories have all failed. This can be offered as a step prior to surgery.

Studies continue to be done using PRP as a treatment agent versus placebo to judge the effectiveness in various conditions. There have been a number of published studies stating that PRP works better than placebo in the treatment of plantar fasciitis, for example. However, insurance companies still consider the use of PRP experimental and therefore will not provide coverage for its use. Thus, in most centers, PRP is a cash service. Depending upon your geographic location, PRP injections usually range in price between $750 to $1500. This depends on the use of adjunctive modalities such as inclusion of ultrasound which helps us guide the needle to the precisely right location. Most of my patients receive a single injection but, in some cases, a second treatment three to six months later may be helpful. Post injection, we usually recommend taking it easy and allowing the body part to heal over the next 4-8 weeks.

Feel free to discuss the appropriate use of PRP with us at your next visit.

STEM CELLS

Stem cells are immature cells that are currently not specialized and retain the ability to divide. Stem cells in orthopaedics are most commonly found in your bone marrow although they can also be derived from adipose tissue (fat). A stem cell maintains the ability to change into a more specialized cell such as a muscle cell, a bone cell or a cartilage cell and thus is being heavily studied in orthopaedic research today. Stem cells are felt to contribute to the body’s ability to renew and repair its tissues. For this reason, stem cells are now being harvested from the bone marrow and then injected into the injured area to regenerate the tissue. If we then take this bone marrow aspirate and spin it in a centrifuge, we can concentrate the number of stem cells, greatly increasing the number of cells injected over a simple aspiration. We refer to this process as bone marrow aspirate concentrate (BMAC). Outside the US, centers can then take these stem cells and manipulate them by a process that greatly amplifies these stem cells even further to create a “super” concentrate. The FDA, as of 2018, has not allowed for this type of manipulation in the US so we are using BMAC currently if you reside in the US.

PRP injections bring growth factors into the region but stem cells actually bring in new cells that are capable of becoming the injured type of cell and in this way may be forming new healthy tissue. Uses in the foot and ankle are many. Most popular is as an adjunct to healing bone in fractures as well as fusion surgery. We have used it to help heal osteochondral defects of the talus where there is a missing piece of cartilage. Other uses include plantar fasciitis, Achilles tendon disorders, peroneal tendon problems and there may be some efficacy in early ankle arthritis. It may be beneficial to trial PRP as a first line treatment since it is significantly easier to harvest and less expensive. However, in surgery, often we will use stem cells in higher risk cases or in athletes that want to return to play as quickly as possible.

The cost of stem cells is much higher and sometimes requires sedation. The cost may be between $2500 and $7500 depending on where it is performed (surgery center versus office).

It should be noted that further studies are necessary for all biologics and no guarantee can be made concerning outcomes with these modalities.