New Technologies

Platelet Gel and Uses in Orthopaedic Surgery

As part of my nature, and commitment to excellence for my patients, I enjoy both staying abreast of new technology, and occasionally helping to invent new procedures. This is my pledge to you, to try and deliver excellence and innovation in orthopaedics. To that end, I would like to share with you an exciting new technology available to my patients with hip and knee arthritis.

For the past 18 months I have used a technique on our patients that I am proud to report I have helped pioneer in orthopaedics. This is the use of autologous platelet rich plasma combined with thrombin to create a Platelet Gel (PG). This PG is then sprayed into the knee recesses and soft tissues at the end of the case. The PG forms a sticky, glue like substance which conveys some amazing properties to the tissues. As detailed below, it helps to decrease bleeding, decrease pain and enhance wound healing, among other things. As a matter of fact, the results are so dramatic that we have almost eliminated the need for transfusions after surgery in most knee patients receiving this modality. In a recent retrospective review of 80 patients, we have shown an amazing reduction in the need for bank and autologous blood when using PG during surgery. Specifically, 40 patients prior to the current regimen and having Total Knee Surgery without PG needed 21 units of bank blood and 26 units of autologous blood. The 40 patients having Total Knee Surgery with PG used only 1 unit of autologous blood. This means that 39 out of 40 patients did not need any blood products. This is an amazing statistic, and one of the most significant breakthroughs in this type of surgery in recent memory. (According to studies, the average blood loss for a Total Knee replacement is around 1800 cc-about 2 and one half units of blood.) As a matter of fact, when comparing our PG patients to non-PG patients, we have had a reduction in their length of stay by 1.4 days. This is due to the decreased blood loss, and improved wound healing. We have had similar results, though not quite as dramatic, in our Total Hip patients.

These results prompted me to learn more about this amazing by product of the patient's own blood. I have extrapolated this knowledge into another use for this product in the field of arthroscopy. In patients with full thickness cartilage loss of the knee and hip, we combine PG with a technique of marrow stimulation to produce dramatic results. In this technique, we "pick" the subchondral bone with a device that looks like an ice pick. This pick is gently driven into the bone until we see marrow elements coming from the hole it forms. This is then combined with PG, which is delivered into the area at the end of the case. Patients having had this technique performed exhibit truly remarkable results. From experience, I can tell you that without this technique, patients such as these do very poorly. These are the patients most disappointed with the results of arthroscopic surgery. Soon I will have one year follow up on 50 patients using this technique, and to date we are approaching around 75 patients. 75% of those patients have significantly improved after our technique of marrow stimulation and PG in those arthritic knees. Not only that, but the results are holding up. The uses for this product continue to expand, and recently we have used it for rotator cuff repairs, various tendon repairs and as stated, hip arthroscopy and hip replacement.

Sincerely,

H. Morton Bertram III, M.D.
Bertram Total Joint Centers
Naples, Florida

What is Platelet Gel?

"Autologous Platelet Rich Plasma" (Platelet Gel) was developed in the early 1970's as a by-product of multicomponent pheresis. Techniques and equipment have dramatically improved through the 1990's. This is a new procedure which utilizes the patient's own (autologous) platelets. Briefly, here's how the procedure works:

Approximately 150 milliliters is drawn, either pre-operatively or in the Operating Room, into a standard blood collection bag containing a citrate-phosphate-dextrose anticoagulant. There are also new machines that are able to utilize as little as 50 milliliters of blood to produce Platelet Gel. The blood is then centrifuged by using a variable-speed centrifuge autotransfusion machine or portable machine, to separate the buffy coat suspended in plasma from the red blood cell pack and platelet-poor plasma fraction. This is the platelet concentrate used for Platelet Gel. Depending on the initial platelet counts, it is common to achieve platelet counts in excess of over three to five (3-5) times baseline counts. Other important factors in quality of Platelet Gel are platelet viability and percent retained on the procedure. While white cell content increases 125% with selection for lymphocytes and monocytes, the inclusion of platelets and white cells appears have several beneficial aspects. White cells confer additional healing cytokines while providing antibacterial activity.

On activation with thrombin/calcium to form a coagulum, the platelets interdigitate with the forming fibrin web, developing a gel with adhesiveness and strength materially greater than the plasma alone. Thrombin/calcium also causes platelets to immediately release highly active vasoconstrictors, including beta thromboxane, serotonin and PDGF.

In addition, platelets contain many tissue growth factors. These predominant growth factors are:

• PDGF (Platelet Derived Growth Factor) - PDGF is a very powerful regulatory growth factor and a sentinel growth factor that begins nearly all wound healing. PDGF's main function is to stimulate cell replication (mitogenesis) of healing capable stems and premitotic partially differentiated osteoprogenitor cells which are part of the connective tissue-bone healing cellular make-up. PDGF also causes replication of endothelial cells, causing budding of new capillaries (angiogenesis). PDGF exists in three forms: PDGFaa, PDGFbb, PDGFab.

• TGF (Transforming Growth Factor) - TGF regulates proliferation and differentiation of multiple cell types. TGF found in platelets is subdivided into TGFB1 and TGFB2, which are the more generic connective tissue growing factors involved with matrix formation influencing osteoblasts to lay down bone matrix through the process of osteogenesis. Also cells activated by TGFB1 and TGFB2 include fibroblasts, endothelial and osteoprogenitor cells, chondroprogenitor cells and messenchymal stem cells. A chondoroprogenitor cell will further differentiate and produce the matrix for cartilage. A messenchymal stem cell stimulated to mitose provides wound healing cells.

Other important growth factors in platelets are:

• EGF (Epidermal Growth Factor) - EGF is responsible for cell differentiation and stimulates re-epitheliation, angiogenesis and collangenase activity.

• IGF (Insulin Growth Factors) - IGF is also important in wound healing, and stimulates both proliferation and differentiated function in osteoblasts.

Autologous Platelet Gel is the Perfect Operating Sealant!

Autologous Platelet Rich Plasma (Platelet Gel), on activation with thrombin/calcium, is a fibrin tissue adhesive, having hemostatic and tissue sealing properties, is the perfect surgical sealant.

There are over 30 known growth factors to date. These Platelet Growth Factors :

• Increase tissue vascularity through increased angiogenesis - This enhances wound healing

• Are chemotactic for monocytes, macrophages, and fibroblasts - This improves the ability to fight infection

• Enhance collagen synthesis - Again enhancing wound healing

• Increase the rate of epitheal and granulation tissue production - As above

• Enhance osteogenesis

• The high concentration of leukocytes in the buffy coat add an antimicrobial effect, while wound hemostasis and lymphatic sealing provide an opportunity to eliminate post-operative drains and reduce pain

• Provides watertight seal for dural closures

• When mixed auto/allograft bone fragments, it forms a putty-like consistency ideal for packing of structural reconstructions

• Provides for an immediate surgical hemostatic agent that is biocompatible, effective and safe.

Autologous Platelet Gel:

• is safe

• is non-toxic to tissue

• is autologous

• is easily prepared

• is readily available

• is cost effective

• promotes a firm seal in minutes

• is reabsorbed by the body in days to a few short weeks

• promotes local tissue growth and repair

Related Reference Articles:

• Scott, John D., Pawson, Tony, Cell Communication: The Inside Story, Scientific American , 2000; 282:72-79.

• Martin, P., et al, Growth Factors and Cutaneous Wound Repair, Progress in Growth Factor Research , 1992; 4:25-44.

• Hom, David B., Maisel, Robert H., Angiogenic Growth Factors: Their Effects and Potential in Soft Tissue Wound Healing, Ann Otol Rhinol Laryngol , 1992; 101:349-354.

• Herndon, D., et al, Growth Factors Local and Systemic, Archives of Surgery , 1993; 128:1227-1233.

• Lind, et al, Growth Factors: Possible New Clinical Tools, Acta Orthop Scand , 1996; 67(4): 407-417.

• Roberts, et al, Physiological Actions and Clinical Applications of Transforming Growth Factor-beta (TGF-beta), Growth Factors, 1993; 8:1-9.

• Slater, Micheal, et al, Involvement of Platelets in Stimulating Osteogenic Activity, Journal of Orthapaedic Research , 1995; 13:655-663.

• Hannon, Timothy J., Autologous Platelet Gel, 1999; 1-13.

• Harrison, P., Cramer, E.M., Platelet a-Granules, Blood Reviews , 1993; 7:52-62.

• Lozano, Teresa, Broumand, Vistaub, Marx, Robert E., Evaluation of Risk with the use of Bovine Thrombin in the Clot Initiation of Platelet Rich Plasma, 1998; 1-2.

• Funheer, R., Pietersz, R.N.I., Korte, D., Gouwerok, C.W.N., Dekker, W.J.A., Reesink, H.W., Platelet activation during preparation of platelet concentrates: a comparison of the platelet-rich plasma and the buffy coat methods, Transfusion , 1990; 634-638.

• Ernesto, C., Clinical Review 35: Growth Factors and their Potential Clinical Value, J. Clin Endocrinology Metabol., 1992; 75:1-4.

• Lynch, S.E., Colvin, R.B., Antoniades, H.N., Growth Factors in Wound Healing: Single and Synergistic Effect on Partial Thickness Porcine Skin Wounds, J. Clin Invest, 1989; 84:640-646.

• Zimmermann, R., Jakubietz, R., Jakubietz, M., Strasser, E., Schlegel, A., Wiltfang, J., Eckstein, R., Different Preparation Methods to Obtain Platelet Components as a Source of Growth Factors for Local Application, Transfusion AABB , Volume 41, October 2001, 1217-1223.

• Editorial: Topical Platelet Growth Factor Therapy: Of Lotions and Potions, Transfusion AABB , Volume 41, October 2001, 1186-1189.

Related Reference Articles to Thrombin:

• Rapaport, S.I., Zivelin, A., Minow, R.A., et al. Clinical Significance of Antibodies to Bovine and Human Thrombin and Factor V After Surgical Use of Bovine Thrombin, Am J. Clin Pathol , 1992; 97:84-96.

• Zehnder, J.L., Leung, LLK., Development of Antibodies to Thrombin and Factor V with Recurrent Bleeding in a Patient Exposed to Topical Bovine Thrombin, Blood , 1990; 76:2011-2016.

• Nichols, W.L., Daniels, T.M., Fisher, P.K., et al, Antibodies to Bovine Thrombin and Coagulation Factor V Associated with the Surgical Use of Topical Bovine Thrombin or "Glue": A Frequent Finding, Blood , 1993; 82:59 (abstract).

• Christie, R.J., Carrington, L., Alving, B., Postoperative Bleeding Induced by Topical Bovine Thrombin: Report of Two Cases, Surgery , 1997; 121(6):708-710.

TOP

<<RETURN TO PREVIOUS PAGE