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33 Blood Conservation andManagement inCardiac Surgery
https://t.me/medicina_free
Fig. 33.3 Pyramid of therapy in coagulopathic patients. (Modied
from Görlinger [31]). The sequence of hemostatic therapeutic interventions starts from the bottom of the pyramid and then continues to the top
until hemostasis is achieved. Cai, ionized calcium; FFP, fresh frozen
plasma; FVIII, coagulation factor VIII/von Willebrand factor concentrate; FXIII, coagulation factor XIII concentrate; Hb, hemoglobin;
PCC, prothrombin complex concentrate; rFVIIa, activated recombinant
factor VII; Tc, core temperature [31, 32]
recently, the role of brinogen therapy has been assessed by
consensus in a subcommittee of the European Association of
Cardiothoracic Anesthesiology. The recommendations
341
include testing and correction of hypobrinogenemia but
also recognize the paucity of data to endorse the routine use
of brinogen concentrate [
36]. A recent noninferiority study
(FIBRES) of brinogen concentrate versus cryoprecipitate
for the management of symptomatic hypobrinogenemia
(dened as <150–200mg/dL) demonstrated that concentrates
are noninferior to cryoprecipitate administration [37].
Fibrinogen levels necessary to counter coagulopathy have
yet to be determined, but hypobrinogenemia as dened by
<150–200 mg/dL in the setting of coagulopathic bleeding
should be considered as a corrective measure to minimize
other allogeneic blood products or riskier prothrombotic
concentrates, such as PCCs or rVIIa [38].
The use of platelets in cardiac surgery should be lim-
9
ited to severe thrombocytopenia (<50×10
/L) or in the
setting of concomitant antiplatelet drug use with evidence
of bleeding [11]. The prothrombin complex concentrate
(PCCs) are three- or four-factor preparations that include
vitamin K-dependent coagulation factors (II, IX, X, VII)
and varying concentrations of protein C, protein S, and
antithrombin. The evidence for administration of these
agents or fresh frozen plasma (FFP) involve bleeding with
deciency of vitamin K-dependent coagulation factors.
There is no evidence to support the use of recombinant
factor seven (rFVIIa) in cardiac surgery at this time. Its
use should be used in uncontrolled bleeding refractory to
other measures only.
Cardiac surgical patients are at high risk for the complications of allogeneic transfusion given the massive
assault on the coagulation cascade as a result of systemic
heparinization, preoperative comorbidities (anemia, kidney disease), perioperative medical therapy targeting
platelet function or the coagulation system, hypothermia, ischemia, and the proinflammatory response that
occurs in response to a surgical stress. While much work
is needed to determine optimal management of these
patients, there is consensus on a framework of management that involves a large, multidisciplinary team. The
perioperative physician should be apprised of the recommendations to provide optimal care for these patients.
Figure33.4 provides an overview of the entire perioperative period, wherein monitoring, interrogation, and intervention are needed to limit unnecessary transfusion and
provide evidence- based care.
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B. A. Moore and P. O. McConville
Fig. 33.4 Hemostatic monitoring throughout the perioperative period
and possible treatment modalities. ACT, activated clotting time; CPB,
cardiopulmonary bypass; DAPT, dual antiplatelet therapy; DDAVP,
desmopressin; EACA, e-aminocaproic acid; EPO, erythropoietin; FFP,
fresh frozen plasma; i.v., intravenous; MiECC, minimally invasive
References
1. Wells AW, Mounter PJ, Chapman CE, Stainsby D, Wallis JP.Where
does blood go? Prospective observational study of red cell transfusion in North England. BMJ. 2002;325(7368):803.
2. Stover EP, Siegel LC, Parks R, Levin J, Body SC, Maddi R, etal.
Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24- institution
study. Institutions of the Multicenter Study of Perioperative
Ischemia Research Group. Anesthesiology. 1998;88(2):327–33.
3. Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM,
Santos MH, et al. Transfusion requirements after cardiac
surgery: the TRACS randomized controlled trial. JAMA.
2010;304(14):1559–67.
4. Society of Thoracic Surgeons Blood Conservation Guideline Task
F, Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB,
et al. 2011 update to the Society of Thoracic Surgeons and the
Society of Cardiovascular Anesthesiologists blood conservation
clinical practice guidelines. Ann Thorac Surg. 2011;91(3):944–82.
5. Koch CG, Li L, Duncan AI, Mihaljevic T, Cosgrove DM, Loop
FD, etal. Morbidity and mortality risk associated with red blood
cell and blood-component transfusion in isolated coronary artery
bypass grafting. Crit Care Med. 2006;34(6):1608–16.
6. Koch CG, Li L, Duncan AI, Mihaljevic T, Loop FD, Starr NJ, etal.
Transfusion in coronary artery bypass grafting is associated with
reduced long-term survival. Ann Thorac Surg. 2006;81(5):1650–7.
7. Hogan M, Klein AA, Richards T.The impact of anaemia and intravenous iron replacement therapy on outcomes in cardiac surgery.
Eur J Cardiothorac Surg. 2015;47(2):218–26.
8. Harker LA, Malpass TW, Branson HE, Hessel EA 2nd, Slichter
SJ.Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction
associated with selective alpha-granule release. Blood.
1980;56(5):824–34.
9. Edmunds LH Jr. Inammatory response to cardiopulmonary
bypass. Ann Thorac Surg. 1998;66(5 Suppl):S12–6; discussion
S25-8.
extracorporeal circulation circuit; PCC, prothrombin complex concentrate; PRBC, packed red blood cells. (Modied from Task Force on
Patient Blood Management for Adult Cardiac Surgery of the European
Association for Cardio-Thoracic S etal. [
10. Kaplan JA, Augoustides JGT, Manecke GR, Maus T, Reich DL.
Kaplan’s cardiac anesthesia: for cardiac and noncardiac surgery 7th
Edition. Elsevier 2017.
11. Task Force on Patient Blood Management for Adult Cardiac Surgery
of the European Association for Cardio-Thoracic S, the European
Association of Cardiothoracic A, Boer C, Meesters MI, Milojevic
M, Benedetto U, etal. 2017 EACTS/EACTA Guidelines on patient
blood management for adult cardiac surgery. J Cardiothorac Vasc
Anesth. 2018;32(1):88–120.
12. Lazar HL.The use of preoperative aspirin in cardiac surgery: the
ruling on the eld stands. J Card Surg. 2017;32(12):775–6.
13. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne
JG, etal. 2011 ACCF/AHA guideline for coronary artery bypass
graft surgery. A report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice
Guidelines. Developed in collaboration with the American
Association for Thoracic Surgery, Society of Cardiovascular
Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll
Cardiol. 2011;58(24):e123–210.
14. Liu H, Li J, Chen M, Yang T, Ruan Z, Su J, etal. A meta-analysis
of randomized and observational studies: aspirin protects from
cardiac surgery-associated acute kidney injury. Heart Surg Forum.
2019;22(4):E301–E7.
15. Mangano DT, Multicenter Study of Perioperative Ischemia
Research G.Aspirin and mortality from coronary bypass surgery.
N Engl J Med. 2002;347(17):1309–17.
16. Terwindt LE, Karlas AA, Eberl S, Wijnberge M, Driessen
AHG, Veelo DP, et al. Patient blood management in the cardiac surgical setting: an updated overview. Transfus Apher Sci.
2019;58(4):397–407.
17. Hofmann B, Kaufmann C, Stiller M, Neitzel T, Wienke A, Silber
RE, etal. Positive impact of retrograde autologous priming in adult
patients undergoing cardiac surgery: a randomized clinical trial. J
Cardiothorac Surg. 2018;13(1):50.
18. Rosengart TK, DeBois W, O’Hara M, Helm R, Gomez M, Lang SJ,
etal. Retrograde autologous priming for cardiopulmonary bypass:
a safe and effective means of decreasing hemodilution and transfu-
11])
33 Blood Conservation andManagement inCardiac Surgery
https://t.me/medicina_free
343
sion requirements. J Thorac Cardiovasc Surg. 1998;115(2):426–38;
discussion 38–9.
19. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S,
Paolasso E, etal. Off-pump or on-pump coronary-artery bypass
grafting at 30 days. N Engl J Med. 2012;366(16):1489–97.
20. Diegeler A, Borgermann J, Kappert U, Breuer M, Boning
A, Ursulescu A, et al. Off-pump versus on-pump coronaryartery bypass grafting in elderly patients. N Engl J Med.
2013;368(13):1189–98.
21. Hallowell P, Bland JH, Buckley MJ, Lowenstein E.Transfusion
of fresh autologous blood in open-heart surgery. A method for
reducing bank blood requirements. J Thorac Cardiovasc Surg.
1972;64(6):941–8.
22. Lawson NW, Ochsner JL, Mills NL, Leonard GL.The use of hemodilution and fresh autologous blood in open-heart surgery. Anesth
Analg. 1974;53(5):672–83.
23. Jarnagin WR, Gonen M, Maithel SK, Fong Y, D’Angelica MI,
Dematteo RP, et al. A prospective randomized trial of acute normovolemic hemodilution compared to standard intraoperative management in patients undergoing major hepatic resection. Ann Surg.
2008;248(3):360–9.
24. Henderson RA, Mazzef MA, Strauss ER, Williams B, Wipi C,
Dawood M, et al. Impact of intraoperative high-volume autologous blood collection on allogeneic transfusion during and after
cardiac surgery: a propensity score matched analysis. Transfusion.
2019;59(6):2023–9.
25. Barile L, Fominskiy E, Di Tomasso N, Alpizar Castro LE, Landoni
G, De Luca M, etal. Acute normovolemic hemodilution reduces
allogeneic red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis of randomized trials. Anesth Analg.
2017;124(3):743–52.
26. Licker M, Sierra J, Kalangos A, Panos A, Diaper J, Ellenberger
C.Cardioprotective effects of acute normovolemic hemodilution in
patients with severe aortic stenosis undergoing valve replacement.
Transfusion. 2007;47(2):341–50.
27. Harke H, Tanger D, Furst-Denzer S, Paoachrysanthou C, Bernhard
A.Effect of a preoperative separation of platelets on the postoperative blood loss subsequent to extracorporeal circulation in open
heart surgery (author’s transl). Anaesthesist. 1977;26(2):64–71.
28. Zhou SF, Estrera AL, Loubser P, Ignacio C, Panthayi S, Miller C
3rd, etal. Autologous platelet-rich plasma reduces transfusions dur-
ing ascending aortic arch repair: a prospective, randomized, controlled trial. Ann Thorac Surg. 2015;99(4):1282–90.
29. Bai SJ, Zeng B, Zhang L, Huang Z. Autologous platelet-rich
plasmapheresis in cardiovascular surgery: a narrative review. J
Cardiothorac Vasc Anesth. 2020;34(6):1614–21.
30. von Heymann C, Sander M, Foer A, Heinemann A, Spiess B, Braun
J, et al. The impact of an hematocrit of 20% during normothermic cardiopulmonary bypass for elective low risk coronary artery
bypass graft surgery on oxygen delivery and clinical outcome--a
randomized controlled study [ISRCTN35655335]. Crit Care.
2006;10(2):R58.
31. Görlinger K.Coagulation management during liver transplantation.
Hamostaseologie. 2006;26(3 Suppl 1):S64–76.
32. Görlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, RaheMeyer N, Tanaka KA.Management of hemorrhage in cardiothoracic
surgery. J Cardiothorac Vasc Anesth. 2013;27(4 Suppl):S20–34.
33. Karlsson M, Ternstrom L, Hyllner M, Baghaei F, Nilsson S,
Jeppsson A. Plasma brinogen level, bleeding, and transfusion
after on-pump coronary artery bypass grafting surgery: a prospective observational study. Transfusion. 2008;48(10):2152–8.
34. Karkouti K, McCluskey SA, Syed S, Pazaratz C, Poonawala H,
Crowther MA.The inuence of perioperative coagulation status on
postoperative blood loss in complex cardiac surgery: a prospective
observational study. Anesth Analg. 2010;110(6):1533–40.
35. Li JY, Gong J, Zhu F, Moodie J, Newitt A, Uruthiramoorthy L, etal.
Fibrinogen concentrate in cardiovascular surgery: a meta-analysis of
randomized controlled trials. Anesth Analg. 2018;127(3):612–21.
36. Erdoes G, Koster A, Meesters MI, Ortmann E, Bolliger D,
Baryshnikova E, etal. The role of brinogen and brinogen concentrate in cardiac surgery: an international consensus statement
from the Haemostasis and Transfusion Scientic Subcommittee
of the European Association of Cardiothoracic Anaesthesiology.
Anaesthesia. 2019;74(12):1589–600.
37. Callum J, Farkouh ME, Scales DC, Heddle NM, Crowther M, Rao
V, etal. Effect of brinogen concentrate vs cryoprecipitate on blood
component transfusion after cardiac surgery: the bres randomized
clinical trial. JAMA. 2019;322:1–11.
38. Ranucci M, Pistuddi V, Baryshnikova E, Colella D, Bianchi
P.Fibrinogen levels after cardiac surgical procedures: association
with postoperative bleeding, trigger values, and target values. Ann
Thorac Surg. 2016;102(1):78–85.
Platelet-Rich Plasma: Not forAthletes Only
https://t.me/medicina_free
RyanT.Gualtier, LuisChabla-Penael, andAnuraghTrikha
34
Platelet Rich Plasma (PRP) is increased concentration of
autologous platelet suspended in small amount of plasma produced by centrifugation of patient’s own blood. Use of PRP
has been widely studied in bone and tendon tissue healing and
reconstruction [1]. Platelets contains alpha granules which are
important source of anabolic growth factors including broblast growth factors (FGF), bone morphogenic proteins
(BMP), transformation growth factor beta-1 (TGF-β1), platelet-derived grown factor (PDGF), basic broblast grown factor (BFGF), vascular endothelial grown factor (VEGF),
epidermal grown factor, insulin-like growth factor, and several
others [2]. In fact, PRP is known to contain more than 1,500
bioactive proteins [1]. These factors are important for biological processes including wound healing, inhibiting inammation and pain, chemotaxis, neovascularization, synthesis of
extracellular matrix, and scar formation which aides in
improvement in soft tissue healing, vascularization of grafts
and bone [3]. Normal platelet ranges between 150,000 and
350,000 μ/L. PRP contains four to six times concentration
greater than whole blood. Improvement in bone and soft tissue
healing properties have been demonstrated with concentration
of platelets of 1,000,000 μ/L, which is the concentration of
platelets in commercial platelet systems [2].
There are four different types of PRP variations which
give each commercial system its unique properties, including leukocyte-rich PRP (LR-PRP), pure PRP, or leukocytepoor PRP (LP-PRP), platelet-rich brin, and
leukocyte-and- platelet- rich brin. LP-PRP increases antiinammatory mediators including IL-4 and IL-10, whereas
LR-PRP signicantly increases proinammatory markers
including TNF-alpha, IL-6, INF-gamma, and IL-1-beta and
metalloproteinases which antagonize the anabolic cytokines
within platelets [2].
R. T. Gualtier (*) · L. Chabla-Penael · A. Trikha
New York University School of Medicine, Department of
Anesthesiology, Perioperative Care, and Pain Medicine,
New York, NY, USA
e-mail: Ryan.gualtier@nyulangone.org
Commercial PRP systems use different methods to collect
platelets concentrate layer. Generally, whole blood is mixed
with anticoagulation factors and centrifuged to obtain platelets. The centrifugation process separates whole blood to
RBC layer, platelet-poor plasma layer, and “buffy coat” layer
containing platelets with or without leukocytes. The platelet
concentrate layer is isolated using various processing techniques. These platelets can then be either directly injected
into the patient or activated via different compounds that
leads to degranulation and release of growth factors [2].
The current clinical review shows abundant high-quality
evidence of use of LP-PRP for osteoarthritis (OA) of the
knee and LR-PRP for lateral epicondylitis. Moderate highquality evidence supports the use of LR-PRP injection for
patellar tendinopathy and LP-PRP for donor site pain in
patellar tendon graft BTB (bone-tendon-bone) ACL reconstruction and plantar fasciitis [1]. At this time, the following
diagnoses do not have high-quality evidence available; however, small clinical trials have shown promising results.
These include rotator cuff tendinopathy, osteoarthritis of the
hip, donor site pain in ACL reconstruction with patellar tendon autograft, and high ankle sprains.
Osteoarthritis oftheKnee
Osteoarthritis is a disease of synovial joints caused by failure
in repair of joint damage resulting in alteration of joint structures. It is the most common musculoskeletal disorder leading to functional decline, mobility limitations, and disability
of aging population. The most common clinical manifestation of osteoarthritis is joint pain. 240 million people suffer
from osteoarthritis globally. Current nonsurgical treatment
modalities include physiotherapy, analgesia, nonsteroidal
anti-inammatory drugs, and intra-articular injections, such
as hyaluronic acid, corticosteroids, or ozone, with the purpose of reducing symptoms and improving joint function [4].
In vitro and exvivo studies have provided the foundation for
© Springer Nature Switzerland AG 2021
C. S. Scher et al. (eds.), Essentials of Blood Product Management in Anesthesia Practice,
https://doi.org/10.1007/978-3-030-59295-0_34
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this interest, and positive effects of PRP have been observed,
including chondrogenic differentiation of pluripotent mesenchymal cells with expression of cartilage specic genes,
chondrocyte proliferation, increased extracellular matrix
production, and inhibition of catabolic pathways [5]. Despite
the prevalence, no FDA-approved disease- modifying osteoarthritis drugs currently exist to prevent, slow, or halt knee
osteoarthritis [6].
Abundant high-quality evidence supports the use of
LP-PRP intra-articular injection for osteoarthritis of the
knee. Shen etal. [4] performed a meta-analysis of 14 randomized clinical trials comprising 1423 individuals between
2011 and 2016 to compare intra-articular PRP injections to
various controls including saline placebo, hyaluronic acid,
ozone, and corticosteroids. Compared with control, PRP
injections signicantly reduced WOMAC (Western Ontario
and McMaster Universities Osteoarthritis Index) pain subscores at 3, 6, and 12 months follow-up (p = 0.02, 0.004,
<0.001, respectively); PRP signicantly improved WOMAC
physical function sub-scores at 3, 6, and 12 months
(p = 0.002, 0.01, <0.001, respectively); PRP also signicantly improved total WOMAC scores at 3, 6, and 12months
(all p<0.001). PRP did not signicantly increase the risk of
post-injection adverse events (RR, 1.40 [95% CI, 0.80–2.45],
2
I
=59%, p=0.24). Subgroup analysis further showed that
PRP is more efcacious in patients with mild-to-moderate
osteoarthritis [2].
Lucia etal. [7] performed a narrative review of the metaanalysis and systemic reviews in 2019, and according to the
narrators, at present, results from RCTs seem to favor PRP
use over other intra-articular treatments to improve pain
scales in the short and medium term (6–12months), but the
overall level of evidence is low. They concluded that this is
likely the result of a lack of standardization of PRP products, scarceness of high-quality RCTs not showing high
risks of bias, and poor patient stratication for inclusion in
the RCTs.
A meta-analysis by Riboh etal. [5] included six randomized controlled trials and three prospective comparative studies with a total of 1055 patients. Injection of LP-PRP resulted
in signicantly better WOMAC scores than did injection of
hyaluronic acid (mean difference, −21.14; 95% CI, −39.63
to −2.65) or placebo (mean difference, −17.84; 95% CI,
−34.95 to −0.73). No difference was observed in
LR-PRP. SUCRA (surface under the cumulative ranking)
analysis showed that LP-PRP was the highest ranked treatment for both measures of clinical efcacy using the
International Knee Documentation Committee (IKDC) subjective score and WOMAC score. This is likely due to the
biological basis of LP-PRP and LR-PRP as mentioned in the
Introduction section. Thus, intra-articular LP-PRP may be
the preferred preparation for the treatment of knee osteoarthritis symptoms [2].
Lateral Epicondylitis
Lateral epicondylitis, also known as tennis elbow, affects
1–3% of adults each year. It often affects the dominant arm
in patients with high demand of gripping or repetitive wrist
movements. Individuals between the ages of 35 and
50years are at high risk. Elbow tenderness and pain with
resisted wrist extension are common manifestations of lateral epicondylar tendinopathy. Overuse and repetitive
microtraumas of wrist extensor tendons are believed to be
the mechanism of injury of lateral epicondylitis. The lesion
starts as a tear in the extensor tendon leading to abnormal
microvascular response. It is commonly associated with
functional disorder and pain of the elbow joint. Initial
interventions include rest, activity or equipment modication, nonsteroidal anti- inammatory medication, bracing,
and physical therapy. If these treatments fail to improve
the pain and tenderness, second-line treatments such as
cortisone injections, prolotherapy, autologous blood injections, PRP injections, and needling of the extensor tendon
origin have been recommended. If patients continue to
report pain and dysfunction despite these measures, surgery is then considered [8]. Abundant high-quality evidence supports the use of LR-PRP injection for lateral
epicondylitis who have failed to respond to conservative
treatments [2].
Mishra etal. [8] evaluated 230 patients in a large multicenter double-blinded prospective randomized controlled
trial. All the patients had at least 3months of symptoms and
failed conservative therapy. The patients were randomly
divided into PRP treatment and active control, and all patients
had their extensor tendon needled with and without PRP,
respectively. No statically signicant difference was found at
12 weeks in this study. However, at 24 weeks, the PRPtreated patients reported an improvement of 71.5% in their
pain scores compared with 56.1% in the control group
(P=0.019). 29.1% of the PRP-treated patients reported signicant elbow tenderness versus 54.0% in the control group
(P=0.009). Success rates for patients with 24weeks of follow- up were 83.9% in the PRP group compared with 68.3%
in the control group (P=0.037).
Gosens etal. [9, 10] conducted a double-blind randomized controlled trial with a 2-year follow-up to determine
effectiveness of LR-PRP compared with corticosteroid injection in patients with chronic lateral epicondylitis. The primary analysis included visual analog scale (VAS) pain scores
and disabilities of the arm, shoulder, and hand (DASH) outcome scores. When baseline VAS and DASH scores were
compared with the scores at 1year follow-up, VAS was successful and statistically signicant in PRP as compared to
corticosteroid (73% vs. 49%, P< 0.001), as well as DASH
when compared to corticosteroid (73% vs. 51%, p=0.005).
When baseline VAS and DASH scores were compared with
34 Platelet-Rich Plasma: Not forAthletes Only
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347
the scores at a 2-year follow-up, both groups signicantly
improved over time. However, the DASH scores of the corticosteroid group returned to baseline levels, while those of
the PRP group signicantly improved.
Rotator Cu Tendinopathies
Rotator cuff tendinopathies are one of the most common reasons why patients present with shoulder pain and disability.
In fact, it’s not only athletes who suffer from rotator cuff
tears, but they can happen to anyone with routine daily activities or with overuse. An estimated 50% of patients presenting with shoulder pain may be diagnosed with rotator cuff
tendinopathy, including supraspinatus partial thickness tears
and tendonosis [11]. The goal of the treating physician is to
reduce patients’ pain and, by doing so, hopefully improve
function. Unfortunately, many patients are refractory to these
conservative therapies, which include rest, multimodal pain
regimen, physical therapy, and corticosteroid injections, and
surgery becomes the only viable option. Due to the relative
avascular nature of tendons, their regenerative potential is
limited; however, there is some clinical evidence that PRP
may help revascularize the area of injury and promote
healing. Several RCTs have investigated whether PRP can be
utilized for improving pain and functional outcomes in rotator cuff pathology.
In a placebo-controlled double-blind randomized clinical
trial by Kesikburun etal. [12], a total of 40 patients were
enrolled, with [12] history of shoulder pain for >3months
during overhead-throwing activities [1], MRI ndings of
rotator cuff tear, and [11] minimum of 50% reduction in
shoulder pain with administration of anesthetic injection.
Patients received 5ml of PRP or 5ml of saline via ultrasound-guided injection into the subacromial space. In addition, all patients underwent a 6-week standard exercise
program. Outcomes were measured via the Western Ontario
Rotator Cuff (WORC) Index, Shoulder Pain and Disability
Index (SPADI), VAS, and shoulder pain with Neer Test at 3,
6, 12, and 24weeks, as well as 1year after injection. At the
1-year follow- up, PRP was found to be no more effective in
improving quality of life, pain, disability, and shoulder ROM
than placebo patients who were treated with physical
therapy.
Rha etal. [2] went on to compare the effects of PRP with
those of dry needling on shoulder pain and function in
patients with rotator cuff disease. 39 patients with supraspinatus tendon lesions less than 1.0 cm, but not a complete
tear, were included. Half of the group received two dryneedling procedures, and the other half received two PRP
injections to the affected shoulder at 4-week intervals utilizing ultrasound guidance. SPADI, passive ROM, and a physician rating scale at 6months follow-up were used to measure
outcomes. The clinical effect of PRP was found to be superior to dry needling at 6months.
In another study by Shams etal. [11], a similar outcome
was reached in regard to PRP vs corticosteroid for the treatment of symptomatic rotator cuff tears. 40 patients with
symptomatic rotator cuff tears were assessed pre-injection,
6 weeks, and 3 and 6 months after injection utilizing the
American Shoulder and Elbow Surgeons Standardized
Shoulder Assessment Form (ASES), Constant-Murley Score
(CMS), Simple Shoulder Test (SST), and Visual Analog
Scale (VAS) for pain. Both injection groups showed statistical signicance with outcomes over time compared to those
pre-injection. At 12weeks, there was also a statistically signicant difference between the PRP and corticosteroid
group, in favor of PRP, although there was no signicance
after 6months. Therefore, the group summarized that subacromial PRP may be considered a good alternative to corticosteroid injections in those with a contraindication to
corticosteroid administration.
Osteoarthritis oftheHip
Osteoarthritis (OA) of the hip has not been studied as extensively as OA of the knee; however, little evidence of its efcacy does exist. OA is a slowly evolving process, which
typically is characterized by pain, stiffness, and decreased
range of motion. Overall, roughly 40% of those over 65years
old may suffer from OA of the hip or knee [13]. The prevalence of hip OA alone may account for 7–25% in white
patients over 55years [11]. OA is brought on by biomechanical and biochemical factors which leads to cartilage disruption and bone hypertrophy. Within the knee or hip joint,
proinammatory cytokines and proteinases interfere with the
normal production of hyaluronic acid (HA), which results in
a signicantly reduced molecular weight and viscoelasticity
leading to degradation of articular cartilage and joint function [14]. As the joints affected by OA have a lower than
normal concentration of HA, any exogenous administration
of HA should increase the synovial uid viscosity, leading to
improved shock absorption and lubricating capabilities. In
addition, HA is known to stimulate the body’s own endogenous HA synthesis via CD44 receptor binding [15].
The current non-operative treatment modalities for OA of
the hip include both non-pharmacologic and pharmacological therapies aimed at reducing pain, stiffness, and disability.
Intra-articular corticosteroid injections tend to temporarily
reduce pain and improve function [16], however do not
change the natural progression of the disease and may also
have negative effect on hip structures [17].
There have been four major RCTs comparing PRP to
hyaluronic acid for OA of the hip. Battaglia etal. [5] looked
to compare clinical efcacy of PRP vs HA at 12months of
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R. T. Gualtier et al.
follow-up in patients with hip OA. 100 patients with chronic
unilateral hip OA were enrolled and randomly assigned PRP
or HA via ultrasound-guided injection. Patients were evaluated at 1, 3, 6, and 12months using visual analog scale and
Harris Hip Score (HHS). At the 1- and 3-month follow-up,
both groups showed overall improvement. At 6 and
12months, there was a slight worsening, however no statistical difference between HA and PRP.In conclusion, the study
noted PRP injections to be efcacious in terms of functional
improvement and pain reduction, but not superior to HA at
12months’ follow-up.
Di Sante etal. also compared the efcacy of HA vs PRP
with ultrasound-guided intra-articular injection [18]. They
looked at 43 patients with unilateral severe hip OA.Patients
were randomly assigned to receive HA or PRP and received
three injections in total (one per week). Patients were evaluated at baseline, week 4, and week 16. Primary outcomes
were measured with VAS and WOMAC. Results revealed
that compared to baseline, the PRP-treated VAS scores were
signicantly decreased at 4 weeks, but not at 16 weeks,
which indicates an early effect on pain that was not sustained
at a longer-term follow-up. In contrary, the HA group had a
signicant decrease in both VAS and WOMAC values
between baseline and 16weeks.
In an RTC performed by Dallari etal. [14], ultrasoundguided injection of PRP and hyaluronic acid was performed separately and in combination for hip osteoarthritis.
The primary outcome measure was a change in pain intensity as assessed by VAS at 2, 6, and 12months. Other measures included WOMAC and concentration of growth
factors in PRP and their correlation with clinical outcomes.
A total of 111 patients were randomly assigned to receive
three weekly injections of either PRP (44 patients),
PRP+HA (31 patients), or HA (36 patients). At all followups, PRP had the lowest VAS scores. The results indicated
the intra-articular PRP injections do offer signicant clinical improvement in patients with hip OA without relative
side effects.
Doria etal. [13] also performed a prospective controlled
double-blinded RCT on 80 patients with symptomatic early
hip OA.The measures included WOMAC, VAS, and Harris
Hip Score, which were evaluated before and at 6 and
12months post-treatment. Both groups showed a signicant
improvement from baseline at both endpoints; however, PRP
did not offer signicantly better results compared to HA in
patients with moderate OA.
Although data is limited in regard to PRP for intraarticular injections for hip osteoarthritis, it does show some
promising results with pain reduction and improved function
by patient-reported scores. Several studies do show PRP
with an earlier onset to pain reduction compared to HA;
however there is no statistical difference as time goes on,
particularly at 12months post-injection. More high-quality
studies are necessary to see whether PRP can be utilized as a
modality for delaying hip surgery due to OA.
Anterior Cruciate Ligament Tears
Anterior cruciate ligament (ACL) tears are one of the most
common sports medicine-related injuries, which makes ACL
reconstructive surgery one of the most frequently performed
procedures in the eld [19]. Majority of these patients are
young and athletic, with high expectations of recovering
from their injury and returning to the sport. Although most of
the current surgical techniques can provide satisfactory
results, it’s not 100% guaranteed, and not all patients are able
to regain their pre-injury activity level. Clinical results may
be shaped not only by the type of graft used but even factors
such as pre-injury knee laxity. Due to the nature of these
injuries and the expectations by the patients, most research is
looking into ways to improve ACL healing, reduce failure
rate, and improve on recovery times. PRP is one of these
sought-after approaches that are being looked at more closely
as a potential therapeutic agent.
A prospective randomized trial performed by Vogrin etal.
[20] concluded that platelet gel produced from autologous
platelet-rich plasma and applied locally demonstrated a signicantly higher level of vascularization in the osteoligamentous
interface in 4–6weeks (0.33±0.09) in PG-treated group than
the control group (0.16±0.09, p< 0.001). An observational
study performed by Sanchez et al. [21] evaluated the gross
morphologies of the grafts on second-look arthroscopy in 37
volunteers who underwent either conventional (control group,
n=15) or platelet-rich plasma preparation rich in growth factors assisted (n=22) ACL reconstruction with an autogenous
hamstring. Biopsy specimen was evaluated by the use of
Ligament Tissue Maturity Index to assess the histologic
changes during the 6- to 24-month postoperative period of graft
maturation. It was found that newly formed connective tissue,
resembling synovial-like tissue, enveloped the treated graft in
77.3% of the PRGF-treated grafts and 40% of the controls.
Systematic literature review by Di Matteo et al. [22]
showed that the only advantage of PRP is related to a better
graft maturation over time, without clear benecial effects in
terms of clinical outcome, bone-graft integration, and prevention of bony tunnel enlargement. Recent literature review
by Riediger etal. [23] concluded that the research failed to
show signicant clinical benet of using biologics like PRP
and therefore does not support the routine use in
ACLR. However, there is some evidence that use of PRP
may promote graft harvest site healing, graft maturation and
reduce tunnel widening in the short term. A prospective, randomized, and double- blinded clinical study by Seijas etal.
[24] evaluated the donor site anterior knee pain in “patellar
graft” or “bone- tendon- bone” (BTB) autograft ACL recon-
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349
struction with the application of autologous plasma rich in
growth factors (PRGF). PRGF group showed decreased
donor site pain in comparison to the control group, with signicant differences in the rst two postoperative months of
follow-up. The current study does not show clinical effect of
PRP on graft integration or maturation, but limited studies
have shown positive results in decreasing patellar tendon
donor site pain.
Patellar Tendinopathy
Patellar tendinopathy is a common cause of pain among athletes, known as “jumper’s knee.” It has been associated with
activities involving jumping, more specically repetitive
jumping. Patellar tendinopathy is not an inammatory disorder; it’s a degenerative disorder. Tendinosis occurs with progressive degeneration of the tendinous tissue and inability
for repair.
Risk factors associated with patellar tendinopathy include
high body mass index, large abdominal circumference, limblength discrepancy, at foot arch, weak quadriceps, and low
exibility of both quadriceps and hamstring muscles.
However, tendinopathy does not occur in all people with the
same type of activity; therefore there must be both intrinsic
and extrinsic factors.
Patellar tendinopathy can cause pain that is debilitating
and impede with a patient’s mobility. Patients usually present with pain over the proximal and distal part of the patella
tendon. Patients will report pain of the proximal tendon
when the knee is exed and report pain of the distal tendon
when the knee is extended. A provocative test is the single
leg squat test, which causes increased load on the patellar
tendon. Ultrasound and MRI are useful imaging for diagnosis. Common differential diagnosis includes patellofemoral
pain syndrome, fat-pad syndrome, meniscal tears, cartilage
lesions, and referred pain.
Common treatment modalities include eccentric exercises, extracorporeal shock wave therapy, steroid injections,
sclerosing agents, and hyaluronic acid. The last resort is surgery. There is interest in PRP.PRP has a high concentration
of growth factors, which can help stop the degeneration of
the tendon. These growth factors work on tenocytes, cells
that maintain homeostasis in tendons. Some of these growth
factors include platelet-derived growth factor, vascular endothelial growth factor, epidermal growth factor, and insulinlike growth factor. They promote proliferation, cell
differentiation, chemotaxis, and angiogenesis. However,
there is conicting evidence to support PRP over other
modalities for patellar tendinopathy.
There have been several studies looking at PRP for patellar tendinopathy. They have looked at PRP vs saline, PRP vs
dry needling, PRP vs extracorporeal shock wave therapy, and
PRP vs steroids. Some studies have shown that PRP is superior over other modalities, and some studies have not. A
study conducted by Scott etal. [17] showed that PRP was not
more effective than saline for the improvement of patellar
tendinopathy symptoms. His study looked at both LR-PRP
and LP-PRP.The study occurred over 3 sites, with a sample
size of 20 patients in each arm, followed over 12weeks.
There was no statistical difference, but he noted that the
LR-PRP arm at both 6weeks and 12weeks had an increase
in pain. They hypothesized that this was due to the introduction of WBC, which increased the inammatory process.
The study was limited by the sample size and the lack of
standardization of physical therapy, and the patients were
mostly young adults to middle-aged males.
PRP may be effective over dry needling. A study conducted by Dragoo etal. [15] showed that PRP plus dry needling was superior over dry needling alone. He showed an
acceleration in recovery but that over time the effects were
decreased. Notable in this study was that the PRP group
reported signicant decrease in pain and an improvement in
symptoms and function. PRP may also be more effective
over extracorporeal shock wave therapy (ESWT). Vetrano
etal. [25] looked at a total of 43 patients that were comparable in age, sex, and level of sport participation. He followed the patients over 1 year. At both 6 months and
12months, there was an improvement in pain and function.
The researchers noted that the improvement of tendinopathy
with PRP might be possible because they did not inject PRP
with local anesthetics. However, previous investigations
have shown that both ESWT and PRP increase the number of
tenocytes and production of collagen type I and type III,
which are needed for tendon repair.
The discrepancies in the studies can be attributed to the
preparation of PRP and with the amount of PRP injected into
the tendon. Amounts have ranged from 3mL to 5mL.Moreover,
there is a lack of standardization on how PRP is prepared.
Another question that has yet to be answered is the frequency
of injections. Most studies have looked at single injections,
with an average follow-up of 1year. These patients may benet from repeat injections in lieu of a single injection.
Plantar Fasciitis
Plantar fasciitis is a common cause of heel pain, affecting
people of different lifestyles. It can be caused by overuse
from prolonged standing and running. Risk factors include
high arch, leg length discrepancy, obesity, sedentary lifestyles, and tightness of the Achilles tendon and intrinsic foot
muscles. Like patellar tendinopathy, it is a chronic process of
degeneration and not believed to be secondary to acute
inammation. Plantar fasciitis is diagnosed through physical
exam and history. Patients will report heel pain, tightness in
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R. T. Gualtier et al.
the morning, and improvement of pain after ambulation.
However, toward the end of the day, there may be increased
pain. On physical exam, it will be noted that the patient usually guards the foot that is affected. Pressure on the medial
plantar calcaneal region will cause a sharp and stabbing pain.
Imaging is not necessary to diagnose plantar fasciitis. But
both ultrasound and MRI are the best modalities.
Plantar fasciitis is treated conservatively. This includes
rest, acetaminophen, nonsteroidal anti-inammatory drugs,
massage, and modication of activity. If there is no improvement, or little improvement with physical therapy, other
modalities are recommended. These include percutaneous
needling, steroid injection, anterior night splint, and Botox.
The use of PRP for plantar fasciitis seems appealing and is
being used more.
A study by Sherpy etal. [26] showed that PRP vs steroid
injection had comparable results. Patients in both groups
improved clinically. Patients that received steroid injection
had better outcome with ultrasound evaluation, with a
decrease in thickness, and the fascia became more hyperechoic. Monto etal. [27] showed that PRP was superior to
steroid injections for severe chronic plantar fasciitis. He
studied patients over 24months and showed that patient’s
function initially improved with steroid injections, and then
there was a decline. With PRP there was a steady increase in
function, the maximum function at 3months, which stayed
stable until 24months. It should be noted that most studies
looking at PRP injections usually use a volume of 3–5mL;
Monto etal. [27] used 9 mL. It is uncertain if the volume
contributed to a positive effect. But it can be hypothesized
that with increased volume, there are more growth factors
released that aid in the repair of the damaged collagen.
Research conducted by Jain etal. also showed the PRP was
more benecial over steroid injections, highlighting that the
effects of PRP were longer-lasting than steroids.
A meta-analysis by Yang et al. [28] showed that PRP
does not have a short-term benet on functional status or
pain, but it has a better long-term effect. The reason why
PRP may not have a short-term effect is because the growth
factors in PRP need time for the regenerative process. The
advantage of PRP compared to steroids is that there is less
risk for abscesses, osteomyelitis, fat pad atrophy, and plantar fascia tears.
In contrast to steroid injections, Kim etal. [29] looked at
PRP vs dextrose prolotherapy (DP). He took 11 patients and
injected them with dextrose prolotherapy, a total of 2 injections. Ten patients were injected with PRP, in a series of two
injections. He found that there was an improvement in both
pain and function that was sustained over 6 months, and
there was no difference between DP and PRP.His study was
limited by the small sample size, and there was no placebo.
Therefore, there are an abundance of studies looking at PRP
for PF, with conicting efcacy. However, PRP may be more
appealing with less risk of side effects when compared to
steroids. Moreover, patients may need more than one injection of PRP.
Conclusion
PRP shows promise in treating several musculoskeletal diseases. PRP works by releasing factors that are important for
wound healing, inhibiting inammation and pain, chemotaxis, neovascularization, synthesis of extracellular matrix,
and scar formation, which aids in soft tissue healing. There
are several studies looking at PRP for osteoarthritis of the
knee, lateral epicondylitis, ACL reconstruction, rotator cuff
tendinopathy, osteoarthritis of the hip, patella tendinopathy,
and planter fasciitis. These studies have demonstrated that
PRP may be an alternative treatment and may avoid some
side effects of common treatments, i.e., steroid injections.
However, there is no consensus into which PRP variation is
better and which preparation process is superior. Larger
studies and standardization of PRP processing may be moving forward.
References
1. Han C, Na Y, Zhu Y, Kong L, Eerdun T, Yang X, Ren Y.Is plateletrich plasma an ideal biomaterial for arthroscopic rotator cuff repair?
A systematic review and meta-analysis of randomized controlled
trials. J Orthop Surg Res. 2019;14(1):183. https://doi.org/10.1186/
s13018- 019- 1207- 9.
2. Le AD, Enweze L, Debaun MR, Dragoo JL.Platelet-rich plasma.
Clin Sports Med. 2019;38(1):17–44. https://doi.org/10.1016/j.
csm.2018.08.001
3. Urits I, Viswanath O, Galasso AC, Sottosani ER, Mahan KM, Aiudi
CM, etal. Platelet-rich plasma for the treatment of low back pain:
a comprehensive review. Curr Pain Headache Rep. 2019;23(7):52.
https://doi.org/10.1007/s11916- 019- 0797- 6.
4. Shen L, Yuan T, Chen S, Xie X, Zhang C.The temporal effect of
platelet-rich plasma on pain and physical function in the treatment of knee osteoarthritis: systematic review and meta-analysis
of randomized controlled trials. J Orthop Surg Res. 2017;12(1):16.
https://doi.org/10.1186/s13018- 017- 0521- 3.
5. Riboh JC, Saltzman BM, Yanke AB, Fortier L, Cole BJ. Effect
of leukocyte concentration on the efcacy of platelet-rich
plasma in the treatment of knee osteoarthritis. Am J Sports Med.
2015;44(3):792–800. https://doi.org/10.1177/0363546515580787.
6. Rashid H, Kwoh CK. Should platelet-rich plasma or stem cell
therapy be used to treat osteoarthritis? Rheum Dis Clin North Am.
2019;45(3):417–38. https://doi.org/10.1016/j.rdc.2019.04.010.
7. Gato-Calvo L, Magalhaes J, Ruiz-Romero C, Blanco FJ, Burguera
EF.Platelet-rich plasma in osteoarthritis treatment: review of current evidence. Ther Adv Chronic Dis. 2019;10:2040622319825567.
https://doi.org/10.1177/2040622319825567.
8. Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson
S, Vermillion DA, Vermillion DA, Ramsey ML, Karli DC,
Rettig AC. Efcacy of platelet-rich plasma for chronic ten-
.
34 Platelet-Rich Plasma: Not forAthletes Only
https://t.me/medicina_free
351
nis elbow. Am J Sports Med. 2013;42(2):463–71.
org/10.1177/0363546513494359
9. Gosens T, Peerbooms JC, Laar WV, Oudsten BLD.Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in
lateral epicondylitis. Am J Sports Med. 2011;39(6):1200–8. https://
doi.org/10.1177/0363546510397173
10. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect
of an autologous platelet concentrate in lateral epicondylitis in
a double-blind randomized controlled trial. Am J Sports Med.
2010;38(2):255–62.
11. Shams A, El-Sayed M, Gamal O, Ewes W.Subacromial injection
of autologous platelet-rich plasma versus corticosteroid for the
treatment of symptomatic partial rotator cuff tears. Eur J Orthop
Surg Traumatol. 2016;26(8):837–42.
s00590-
12. Kesikburun S, Tan AK, Yılmaz B, Yaşar E, Yazıcıoğlu K.Platelet-
13. Dawson J, Linsell L, Zondervan K, Rose P, Randall T, Carr A,
14. Dallari D, Stagni C, Rani N, Sabbioni G, Pelotti P, Torricelli P,
15. Dragoo JL, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich
16. Battaglia M, Guaraldi F, Vannini F, Rossi G, Timoncini A, Buda
17. Scott A, Laprade RF, Harmon KG, Filardo G, Kon E, Villa SD,
18. Sante LD, Villani C, Santilli V, Valeo M, Bologna E, Imparato L,
19. Anitua E, Sánchez M, Nurden AT, Nurden P, Orive G, Andía I.New
016- 1826- 3.
rich plasma injections in the treatment of chronic rotator cuff tendinopathy. Am J Sports Med. 2013;41(11):2609–16.
org/10.1177/0363546513496542
Fitzpatrick R.Epidemiology of hip and knee pain and its impact on
overall health status in older adults. Rheumatology. 2004;43:497–
504. https://doi.org/10.1093/rheumatology/keh086.
Tschon M, Giavaresi G.Ultrasound-guided injection of plateletrich plasma and hyaluronic acid, separately and in combination, for
hip osteoarthritis: a randomized controlled study. Am J Sports Med.
2016;44:664–71. https://doi.org/10.1177/0363546515620383.
plasma as a treatment for patellar tendinopathy. Am J Sports Med.
2014;42(3):610–8.
R, Giannini S. Efcacy of ultrasound-guided intra-articular
injections of platelet-rich plasma versus hyaluronic acid for hip
osteoarthritis. Orthopedics. 2013;36(12):e1501–8. https://doi.
org/10.3928/01477447- 20131120- 13.
etal. Platelet-rich plasma for patellar tendinopathy: a randomized
controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline. Am J Sports Med. 2019;47(7):1654–61. https://doi.
org/10.1177/0363546519837954.
etal. Intra-articular hyaluronic acid vs platelet-rich plasma in the
treatment of hip osteoarthritis. Med Ultrason. 2016;18(4):463.
https://doi.org/10.11152/mu- 874.
insights into and novel applications for platelet-rich brin therapies.
https://doi.org/10.1177/0363546509355445.
https://doi.org/10.1177/0363546513518416.
.
.
https://doi.org/10.1007/
.
https://doi.
https://doi.
Trends Biotechnol. 2006;24(5):227–34.
tibtech.2006.02.010
20. Vogrin M, Rupreht M, Dinevski D, Hašpl M, Kuhta M, Jevsek M,
etal. Effects of a platelet gel on early graft revascularization after
anterior cruciate ligament reconstruction: a prospective, randomized, double-blind, clinical trial. Eur Surg Res. 2010;45(2):77–85.
https://doi.org/10.1159/000318597.
21. Sánchez M, Anitua E, Azofra J, Prado R, Muruzabal F, Andia
I. Ligamentization of tendon grafts treated with an endogenous
preparation rich in growth factors: gross morphology and histology.
Arthroscopy J Arthrosc Relat Surg. 2010;26(4):470–80.
org/10.1016/j.arthro.2009.08.019
22. Matteo BD, Loibl M, Andriolo L, Filardo G, Zellner J, Koch M,
Angele P.Biologic agents for anterior cruciate ligament healing:
a systematic review. World J Orthop. 2016;7(9):592. https://doi.
org/10.5312/wjo.v7.i9.592
23. Riediger MD, Stride D, Coke SE, Kurz AZ, Duong A, Ayeni
OR. ACL reconstruction with augmentation: a scoping review.
Curr Rev Musculoskelet Med. 2019;12(2):166–72. https://doi.
org/10.1007/s12178-
24. Seijas R, Cuscó X, Sallent A, Serra I, Ares O, Cugat R.Pain in
donor site after BTB-ACL reconstruction with PRGF: a randomized trial. Arch Orthop Trauma Surg. 2016;136(6):829–35.
doi.org/10.1007/s00402- 016- 2458- 0.
25. Vetrano M, Castorina A, Vulpiani MC, Baldini R, Pavan A, Feretti
A.Platelet-rich plasma versus focused shock wave in the treatment
of jumper’s knee in athletes. Am J Sports Med. 2013;41(4):795–
803. https://doi.org/10.1177/0363546513475345.
26. Sherpy NA, Hammad MA, Hagrass HA, Samir H, Abu-ElMaaty
SE, Mortada MA. Local injection of autologous platelet rich
plasma compared to corticosteroid treatment of chronic plantar
fasciitis patients: a clinical and ultrasonographic follow-up study.
Egypt Rheumatol. 2016;38:247–52.
ejr.2015.09.008.
27. Monto RR.Platelet-rich plasma efcacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot Ankle Int.
2017;35(4):313–8. https://doi.org/10.1177/1071100713519778.
28. Yang WY, Han YH, Cao XW, Pan JK, Lin JT, Liu J.Platelet-rich
plasma as a treatment for plantar fasciitis: a meta-analysis of randomized controlled trails. Medicine (Baltimore). 2017;96(44):e8475.
https://doi.org/10.1097/MD.0000000000008475.
29. Kim E, Lee JH. Autologous platelet-rich plasma versus dextrose prolotherapy for the treatment of chronic recalcitrant plantar fasciitis. PMR. 2014;6(2):152–8. https://doi.org/10.1016/j.
pmrj.2013.07.003.
.
.
019- 09548- 4.
https://doi.org/10.1016/j.
https://doi.
.
https://
https://doi.org/10.1016/j.
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