Ross Hauser, MD, Danielle Matias, PA-C, Demi Foster, APRN

Platelet-Rich Plasma (PRP) is a healing compound made from concentrating a patient’s own blood platelets and injecting them (in the case of this subject at the surgical site) to hopefully stimulate a better, faster more complete healing following arthroscopic repair. Research, like that below suggests PRP can be beneficial though findings remain controversial as the research reveals below.

Often a patient will come in for a consultation asking about PRP treatments during an arthroscopic procedure. Many with a surgeon eager to use PRP during their surgery. A team of Polish medical researchers helped explain in the journal BioMed Research International (1) why PRP would be used during a meniscus arthroscopic surgery and what the benefit may be to teh patient.

• “Meniscus healing has always been a major challenge for orthopedic surgeons. All types of meniscectomies can lead to an increase in the risk of osteoarthritis. “
• “Clinical studies comparing total and partial meniscectomy have documented the beneficial effects of meniscus preservation (not removing the meniscus tissue). However, only limited data exist and it so far fails to unequivocally support the benefits of meniscal repair over the partial meniscectomy.”
  • Note: The surgical repair procedure to stitch up a torn meniscus does not show more benefit than partial meniscectomy.
• Although the reoperation rate for partial meniscectomy is significantly lower than for meniscal repair (3% versus 20%), recent studies provided some evidence concerning the benefits of the latter. In the long-term follow-up (10 years) 78% of the patients who underwent the meniscal repair had no radiologic signs of osteoarthritis versus only 63% in the partial meniscectomy group. So, the current practice is to preserve meniscus tissue, with minimal resection.

The most important finding of this study is that PRP augmentation improved the healing rate of complete vertical meniscus tears located in the red-white zone. Additionally, the functional outcomes at 42 months were better in patients treated with PRP-augmented meniscus repair than in those treated with only meniscus repair; however, pain levels were comparable between these patient groups.

What does all this mean to the patient who is exploring treatment for a meniscus tear, especially a tear that extends from the blood-rich meniscus to the blood-deprived meniscus white zone?

• It is better not to remove meniscus tissue
• Treating with PRP at the time of surgery helped
• BUT – this is the BIG BUT – “the functional outcomes at 42 months were better in patients treated with PRP-augmented meniscus repair (at the time of surgery) than in those treated with only meniscus repair; however, pain levels were comparable between these patients groups.” Why the pain? Because the treatment isolated the meniscus and not the whole knee capsule as PRP injections do.

Doctors at the Department of Orthopaedics, Xiangya Hospital, Central South University in China published their research in the journal Medical Science Monitor. (2)

In this research, they discuss the meniscus white-white tears which they describe as “a meniscus lesion completely in the avascular zone (white zone) are without blood supply and theoretically cannot heal.”

They hypothesize that doctors need to get blood to this meniscal zone for healing to occur but face the task that the problem of promoting meniscal healing in the avascular area has not yet been resolved. The possible answer? Platelet-rich plasma (PRP). The Chinese team supports the idea that the application of platelet-rich plasma for white-white meniscal tears will be a simple and novel technique of high utility in knee surgery.

Platelet-rich plasma (PRP) can be the answer for some surgical patients during surgery to address the healing challenges of the “white-on-white” meniscus tear.

So the idea is to bring PRP in during the surgery and apply it to areas where normal blood supply is limited and this should accelerate healing. In theory, should work great. But it does not.

Meniscus arthroscopic surgery with PRP augmentation

There is no question that cartilage heals slowly and poorly this includes the meniscus. Recommendations for surgeries involving shaving or removing the torn portion of the tear using arthroscopic surgery, or sewing the tear together is flawed because it does not repair the deteriorated meniscus.

By failing to heal the damaged meniscal cartilage, surgery does not alleviate the chronic pain that people with this condition experience.

Here is research from the University of Virginia Health System. Here doctors focused on the problem of increased contact stresses in the knee after meniscectomy. (3)

They note that since Platelet-rich plasma has received attention as a promising strategy to help induce healing, the doctors then sought to:

• evaluate whether PRP augmentation at the time of (surgical) meniscal repair decreases the likelihood that subsequent meniscectomy will be performed; in other words, could PRP prevent the need for a second meniscus surgery?
• determine if PRP augmentation in arthroscopic meniscus repair influenced functional outcome measures; and
• examine whether PRP augmentation altered clinical and patient-reported outcomes.

In this study, the experiment was to remove meniscus tissue and see if PRP treatment made a significant impact on the surgical outcome. Before we go on, a quick citation is needed to help with the understanding of the dilution of PRP during surgery.

• University of South Alabama College of Medicine published in the Journal of Surgical Orthopaedic Advances a troubling study with implications for healing after arthroscopic surgery. These researchers hypothesized that agents injected into the knee during and after knee arthroscopy will be significantly diluted by residual arthroscopic fluid by 27%. (4)

So theoretically, during surgery, a weakened PRP treatment is asked to heal the surgical and meniscal damage

Returning to the University of Virginia Health System research, its conclusion should then not be surprising:

“Patients who sustain meniscus injuries should be counseled at the time of injury about the outcomes after meniscus repair. With our limited study group, outcomes after meniscus repair with and without PRP appear similar in terms of reoperation rate.”

In the two above studies, researchers sought to improve the surgical outcomes in meniscal surgery by applying a PRP solution to the torn meniscus during the procedure. PRP could not be confirmed as effective – the culprit for non-conclusive results was not the PRP but the surgical procedure.

Let’s wrap up this section by reviewing the February 2019 research from the same Polish researchers we cited earlier. This time published in the International Journal of Molecular Sciences. (5)

Here are the learning points:

• In cases of Meniscal tears, no benefit with surgical treatment is observed.
• The purpose of this study was to investigate the effectiveness and safety of platelet-rich plasma application to complement the repair of a chronic meniscal lesion.
• The repair was a meniscal trephination with or without concomitant PRP injection.
  • In this procedure, a hole is drilled through the meniscus tissue to allow blood to flood the damaged area.
• This double-blind, placebo-controlled study included 72 patients. All subjects underwent meniscal trephination with or without concomitant PRP injection.
• Meniscal non-union (the failure of the meniscus to regenerate and repair) observed in magnetic resonance arthrography or arthroscopy were considered failures.
• The failure rate was significantly higher in the control group (70% failure)  than in the PRP augmented group (48% failure).
• There was a significant reduction in the number of (second) performed arthroscopies in the PRP augmented group.
• A notably higher percentage of patients treated with PRP achieved minimal clinically significant difference in pain scores.
• The conclusion of the study indicates that percutaneous meniscal trephination augmented with PRP results in a significant improvement in the rate of chronic meniscal tear healing and this procedure decreases the necessity for arthroscopy in the future (8% vs. 28%).
• A brief explanation of PRP treatment by Danielle R. Steilen-Matias, MMS, PA-C.
• PRP treatment addresses the ligament instability of a loose knee.
• The impact of knee instability on squeezing the meniscus out of the knee joint.
• Can PRP address the problems of a “White Zone Tear”
• PRP for meniscus repair, best during surgery or in-office injection?
• Meniscus arthroscopic surgery with PRP augmentation.
• The use of PRP during arthroscopic surgery remains controversial.
• Summary

The use of PRP during arthroscopic surgery remains controversial

A February 2022 paper in the Journal of Orthopaedics and Traumatology (6) from a combined team of European researchers did not find PRP application in arthroscopic meniscal repair helped repair the meniscus any faster. The subject, according to the authors remains controversial.

In a September 2022 paper in the Journal of Orthopaedic Surgery (Western Pacific Orthopaedic Association journal) (7), researchers found similar and somewhat disappointing results of adding PRP during surgical application. “Based on 9 random control studies, the application of PRP in meniscus repair might have a positive effect on patient’s pain score and knee joint function scores at 6 months, and the healing rate at follow-up. However, we don’t find significant improvement in patient’s pain score and knee joint function scores at 1 month and beyond 12 months.”

A March 2022 study from doctors at the Department of Orthopedic Surgery-Sports Medicine Service, Massachusetts General Hospital and published in the journal Knee Surgery, sports traumatology, arthroscopy (8) the following observations following meniscal surgery with PRP augmentation. “Patients reported significant improvements in functional outcomes scores after repair with biological augmentation, though the benefit over standard repair controls is questionable. Revision rates after biologically augmented meniscal repair also appear similar to standard repair techniques.”

An April 2023 paper (9) from doctors at the Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, the University of Florida, Ohio State University Wexner Medical Center, Indiana University, et al.  Wrote: “Evidence supporting (PRP) augmentation of meniscal repair is limited at this time but suggests that the highest likelihood for the effectiveness of augmentation is in the settings of isolated meniscal repair or meniscal repairs that would normally not be amenable to repair.” The last statement suggests that PRP may be more effective for some patients whose meniscus cannot be repaired and who are generally recommended for a form of meniscectomy.

What are we seeing in this image?

The knee in this MRI had prior meniscus surgery. Post-surgical changes in the meniscus are demonstrated because the meniscus is smaller than it should be. Part of the meniscus is missing. This MRI followed another post-surgical MRI which revealed similar meniscus damage. (MRIs after surgery are to confirm the success of the surgery or to look for reasons the patient continues to have). The problem for the radiologist is that he/she cannot tell if this person’s meniscus is still degenerating or if the damage that is in the meniscus now is surgical damage.

Summary and can we help you?

One of the most common calls our office receives involves patients who have had part or all of their meniscus removed and are suffering from continued pain or arthritis that was accelerated due to the surgery. The use of PRP during surgery hopes to minimalize that damage. For those who are considering meniscectomy surgery, we strongly suggest at least a consultation in non-surgical use of PRP treatments. We should also point out that regenerative medicine injections such as PRP will not regrow a meniscus that has been completely or partially removed in previous surgeries.

References

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