Platelet Rich Plasma Regenerative Medicine Sports

Medicine, Orthopedic, and Recovery of Musculoskeletal

Injuries

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vi Foreword I

I hope this short tour through the history of Orthopaedic Surgery and this brief
summary of biological therapies serve to encourage the reader to delve into the
exciting world of tissue regeneration.
I would like to give my most sincere congratulations to the editors for the work
they have done.

Barcelona, April 2013 Ramon Cugat

Foreword II

Platelet Rich Plasma (PRP) is now gaining international recognition as a treatment

modality. PRP came into existence during the 1980s and has since been used in
many areas of medicine.
My exposure to PRP and Regenerative Medicine began during my Sports
Medicine Fellowship at South Pointe Cleveland Clinic, with Dr. Zenos Vangelos.
The Orthobiologic premise of helping to facilitate healing of tissue had tremen-
dous appeal to me. Having also experienced PRP treatments, I can speak of the
effective treatment outcome, which I have now seen replicated in thousands of my
patients.
To date, there have been thousands of research studies published on the topic of
PRP, yet as with many relatively new treatments, there are often many more
questions than answers. This challenge has galvanized our authors to provide the
first complete textbook on Platelet Rich Plasma. This comprehensive textbook
lists the most current thoughts on PRP basic science, surgical applications, and
non-surgical applications. In doing so, it is our hope that this textbook will help
provide answers to some of these difficult questions and serve as a springboard for
further research in this treatment modality.
I would like to thank Dr. Steven Sampson for his kind invitation to be a part of
this endeavor and Dr. José Fábio Santos Duarte Lana for compiling an outstanding
group of internationally renowned authors in this groundbreaking textbook on
Platelet Rich Plasma.
Special thanks to my wife Yael, for being very understanding, supportive, and
loving.

Adam Weglein

vii
Foreword III

Regenerative Medicine holds tremendous promise and is quickly gaining popu-

larity worldwide. With today’s global communication, leading physicians are
creating a community to foster development of innovative therapies. Although
publishing literature as a clinician is tedious and challenging, it is critical to share
our experiences with one another to advance our understanding of ‘‘orthobiologic’’
treatments. Dr. José Fábio Santos Duarte Lana, a world renowned orthopedist,
should be commended for assembling such an international collaborative effort
with physicians and researchers.
Currently there are few, if any, medical textbooks that attempt to cover the span
of regenerative medicine techniques in orthopedic medicine. As clinicians in our
respective offices we practice the art of medicine daily. Often times when it comes
to regenerative medicine we must become ‘‘pioneers’’ deciding on protocols that
have not been laid out before us. For example, when I first began using PRP
(Platelet Rich Plasma) for knee osteoarthritis there was no evidence-based medi-
cine or guidelines to follow. I was driven to help patients that have failed all of the
current treatment options and the science theoretically made sense. Several years
later this textbook may serve as a reference for new doctors or ‘‘pioneers’’ to
follow and to stimulate creativity and further evolution of this most exciting field.
After using PRP to treat thousands of patients with complex conditions, we
continue to modify our protocols and ask more questions. Every month new
research is emerging, adding to our understanding of this novel therapy. This text
addresses the growing need for standardization of technique and platelet prepa-
ration when assessing its validity for clinical outcomes. While science has allowed
us to greatly understand that platelets may amplify tenocytes or chondrocytes in
vitro, we are now just collecting robust data in the clinical realm.
Most physicians implementing biologic medicine share a common enthusiasm
and passion for our work. This book brings together our collective efforts to
challenge the medical community to decide if and how they will integrate these
principles into their medical practice.
This comprehensive textbook covers numerous critical topics including PRP
basic science, literature review, treatment of tendon, ligament, muscle, meniscus,
cartilage, bone and wound healing, and surgical applications.
PRP is the first true biologic therapy that has hit orthopedics by storm. Its ease
of use and generally high safety profile has allowed it to propel itself into the

ix
x Foreword III

mainstream of physicians and their patients worldwide. Through the early

administration of PRP in professional athletes, this sensationalized therapy is
gradually sustaining itself with general use in everyday patients seeking alternative
conservative options. Textbooks like this are critical to provide a framework for
which future biologically based treatments may emerge and proliferate.

Steve Sampson
Preface

I first came across Platelet Rich Plasma (PRP) while attending the World Congress
of Arthroscopy and Sports Medicine in Buenos Ayres, Argentina 2006. Dr. Ramon
Cugat, from Spain, gave a fascinating PRP lecture at this meeting titled ‘‘Los
Factores de Crescimiento in la Medicina Deportiva.’’ I was delighted with the
possibility of stimulating healing through the use of an anabolic-autologous
environment with minimal risk to the patient.
I subsequently visited Dr. Cugat in Barcelona and became trained in Platelet
Rich in Growth Factors (PRGF).
I returned to Brazil with a strong interest in Regenerative Medicine and PRP.
This newfound interest galvanized me to find a university with a strong focused
regenerative research division. The University of Campinas (UNICAMP) has an
outstanding, world-renowned reputation as leaders in medical innovation. The idea
of researching PRP was enthusiastically received by a group of professors who set
up a project involving basic and applied sciences. UNICAMP has now developed a
PRP research center in large part due to the hard work of professors William D.
Belangero, Angela C. M. Luzo, Joyce M. A. Bizzacchi, and Maria Helena A.
Santana.
Platelet Rich Plasma is a rapidly growing and developing treatment modality,
with new research coming out weekly. The aim of this text will be to provide a
concise review of the current literature and practical aspects of PRP. We hope that
this text will serve as a guide to both clinicians and researchers. Platelet Rich
Plasma is emerging as a primary source of autologous products in Regenerative
Medicine. A true precursor and promoter of the healing process along with the
Scaffolds and Stem Cells. This new technology opens up a broad spectrum of
action and simultaneously increases the challenges to be scientifically confronted.
Standardized products or autologous biomaterial often seem impossible. Unlike
synthetic biomaterial that comes from the industry with a controlled quality, an
autologous biomaterial depends on the health of the individuals. Therefore, it is
impossible to set an exact quality when it involves a plethora of variables of each
individual’s general health. Several studies that have collected data had difficulties
to compare and standardize the technique. However, scientific knowledge of the
phenomena, variables, and interactions involved in the formulation of PRP have
allowed us to modulate its behavior and form the basis of its standardization for
clinical applications. Moreover, it is also possible to have PRP tailored for specific

xi
xii Preface

applications. It is with this approach that we believe that the science of PRP should
be developed.
Our expectation is to use the healing potential of the human body and specif-
ically the blood of each individual. The blood cells collection, processing, and
activation, as well as the choice of the best way for clinical application are widely
discussed topics in this book. The best indications, along with the expected results
for each type of nosology will be presented here.
My great motivation was to bring together in the same book the authors who
have seriously experienced this technique, collect, and publish their results.
Herein, renowned professionals, pioneers, and also those who accumulated
expressive results in the last ten years were invited to write about their experi-
ences. I emphasize that this book would not exist without the confidence and
friendship that international and national authors had in me when I asked and they
kindly agreed to write their experiences in the form of chapters that compose this
work. My special gratitude to Maria Helena Andrade Santana who effectively
helped me organize this book.
I hope that this work will contribute in this wonderfully emerging phase of
Medicine, which is Tissue Regeneration.

José Fábio Santos Duarte Lana

Contents

Platelet Rich Plasma and Its Growth Factors: The State of the Art. . . 1
José F. Lana, Adam Weglein, Eduardo Vicente, Amanda G. M. Perez,
Ana A. Rodrigues, Ângela C. M. Luzo, Maria H. A. Santana
and William D. Belangero

Platelet-Rich Plasma (PRP) as a Therapeutic Agent: Platelet Biology,

Growth Factors and a Review of the Literature . . . . . . . . . . . . . . . . . 61
Jamie Textor

Preparing the Soil: Practical Cellular Biochemistry

for Regenerative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Lewis K. Clarke

Challenges and a Feasible Strategy for Studies and Standardization

of Platelet-Rich Plasma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Amanda G. M. Perez, José F. Lana, Ana A. Rodrigues,
Angela C. M. Luzo, William D. Belangero and Maria H. A. Santana

Platelet-Rich Plasma and Tissue Engineering . . . . . . . . . . . . . . . . . . . 139

Ana A. Rodrigues, José F. Lana, Ângela C. M. Luzo,
Maria H. A. Santana, Amanda G. M. Perez, D. B. Lima-Silva
and William D. Belangero

Therapy with Use of Platelet-Rich Plasma in Orthopedics

and Sports Traumatology: Literature Review, Evidence
and Personal Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Rogério T. da Silva and Fernando Heidrich

The Use of PRP Injections and Stem Cells in an Office Setting . . . . . . 171
Joseph Purita

Platelet Rich Plasma Practical Use in Non-Surgical

Musculoskeletal Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Adam Weglein, Steve Sampson and Danielle Aufiero

xiii
xiv Contents

Platelet-Rich Plasma: Clinical Experience . . . . . . . . . . . . . . . . . . . . . 203

José C. Noronha

Platelet-Rich Plasma (PRP) in Ligament and Tendon Repair . . . . . . . 215

Linda Chao, Martha M. Murray and Patrick Vavken

Platelet Rich Plasma (PRP) in Osteoarthritis . . . . . . . . . . . . . . . . . . . 231

Alberto Gobbi, Georgios Karnatzikos, Somanna Malchira
and Anup Kumar

PRP in the Ambulatory Therapy of Tendinopathy of the Elbow,

Knee and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Marta Tarczyńska and Krzysztof Gaweda

Platelet-Rich Plasma and Biocellular Grafts . . . . . . . . . . . . . . . . . . . . 249

David Crane and Kristin Oliver

Disc Regeneration with Platelets and Growth Factors. . . . . . . . . . . . . 265

Marko Bodor, Andrew Toy and Danielle Aufiero

Use of Platelet-Rich Plasma (PRP) in Treating Chronic Wounds. . . . . 281

André M. Cancela, José F. Lana, Joyce M. Annichino-Bizzachi,
William D. Belangero and Ângela C. M. Luzo

The Use of Platelet-Rich Plasma in Orthopaedic Injuries . . . . . . . . . . 289

C. H. Bittencourt, P. B. Bittencourt, O. A. L. Neto and G. C. F. Arenas

Rehabilitation After Platelet-Rich Plasma Injections

for Tendinopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
E. Peck and K. Mautner

Platelet Rich Plasma on Pain Management. . . . . . . . . . . . . . . . . . . . . 329

Fabricio D. Assis, Charles A. Oliveira, Thais K. Vanetti,
Alexandra T. R. Luba, José F. Lana and Nelson S. A. Melo

PRP Experience in MOR Institute: Brazil (iMOR – Research

Institute for Sports Medicine, Orthopedics and Regeneration) . . . . . . 339
José F. Lana, Eduardo F. Vicente, Angela B. S. D. Lana,
Rodrigo K. Zogaib, Fabiano S. Magnino, Daniela B. Lima-Silva
and Luis F. Araújo-Junior
Contributors

Joyce M. Annichino-Bizzachi Department of Orthopaedic and Traumatology,

Faculty of Medical Sciences, University of Campinas, Campinas, SP, Brazil
Luis F. Araujo-Junior Research Institute of Sports Medicine Orthopedics and
Regeneration—iMOR, Av. Santos Dumont, 2946, Uberaba, Minas Gerais CEP
38050-400, Brazil
Géssica C. F. Arenas Clinical and Toxicological Analysis, Mariana, Brazil
Danielle Aufiero The Orthobiologic Institute, Los Angeles, CA, USA
William D. Belangero Department of Orthopaedic and Traumatology, Faculty of
Medical Sciences, University of Campinas, Campinas, SP, Brazil
Carlos H. Bittencourt Universidade Federal Fluminense, Icaraí, Brazil, e-mail:
[email protected]
Pauline B. Bittencourt Brazilian Society of Orthopaedics and Traumatology,
Universidade Federal Fluminense, Icaraí, Brazil
Marko Bodor Department of Physical Medicine and Rehabilitation, University
of California Davis, Davis, USA; Department of Neurological Surgery, University
of California San Francisco, San Francisco, USA; Interventional Spine and Sports
Medicine, Napa, CA, USA
André M. Cancela Regenerative and Cell Therapy Group, Hemocentro,
University of Campinas, Unicamp, Campinas, SP, Brazil
Linda Chao Sports Medicine Research Laboratory, Children’s Hospital Boston,
Harvard Medical School, Boston, MA, USA
Lewis K. Clarke Research Institute of Sports Medicine, Orthopedics and
Regeneration—iMOR, Uberaba, MG, Brazil, e-mail: [email protected]
David Crane BlueTail Medical Group, St. Luis, MO, USA, e-mail: dcranemd@
gmail.com

xv
xvi Contributors

Rogério T. da Silva NEO—Center for Research in Sports and Orthopedics, São

Paulo, Brazil; Orthopaedics and Sports Medicine–UNIFESP, Center for Ortho-
pedics Samaritano Hospital, São Paulo, SP, Brazil
Krzysztof Gaweda NZOZ Arthros, Al.Kasztanowa 6, 20-144 Nałe˛czów, Poland;
Orthopaedic Surgery and Traumatology Department, Medical University of Lub-
lin, Lublin, Jaczewskiego, Poland
Alberto Gobbi O.A.S.I Bioresearch Foundation, N.P.O, Via Amadeo, 24, Milan,
Italy
Fernando Heidrich Brazilian Society of Orthopaedics and Traumatology
(SBOT), Samaritano Hospital, São Paulo, SP, Brazil
Georgios Karnatzikos O.A.S.I Bioresearch Foundation, N.P.O, Via Amadeo, 24,
Milan, Italy
Anup Kumar O.A.S.I Bioresearch Foundation, N.P.O, Via Amadeo, 24, Milan,
Italy
José Fábio Santos Duarte Lana Research Institute of Sports Medicine, Ortho-
pedics and Regeneration—iMOR, Uberaba, MG, Brazil
Angela B. S. D. Lana Research Institute of Sports Medicine Orthopedics and
Regeneration—iMOR, Av. Santos Dumont, 2946, Uberaba, MG CEP 38050-400,
Brazil
Daniela B. Lima-Silva Research Institute of Sports Medicine Orthopedics and
Regeneration—iMOR, Av. Santos Dumont, 2946, Uberaba, MG CEP 38050-400,
Brazil
Ângela C. M. Luzo Haematology and Hemotherapy Center, Umbilical Cord
Blood Bank, University of Campinas, Campinas, SP, Brazil
Fabiano S. Magnino Orthopedic and Sports Physical Therapy, Research Institute
of Sports Medicine Orthopedics and Regeneration—iMOR, Av. Santos Dumont,
2946, Uberaba, MG CEP 38050-400, Brazil
Somanna Malchira O.A.S.I Bioresearch Foundation, N.P.O, Via Amadeo, 24,
Milan, Italy
Ken Mautner Departments of PM&R and Orthopedics, Emory University,
Atlanta, Georgia
Martha M. Murray Sports Medicine Research Laboratory, Children’s Hospital
Boston, Harvard Medical School, Boston, MA, USA
Ozório A. L. Neto Orthopedics and Traumatology—UNIFESP, Brazilian Society
of Orthopaedics and Traumatology, Society of Knee Surgery, SP, Brazil
Kristin Oliver BlueTail Medical Group, St. Luis, MO, USA
Contributors xvii

Evan Peck Section of Sports Medicine, Department of Orthopaedic Surgery,

Cleveland Clinic Florida, West Palm Beach and Weston, FL, USA; Charles E.
Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
Amanda G. M. Perez Department of Materials and Bioprocesses Engineering,
School of Chemical Engineering, University of Campinas, Campinas, SP, Brazil
Ana A. Rodrigues Research Institute of Sports Medicine, Orthopedics and
Regeneration—iMOR, Uberaba, MG, Brazil
Steve Sampson The Orthohealing Center and The Orthobiologic Institute
(TOBI), Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los
Angeles, CA, USA
Maria H. A. Santana Department of Materials and Bioprocesses Engineering,
School of Chemical Engineering, University of Campinas, Campinas, SP, Brazil
Marta Tarczyńska NZOZ Arthros, Al.Kasztanowa 6, 20-144 Nałe˛czów, Poland;
Orthopaedic Surgery and Traumatology Department, Medical University of Lub-
lin, Lublin, Jaczewskiego, Poland
Jamie Textor Department of Anatomy, Physiology and Cell Biology and
Department of Veterinary and Surgical Radiology, School of Veterinary Medicine,
University of California Davis, Davis, CA 95616, USA, e-mail: jamietextor@
gmail.com
Andrew Toy Interventional Spine and Sports Medicine, Napa, CA, USA
Patrick Vavken Sports Medicine Research Laboratory, Harvard Medical School,
Children’s Hospital Boston, Boston, MA, USA
Eduardo F. Vicente Research Institute of Sports Medicine, Orthopedics and
Regeneration—iMOR, Av. Santos Dumont, 2946, Uberaba, MG CEP 38050-400,
Brazil
Adam Weglein Regenerative Ortho Med Clinic, Houston, TX, USA; Houston
Medical School, University of Texas Health Science Center, Houston, USA,
e-mail: [email protected]
Rodrigo K. Zogaib Santos Football Club, Vila Belmiro, Santos, SP CEP 11075-
501, Brazil
Platelet Rich Plasma and Its Growth
Factors: The State of the Art

José F. Lana, Adam Weglein, Eduardo Vicente,

Amanda G. M. Perez, Ana A. Rodrigues, Ângela C. M. Luzo,
Maria H. A. Santana and William D. Belangero

Abstract This study aims to offer a general idea of the current progress and
discussions about the aspects of technical preparation and biological foundation of
PRP for clinical application. We seek to gather the best therapeutic indications that
have a scientific foundation on the use of this new tool of Regenerative Medicine. The
articles of this study were acquired from the leading data bases of medical literature.

History

The potential of autologous fibrin glue for clinical use was first documented in
1909 (Bergel 1909). It was first introduced in surgical procedures for its sealing
properties and to help with homeostasis (Anitua et al. 2004; Staindl et al. 1981).
Throughout the twentieth century, discoveries were made regarding platelet

J. F. Lana (&)  E. Vicente

Research Institute of Sports Medicine, Orthopedics and Regeneration-iMOR,
Uberaba, MG, Brazil
e-mail: [email protected]
A. Weglein
University of Texas Health Science Center at Houston Medical School,
Houston, TX, USA

Amanda G. M. Perez  Maria H. A. Santana

Department of Materials and Bioprocesses Engineering, School of Chemical Engineering,
University of Campinas, Campinas, SP, Brazil
A. A. Rodrigues  W. D. Belangero
Department of Orthopaedic and Traumatology, Faculty of Medical Sciences,
University of Campinas, Campinas, SP, Brazil
Â. C. M. Luzo
Haematology and Hemotherapy Center, Umbilical Cord Blood Bank,
University of Campinas, Campinas, SP, Brazil

J. F. S. D. Lana et al. (eds.), Platelet-Rich Plasma, 1

Lecture Notes in Bioengineering, DOI: 10.1007/978-3-642-40117-6_1,
 Springer-Verlag Berlin Heidelberg 2014
2 J. F. Lana et al.

activation and the role of growth factors in tissue regeneration (Matras et al. 1972;
Staindl 1981).
The use of platelet concentrates to substitute fibrin glues has been explored
since the 1990s due to the complexity and high costs of producing fibrin
concentrates (Gibble and Ness 1990). In 1990, Knighton et al. (1990) tested the use
of autologous platelets to treat chronic ulcers, with a reduction of almost 50 % in
healing time. Similarly, Ganio et al. (1993) observed expressive results when using
the same technique to treat chronic ulcers in patients for whom limb amputation
was initially recommended, with amputation prevented in 78 % of the cases. Such
good results made the 1990s a milestone for studies showing the positive action of
platelet-derived growth factors (Lenharo et al. 2004).
From 1995 to 1997, attempts were made to experimentally confirm the multi-
centric therapeutic utilization of growth factors derived from autologous platelets,
their biological safety and techniques for their clinical application to stimulate
fibroblastic, endothelial and/or osteoprogenitor cells. During this period, the
osteoinductive and catalyst capacity of fibrin adhesives led to the discovery of their
mechanisms of action. Studies also described techniques for usingplatelet gel as an
autologous alternative for fibrin glue, which was initially applied in oral surgeries
(Whitman et al. 1977).
In 1998, Lind (1988) studied the action of several growth factors on bone repair
in vitro and in vivo, evaluating their effect on osteoblastic cells after osteotomies
and their fixation effect in orthopedic implants. The association of growth factors
with the biological fixation of implants yielded promising results.
Since then, platelet rich plasma (PRP) gradually began to be studied and used in
several branches of orthopedic surgery, particularly for perfecting and accelerating
healing (Wroblewski et al. 2010).

Basic Science

Platelet Biology

Platelets, or thrombocytes, are formed during hematopoiesis, and consist of

cytoplasmic fragments of large and multinucleated cells of red bone marrow
(megakaryocytes). These cell fragments are found in blood plasma, the yellow
liquid fraction of the blood that contains water, proteins such as albumin, globu-
lins, clotting factors such as fibrinogen, and prothrombin (Francone et al. 1990).
Platelets measure from 1 to 4 lm in diameter and, although anucleated, they
contain organelles such as mitochondria, dense granules, alpha granules and lyso-
somal granules. Dense granules contain adenosine diphosphate (ADP), adenosine
triphosphate (ATP), calcium ions (Ca2+), serotonin, histamine, dopamineandcate-
cholamine.The alpha granules contain adhesion molecules, coagulation factors,
fibrinolytic factors, antiproteases, growth factors, cytokines and antibacterial
proteins (Anitua et al. 2004; Pietrzak and Eppley 2005). Platelet membranes consist
Platelet Rich Plasma and Its Growth Factors 3

of a phospholipid bilayer covered with glycoprotein receptors that act as mediators

in surface interactions with other platelets and with bioactive molecules (Pietrzak
and Eppley 2005, Hanson and Harker 1996).

Platelet Activity

Hemostasis is the result of the combined action of three main mechanisms:

vascular response, platelet activity and blood clotting. When in contact with an
injured vascular endothelial surface, even of biological origin, the platelets begin
an adhesion reaction to the injury location, releasing pseudopods that facilitate
their aggregation, which initiates the hemostatic plug that serves as a base for
aggregation factors to affix themselves to the area, which results in the formation
of the fibrin network that will obstruct the vascular injury (Souza and Elias 2005).
This process makes the platelets bloated and emit extensions, or pseudopodia,
which increase their adhesion capacity and mark the beginning of platelet aggre-
gation and the secretion and release of the substances contained in the dense and
alpha granules (Fig. 1). The released serotonin contributes to vasoconstriction. The
conversion of ATP into ADP releases the energy necessary to establish and
maintain the aggregation. The release of the calcium ions inside the platelet makes
the myofibril within it contract, thus allowing the aggregation and release of the
content of the granules. This is serum calcium, which is necessary for the formation
of the fibrin network. The presence of the Ca2+ ions in the plasma makes the
coagulation factors activate and group, forming the fibrin network, which is sta-
bilized by factor XIII and transformed in a stable clot. The calcium ions also inhibit
the anticoagulant activity of heparin, preserving the clot (Souza and Elias 2005).

Fig. 1 Process of platelet

activation (PDGF, platelet
derived growth factor).
Source adapted from Everts
et al. (2006c)
4 J. F. Lana et al.

The presence of thrombin induces the conversion of fibrinogen into fibrin and acts
as a platelet activator. After they are activated, the platelets begin to release anti-
microbial peptides that help amplify the organism’s immune response to the
invasion and proliferation of possible infectious agents in the injured area. Human
platelet antimicrobial peptides (HPAPs) are released only in the presence of
thrombin, and act basically in two ways: inhibiting or killing pathogens and
recruiting a larger quantity of leucocytes and/or lymphocytes to the injured area
(Tang 2002). Thromboxane A2 then recruits nearby platelets and aggregates them
to those that are already activated, continuing the formation of the platelet plug and
interrupting bleeding (Guyton and Hall 1997; Leão and Magini 2004).
The coagulation system involves complex alterations of a set of plasma proteins
that participate in the homeostasis process. Its formation begins with the structuring
of a fibrin network, which is a protein matrix retaining platelets and red cells that
occludes vascular injury. Soon afterwards the clot is retracted, which forces the edges
of the injured vessel closer together. Then the clot goes through an organization
process, characterized by the invasion of fibroblasts that are attracted by the platelet
growth factors, which forms scar tissue (Marx 1999). Concomitantly, proteolytic
enzymes participate in the clot’s dissolution process (Souza and Elias 2005).

Healing Cascade

The healing of soft or hard tissues involves a sequence of events that begin at the
moment of injury and continue for several subsequent months and can be divided
into three stages: inflammation, proliferation and remodeling (Pietrzak and Eppley
2005; Marx 1999; Clark 1996).
The first, or inflammatory, phase involves platelet activation and aggregation
and the formation of the fibrin matrix. During degranulation the platelets begin the
coagulation cascade and release cytokines, which orchestrate the healing process
(Fig. 2). The cytokines attract white blood cells (WBC) by chemotaxis, which
begin to migrate to the injured area. The neutrophils are the first WBC to be
recruited and are responsible for the initial local cleansing by removing bacteria
and cellular debris (Clark 1996; Lorenz and Longaker 2001).
Over the next few days, a proliferative phase occurs in which monocytes
migrate to the injured area, attracted by chemical signals from the growth factors.
The circulating monocytes are differentiated into macrophages and begin to
perform the signaling and modulation function that to this point had been per-
formed by the platelets, which begin to vacate the area. The macrophages debride
the area through phagocytosis and secrete factors responsible for initiating new
healing events such as the formation of granulation tissue through fibroblasts.
Angiogenesis then begins, due especially to the action of growth factors and
thrombin. Neocapillary development depends on the recruitment of vascular
endothelial cells and their activation by thrombin, which also provides negative
feedback that limits the intensity of neovascular formation (Minami et al. 2004).
Platelet Rich Plasma and Its Growth Factors 5

Fig. 2 Platelet degranulation

and action of cytokines
released in the coagulation
and healing processes (EGF,
epidemic growth factor;
VEGF, vascular endothelium
growth factor; FGF,
fibroblastic growth factor;
PDGF, platelet derived
growth factor; TGF-b,
transforming growth factor).
Source adapted from Everts
et al. (2006c)

The arrival of mesenchymal stem cells and their differentiation into specific tissues
such as bone, cartilaginous and vascular tissue (Fig. 3) begins in this phase and
depends on chemical signals (Clark 1996; Lorenz and Longaker 2001).
During the final, or remodeling, phase, the collagen contracts and the edges of
the injury are drawn together. Cell density and vascularization decrease, excess
repair matrix is removed and the collagen fibers are aligned along the stress lines,
which increases the strength of the newly formed tissue (Pietrzak and Eppley
2005). Granulation tissue accumulates and either slowly remodels the scar tissue
or is transformed into specific tissues such as skin and bone (Clark 1996; Lorenz
and Longaker 2001).

Fig. 3 Platelet degranulation

and action of the released
cytokines in the processof
formation of new bone tissue
(VEGF, vascular endothelial
growth factor; PDGF, platelet
derived growth factor; BMP,
bone morphogenetic protein;
TGF-b, transforming growth
factor). Source adapted from
Everts et al. (2006c)