ANTOINE I. JABBOUR, MDwww.drjabbour.com

TULSA BONE & JOINT ASSOCIATES918-392-1400

4/24/10 ANTOINE I. JABBOUR, MD

PROFFESIONAL ATHLETES RECEIVING PRP

4/24/10 ANTOINE I. JABBOUR, MD

TIGER WOODS AND PRPTiger Admits to Platelet-Rich Plasma

Therapy, What's That?Golfer Says Doctor Under Investigation Injected Blood, Not Human Growth

4/24/10 ANTOINE I. JABBOUR, MD

PLATELET RICH PLASMA

4/24/10 ANTOINE I. JABBOUR, MD

PLATELET RICH PLASMAAPPLICATIONS

4/24/10 ANTOINE I. JABBOUR, MD

CHRONIC TENDONITIS

WOUND HEALING

CARTILAGE REGENERATION

CARDIAC APPLICATIONS

HEALING CASCADETHREE PHASES

INFLAMMATORYPROLIFERATIVEREMODELING

TRULY OVERLAP IN REALITY

4/24/10 ANTOINE I. JABBOUR, MD

INFLAMMATORY PHASEOBTAIN HEMOSTASISRELEASE CHEMICAL MESSENGERSATTRACT PHAGOCYTES

4/24/10 ANTOINE I. JABBOUR, MD

INFLAMMATORY PHASE OF HEALING

BLOOD CONTACTS COLLAGENPLATELETS SECRETE

COAGULATION FACTORSPLATELET ACTIVATING FACTORSCYTOKINESCHEMOKINES

4/24/10 ANTOINE I. JABBOUR, MD

INFLAMMATORY PHASETHROMBOXANE/PROSTOGLANDINS LEAD

TO VASOCONSTRICTION (PEAKS AT 5-10 MINUTES)

HISTAMINE RELEASE LEADS TO VASODILATION (PEAKS AT 20 MINUTES)

INCREASE IN BLOOD FLOWCELL MEMBRANE BECOMES POROUSPROTEINS/LEUKOCYTES LEAK INTO

INJURED AREASWELLING/INFLAMMATION

4/24/10 ANTOINE I. JABBOUR, MD

INFLAMMATORY PHASE• PMN FIRST WBC TO ARRIVE• MOST ABUNDANT CELL DURING FIRST 48

TO 72 HOURS• KILL BACTERIA, INGEST DEBRIS• SECRETE FACTORS FOR ANGIOGENESIS,

EPITHELIALIZATION,EXTRACELLULAR MATRIX (KEY IN INDUCING PROLIFERATIVE PHASE)

4/24/10 ANTOINE I. JABBOUR, MD

INFLAMMATORY PHASEANTIMICROBIAL LEADS TO PROLIFERATIVE PHASEVERY NECESSARYDON’T WANT IT TO LAST TOO LONG

4/24/10 ANTOINE I. JABBOUR, MD

PROLIFERATIVE PHASEAFTER 48-72 HOURSFIBROBLASTS ENTER WOUNDENDOTHELIAL CELLS START

NEOVASCULARIZATIONSOME CLOT IS DISSOLVED FOR NEW

VESSELSPEAKS AT 5-15 DAYS

4/24/10 ANTOINE I. JABBOUR, MD

REMODELING PHASECAN LAST ONE YEARTYPE III COLLAGEN REPLACED BY TYPE IREORGANIZATIONBLOOD VESSELS DISAPPEAR

4/24/10 ANTOINE I. JABBOUR, MD

WE NEED INFLAMMATORY PHASEPLATELET SECRETION VERY IMPORTANT

IN INFLAMMTORY PHASE TO INDUCE FIBROBLAST MIGRATION IN THE PROLIFERATIVE PHASE

4/24/10 ANTOINE I. JABBOUR, MD

PLATELET BIOLOGYPERIPHERAL BLOOD HAS

RBCWBCPLATELETS (0.4%)

4/24/10 ANTOINE I. JABBOUR, MD

PLATELET CLOT FUNCTIONSTOPS BLEEDINGSCAFFOLD FOR TISSUE REGENERATIONGROWTH FACTORS CONCENTRATIONSTEM CELL BINDING

4/24/10 ANTOINE I. JABBOUR, MD

PLATELET RICH PLASMA (PRP)

4/24/10 ANTOINE I. JABBOUR, MD

PLATELET ACTIVATIONRESTING STATE ACTIVATED PLATELET

CELL FEET RELEASE OF GROWTH FACTORS

4/24/10 ANTOINE I. JABBOUR, MD

PRPMORE PLATELETS, MORE GROWTH

FACTORS

MORE GROWTH FACTORS, MORE TISSUE REGENERATION

4/24/10 ANTOINE I. JABBOUR, MD

GROWTH FACTORS FUNCTIONCHEMOTAXIS

DIRECTIONAL MOVEMENT OF CELLS IN RESPONSE TO A CHEMICAL STIMULUS

STEM CELLS ATTRACTED TO GROWTH FACTORS AND MIGRATE INTO THE AREA

PROLIFERATION CELL DIVISION IN RESPONSE TO A STIMULUS

PLATELET SIGNALING GROWTH FACTORS BIND TO STEM CELL MEMBRANE GROWTH FACTORS STIMULATE CELL DIVISION

4/24/10 ANTOINE I. JABBOUR, MD

GROWTH FACTORSGROWTH FACTORS ATTACH TO

DIFFERENT CELLS RECEPTORS WHICH THEN SENDS MESSAGE INSIDE THE CELL TO CHANGE THE FUNCTION OF THE CELL

4/24/10 ANTOINE I. JABBOUR, MD

GROWTH FACTORS IN PRPPDGF

PLATELET DERIVED GROWTH FACTORTGF-B

TRANSFORMING GROWTH FACTOR-BETAVEGF

VASCULAR ENDOTHELIAL GROWTH FACTORIGF-1

INSULIN LIKE GROWTH FACTOR

4/24/10 ANTOINE I. JABBOUR, MD

GROWTH FACTORS IN PRPPDGF

ATTRACTS WBC, MESENCHYMAL STEM CELLS BONE, LIGAMENT,TENDON,CARTILAGE

TGF-BINCREASE TYPE I COLLAGEN PRODUCTION IN

TENDON SHEATH FIBROBLASTS (KLEIN, 2002)PROMOTE CELL DIVISION

VEGFSTIMULATES ANGIOGENESIS

4/24/10 ANTOINE I. JABBOUR, MD

GROWTH FACTORS IN PRP

4/24/10 ANTOINE I. JABBOUR, MD

MORE CONCENTRATED PLATELETS THE MORE GROWTH FACTORS

LINEAR RELATIONSHIP

EPPLEY , 2004

GROWTH FACTORS IN PRPTENDON CELLS GROWN IN VITRO WITH

PRP HAVE HIGHER CONCENTRATION OF COLLAGEN.

PDGF AND TGF PROMOTE CELL GROWTH AND SYNTHESIS OF COLLAGEN I AND III

4/24/10 ANTOINE I. JABBOUR, MD

GROWTH FACTORS IN PRP

TENDON CELLS GROWN IN VITRO WTH VEGF PRP STIMULATES GROWTH OF BLOOD VESSELS.

NEW BLOOD SUPPLY INCREASES CHANCE OF TENDON HEALING

4/24/10 ANTOINE I. JABBOUR, MD

HOW TO GET PRPWITHDRAW 60 cc OF PERIPHERAL BLOOD

4/24/10 ANTOINE I. JABBOUR, MD

HOW TO GET PRPSPIN IN CENTRIFUGE

4/24/10 ANTOINE I. JABBOUR, MD

HOW TO GET PRPREMOVE PRODUCT

4/24/10 ANTOINE I. JABBOUR, MD

PRP APPLICATIONSCHRONIC TENNIS ELBOWCHRONIC GOLFER’S ELBOWPARTIAL ROTATOR CUFF TEARACHILLES TENDONITISPLANTAR FASCIITISWOUND HEALINGCARTILAGE RESTORATION ?SPINE DISC REGENERATION ?

4/24/10 ANTOINE I. JABBOUR, MD

PRP CONCLUSIONPRP PROVIDES HIGH CONCENTRATION OF

PLATELETS

HIGH CONCENTRATION OF GROWTH FACTORS, TRIGGERS AND ACCELERATES REGENERATION OF CHRONIC TISSUE PROBLEMS SUCH AS INFLAMMATION AND DEGENERATION

4/24/10 ANTOINE I. JABBOUR, MD

PRP CAUTION HOW MANY TIMES NORMAL PLATELETS

IS NEEDED TO PROVIDE ENOUGH GROWTH FACTORS (6X NORMAL)

DO NOT ACTIVATE PLATELETS TOO EARLY

MUST INJECT PRP INTO SPECIFIC AREA WITHIN 0.5 mm

ACCURACY CAN ONLY BE ACHIEVED WITH ULTRASOUND GUIDED INJECTIONS

4/24/10 ANTOINE I. JABBOUR, MD

MUSCULOSKELETAL ULTRASOUND(MSKUS)

MUSCULOSKELETAL SONOGRAPHY RAPIDLY EVOLVING MODALITY WHICH IS

GROWING IN POPULARITY IN THE MANAGEMENT OF SOFT TISSUE AND JOINT DISORDERS

4/24/10 ANTOINE I. JABBOUR, MD

MSKUSADVANTAGES OVER MRI

READILY ACCESSIBLEPORTABLEQUICK SCAN TIMEBETTER PATIENT TOLERABILITYLESS COST

MRI STILL GIVES BETTER INTRAARTICULAR VIEWS. (LIGAMENTS,LABRUM, CARTILAGE)

4/24/10 ANTOINE I. JABBOUR, MD

MSKUS TRANSDUCERS12 L Mhz transducers

Tennis elbow achilles shoulder knee

4 C Mhz transducersHipspine

4/24/10 ANTOINE I. JABBOUR, MD

MSKUSMODERN ULTRASOUND MACHINES WORK

ON PULSE ECHO TECHNOLOGY TO PRODUCE HIGH RESOLUTION IMAGE

COMPUTERS NOW ARE MUCH BETTER AT PRODUCING HIGH RESOLUTION IMAGES WITH CROSS BEAM TECHNOLOGY

4/24/10 ANTOINE I. JABBOUR, MD

WHY DO WE NEED ULTRASOUND TO GUIDE OUR INJECTIONS?Accuracy of anterior intra-articular injection

of the glenohumeral joint. Arthroscopy. 2005 Jan;21(1):77-80. Sethi PM, et at.

Accuracy of needle placement into the intra-articular space of the knee. Journal of Bone & Joint Surgery. 2002 Sep; 84-A(9):1522-7.Jackson, Evans, Thomas

4/24/10 ANTOINE I. JABBOUR, MD

WHY DO WE NEED ULTRASOUND TO GUIDE OUR INJECTIONS?Sacroiliac Joint Injections performed with

sonographic guidance. J Ultrasound Med 22:553-559, 2003. Pekkafali, Kiralp, et al.

AC JOINT: Accuracy of needle placement in ACJ injections. Knee Surg Sports Traumatol Arthrosc. 2006.14:762-765. Bisbinas, Belthur, Said, Green, Learmonth.

4/24/10 ANTOINE I. JABBOUR, MD

WHY DO WE NEED ULTRASOUND TO GUIDE OUR INJECTIONS?THESE AND OTHER STUDIES HAVE SHOWN

THAT EVEN EXPERIENCED PHYSICIANS AND SURGEONS ARE NOT INTRAARTICULAR >20%

SOFT TISSUE INJECTIONS CAN BE DONE WITH 0.2 mm ACCURACY

4/24/10 ANTOINE I. JABBOUR, MD

CLINICAL USES IN ORTHOPEDICSCURRENT CONCEPTS

THE USE OF PLATELET RICH PLASMA IN ARTHROSCOPY AND SPORTS MEDICINE:

OPTIMIZING THE HEALING ENVIRONMENT

ARTHROSCOPY: VOL 26, No 2 February 2010

4/24/10 ANTOINE I. JABBOUR, MD

CHRONIC ACHILLES TENDINOPATHY

SANCHEZ IN AM J SPORTS MEDICINE 2007SURGERY + PRGF DID BETTER AND

RECOVERED SIGNIFICANTLY BETTER AND HAD A SMALLER AREA OF FIBROTIC TENDON AFTER 18 MONTHS AS COMPARED TO CONTROL GROUP

4/24/10 ANTOINE I. JABBOUR, MD

CHRONIC TENNIS ELBOWARNOCZKY, MISHRA ORTHOPEDICS

TODAY 2009. THE ROLE OF PRP IN CONNECTIVE TISSUE.PRP COMPARED TO BUPIVICAINE. FASTER

WITH PRP

4/24/10 ANTOINE I. JABBOUR, MD

CHRONIC TENNIS ELBOWGOSEN FROM NETHERLANDS REPLICATED

PROTOCOL WITH PRP VS STEROIDS. PORTUGAL 2008

4/24/10 ANTOINE I. JABBOUR, MD

CHRONIC ROTATOR CUFF TENDINOPATHY

ANDERSON & COLLEAGUES 2009PLATELET RICH FIBRIN MATRIX USED LESS

NARCOTICS AFTER SURGERY

MANISCALO. ACTA BIOMED 2008SHOWED GOOD RESULTS USING THE

CASCADE MEMBRANE

4/24/10 ANTOINE I. JABBOUR, MD

CHRONIC JUMPER’S KNEEMARCACCI AT THE RIZZOLI INSTITUTE

INT ORTHOPEDICS JULY 2009REFRACTORY PATELLAR TENDINOPATHY DID

BETTER WITH PRP AS COMPARED TO PT ONLY

4/24/10 ANTOINE I. JABBOUR, MD

MUSCLE INJURIESSANCHEZ, GERMANY MAY 2005PRGF SYSTEM FROM BTI BIOTECHNOLOGY

INSTITUTE EXTRACT HEMATOMA EARLY WITH

ULTRASOUND AND THEN BACKFILL WITH PRGF 20 ATHLETES HEALED IN HALF THE EXPECTED

TIME AND FIBROSIS NOT APPARENT AND NO RECURRENT PROBLEMS

4/24/10 ANTOINE I. JABBOUR, MD

MENISCAL REPAIRISHIDA: TISSUE ENG 2007

PRP ENHANCED RABBIT MENISCI HEALING IN VIVO AND IN VITRO

SCAGLIONE, 2009 USED PRP AND MENISCAL REPAIR AND HAD 80% SUCCESS IN CLINICAL OUTCOMES

4/24/10 ANTOINE I. JABBOUR, MD

SHOULDER SLAP REPAIRSHIRAHURA. CANADIAN ORTHOPEDIC

ASSOCIATION JULY 2009ENHANCED SLAP REPAIRS WITH FIBRIN-

PRP CLOTS

4/24/10 ANTOINE I. JABBOUR, MD

HIP LABRAL REPAIRSNO PUBLISHED REPORTS

4/24/10 ANTOINE I. JABBOUR, MD

KNEE OSTEOCHONDRAL LOOSE BODY

SANCHEZ; MED SCI SPORTS EXERCISE 2003.CASE REPORT

4/24/10 ANTOINE I. JABBOUR, MD

KNEE ARTHRITISSANCHEZ; CLIN EXP RHEUMATOLOGY,

2008CUGAT; OSAKA JAPAN APRIL 2008

INTRAARTICULAR INJECTIONS OF PRGF TO TREAT OA

4/24/10 ANTOINE I. JABBOUR, MD

KNEE ARTHRITISANITUA; RHEUMATOLOGY (OXFORD) 2007

PRP ENHANCE THE SECRETION OF HYALURONIC ACID AND INDUCE HEPATOCYTE GROWTH FACTOR PRODUCTION BY SYNOVIAL FIBROBLASTS FROM ARTHRITIC PATIENTS

4/24/10 ANTOINE I. JABBOUR, MD

ACLFANELLI; ORTHOPEDICS TODAY 2009

PRP GRAFT WITH ALLOGRAFT ACL NO INFECTIONS, HEALED FASTER

• RADICE FROM CHILE. REV ARGENT. ARTOROSC 2008PRP ACCELERATES GRAFT MATURATION

BY HALF OF THE EXPECTED TIME• SILVA; KNEE SURG SPORTS TRAUMATOLOGY

ARTHROSCOPY 2009• PRP DID NOT CHANGE HEALING

• SMALL SAMPLE SIZE, NO ACTIVATION, NO SCAFFOLD)

4/24/10 ANTOINE I. JABBOUR, MD

ACL AND PRPLIGAMENTIZATION OF TENDON GRAFTS

TREATED WITH AN ENDOGENOUS PREPARATION RICH IN GROWTH FACTORS. SANCHEZ; ARTHROSCOPY VOL 26 No24,

APRIL 2010

MORE REMODELING COMPARED WITH UNTREATED GRAFTS

4/24/10 ANTOINE I. JABBOUR, MD

CONCLUSIONNEED MORE DOUBLE BLIND

RANDOMIZED STUDIESLONG TERM STUDIESHOW MANY PLATELETS ARE ENOUGH?WHICH GROWTH FACTORS NEEDED

MORE?WHERE DOES IT WORK BEST?COST IS A MAJOR ISSUE HELP OUR PATIENTS AND NEVER

CAUSING HARM4/24/10 ANTOINE I. JABBOUR, MD

PLATELET RICH PLASMA AND MUSCULOSKELETAL ULTRASOUND

ANTOINE I. JABBOUR, MD

TULSA BONE & JOINT ASSOCIATES918 392 1400

www.drjabbour.com

4/24/10 ANTOINE I. JABBOUR, MD

PLATELET RICH PLASMA AND MUSCULOSKELETAL ULTRASOUND

4/24/10 ANTOINE I. JABBOUR, MD