Does the Use of Platelet-Rich Plasma at the

Time of Surgery Improve Clinical Outcomes

in Arthroscopic Rotator Cuff Repair When

Compared With Control Cohorts?

A Systematic Review of Meta-Analyses

Principle Investigator:

Bryan M. Saltzman, MD

Co-authors:

Akshay Jain, BS

Kirk A. Campbell, MD

Randy Mascarenhas, MD, FRCSC

Anthony A. Romeo, MD

Nikhil N. Verma, MD

Brian J. Cole, MD, MBA

Background

• Incidence of rotator cuff tear repair

continues to increase

…so too do retear rates

• Patient-related factors

• Extrinsic factors

• Biologic augmentation to improve quality

of repair tissue and ultimately, improve

outcomes and patient satisfaction

Background

• Platelet-rich plasma

– Collagen synthesis

– Vascularization

– Cell proliferation

• Use at time of rotator cuff

repair?

• Discordance in results of

recent meta-analyses Reproduced from: www.arthrex.com

Objective

(1) To conduct a systematic review of meta-analyses

evaluating PRP use at time of arthroscopic RCR

- Clinical Outcomes?

- Re-tear rates?

(2) To provide a framework for the analysis and

interpretation of the best currently available evidence

(3) To identify gaps in the literature where suggestions

for continued investigational efforts would be valid

Methods

Search Methodology

6 Level II + 1 Level III meta-analyses included

Search Methodology

Study Results

Variability among referenced studies in:

– Outcome measures

Study Results

• Variability among referenced studies in:

– Outcome measures

– Surgical fixation technique

– Concomitant acromioplasty

– Size of rotator cuff tear

– Imaging to assess for postop re-tear occurrence

– PRP

• Characteristics

• Preparation

• Consistency

• Administration during surgery

Study Results

Mean patient age range: 58.9 to 60.7 years

– Range in individual studies reported between

29 – 77 yrs

– Age is an indirect reflection of physiology

Study Results

• PRP does not provide significantly better…

– Constant score

– UCLA Score

– Constant Pain Score

– SANE score

– ASES score

– SST score

– VAS score more than 1 week postoperatively

• Isolated discordant results:

– 1 study reported PRP had superior Constant score, SST score, and

VAS score at 7 days postop

Study Results

Overall: Re-tear Rate

– All 7 included meta-analyses included individual studies

which identified re-tear through MRI or US

– Re-tear rate in patients with PRP use: 25.6% to 28.7%

– Re-tear rate in control patients: 28% to 36.7%

– No significant difference in any study

• RR ranged from 0.55 to 0.94

Study Results

Subgroup Analysis: Re-tear Rate

– 4 studies performed subgroup analyses

– PRP showed significantly lower re-tear rates in

“small/medium” cuff tears

• 7.9% versus 26.8% in one of the studies

• RR range from 0.32 to 0.60

– NNT with PRP in “small/medium” tears: 6 to 14

– No difference PRP vs. control patients with

“large/massive” tears

Study Results

Subgroup Analysis: Retear Rate

– 1 study determined PRP use exhibited a larger re-

tear reduction effect after:

• Double-row repair with

Initial tear sizes > 3 cm (AP length) (25.9% with PRP

vs 57.1% without PRP)

• PRFM (14.8%) vs liquid-based PRP use (46.8%)

Study Results

• Subgroup Analysis: Constant score

– PRP injection at the tendon-bone

interface may provide a higher gain (vs.

“injection at repair site”)

Study Results

Overall…

– None of the included meta-analyses

supported the routine use of PRP at the time

of arthroscopic rotator cuff repair

Study Quality and Validity

• QUOROM Scores ranged from 15 to 17 (max = 18)

• Oxman-Guyat score of 7 (max = 7) for all studies

• All 7 included meta-analyses provided a high level of

currently available evidence

• However, studies reported high risk of bias in many

individually-included studies

Conclusion

• All 7 included meta-analyses provided a high level

of currently available evidence

• Thus:

– Current highest level of evidence suggests

that nondiscriminatory, routine PRP use at

the time of arthroscopic RCR surgery does

not universally improve re-tear rates or

affect clinical outcome scores

Conclusion

However, effects of PRP use on re-tear rate

may be beneficial if…

(1) A composition of PRFM

(2) Application at the tendon-bone interface

(3) in double-row technique repair

(4) with small- and/or medium-sized rotator

cuff tears

Future Questions

• Best volume or preparation of PRP?

• LR-PRP vs LP-PRP?

• PRP injection postop? Multiple doses?

• Cost-efficacy?

Thank You