Platelet Rich Plasma and ACL graft healing
This is an area that will receive a lot of attention in the Sports Medicine journals over the next 2 years. The exciting question is can Platelet Rich Plasma (PRP) enhance the healing of the anterior cruciate ligament graft?
If it can then the time to return to full sport could be shortened. At the moment I think that it is best to wait for 12 months before a full return to sport as this gives time for the graft to become more like a ligament. In fact there is evidence that it takes 2 years for this process to be complete. If PRP could reduce the time for ligamentisation to 3 months then this would be a great advance.
I believe that a lot of failures are caused by a return to sport when the graft is not fully integrated with the bony tunnels and has not developed a proper blood supply and so has not become a ligament. The graft ruptures as it has not been given the time to develop fully. Of course tunnel placement is of great importance but I would like to emphasis the importance of graft integration.
There is quite a way to go yet with PRP and ACL recon. With many different concentrations and systems of PRP and different ways they are used with ACL surgery it is very difficult to nail down what system is best. Some studies have shown a decrease in tunnel widening which I believe is a good thing. The South American experience with PRP and ACL reconstruction has been led by Radice et al. in Chile. The authors found that the time to complete homogeneity of the ACL graft on MRI was 177 days for the group with surgery plus PRP, whereas the group with surgery alone required 369 days to acquire a matured graft. Moreover, when the subgroup of BTB autograft was analyzed, the maturation time in the PRP group was 109 days versus 363 days. In light of these results, Radice et al. concluded that the use of PRP accelerates graft maturation by half of the expected time, with an additional reduction in maturation time from 12 months to 3.6 months in the BTB graft and PRP group. These results are especially significant in light of the accelerated recovery time desired in sports medicine.
This is exciting stuff. It is probably the most promising advance in ACL reconstructive surgery in the last 10 years. Together with double bundle grafts this is where the future of reconstructive ACL surgery is going. First there was anatomical positioning and now the use of biologics to speed up healing. Let’s hope that the studies will prove that the hope is real.