Letter to the Editor
Therapeutic potential of platelet rich plasma. Reflections on its research and development
Potencial terapéutico del plasma rico en plaquetas. Reflexiones sobre la investigación y su desarrollo
J. González-Iglesias
Unidad de Terapias Biológicas, Hospital San Juan de Dios, Santurce, Vizcaya, Spain
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Determination of platelet aggregation, perioperative bleeding and a review of annual mortality" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "240" "paginaFinal" => "253" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio comparativo aleatorizado de la intervención quirúrgica temprana frente a la demorada en los pacientes con fractura de cadera tratados con antiagregantes plaquetarios. Determinación de la agregabilidad plaquetaria y el sangrado perioperatorio, y la revisión de la mortalidad al año" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2408 "Ancho" => 2880 "Tamanyo" => 419720 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Scheme showing platelet activation pathways.</p> <p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">ADP: adenosine diphosphate; COX: cyclooxygenase; PGE1: prostaglandin E1; TRAP: Thrombin receptor activator peptide.</p> <p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Source: adapted from <span class="elsevierStyleItalic">Compendium multiplate final</span> by Calatzis A, Loreth R and Spannagl M, 2007.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Mas-Atance, C. Marzo-Alonso, M. Matute-Crespo, J.J. Trujillano-Cabello, N. Català-Tello, M. de Miguel-Artal, P. Forcada-Calvet, J.J. Fernández-Martínez" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Mas-Atance" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Marzo-Alonso" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Matute-Crespo" ] 3 => array:2 [ "nombre" => "J.J." "apellidos" => "Trujillano-Cabello" ] 4 => array:2 [ "nombre" => "N." "apellidos" => "Català-Tello" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "de Miguel-Artal" ] 6 => array:2 [ "nombre" => "P." "apellidos" => "Forcada-Calvet" ] 7 => array:2 [ "nombre" => "J.J." "apellidos" => "Fernández-Martínez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1888441513000635" "doi" => "10.1016/j.recot.2011.12.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1888441513000635?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1988885613000527?idApp=UINPBA00004N" "url" => "/19888856/0000005700000004/v1_201309060049/S1988885613000527/v1_201309060049/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Therapeutic potential of platelet rich plasma. Reflections on its research and development" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "237" "paginaFinal" => "239" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J. González-Iglesias" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "González-Iglesias" "email" => array:2 [ 0 => "javi.g.iglesias@gmail.com" 1 => "jgiglesias@hsjd.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Terapias Biológicas, Hospital San Juan de Dios, Santurce, Vizcaya, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Potencial terapéutico del plasma rico en plaquetas. Reflexiones sobre la investigación y su desarrollo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">At present biological therapies represent an area of ongoing research and development in medicine, with a present full of applications and a promising future. Numerous therapeutic techniques have been developed in the field of Traumatology, Orthopedics and Sports Medicine in recent years. The potential applications of platelet rich plasma (PRP) stand out due to the number of publications and different lines of research. There is also considerable controversy regarding its use.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A review of the scientific literature clearly shows the increasing number of publications on this subject. Over 1400 items have been published internationally in relation to the different types of PRP in the past 2 years. The Spanish Journal of Orthopedics and Traumatology has published more than 30 articles. However, this field of research is supported by scarce scientific evidence regarding its benefits, as there are few articles with evidence level I.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A prospective, randomized, double-blind and multicentre article was published in <span class="elsevierStyleItalic">Arthroscopy</span> in August 2012, which compared infiltrations with plasma rich in platelet growth factors and hyaluronic acid regarding pain reduction.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The results were in favor of the use of plasma. It is worth noting the difficulty in assessing pain, regardless of the rating scales employed, due to the subjective component of perception. In January 2013, this study obtained the award for “Best article with level I evidence published in <span class="elsevierStyleItalic">Arthroscopy</span> in 2012”.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Previously, a meta-analysis of published scientific literature on the different uses of platelet rich plasma (PRP) was conducted in early 2012.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the conclusions section, the authors stated that there was no significant evidence supporting the use of plasma. The study assessed the results of research with various different products (plasma with leukocytic or hematic content, whilst others used plasma containing only platelets), different techniques (ultrasound-guided injections in some studies, whilst others did not use this kind of aid) and diverse locations (tendons, muscles and intra-articular spaces). In other words, the results were hardly comparable.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In Spain, there are various centers and researchers working in the field of biological therapies. These are essential because, regardless of the period of crisis or prosperity, through their efforts and with the support of the institutions, we will be able to discover the benefits of new therapies and to develop applications with extensive social impact.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The position on the use of a therapeutic technique is determined by the degree of scientific evidence regarding its benefits, that is, it must be based on information, on published articles, and evaluate the potential benefits, taking into account that any risks must be minimized.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Novel technique<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>benefits<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>risks<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0 (variable: costs)</p><p id="par0040" class="elsevierStylePara elsevierViewall">In my opinion, this position is not so much for or against use, because it is likely that this is not sufficiently supported at the outset. However, we should always be in favor of <span class="elsevierStyleItalic">research</span>, seeking the benefit for patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore, we must base the use of new techniques on the published literature and the potential benefits, developing research projects and minimizing costs to make them viable, in order to advance.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Symphony of signals</span><p id="par0050" class="elsevierStylePara elsevierViewall">Cells interact with each other as an “orchestra”, based on a large number of signals, such as the numerous proteins acting as messengers. Small changes in our therapeutic actions can lead to very disparate results. The concentration of chondrocytes implanted in chondral lesions or the regularization of mechanical stimuli may influence the clinical outcomes of our interventions. It is essential to investigate the underlying biological principles at a cellular and molecular level<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and thus be able to develop new therapeutic tools for processes such as inflammatory and degenerative cartilage diseases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Difficulties</span><p id="par0055" class="elsevierStylePara elsevierViewall">At present, there is an excess of indications to be determined. The same set of signals are used for an acute muscle injury (fibrillary injury) and a chronic injury (predominance of fibrosis and cysts). The same signals are used at different times, when muscle repair has a clear temporal pattern (different molecules are predominant at different times). The number of infiltrations into a muscle tear is also variable. If, following a second infiltration, we observe scarce improvement during the third week of recovery, why continue with a third infiltration? If there is no favorable initial evolution, the process is likely to continue its natural course.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The specific benefits may cause conflicts of interest and produce biases in studies or highlight differences with scarce statistical significance in favor of or against a particular technique.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The difficulty in comparing studies is characteristic of many novel biological therapies. Homogenizing the type of products, doses, techniques and application times requires considerable research. How can we compare the results of a study where PRP is applied in a tendon with those of another study applying plasma with different cell lines, that is, with different biological signals? Let us maintain the perspective. We do not even know the different protein concentrates being introduced in the lesion. These are not previously analyzed and these concentrations can vary greatly from one person to another, and even within the same person at different times.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Controversy</span><p id="par0070" class="elsevierStylePara elsevierViewall">In November 2009, Nin et al. published an article in <span class="elsevierStyleItalic">Arthroscopy</span> evaluating the use of PRP on autogenous grafts used in anterior cruciate ligament reconstruction.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the conclusions, they did not indicate any clinical or biomechanical variations from the use of PRP with the methodology employed. They emphasized the need for further clinical studies to show the effectiveness of PRP in this type of surgery. The article led to an interesting exchange of views in June 2010 in the same journal (Letters to the Editor), which reviewed important issues such as the process of obtaining PRP and the protocol for application of plasma during surgery, highlighting the need for prospective, randomized, double-blind studies with level I evidence.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Present and future</span><p id="par0075" class="elsevierStylePara elsevierViewall">This is a constantly evolving field and one where recent studies conducted in our country have had considerable international impact. Patients come to us with questions that arise after news items related to biological therapies appear in the press and on television. Our duty is to <span class="elsevierStyleItalic">know the different therapeutic possibilities</span>, to seek and analyze the articles with <span class="elsevierStyleItalic">the highest level of scientific evidence</span>, and to use the treatments which can offer the greatest benefit for our patients.</p><p id="par0080" class="elsevierStylePara elsevierViewall">We must encourage and develop research, from the laboratory to clinical practice, and legislation plays a major role in this regard. The next law which considers plasma rich in platelet growth factors as a <span class="elsevierStyleItalic">special medication</span> must help to regulate its use and to compare different studies.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In coming years, research lines which achieve greater development will be those where <span class="elsevierStyleItalic">combination therapies</span> are prominent, going from the repair of tissues to their regeneration. The use of biological signals, such as platelet growth factors, along with the culture of different cell lines, will lead to significant advances with a great impact on the quality of life of our patients.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Level of evidence</span><p id="par0090" class="elsevierStylePara elsevierViewall">Level of evidence v.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Protection of people and animals</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that this work does not reflect any patient data.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Right to privacy and informed consent</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that this work does not reflect any patient data.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Symphony of signals" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Difficulties" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Controversy" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Present and future" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 5 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Iglesias J. Potencial terapéutico del plasma rico en plaquetas. Reflexiones sobre la investigación y su desarrollo. Rev Esp Cir Ortop Traumatol. 2013;<span class="elsevierStyleBold">57</span>:237–9.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Applications of platelet-rich plasma in musculoskeletal and spots medicine: An evidence-based approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.T. Nguyen" 1 => "J. Borg-Stein" 2 => "K. 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Hernandez Gonzalez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arthro.2009.06.002" "Revista" => array:6 [ "tituloSerie" => "Arthroscopy" "fecha" => "2009" "volumen" => "25" "paginaInicial" => "1206" "paginaFinal" => "1213" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19896041" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/19888856/0000005700000004/v1_201309060049/S1988885613000515/v1_201309060049/en/main.assets" "Apartado" => array:4 [ "identificador" => "7598" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/19888856/0000005700000004/v1_201309060049/S1988885613000515/v1_201309060049/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1988885613000515?idApp=UINPBA00004N" ]
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| 2023 May | 33 | 0 | 33 |
| 2023 April | 36 | 5 | 41 |
| 2023 March | 7 | 2 | 9 |
| 2023 February | 10 | 0 | 10 |
| 2023 January | 6 | 8 | 14 |
| 2022 December | 8 | 5 | 13 |
| 2022 November | 17 | 5 | 22 |
| 2022 October | 10 | 6 | 16 |
| 2022 September | 10 | 6 | 16 |
| 2022 August | 13 | 7 | 20 |
| 2022 July | 10 | 9 | 19 |
| 2022 June | 7 | 6 | 13 |
| 2022 May | 20 | 7 | 27 |
| 2022 April | 15 | 5 | 20 |
| 2022 March | 8 | 3 | 11 |
| 2022 February | 25 | 8 | 33 |
| 2022 January | 18 | 5 | 23 |
| 2021 December | 10 | 7 | 17 |
| 2021 November | 3 | 5 | 8 |
| 2021 October | 13 | 10 | 23 |
| 2021 September | 22 | 7 | 29 |
| 2021 August | 37 | 7 | 44 |
| 2021 July | 15 | 8 | 23 |
| 2021 June | 10 | 6 | 16 |
| 2021 May | 12 | 5 | 17 |
| 2021 April | 13 | 5 | 18 |
| 2021 March | 9 | 7 | 16 |
| 2021 February | 11 | 6 | 17 |
| 2021 January | 8 | 10 | 18 |
| 2020 December | 1 | 0 | 1 |
| 2018 February | 5 | 1 | 6 |
| 2018 January | 5 | 1 | 6 |
| 2017 December | 7 | 0 | 7 |
| 2017 November | 5 | 1 | 6 |
| 2017 October | 8 | 1 | 9 |
| 2017 September | 11 | 1 | 12 |
| 2017 August | 9 | 1 | 10 |
| 2017 July | 10 | 1 | 11 |
| 2017 June | 13 | 2 | 15 |
| 2017 May | 6 | 0 | 6 |
| 2017 April | 7 | 1 | 8 |
| 2017 March | 16 | 29 | 45 |
| 2017 February | 7 | 5 | 12 |
| 2017 January | 9 | 1 | 10 |
| 2016 December | 21 | 3 | 24 |
| 2016 November | 13 | 0 | 13 |
| 2016 October | 20 | 3 | 23 |
| 2016 September | 20 | 10 | 30 |
| 2016 August | 15 | 3 | 18 |
| 2016 July | 21 | 2 | 23 |
| 2016 June | 19 | 6 | 25 |
| 2016 May | 19 | 14 | 33 |
| 2016 April | 18 | 5 | 23 |
| 2016 March | 20 | 19 | 39 |
| 2016 February | 13 | 10 | 23 |
| 2016 January | 12 | 8 | 20 |
| 2015 December | 13 | 10 | 23 |
| 2015 November | 3 | 1 | 4 |
| 2015 October | 11 | 5 | 16 |
| 2015 September | 5 | 7 | 12 |
| 2015 August | 13 | 5 | 18 |
| 2015 July | 7 | 3 | 10 |
| 2015 April | 0 | 1 | 1 |
| 2015 February | 1 | 0 | 1 |
| 2014 August | 3 | 0 | 3 |
| 2014 June | 5 | 0 | 5 |
| 2014 May | 1 | 1 | 2 |
| 2014 April | 0 | 1 | 1 |
| 2013 September | 0 | 1 | 1 |
Show all
