The Role of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review With Quantitative Synthesis
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Rotator cuff tears are a common cause of shoulder pain, and it has been estimated that greater than 75,000 rotator cuff repairs are performed annually in the United States. Over the last 2 decades, the surgical treatment of rotator cuff tears has evolved from open repair with transosseous sutures to, more recently, all-arthroscopic techniques including single-row, double-row, and transosseous-equivalent suture anchor constructs. Despite variations in technique, the emphasis over this period has largely been on biomechanical principles and optimizing the strength of the repair. Gerber have proposed that an ideal rotator cuff tear would have high initial fixation strength, permit minimal gap formation, and sustain mechanical stability until healing has occurred. Additional work has been focused on the utilization of stronger sutures, knot-tying techniques, and recreation of the footprint through double-row repairs. A recent meta-analysis by Dehaan showed a strong trend (P .057) toward higher failure rates in patients undergoing single-row compared with double- row rotator cuff repair, which is consistent with the superiority of double-row repairs that has been observed in biomechanical studies. However, even in patients undergoing double-row repairs, the pooled retear rate (partial and complete) has been estimated to be 27.3%, which suggests that the intrinsic potential of the rotator cuff to heal back to the rotator cuff footprint after repair remains a valid concern.
Despite improvements in pain and function after rotator cuff repair, tendon failure has been historically reported to be 11% to 95% at 2-year follow-up. Other than the biomechanical causes highlighted earlier, additional factors associated with retear after rotator cuff repair include patient-related factors (e.g., increasing patient age, tear size, tissue quality, systemic disease, and smoking), extrinsic factors (e.g., overaggressive postoperative rehabilitation), and biological factors (e.g., failure to restore normal histology at the repair site). Although improved biomechanics may modestly improve healing, it appears that biological augmentation of the healing process needs to be investigated to further reduce failure rates by improving tendon-to-bone integration. Biological strategies that are currently under investigation include the use of growth factors and cytokines, gene therapy, tendon augmentation grafts/scaffolds, and tissue engineering with mesenchymal stem cells.
The use of platelet-rich plasma (PRP) or platelet- rich fibrin matrix as a biological solution to improve rotator cuff tendon healing has gained popularity over the last several years. PRP, most simply defined as a sample of autologous blood with concentrations of platelets above baseline values, can be applied by either direct injection or physical application of a PRP matrix scaffold to repaired tissues. After an initial release of growth factors from alpha granules, administered platelets will go on to synthesize and secrete additional factors for 7 to 10 days, which coincides with the inflammatory and repair phases of tendon healing. Although there is variability among different commercially available products, the main growth factors in PRP are transforming growth factor 1, platelet-derived growth factor, vascular endothelial growth factor, hepatocyte growth factor, and insulin-like growth factor 1. These autologous growth factors may play a role in regeneration of tendon tissue through increased tendon cell proliferation, collagen synthesis, and vascularization. At present, there are ample basic science and animal data that have shown the positive effect of PRP on tendon collagen deposition and tendon vascularization.
Despite the strong theoretic basis and interest in using PRP to improve the potential for rotator cuff healing, there remains ongoing controversy regarding the clinical efficacy of PRP. To our knowledge, there is no systematic review published in the literature that has addressed this controversy. The objective of this systematic review was to identify and summarize the available evidence to determine the efficacy of arthroscopic rotator cuff repair in patients with full- thickness rotator cuff tears who were concomitantly treated with PRP. We hypothesized that there would be no difference in retear rates or functional outcomes among patients who did receive administration of PRP during arthroscopic repair of full-thickness rotator cuff tears and those who did not.