Dr. Patrick Denard explains three orthobiologic treatments for shoulders. PRP, made from your own blood and costing around $500, helps partial rotator-cuff tears and mild arthritis. BMAC from hip bone may aid surgery healing. True stem-cell treatments lack evidence, cost $20-25k, and should be avoided.
Hi, I'm Dr. Patrick Denard. I'm a shoulder specialist at the Oregon Shoulder Institute where I do 100% shoulder in my practice. And I want to talk about platelet-rich plasma, BMAC, and stem cells because these are things that are often used to treat shoulder conditions and unfortunately often, uh, over-advertised or used in an inappropriate manner. So let's talk about PRP first. So PRP is platelet-rich plasma. What you do here is you take blood off of your own body. You usually take about 15 millimeters or 3 tablespoons of blood. You spin it in a centrifuge, which, which concentrates the cells and separates layers. And by doing so, you can take off the platelet-rich plasma rich area. This area is really important because it has growth factors in it. And one of the appealing aspects here is that you have growth factors and it's your own body, your own cells. And platelet-rich plasma is very effective for treating shoulder pain. And I use this really in two places. Number one is with rotator cuff tears. For conservative treatment, it can be beneficial to do this in people who have partial tears, especially low-grade partial tears and those associated with pain. There's data showing that platelet-rich plasma is as effective or more effective than steroid. One of the differences compared to steroid injections is that with platelet-rich plasma, it is a slower onset. You essentially have an anti-inflammatory type of effect. That process will help over time. And when you look at 6 to 12 months later, you'll typically see that people do better than with a steroid injection. But one of the consequences is that it doesn't occur as quickly. The second place in rotator cuff tears that platelet-rich plasma has a, an effect or impact that's proven is with rotator cuff healing. Now, this is done at the time of repair. I do not want to imply that platelet-rich plasma injections will heal your rotator cuff. That is not the case. However, if you do a rotator cuff repair, an arthroscopic rotator cuff repair, in my hands, I look in the shoulder with a camera, I repair the tendon down to the bone, and I place platelet-rich plasma at the tendon bone interface at the time of the repair. Data shows that this improves healing after a rotator cuff repair, and that's shown in large systematic reviews. The next large category or place where platelet-rich plasma is utilized is arthritis. Now there's not as much data for shoulder arthritis, but there's data looking at knee arthritis, and those studies have found that platelet-rich plasma is as effective or more effective than alternatives such as hyaluronic acid. Hyaluronic acid are essentially like Synvisc. These, uh, the idea here is to inject normal anti-inflammatory properties that are normally in the joint. Platelet-rich plasma is an alternative to that, again with an anti-inflammatory effect. This does not regenerate cartilage, but what I will see in my practice is success that is by marked by reduction in pain with the use of PRP, especially in people with more mild to moderate arthritis at the most. If somebody has severe arthritis, that is their bone-on-bone arthritis, PRP is not recommended in my view. That's going to be a waste of somebody's money, which gets into the cost. So currently at this time, PRP is not approved by most insurances, which means it's an out-of-pocket expense. Now what we do in my clinic is we try to offer that in a manner that is cost-effective. Uh, essentially that costs a little over $500 for an injection. And we do that because we're trying to pass on the opportunity to patients to have this treatment. Um, the companies that serve, uh, supply platelet-rich plasma syringes and materials, they will charge a few hundred dollars for that. And what we will see as a consequence is facilities will say, we're gonna mark this up and charge thousands of dollars for PRP. And to me, that is an outrageous, uh, thing. So, We try to make this very affordable for patients, but it's typically a cash pay item. Somebody can use an HSA or FSA, uh, spending account to do so, but they have to pay out of pocket. In other words, it's not covered by insurance. What does the process look like? Again, I said you draw PRP off the blood, you take a few tablespoons on sterile conditions, meaning done cleanly. You spin it in a centrifuge for about 15 minutes, and then my preference is to do the injection under ultrasound guidance, meaning I look with an ultrasound device so I can tell exactly where I'm going to put the injection. And we put that injection either above the rotator cuff in the setting of rotator cuff problems, or into the ball and socket joint in the setting of arthritis. Now, the last thing I'd want to do is have somebody pay a lot of money for PRP and then have it not put in the right place. So ultrasound guidance, in my view, is very, very important when somebody is doing injections. So the next thing to talk about is stem cells or BMAC. So there's kind of two categories here. One is BMAC, where you take blood off of the hip bone and and you do essentially the same process as platelet-rich plasma. So you spin down the cells, you get the growth factor-rich area. But the idea here is because the hip bone is where the stem cells are in adults, you get cells that may have greater potentiating effect. So that's the first broad category. My use of that is primarily at the time of rotator cuff repair. There's data showing that that can improve rotator cuff healing when you do that at the time of the repair. It kind of makes sense that it's sort of a supercharge charge PRP in a way because again, you have more pluripotent cells, that is cells that have more potential to create an impact on the body. Unfortunately, that costs because again, the companies that supply instrumentation for this charge even more for that. It's a more expensive process. So typically that's gonna take a couple thousand dollars. I don't typically do that in clinic for people. We do that in some occasions, but generally speaking, we limit that to, uh, the surgery time because it's just much easier to do that when somebody is undergoing a general anesthesia. I don't want to imply that BMAC is going to regenerate cartilage by any means or heal a rotator cuff. Again, the data does not show that. The other category is true stem cells where you get stem cells either from a source in your own body or an external source like embryonic stem cells. Those are concentrated, perhaps even grown up and then injected back in. And this is widely variable. This can vary from somebody being charged thousands and thousands of dollars in another country to go and do this. Now, while this is a appealing from the standpoint of, oh, could I regenerate something? The reality is, as of this time, we cannot yet direct cells. So yes, you can take cells that have the potential to go onto different tissue, but it's a shotgun approach. In other words, you're putting a concentration of cells in there and you're not giving them direction in how to go. And so we are not at the point where we can have stem cells regenerate cartilage or regenerate rotator cuff. So my advice as a conservative treatment is to avoid stem cells. There's also a lot of regulatory hurdles around this, and some of the places that are doing this unfortunately are playing into the psychology of people and the desire to really get better without surgery. But before I spent thousands of dollars on something like that, sometimes in the upwards of $20,000, $25,000, I would be very, very careful about the use of stem cells.
