Platelet-rich plasma therapy is all the rage for the treatment of such sports-related injuries as torn tendons, muscles and ligaments. The technique involves drawing blood from the patient and putting it into a centrifuge that spins off the red and white blood cells, leaving only the platelet-rich plasma. The plasma is turned into a putty or gel and re-injected into the patient around the surgical site at the end of the procedure, while still in the OR. As a pre-surgical treatment for injuries, the plasma doesn't need to be turned into a putty; it's injected directly back into the site of the injury. In both applications, the theory behind the treatment is that the concentrated platelets will stimulate an inflammatory response that can enhance and speed the healing process.

Not new, but newly popular
PRP isn't exactly new, just newly popular. Doctors have used PRP therapy since the mid-1990s to aid bone healing after spinal injury and soft tissue recovery following plastic surgery. It's only been very recently that the treatment has caught on for sports injuries. For that you can thank such high-profile athletes as Tiger Woods, who returned to competition sooner than expected after famously receiving PRP therapy while rehabbing his knee.

The question is, does it work? "The theory behind it is encouraging," says C. David Geier Jr., MD, director of sports medicine at the Medical University of South Carolina in Charleston, but for now it's still too early to say whether PRP therapy really achieves the healing benefits it's supposed to. "There have been some case studies showing great results, but no randomized controlled studies." Despite the questions surrounding its efficacy, Dr. Geier says there's no indication that the therapy is detrimental to patients. What is clear is that "more and more physicians are wanting to use it" as more patients hear about their favorite athletes getting the treatment and request it for themselves.

If physicians come to you asking to do platelet-rich plasma injections unrelated to a surgical procedure at your facility, tell them to do it in their offices. "The reimbursement's not adequate" to justify doing just the injection at a surgical facility, says Greg DeConciliis, PA-C, CASC, administrator of Boston Out-Patient Surgical Suites in Waltham, Mass. Doing the PRP injection in tandem with a surgical procedure to enhance recovery, however, can be worthwhile. Start to finish, the procedure will add about 10 minutes to the end of the case. While it's relatively simple, make sure your nurses are well-trained in phlebotomy, and have the vendor come in and train them on how to use the centrifuge.

Several of the large orthopedic equipment manufacturers sell the centrifuges and disposables to do PRP therapy. You shouldn't have to pay for the centrifuge: You can either work out an agreement with the vendor to acquire the equipment for free as long as you buy all the disposables from that company, or have the vendor bring the centrifuge in on the days you're going to do PRP. Your biggest costs will be the disposables, with the syringe and kits starting at about $200, says Mr. DeConciliis. The best way to get paid for the procedure is to bill for the joint injection and have the patient cover the cost of the disposables out of pocket. Janis Snyder, RN, clinical manager of the Adult and Children's Surgery Center of Southwest Florida, says it's like anything else: The more PRP injections you do, the more worthwhile an investment it is for your facility.

Anatomic ACL reconstruction
The big difference between traditional ACL reconstruction and the anatomic approach has to do with the location of the femoral tunnel. With the anatomic approach, the femoral tunnel is positioned much lower on the femur, resulting in a more horizontally positioned graft. This lower position has largely been achieved by drilling through an extra skin incision called the accessory medial portal. "The accessory medial portal frees up the surgeon to place the femoral socket in a more anatomic location, instead of being constrained by drilling through the tibial tunnel," says orthopedic surgeon Matthew Lavery, MD, of OrthoIndy and Indiana Orthopaedic Hospital in Indianapolis. By localizing the native origin of the ACL on the femur with more accuracy, the accessory medial portal may help surgeons improve upon and decrease the failure rate of single-bundle ACL reconstructions, a procedure that already has a good track record in terms of patient outcomes, says Dr. Lavery.

Don't confuse the term "anatomic approach" with the "anatomic double-bundle" technique. The latter is a much more involved procedure than traditional single-bundle ACL reconstruction and requires new equipment, twice as many implants and significant additional surgical time (as much as double the procedure time for single bundle). The added cost and surgical time have largely limited double-bundle reconstructions to academic settings, says Dr. Lavery. However, he says, "a lot of the concepts from double-bundle ACL reconstruction have carried over to the single-bundle technique," resulting in more anatomically positioned grafts without the added labor and costs associated with the double-bundle technique.

While the double-bundle technique hasn't gone mainstream, surgeons are slowly modifying their single-bundle procedures for a more anatomic approach rather than completely changing their techniques. Dr. Geier agrees that "A lot of people are trying to figure out ways to drill the tunnel in a better position using existing equipment." Still, if your surgeons are adopting the anatomic approach, they are most likely going to need some new equipment to assist with the new technique. "You have to have special devices," such as a flexible reamer and different fixation devices to work within shorter tunnels, says Mr. DeConciliis. You may also have to purchase over-the-top guides for the accessory medial portal, which are slightly different from the traditional trans-tibial guides. "It's a guide that allows you to place a pin, and it's not a huge capital outlay," explains Dr. Lavery, who says reps are often "willing to bring them in on a loaner basis."

Manufacturers have clearly caught on to the anatomic ACL trend and are offering new systems, complete with specialized guides and reamers (see "What's New in Orthopedic Surgery," May 2010). You'll have to work with your surgeons and vendors to come up with a formula, whether it's using a mix of old and new equipment or starting from scratch with a brand new system, that works best for your facility. "Use the vendors to the best of your ability," says Mr. DeConciliis. "Make sure they come and in-service your employees. Share your reimbursement methodology with them, let them know if you're not being reimbursed for high-cost supplies and see if they'll work with you to reduce costs." Finally, be aware that the single-bundle anatomic technique, while not as lengthy as the double bundle, can add 5 to 15 minutes (or more) to a case, depending on the surgeon's proficiency and experience with the anatomic approach.