EQUINE PRF IN SPORTS MEDICINE
When managing sports horses, orthopedic injuries are one of the top problems. The most frequent equine sports-related issues are tendon or ligament injuries, synovitis, and joint arthritis or arthrosis2–5.
Traditional therapies are typically mid- or short-acting steroids, hyaluronic acid, or PSGAG, in combination or as single drugs. These drugs are merely managing the symptoms by reducing inflammation and pain, and do not aim to cure or reverse the injuries caused by the ongoing degenerative disease.
The latest regenerative therapy to be introduced in equine sports medicine is the platelet-rich fibrin (PRF) and particularly the concentrated PRF (C-PRF) derivative.
WHY EQUINE PRF IS THE NATURAL CHOICE
IN EQUINE SPORTS MEDICINE
Autologous Blood Concentrate
Simplicity and ease of use
One huge advantage of Equine PRF is the easy and quick processing of the final product, making it broadly available to even smaller clinics. Based on the simple setup of a centrifuge and proprietary but fairly standardized vacuum tubes, the treatments are extremely economical.
Safe to use
It is also safe since it´s autologous and without additives. The content of leucocytes furthermore adds to the product’s safety, which is of the greatest importance, since iatrogenic infections after joint injections can be a life-threatening condition in horses.
The complete team of regenerative cells
It is also safe since it´s autologous and without additives. The content of leucocytes furthermore adds to the product’s safety, which is of the greatest importance, since iatrogenic infections after joint injections can be a life-threatening condition in horses. In the Equine PRF, the entire group of white blood cells is included.
A large part of the growth factors and the majority of the long-term effects of treatment lies specifically in the inclusion and interactions of the white blood cells 11. The white blood cells further contribute to a shortening of the inflammatory phase, jumpstarting the proliferative, and thus the regenerative phase at an earlier time. It is also in this proliferative phase, the formation of new blood vessels (angiogenesis) is contributing to increased and better vascularization of the area. In Equine PRF, the white blood cells, platelets, and various cytokines are all included in a carefully selected fraction, both retained in and stimulated by the fibrin, thereby allowing for the full regenerative potential to be utilized.
A large part of the growth factors and the majority of the long-term effects of treatment lies specifically in the inclusion and interactions of the white blood cells 11. The white blood cells further contribute to a shortening of the inflammatory phase, jumpstarting the proliferative, and thus the regenerative phase at an earlier time.
It is also in this proliferative phase, the formation of new blood vessels (angiogenesis) is contributing to increased and better vascularization of the area. In Equine PRF, the white blood cells, platelets, and various cytokines are all included in a carefully selected fraction, both retained in and stimulated by the fibrin, thereby allowing for the full regenerative potential to be utilized.
Promoting M2-like Macrophage Polarizing
Modulate Macrophage phenotype
PRF is able to modulate the polarization of tissue-residing macrophages17–22 and initiate a shift from the destructive M1-like phenotype towards the regenerative M2-like phenotype16,23.
Intrinsic growth factors
The activated platelets, leukocytes, and fibrin matrix in PRF release an elevated amount of growth factors and cytokines, simulating a larger trauma at the site of injection or on lay6–12. In particular, the growth factors PDGF, VEGF, TGF-β, and IGF-1 are important in regeneration and wound healing13,14.
Modulation of inflammation
The release of the growth factors native to the platelets and leucocytes of PRF play a direct role in the modulation of both acute and chronic inflammation, especially by the modulation of tissue-residing activated macrophage polarization 15,16
Stimulate an acute response
The capacity to modulate inflammation, influence macrophage polarization, and stimulate an acute response leading to accelerated healing and regeneration, puts PRF in a unique position as an autologous biological agent for the treatment of chronic inflammation, pain, and damages in joints and tendons, arising from injuries, arthrosis or arthritis.
Interacts on Inflammation
and the Sensory Pathways of Pain
Pain in joints, tendons, ligaments, and muscles, often arise from inflammation affecting the somatosensory nervous system27.
Upon injury, several cell types, including neurons and tissue-residing macrophages, produce soluble pro-inflammatory cytokines, and chemokines that activate surrounding cells8,28–31 and recruit circulating leukocytes, including macrophages, to the site of injury32–34.
Macrophages play a central role
Macrophages have especially significant functions in regulating inflammation and are considered to be common peripheral regulators of neuropathic pain30,34,35. Through the release of inflammatory mediators and interactions with neurotransmitters and receptors, the immune cells form an integrated network with the somatosensory system, coordinating the immune response, tissue healing and modulates the sensory pathways of pain32.
Showing Promising Results
in Cartilage Regeneration,
Meniscus and Tendon Repair
Cartilage and tendons are two of the most avascular and low cell density tissues found in animals, and thus have a very limited potential for repair and regeneration. Left untreated, defects often do not heal at all and stay in a chronic inflammatory state.
The capacity to modulate inflammation, influence macrophage polarization, and stimulate an acute response leading to accelerated healing and regeneration, puts PRF in a unique position as an autologous biological agent for the treatment of inflammation, pain, and damages in joints and tendons, arising from injuries, arthrosis or arthritis.
The introduction of the additive-free liquid PRF, which forms a fibrin clot upon injection, has been a proposed method for the regeneration of cartilage 24,40 and for accelerating the healing of tendons 26.
Drop-by-Drop release – Combination of White Cells, Platelets
and Fibrin ensures a timely release of growth factors
In PRF, the delivery of cytokines and growth factors is done at a rate that is biologically relevant and responding to the needs of the environment17–23. The function of fibrin has in this sense been compared to an irrigation system, where you do not want to drown the plants with large amounts of water in a single shot, but aim at delivering a biologically suitable amount of water and nutrients in a slow and adapted manner.
PDGF, VEGF, TGF-β EGF, fFGF, IGF-1, TGF-α, PAF, thrombospondin, platelet thromboplastin, coagulation factors, serotonin, histamine, hydrolytic enzymes and endostatin
Platelet-Derived Growth Factors
PDGFs (Platelet-Derived Growth Factors) are a family of essential and potent growth factors and chemotactic agents with an important role in wound healing36,37.
Recombinant PDGF is furthermore used in medicine to help heal chronic ulcers and in orthopedic surgery and periodontics as an alternative to bone autograft to stimulate bone regeneration and repair.
Vascular Endothelial Growth Factor
PDGF and VEGF (Vascular Endothelial Growth Factor) work together to establish and increase the blood supply of worn down and ischemic tissue, by promoting the formation of new blood vessels (angiogenesis) .
Transforming Growth Factor Beta
TGF-β (Transforming Growth Factor Beta) is a multi-functional factor important for, amongst other things, the regulation of the inflammatory response. It controls many things, from cell division, differentiation, and controlled cell death of many different cell types along with IGF-1  , to the stimulation of fibroblast production of hyaluronic acid (HA)  and collagen .
Next Generation PRF Solution
Equine PRF offers you the next level in blood-derived regenerative medicine. We are offering you solutions with significantly increased cell content and cell distribution as well as a wast extension of PRF resorption time all based on state-of-the-art research and technology.
Concentrated PRF (C-PRF) the new benchmark
As we have gained insight into how cells distribute across a fibrin clot, a new protocol was formulated to increase the number of leukocytes and Platelets 10 fold from the standard injectable PRF protocols. The C-PRF protocol sets a new benchmark in what to expect from a liquid PRF product and forms the foundation of exciting new products like bio-graft, bio-bone, and bio-filler.
PRF membranes for wound healing
The insight gained from using the novel method for evaluating and quantifying cell types in platelet-rich fibrin has led to a fibrin clot with 4 times higher concentration of cells compared to standard fixed-angle centrifugation systems and protocols. This allow for more potent wound healing using PRF membranes.
Denaturation, extending the resorption properties
One of the main limitations of PRF has been it’s short in vivo turnover rate. However, by combining knowledge about how the heating of platelet-poor plasma (PPP) denature and reorganize albumin, with the C-PRF protocol, our research team created the heating technology setup that vastly widens the potential of PRF in regenerative medicine by extending resorption properties for up to 4–6 months.
Equine PRF Protocols
and Future Perspectives
– a highly concentrated form of injectable PRF(10x), allowing even larger amounts of regenerative cells to be injected into joints and tendons.
– autologous fibrin membranes encapsulating vast amounts of regenerative cells, slowly releasing pro-angiogenic cytokines to accelerate the healing of even problematic leg ulcers.
– utilizing a denaturation process to create an autologous carrier of concentrated regenerative cells – extend the resorption properties of PRF from 2-3 weeks to 3-6 months
PRF Cornea membrane
– Adding an autologous cellular matrix for ophthalmic surgery combining a reservoir of regenerative cells with suturable properties.
– Combination enabling the production of PRF membranes of various sizes. These membranes are flexible and can be sutured offering new perspectives in wound healing and e.g. Gastrogastrointestinal surgery.
– a slowly resorbable platelet-rich fibrin filler loaded with regenerative cells offering an interesting new perspective in Equine Sports Medicine and beyond, as a carrier of medicine or for filling cavities or prolonging the effect of joint injections.
See Research Papers & Literature
To get an overview of the ongoing research in PRF please follow this link and see published and articles in progress.
- Equine Business association. The Equine Industry: A Global Perspective. 5–10 (2018). Available at: https://www.equinebusinessassociation.com/equine-industry-statistics/.
- Dyson, P. K., Jackson, B. F., Pfeiffer, D. U. & Price, J. S. Days lost from training by two- and three-year-old Thoroughbred horses: A survey of seven UK training yards. Equine Vet. J. 40, 650–657 (2008).
- Egenvall, A. et al. Days-lost to training and competition in relation to workload in 263 elite show-jumping horses in four European countries. Prev. Vet. Med. 112, 387–400 (2013).
- Sloet Van Oldruitenborgh-Oosterbaan, M. M., Genzel, W. & van Weeren, P. R. A pilot study on factors influencing the career of Dutch sport horses. Equine Vet. J. 42, 28–32 (2010).
- Murray, R. C., Dyson, S. J., Tranquille, C. & Adams, V. Association of type of sport and performance level with anatomical site of orthopaedic injury diagnosis. Equine Vet. J. 38, 411–416 (2006).
- Nasirzade, J., Kargarpour, Z., Hasannia, S., Strauss, F. J. & Gruber, R. Platelet-rich fibrin elicits an anti-inflammatory response in macrophages in vitro. J. Periodontol. 91, 244–252 (2019).
- Zhang, J. et al. Anti‐inflammation effects of injectable platelet‐rich fibrin via macrophages and dendritic cells. J. Biomed. Mater. Res. Part A 108, 61–68 (2020).
- Arango Duque, G. & Descoteaux, A. Macrophage cytokines: involvement in immunity and infectious diseases. Front. Immunol. 5, 491 (2014).
- Opal, S. M. & DePalo, V. A. Anti-Inflammatory Cytokines. Chest 117, 1162–1172 (1999).
- Vogel, D. Y. S. S. et al. Human macrophage polarization in vitro: maturation and activation methods compared. Immunobiology 219, 695–703 (2014).
- Zhang, F. et al. TGF-β induces M2-like macrophage polarization via SNAILmediated suppression of a pro-inflammatory phenotype. Oncotarget 7, 52294–52306 (2016).
- Murray, P. J. et al. Macrophage Activation and Polarization: Nomenclature and Experimental Guidelines. Immunity 41, 14–20 (2014).
- Parisi, L. et al. Macrophage Polarization in Chronic Inflammatory Diseases: Killers or Builders? J. Immunol. Res. 2018, 1–25 (2018).
- Abd El Raouf, M. et al. Injectable-platelet rich fibrin using the low speed centrifugation concept improves cartilage regeneration when compared to platelet-rich plasma. Platelets 30, 213–221 (2017).
- Wong, C.-C. et al. Platelet-Rich Fibrin Facilitates Rabbit Meniscal Repair by Promoting Meniscocytes Proliferation, Migration, and Extracellular Matrix Synthesis. Int. J. Mol. Sci. 18, 1722 (2017).
- Sánchez, M. et al. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am. J. Sports Med. 35, 245–251 (2007).
- Choukroun, J. & Ghanaati, S. Reduction of relative centrifugation force within injectable platelet-rich-fibrin (PRF) concentrates advances patients’ own inflammatory cells, platelets and growth factors: the first introduction to the low speed centrifugation concept. Eur. J. Trauma Emerg. Surg. 1–9 (2017). doi:10.1007/s00068-017-0767-9
- Kobayashi, E. et al. Comparative release of growth factors from PRP, PRF, and advanced-PRF. Clin. Oral Investig. 20, 2353–2360 (2016).
- Fujioka-Kobayashi, M. et al. Optimized Platelet-Rich Fibrin With the Low-Speed Concept: Growth Factor Release, Biocompatibility, and Cellular Response. J. Periodontol. 88, 112–121 (2017).
- El Bagdadi, K. et al. Reduction of relative centrifugal forces increases growth factor release within solid platelet-rich-fibrin (PRF)-based matrices: a proof of concept of LSCC (low speed centrifugation concept). Eur. J. Trauma Emerg. Surg. 1–13 (2017). doi:10.1007/s00068-017-0785-7
- Dohan Ehrenfest, D. M. et al. The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors, and fibrin architecture of a leukocyte- and platelet-rich fibrin (L-PRF) clot and membrane. Platelets 29, 171–184 (2018).
- Dohan Ehrenfest, D. M., de Peppo, G. M., Doglioli, P. & Sammartino, G. Slow release of growth factors and thrombospondin-1 in Choukroun’s platelet-rich fibrin (PRF): a gold standard to achieve for all surgical platelet concentrates technologies. Growth Factors 27, 63–9 (2009).
- Dohan Ehrenfest, D. M., Del Corso, M., Diss, A., Mouhyi, J. & Charrier, J. Three-dimensional architecture and cell composition of a Choukroun’s platelet-rich fibrin clot and membrane. J. Periodontol. 81, 546–55 (2010).
- Hom, D. B. New Developments in Wound Healing Relevant to Facial Plastic Surgery. Arch. Facial Plast. Surg. 10, 402–406 (2008).
- Sclafani, A. P. Applications of platelet-rich fibrin matrix in facial plastic surgery. Facial Plast. Surg. 25, 270–6 (2009).
- Martinez, F. O., Helming, L. & Gordon, S. Alternative Activation of Macrophages: An Immunologic Functional Perspective. Annu. Rev. Immunol. 27, 451–483 (2009).
- Wang, T. & He, C. Pro-inflammatory cytokines: The link between obesity and osteoarthritis. Cytokine Growth Factor Rev. 44, 38–50 (2018).
- Kiguchi, N., Maeda, T., Kobayashi, Y., Fukazawa, Y. & Kishioka, S. Macrophage inflammatory protein-1α mediates the development of neuropathic pain following peripheral nerve injury through interleukin-1β up-regulation. Pain 149, 305–315 (2010).
- Mueller, M. et al. Rapid response of identified resident endoneurial macrophages to nerve injury. Am. J. Pathol. 159, 2187–2197 (2001).
- Thacker, M. A., Clark, A. K., Marchand, F. & McMahon, S. B. Pathophysiology of peripheral neuropathic pain: Immune cells
- Zhang, F. F. et al. Perineural expression of high-mobility group box-1 contributes to long-lasting mechanical hypersensitivity via matrix metalloprotease-9 up-regulation in mice with painful peripheral neuropathy. J. Neurochem. 136, 837–850 (2016).
- Ren, K. & Dubner, R. Interactions between the immune and nervous systems in pain. Nature Medicine 16, 1267–1276 (2010).
- Scholz, J. & Woolf, C. J. The neuropathic pain triad: Neurons, immune cells and glia. Nature Neuroscience 10, 1361–1368 (2007)
- Kiguchi, N., Kobayashi, Y. & Kishioka, S. Chemokines and cytokines in neuroinflammation leading to neuropathic pain. Current Opinion in Pharmacology 12, 55–61 (2012)
- Ristoiu, V. Contribution of macrophages to peripheral neuropathic pain pathogenesis. Life Sciences 93, 870–881 (2013).
- Miron, R. J. et al. Platelet-Rich Fibrin and Soft Tissue Wound Healing: A Systematic Review. Tissue Eng. Part B. Rev. 23, 83–99 (2017).
- Ng, F. et al. PDGF, TGF-beta, and FGF signaling is important for differentiation and growth of mesenchymal stem cells (MSCs): transcriptional profiling can identify markers and signaling pathways important in the differentiation of MSCs into adipogenic, chondrogenic, and o. Blood 112, 295–307 (2008).
- Sclafani, A. P. & McCormick, S. A. Induction of dermal collagenesis, angiogenesis, and adipogenesis in human skin by injection of platelet-rich fibrin matrix. Arch. Facial Plast. Surg. 14, 132–6 (2012).
- Kakudo, N. et al. Proliferation-promoting effect of platelet-rich plasma on human adipose-derived stem cells and human dermal fibroblasts. Plast. Reconstr. Surg. 122, 1352–60 (2008).
- Kazemi, D., Fakhrjou, A., Mirzazadeh Dizaji, V. & Khanzadeh Alishahi, M. Effect of Autologous Platelet Rich Fibrin on the Healing of Experimental Articular Cartilage Defects of the Knee in an Animal Model. Biomed Res. Int. 2014, 1–10 (2014).