The clinical results of ACL reconstruction and time to return to sports could be improved if the graft healing process is enhanced. In a classic publication on this topic in 1982, Arnoczky and Tarvin1 described the behavior of the graft used in ACL reconstruction in dogs, describing 3 stages in the process of graft metaplasia: incorporation, neoligament formation, and remodeling.2,3

Various authors have tried to study the behavior of the graft in clinical trials, with histology or imaging studies, which experienced a significant boost with the appearance of magnetic resonance imaging (MRI).4-10

In 1995, in a prospective clinical study that relied on second-look arthroscopy to perform a histologic and MRI assessment of the graft at 6, 9, and 12 months of postoperative evolution,11 we described how the patellar tendon graft used in human ACL reconstruction is incorporated. We concluded that the graft maturation takes a long time: 12 months to achieve histology similar to a normal ACL. At 12 months, the MRI study of the graft was homogeneous and hyperintense, without swelling in the bone tunnels. The correlation of the histology with MRI was of great help in establishing a reliable imaging pattern, which allowed us to noninvasively verify the graft healing process.

Weiler et al.12 report correlations between biomechanical properties and vascularity of an ACL graft and MRI in a sheep model.

Clinical applications of autologous platelet-rich plasma gel (PRPG) include maxillofacial surgery, treatment of bone fractures, and tendon repair, reporting excellent outcomes.13-16 Platelets contain different growth factors that facilitate healing. PRPG is a fraction of plasma volume with a platelet concentration above baseline (whole blood). Platelet concentrates contain an enormous amount of activated plateletderived growth factors (PDGFs).17-23

Platelets contain PDGFs, transforming growth factors (TGFs), insulin-like growth factors, epidermal growth factors, vascular endothelial growth factors, and fibroblast growth factors. These factors are involved in the majority of biological remodeling processes in the body. In the specific case of ACL graft, PDGFs, fibroblast growth factor 1, and the various types of TGF-
are responsible for accelerating the healing process, as well as increasing the tensile strength of the graft.24-30

Only 2 articles have shown an enhancing effect of treatment with PRPG on the tendon or ligament in humans. In a human study Orrego et al.31 showed an enhancing effect over the graft maturation process as evaluated by MRI signal intensity, without showing a significant effect on the osteoligamentous interface or tunnel widening evolution. In human tenocyte cultures, de Mos et al.32 showed that PRPG stimulates cell proliferation and collagen production.

Currently, it is practically impossible to perform human clinical trials of biomechanical or histologic assessments of the graft’s behavior in ACL reconstruction. For this reason, we decided to practice an indirect and noninvasive assessment in our patients, using MRI. The purpose of our investigation was to study MRI findings in the ACL graft when PRPG was added during surgery, thus allowing future studies correlating MRI findings with histology and ultimate load and strength. We hypothesized that PRPG has a positive effect on cell proliferation and collagen production in the human tendon and plays a key role in the remodeling and repair processes of the graft used in ACL reconstruction.

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Few hospitals in Europe routinely use autologous platelet gel application techniques as part of a peri-operative blood management program. In the United States, an increasing number of clinicians tend to employ platelet gel applications in various surgical settings, for both in, and out of hospital surgery. The question why this novel and promising technique for the delivery of autologous growth factors has not yet been adopted on a broader scale need to be addressed. The main reason may be the lack of convincing scientific data that provides information whether or not the use of platelet rich plasma (PRP) and platelet gels (PG) are appropriate in the clinical setting. At the Catharina Hospital in Eindhoven The Netherlands, we started to utilize PG techniques in 2001 with a small group of patients undergoing complicated cardiac surgical procedures and in patients undergoing a spinal fusion operation. This was carried out as an adjunct to the already existing perioperative blood management programs with apparently impressive clinical results.

The Department of Peri-operative Blood Management of the Catharina Hospital performs close to 1600 blood management procedures annually, of which 60% are related to obtain whole blood platelets to produce PRP for the utilization of PG procedures. While it’s extended use is based upon positive clinical impressions and on clinical judgment, it still lacks a firm scientific basis. Therefore, clinical trials are required to answer questions on the efficacy, efficiency, and on the safety of PG applications under various surgical and medical conditions.

It is clear that a good understanding of the proper preparation and utilization of this specific blood management technique is mandatory for clinicians to adequately evaluate results of its use and to avoid inconsistent results. Conflicting data have been reported in clinical and experimental research on the efficacy of PG treatment1-5. To understand how this arises it is essential to be in possession of the details of the preparation of PRP and PG. Knowledge of the following factors are of particular importance: the method of drawing blood, the quality of the PRP used, platelet and growth factor counts, the PRP activation, whether autologous or donor PRP was used, and the overall methodology. With respect to these issues, the clinician should be aware that data may sometimes appear to be conflicting in the eventual outcome.

This review addresses a variety of aspects pertaining to the use of PG; these include background on platelet activity, the pivotal role of platelets in hemostasis, soft tissue healing and bone growth, the whole blood PRP production procedure, Platelet rich plasma and platelet gel. A review platelet activation with thrombin, and a description of the various actions of platelet derived growth factors. In addition, a discussion of the most recent clinical and experimental articles is presented with respect to these issues. Some safety issues including possible PG mitogenic effects are also addressed.

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Americans have collectively become the largest nation in the world in a very short time. On a BMI (body mass index) basis 60% of Americans are overweight. A significant increase in obesity among Americans under the age of 21 y/o has occurred and this is trending upwards. There are a number of very important issues that need to be discussed.

Why be thin? Well, the most obvious is that you look better and you probably will get more dates, more gifts and nicer gifts if you are thin. You probably will have lower blood pressure, less chance of getting diabetes and will live a lot longer. So, what are the facts? Americans with a BMI (you will be sick of this term pretty soon) of greater than 30 have a three fold increase in diabetes a four fold chance of having hypertension, a 7 year decrease in life expectancy etc. etc. Get the picture? It’s bad to be fat and it’s good to be thin. That actually is not totally true and that is why you need to keep reading.

We all know that it is healthier to be the “correct” weight. In this book we will explain what the correct weight is. We will teach you how to calculate that “correct” weight. We will teach you about how you gain and lose. Weight. We will teach you about lean body mass and water weight. We will teach you about real life, long term health and how to obtain it. And, we will explain dieting. There are hundreds of diet books on the market and thousands of diets. You, as a reader, have heard it all.” Diet’s don’t work”, “it’s a lifestyle change”, “take these pills and you don’t need to exercise” eat this and don’t eat that. The truth is, weight is modulated by a very complicated mechanism that is made up of central information(your brain), peripheral information(your stomach receptors), blood sugar responses, and many feedback systems controlling hunger , energy levels, mood and well being. It would be easy to just quit eating carbohydrates or just eat pickles for 6 years or eat grapefruit all day. We would all look like Cameron Diaz. Too bad, it doesn’t work that way. We can’t eat the same things every day and we can’t cut out major food groups forever. Everyone who bought this book (me included) have tried the Atkins low carb, eat lots of fat diet. This Atkins diet is a short term miracle. You eat low carb food, you eat steak and cheese, all you want and you lose weight. And the truth is you do lose weight. Short term. The first thing you lose is water weight. Quite simply, when you start to eat less you start to urinate out excess water. You don’t lose fat and you don’t increase lean body mass. Just like when you eat too much salt, you need to drink lots of water, when you don’t eat salt or much food one must discard all of that water. Early in every calorie reduction diet we lose water to match the sodium in our diet as well as the other nutrients that require dilution. After the initial water loss you start to lose caloric weight which can be muscle or fat.We want to lose fat and keep our lean body mass or muscle. After short term water weight loss, ther is real weight loss on the Atkins diet. It is very hard to maintain a diet that discards a whole food group, especially a food group you need. It is also difficult to acclimate to this diet basesd on such low carbs early on. You will be tired, cranky and have very little energy. Oh, back to me, I lost 30 pounds on this diet that you bought the book for. Many of my patients have lost weight on this diet and it is medically and scientifically sound. I have researched the makeup of diets, weight loss and gain, and the natural health of dieting. If you start a diet and you have to spill Ketones in your urine for it to be successful. And in medical school at the University of Miami(good football, cute girls) they taught me that spilling Ketones means you are sick and have to be admitted to the hospital, I don’t think this should be a component of your diet. We want to be healthier and thinner not admitted to a hospital. So, our journey begins.

Chapter 2

This chapter will dicuss lifestyle. Lifestyle is not something you hear about in diet books. Lifestyle is something you hear about from your doctor. For purposes of this chapter, I am your doctor. You kind of are, in luck. No co-pay, no waiting room, no nasty receptionist and the book doesn’t smell like your doctor’s office .(You know ‘that smell’)

Lifestyle means you need to cut down on your drinking. You don’t have to quit drinking unless you drink Jager-bombs. Alcohol is OK. You need to drink it in moderation. This either sounds like your doctor, mother or ex-girlfriend and unfortunately they were all correct. Have a glass of wine (preferably RED). Have a light beer (Corona). Drink some straight vodka (Grey Goose). How about a rum and coke. Great, with diet Coke. You get the idea. No crazy mixed drinks. My Dad always told me never to drink anything with an umbrella in it. He was so right. You need the best bang for your buck. High calorie drinks are off limits. You need to check the caloric content of what and how much you are going to drink BEFORE you get to the soiree. When you have had your 2 glasses of Patron straight up, you are done. This brings up caloric curfew. We will discuss this in detail a little later, but, 11pm. Last call for you is 11pm. It doesn’t matter what time you start only how much you drink and when you finish. So, to recap: stay within your allotted calories, know how many calories each drink is and limit the number. The lights go on at 11pm.

Caloric curfew. No carbohydrates after 6:30. The best concept is to eat relatively early and snack on protein. It’s 8:30 pm, time for a little snack, put down the chips and salsa. Go to your “diet” cupboard and take out the mixed nuts or a piece of cheese or even a few slices of salami. Same deal, know the calories and how much you can eat. Do not sit in front of American Idol with a bag of Doritos, or Mr. Redenbacher’s low fat popcorn. Carb curfew is in place. On this plan you will have many days that you will not be hungry late and not need a snack, SO DON’T EAT.

You have to sleep. Everyone is different and we can’t say all patients need 8 hours of sleep. If you are used to an average of 7 hours of sleep each night then do not vary. Weight loss is intricately involved with your biorhythm and alteration in sleep patterns makes weight loss difficult. Try and get to bed about the same time each night and wake about the same time each morning. Sounds simple. It’s Saturday night and there is a huge party at the Foxtrot club. Your college roommate is getting remarried and he wants you to come over a little early to get “loose”. Remember, you need to get to bed about the same time you are used to and limit your food and beverage. You will get used to these parameters fairly quickly. Know your drinks and don’t eat those little crackers with something on them that you have no idea what it is. Those crackers are BAD and they taste awful. The pink stuff in the middle is all fat and carbs. Do not go to the Foxtrot Club starving. Eat a little something before you go and drink a diet Mountain Dew on the way. If you get to bed a little it is OK, DO NOT stay out until 3:30 am. This will mess up your biorhythm and make it hard to stay on your quest.

Early in your plan try to avoid eating out at restaurants frequently. You will learn quickly what is reasonable and what is not. You will also learn approximate calorie amounts, but until then stay home. Calorie counters are very important. You can buy a little book at the check-out line at the grocery store. When you are in the line right above the magazines that explain how Paris Hilton got impregnated by a Martian there will be a little blue and white book. It will have a picture of a tape measure around a loaf of bread. That is the book. The other option is to go on-line. Google” FREE calorie counter”. Don’t sign up for anything; there are many sites with that special word ” free” in the title. You will become familiar with the caloric number, fat, carb and protein content of most of the foods you eat. Although, early on this will be cumbersome you will get used to it and then you will piss-off all of the people you work with when you start telling them that the Yo-Ho they are about to inhale has 650 calories and 64 grams of fat. You must be able to calculate the numbers. Try to stay away from situations that will pressure you to eat. Larry’s bachelor party, Superbowl pizza parties, all-you-can-eat- buffet’s, and worst of all your mother-in-law,s post Thanksgiving dinner desserts. Stay away. Once you have mastered caloric control, go ahead and give the pizza a ride, but early on, STAY HOME.

Weigh yourself everyday. Do not believe the story that you weigh once a week. Make yourself accountable every morning. Bad day, too many beers, get your punishment and look at the scale. You need a good reliable scale. It will cost about $25.00 . Get your money’s worth and get on it every day. Write down your weight every day.

Start a vitaman regimen and stick wth it. A once-a-day vitaman, one aspirin, Omega 3 supplements and a branch chain amino acid supplement. The supplements are important if your dietary habits are to change.

The Diet
This is a rotation diet. The diet works by faking out your body’s need to preserve energy. When you start a diet the first thing that happens is that you lose water weight. You think you are doing great because the first week you feel like a champ. You lose 3-4 pounds and you think “hey, this is easy”. Then a week later you are pissed off because you think “this is impossible, I will never lose this weight.” The truth is that weight loss is a journey, is a life long change, and is never easy. It is easy to lose some weight, it is easy to stay on a diet for a period of time and it is easy to start your diet in the morning, but to change forever is hard. The good news is once you have made the change and it becomes habit it goes back to easy.

Back to faking out your body. Your body loses weight early because you suddenly decrease your caloric intake. It is used to 2750 calories and you eat 2250 and wham, you lost some weight. But pretty soon your body is used to 2250 and you stop losing weight. So, wham I will just eat 2000. And , just like clockwork, you start to lose weight again. Well, you can see where this is going. You can’t go to 0 so you hit a plateau. And you tell your friends I haven’t lost weight in 3 weeks and I am doing everything the same. So, what is the answer?

The Rick Lehman Rotation Diet. I actually did invent this diet. It makes sense and it is biologically how your metabolism works. The Rick Lehman part has nothing to do with it. So, the little bit you have been waiting for.

Sixty percent of your calories need to be protein. 60% protein, 20% fat 20% carbs. I was going to type this twice. 60% protein 20%fat 20% carbs.

The next parameter is the all important calories. Monday 950 calories Tuesday 1650 calories Wednesday 1100 calories Thursday 1700 Friday 750 calories Saturday 1750 calories Sunday 1000 calories.

These numbers are not etched in stone. Look alive, this is important. If,or when you go over your allotted calories, the next day remains the same. If you go under your calories you may add them to the following day. For example: you eat 1450 calories on Wednesday you go right back to the plan, 1700 on Thursday.. If on Wednesday you eat 900 calories you can now eat 1900 calories on Thursday. This way you can plan for a big bash or a good old fashioned pig-out.

There is no magic. You have to eat less calories and you have to potentiate your metabolism. If you let your metabolism diminish you will not lose weight. You have to be on track most of the time. If you cheat, no worries, start right back up. Do not say ” I have blown it ” and quit. Do not quit. Do not be fat. Change your fat-ass life. You will feel better.

Remember the calories and live by them. Any diet that doesn’t break down your eating into the basics can’t work.
There are 2 things to know:

1. Know the calories
2. know your percentages.

Once you have met your ideal weight, you can then increase your caloric content by 100 calories per day. Remember you weigh yourself everyday. You count your calories everyday and you watch your percentages. When you get to steady state , the calories that stabilize your weight you can then alter your percentages. Initially, you start with 50% protein 25% fat and carbs. Then you can eventually go to 40% protein and 30% fat and carbs. When you get stabilized this is your intake forever. If you notice that you are slowly gaining weight decrease your intake by 200 calories per day. You get the picture.

So here we go. If you have questions please ask on the website. Personalized diets, recipes and can be obtained at the US Center for Sports Medicine.

THERE ARE NO SHORTCUTS KNOW YOUR CALORIES DO NOT BE DENIED

Have perserverance, and do not be distracted. It takes willpower and all those diets that are too good to be true are too good to be true. Fads , and medically unsound techniques always eventually fail. Weight control is for life.

WEIGHT CONTROL IS FOR LIFE WEIGHT CONTROL IS FOR LIFE WEIGHT CONTROL IS FOR LIFE

Platelet-rich plasma (PRP) is defined as a sample of autologous blood with concentrations of platelets above baseline values. Platelets play an instrumental role in the normal healing response via the local secretion of growth factors and recruitment of reparative cells1 (Table 1). As a means of growth factor delivery, PRP was first popularized in maxillofacial and plastic surgery in the 1990s.2 Its use in orthopaedics began early in this decade as PRP was used with bone grafts to augment spinal fusion and fracture healing. Although debate continues regarding the potential benefit of PRP to improve bone healing,3,4 a growing body of laboratory evidence supports the use of PRP injections for the treatment of muscle and tendon injuries and degeneration.5-15 Despite minimal clinical evidence, recent development of marketed devices to enable PRP preparation in the outpatient and surgical settings has led to an increased use in sports medicine in both Europe and North America.16

Platelet-rich plasma is defined as autologous blood with a concentration of platelets above baseline values. Platelet-rich plasma has been used in maxillofacial and plastic surgery since the 1990s; its use in sports medicine is growing given its potential to enhance muscle and tendon healing. In vitro studies suggest that growth factors released by platelets recruit reparative cells and may augment soft-tissue repair. Although minimal clinical evidenceis currently available, the use of platelet-rich plasma has increased, given its safety as well as the availability of new devices for outpatient preparation and delivery. Its use in surgery to augment rotator cuff and Achilles tendon repair has also been reported. As the marketing of platelet-rich plasma increases, orthopaedic surgeons must be informed regarding the available preparation devices and their differences. Many controlled clinical trials are under way, but clinical use should be approached cautiously until high-level clinical evidence supporting platelet-rich plasma efficacy is available.

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Dr. Lehman is currently on the Board of Directors of the Jackie Joyner-Kersee Youth Foundation, the medical director of Webster Surgery Center and the medical director of the U.S. Center for Sports Medicine. He is on the Board of Governors for the National Hockey League and is on the St. Louis Sports Commission. His practice encompasses taking care of professional athletes at all levels and all sports, as well as Division I college athletes.

I have heard so many people talk about PRP. Dr. Rick, what is PRP, what does it treat and is it safe?
— Calvin Drake, University City Mo.

Calvin, PRP stands for Platelet-Rich Plasma. To produce PRP, we take a small amount of your blood, place it in a centriguge and take out the plasma that contain platelets rich in growth factors that help wound healing, tissue remodeling and faster tissue growth.

In short, it allows injuries to heal faster and return athletes to the field and court much faster.

Common injuries treated with PRP include tennis elbow, ACL injuries, muscle pulls (hamstring, calf), achilles tendon injuries and plantar fasciitis. Many, many sports injuries can be treated with PRP and because we are using your blood and injecting it back into you, it is totally safe.

PRP is state of the art medicine and you will be hearing about pro athletes, college athletes and amatuer athletes being treated with this technology.

I am getting ready for baseball season to start. I am a college walk-on and usually play the outfield. What do I need to concentrate on for the next 3 weeks?
— Mike LaBelle, Washington Mo.

In preparing for spring training and the upcoming baseball season there are 3 principles.

1. Rotator cuff and upper body strength. Mike, you need a 1. ballistic upper body strength program that includes rotator cuff, posterior shoulder and upper back excercises. These need to be done in a high intensity, short duration mode once you have established your base. They need to progress to an interval throwing program to get ready for the repetition of practice.
2. Endurance training. This can be a stationary bicycle or a 2. progressive running program or a cross-training program including an elliptical/running/interval program.
   It is very important to have a strong cardio base and be ready for the base running and endurance workouts.
3. Midtrunk/core training will improve the rotation in your swing 3. and allow you to rotate on the ball faster.
   Midtrunk exercises are crucial for improving your hitting, but also allow you to plant and rotate on long throws from the outfield. CORE IS KING.
   In general maintain your nutrition and keep your BMI under control. We will discuss healthy diet habits, the correct foods and proper hydration in “Ask Dr. Rick” and we welcome your questions.

Use of autologous platelet concentrate to accelerate soft and hard tissue healing is strongly supported in medical literature. Studies report accelerated bone regeneration, reduced inflammation, decreased blood loss, reduced postoperative narcotic requirements, and improved hard and soft tissue wound healing. (1) Initially, intended for use in patients undergoing total knee arthroplasty (TKA), its use has expanded to:

• bone fractures
• laminectomy procedures
• lateral epicondylitis (ie, tennis elbow)
• nonunion and bony defects
• other total joint arthroplasty procedures (eg, hip, shoulder)
• plantar fasciitis
• shoulder arthroscopy and distal clavicle resection
• spinal fusion.

New products and instruments frequently are introduced in the perioperative environment; however, perioperative nurses often are not well versed in the scientific rationale behind use of these novel devices before they are introduced in the OR setting. This was the experience of nursing staff members at Parkview Orthopaedic Hospital, Fort Wayne, Ind, in 2003 when intraoperative use of autologous platelet-rich plasma (PRP) and platelet-poor plasma (PPP) was introduced. The purpose of this article is to help other perioperative nurse who may be introduced to this technology. This article defines autologous PRP and PPP; describes processing and application of PRP and PPP; and reports clinical application outcomes of the use of platelet concentrate for a group of patients who underwent TKA.

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Two of the Pittsburgh Steelers’ biggest stars, Hines Ward and Troy Polamalu, used their own blood in an innovative injury treatment before winning the Super Bowl. At least one major league pitcher, about 20 professional soccer players and perhaps hundreds of recreational athletes have also undergone the procedure, commonly called platelet-rich plasma therapy.

Experts in sports medicine say that if the technique’s early promise is fulfilled, it could eventually improve the treatment of stubborn injuries like tennis elbow and knee tendinitis for athletes of all types.

The method, which is strikingly straightforward and easy to perform, centers on injecting portions of a patient’s blood directly into the injured area, which catalyzes the body’s instincts to repair muscle, bone and other tissue. Most enticing, many doctors said, is that the technique appears to help regenerate ligament and tendon fibers, which could shorten rehabilitation time and possibly obviate surgery.

Research into the effects of platelet-rich plasma therapy has accelerated in recent months, with most doctors cautioning that more rigorous studies are necessary before the therapy can emerge as scientifically proven. But many researchers suspect that the procedure could become an increasingly attractive course of treatment for reasons medical and financial.

“It’s a better option for problems that don’t have a great solution — it’s nonsurgical and uses the body’s own cells to help it heal,” said Dr. Allan Mishra, an assistant professor of orthopedics at Stanford University Medical Center and one of the primary researchers in the field. “I think it’s fair to say that platelet-rich plasma has the potential to revolutionize not just sports medicine but all of orthopedics. It needs a lot more study, but we are obligated to
pursue this.”

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Information provided by: Pierre Rouzier,M.D. The Sports Medicine PATIENT ADVISOR

Information provided by: Pierre Rouzier, M.D. The Sports Medicine PATIENT ADVISOR