Injections Intra-Articulaires « Single Shot » de Facteurs de Croissance et d’Acide Hyaluronique

1. I Injections Innttrraa--AArrttiiccuullaaiirreess « SSiinnggllee SShhoott »
ddee FFaacctteeuurrss ddee CCrrooiissssaannccee eett
dd’’AAcciiddee HHyyaalluurroonniiqquuee
CCoonncceepptt ddee « VVIISSCCOO--PPRRPP » ((AAHH ++ PPRRPP))
Philippe ADAM Michel NOAT Olivier MAY
Clinique Médipole Garonne (novembre 2014)

2. Growth Factors Effects (platelets,wbc)
« Tissue Healing is boosted »
1/Collagen Synthesis (cartilage, fibro-cartilage)
2/Growth/migration/recruitment of Cells
3/Neo-angiogenesis (péricytes, MSC)
4/Protein Matrix

3. PPRRPP rriicchhee eenn ffaacctteeuurrss ddee
ccrrooiissssaannccee
2014- SV © Regen Lab
Données issues de Borrione et al Am J Med Rehabil 2010;89:854-861
TGF-beta
Transforming Growth Factor β
Stimule la prolifération cellulaire
Favorise la production de matrice
extracellulaire (collagene I & III)
Stimule l’ angiogenèse
PDGF-AB
Platelet-Derived Growth
Factor
Stimule la prolifération cellulaire
Stimule le chimiotaxisme des
fibroblastes
bFGF Basic Fibroblast Growth Factor
Stimule la prolifération des
fibroblastes
VEGF Vascular Endothelial Growth
Factor
Stimule la prolifération et la migration
des cellules endothéliales, angiogenèse
EGF Epidermal Growth Factor
Stimule l’ angiogenèse
Contrôle le renouvellement de la
matrice extracellulaire
Stimule la migration et la prolifération
des fibroblastes
IGF
(plasma)
Insulin-like Growth Factor
Stimule la prolifération cellulaire
Favorise la synthèse de collagene et de
matrice extracellulaire, remodelage
Stimule la migration des fibroblastes

6. Intérêt Visco-PRP
Le PRP a un effet anti-inflammatoire naturel (secrétion de cytokines
anti-inflammatoires)
PRP : « le corticoide sans les inconvénients »
Il a de fait un effet antalgique
On connaît aussi son effet antibiotique
L’article de Sundman et l’expérience pratique de 3 ans de recul
démontrent que l’association thérapeutique AH exogène + PRP
autologue est très intéressante par effet de sommation (douleur,
fonction)
Le PRP favorise par ailleurs la synthèse d’AH endogène

7. HOW TO PREPARE PRP-HA CELLULAR MATRIXâ ?
THE STEPS : Very fast Procedure !
1/Blood puncture
2/Centrifugation : 5 mn / 3500
3/Turning round PRP & HA to obtain & homogenize the cocktail (≥4 cc)
After withdrawal
of full blood
After
centrifugation
After
homogenization
HA
PRP
CELLULAR MATRIX (PRP-HA, class III material device)
Sampling before injection
4 cc (2 ml PRP + 2 ml non cross linked HA)

8. Comparaison des Kits de prélèvement

9. Les Méchants GB

10. Et les Bons GB

11. Et les Bons GB

12. L’élément majeur est la pauvreté en Neutrophiles
des produits Regenlab (efficacité/disparité littérature)

13. Mode Opératoire de l’Injection Articulaire :
CT ou RX ou US (analgésie, MEOPA)
CT ou RX : bulle d’air, voie postéro-médiale ou latérale selon siège
méniscarthrose genou, voie sous-rotulienne, voie antérieure
hanche/cheville/épaule, coude….poignet….rachis….
Il faut être dans l’articulation et prés de la lésion !

14. Les cibles de la Visco-PRP
1/Lésions méniscales stables stade II et III sur genou stable
Ménisques suturés à risque, Kystes méniscaux
(Ph ADAM, M Noat, Biobridge Venise, Septembre 2013)
Kyste méniscal
Classification IRM

15. *Peripheral Vascularity seem to play an important role in meniscal healing
*But deep meniscus is also soaking into the joint fluid !
*Therefore growth factors can impact meniscal healing by stimulation of
vascular proliferation and by impregnation
R R R W WW

16. Results and Profits of « PRP therapy »
for meniscal lesions
* Positives : 92% for group 1 (grade III, meniscal cyst : 116/126)
Clinical aspect : Constant antalgic effect of PRP (anti inflammatory
effect of growth factors), better joint ability
Imaging aspect : reduced inflammation of the joint , decrease or
stabilization of meniscal lesion (cyst, cleft)
Failures (10/126) are owed to a bad evaluation of lesional stability
(a good diagnosis by imaging is essential+++)
* Positives : 100% for group 2. We can improve the rate success for
meniscal suture

17. Remote Evaluation of the Efficiency

18. Meniscal Lesions : Clinical Cases
Anterior horn cyst of LM january 2013
Anterior horn cyst of LM may 2013

19. LM before and after suture completed by PRP injection
(bucket handle) : no scar is visible !
before
after

20. 1/Big functional disability, pain 4/10, 64 years old 2/walk normally, pain 0/10
After PRP :
Inflammation Decrease
(paratibial fluid collection)
Improved medial meniscal
structure
Before PRP After PRP

21. Cleft and Cyst of MM (ultrasonography)
One month after PRP

22. Running, postural internal pain (6/10) Grade III lesion of MM (before PRP)
At one month : decreasing pain (0/10) decreasing size and intensity of meniscal cleft

24. Les cibles de la Visco-PRP
2/Arthrose du genou : stades non chirurgicaux, nombreux échecs de
la visco simple
Si nécessaire assécher l’articulation avant (ponction + corticoides)
Dr JLRenevier Hôpital de Meulan
Dr Jean-François MARC 42300 Roanne
Dr Philippe ADAM Médipôle Garonne 31100 Toulouse
Dr Jacques LE COZ 75014 Paris
Dr Ivan PROTHOY Polyclinique des Alpes du Sud 0500 Gap
Pr Nicolas SANS Hôpital Purpan Place du Dr Baylac
TSA 40031 31059 Toulouse
Biobridge Venise Septembre 2014

25. RESULTS

26. RESULTS
*87.3% improved after the study patients
*There is a significant difference in the average WOMAC
A1 before the start of treatment and pain 36 weeks after
starting treatment
*This difference was also significant between the first and
the second injection and between the second and third
injection.
*There is no significant difference in pain scores as the
radiological grade (II-III)
*No significant side effects reported.

28. « Méniscarthrose »
Partial meniscectomy / Arthritis (woman 52 yo) /axial plane
May 2013 pain 8/10
August 2013 pain 0/10

29. Woman 40 yo, overweight, internal pain 4/10 MRI at one month, pain 0/10
Obvious decrease of the
oedema of the
internal condyle
Slight modification of the
signal of medial
meniscus
Le marqueur de la
douleur c’est l’oedème
en IRM

30. Les cibles de la Visco-PRP
3/Arthrose de hanche : conflits, complémentaire ou alternative à la
Dysplasia and/or Impingement
chirurgie (labrum)
If impingement : Cam effect/Pincer effect/ or Mixt
Cartilaginous +/- fibro-cartilaginous labral lesions
Sport Practice
Surgery before CM injection for impigement
Failure of NSAIDs and classic visco-supplementation

31. Oxford Score : Synthesis
Mean score before injection is 30 (moderate)
Mean score after two injections is 37,6 (mild) : 25% increase
6/13 have satisfactory joint function (46%) after 2 injections
No side effects after CM injection
Good progress and improvement specially for patients with
impigement (37% versus 17% for other group)
Separated case 14 (cam) : before 16 (severe), and after one CM
injection 37 (mild, over 50%)

32. Conclusions of the study

33. Case 1 : soccer player, M 43 yo, no impigement,
Tönnis 2, oxford 31/34/41 (32% improvement)

34. French XV International Rugby Player : Traumatic lesion of labrum
(acetabular tear/oedema), AH only no result, PRP at one month rapidly
permit decreasing of pain, normal function,
with no recurrence over one year
oedema
Labral tear
No oedema

35. Labral and Meniscal Treatment by Visco-PRP
is the Same fight !
1/ Preventive Labral Treatment is so efficient as meniscal
2/ Hip Labral-Arthritis = Knee Meniscal-Arthritis
3/Save labrum = Protect hip and slow down arthritis

36. Detection of pre-arthritis and Preventive
Treatment are the Goal in the Young !
1/ Corrective surgery to avoid prosthetic device
2/ 40% arthritis (hip) under 50 yo considered as
« idiopathic » : Not detected Impigement ?
3/ Visco-PRP (HA + PRP) complete corrective surgery

37. Which is the new deal for Degenerative Arthritis ?
Early Screening
(bio-markers+++)
+ Early Treatment
= Prevention and Efficiency
Visco-PRP Surgery