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Use of PRP-HA for the treatment of Articular and Periarticular diseases


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Use of PRP-HA (cellular, matrix, em) for the treatment of Articular and Periarticular diseases by ultrasound guidance

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Use of PRP-HA for the treatment of Articular and Periarticular diseases

  1. 1. Use of PRP-HA (Cellular Matrix, CM ) for the Treatment of Articular and Periarticular Diseases by Ultrasound Guidance Dr Philippe Adam Imaging Department “Medipole Garonne” Sports Clinic France Sports Medicine and Arthroscopy Session 4-2: Meniscus and Cartilage Injury
  2. 2. CM is the « All-in-one » Injection with a mix of PRP-HA 1/Into the Articular Cavities : *by US approach of the Synovial Cavity (arthrocentesis for a dry joint before CM) *by US approach of Fibro-cartilage (Meniscus) 2/and also Outside of the Joints : *by direct US access to Synovial Sheaths of Tendons
  3. 3. How to Prepare CM ? The All in one PRP(GF) + HA 1/ Blood puncture 2/ Centrifugation : 5 mn / 1500g 3/ Turning round PRP & HA to obtain & homogenize the cocktail After withdrawal of full blood After centrifugation No red cells No neutrophils After homogenization HA PRP Sampling before injection of 6-8 cc (4-6 ml PRP + 2 ml non cross linked hyaluronic acid)
  4. 4. Medipole Garonne (2012/8 till 2017/3) : 1771 PRP-HA (CM)
  5. 5. 1/Association of PRP + HA (Cellular Matrix, Regen Lab® ) is nor a Placebo neither a Visco-Supplementation improved by PRP ! 2/PRP (GF) produce antalgic and anti-inflammatory effects increase collagen synthesis and endogenous HA production 3/PRP-HA is more efficient than PRP only as a result of synergistic anabolic actions of HA and PRP
  6. 6. •« Visco effect » is not the expected effect •It’s essentially the « biological effect » which interests us •Preparation of PRP in association with HA allows to create a biological network in which platelets are scattered •Fibrin interacts with HA for the creation of a network with wide stitches which is convenient to migration and cellular division Why the association of Growth Factors (« PRP » or « PRGF ») and HA ? Microvasc Res. 2007 Mar;73(2):84-94. Epub 2007 Jan 16. Improved growth factor directed vascularization into fibrin constructs through inclusion of additional extracellular molecules. SMITH JD et al
  7. 7. Our Protocol for PRP-HA is easy to use 1/Medical Consultation before : scores (IKDC, Oxford, Womac…), imaging modality (US,CT,MR), consent of patient, blood count, premedication (antalgic, patch) and stop anticoagulant drugs 2/PRP-HA is a very short procedure (≈20 mn) with blood sample, centrifugation and injection in the UltraSonographic room with Meopa inhalation if necessary 3/Clinical and Imaging control after at 5 weeks (US or MRI) + sports resumption in coordination with sportive medical team 4/Number of injections is from 1 to 3 according to the indication with several months between each injection, but If first injection is highly effective one can wait one year of interval
  8. 8. I/Grade II (closed) and III (open) stable degenerative (or traumatic) meniscal tears “Big” painful meniscus (para and intra-meniscal cyst) A stable knee is needed for a good result of medical treatment by PRP injection for healing of meniscal tears+++ (collagen effect) Stable knee Unstable knee ACL torn
  9. 9. Meniscal Healing (Principles) : 1/We have to use the Vascularity of Meniscus 2/and to Bring PRP close to meniscus by US approach (signalling mollecules): *stimulation of vascular support in meniscal wall (RR, peripheral area) *impregnation of deep meniscus (RW,WW) Images of Meniscal Anatomy by cortesy of Mikel Sanchez R R R W WW
  10. 10. Before injection After PRP injection (meniscal wall) perimeniscal Sub-patellar Peri-meniscal needle US control Intra-meniscal needle US approach of the Meniscus (wall, cyst)
  11. 11. 3 cases of UltraSonographic Meniscal Wall Infiltration 1/Meniscal wall Medial meniscus 2/Meniscal wall Lateral meniscus
  12. 12. 3/Lateral Meniscal Cyst : drilling then evacuation of the cyst by « meniscal wall » way and PRP injection (CM)
  13. 13. Grade III meniscal tear and cyst Initial big functional disability, pain 8/10, woman 23 yo Intra and extra meniscal cyst are decreasing, wall edema also (hypersignal decrease) : stabilization of the meniscal tear after CM Meniscal wall lesion is the area with increased (white) signal (MRI) 3 months after CMTM walk normally, pain 0/10 Grade III
  14. 14. Grade II peripheral meniscal tear before PRP treatment MRI : Grade II meniscal tear has almost disappeared after treatment
  15. 15. Bulging Meniscus (posterior horn) Dancer woman 33 YO Postero-medial pain of knee without trauma Ultrasonography : bulging medial meniscus (not extruded) First MRI 2016 March : cystic degenerative medial meniscus (« big white »)
  16. 16. Flat Meniscus Second MRI 2016 April *One month after PRP-HA Cystic appearance decrease (partial collapse) and pain Dance again with high-heeled shoes 1 1 2 2
  17. 17. May be a new US entity for the US-guided treatment ? The « big bulging round meniscus » (nor discoid neither extruded) This Bulging Meniscus is not* a degenerative meniscus ejected outside the joint as in the OA but* a big degenerative meniscus with a painful para-articular mass
  18. 18. 2/For grade II and III degenerative meniscal tears there was a significant improvement in the IKDC subjective score one year after the beginning of PRP-HA treatment, with a mean score of 7,96 (range 5 to 10/10) compared to 4.20 (range 0 to 6/10) before 3/A follow-up study at 2 years in August 2015 found 52% of subjects with a long-term improvement after only one injection First Meniscal Study in Medipole Garonne Efficiency of PRP-HA 1/From August 2012 to June 2013, 93 patients (23 to 84 years, mean age 49, 24% females vs 75% males) Grade II or III (80% grade III) stable horizontal lesion (85% medial meniscus, 15% lateral meniscus) were treated with only one i-a injection of CM
  19. 19. II/Kellgren and Lawrence (X-Ray) Moderate Grade II and Grade III Knee Osteo-Arthritis Meniscal extrusion demonstated by US is a sign for evolutive arthritis by rupture of perimeniscal fixations
  20. 20. Davies-Tuck et al stated that « the development of new BMLs was associated with progressive knee cartilage pathology, while resolution of BMLs prevalent at baseline was associated with reduced progression of cartilage pathology » (Arthritis Res Ther. 2010;12(1):R10, page 7) US guidance for injection MRI for post-CM control (BME bio-marker) 2/The Early Detection and Early Treatment of BML/BME allows a good Prevention of OA and can delay the prosthetic stage 1/The Correlation between Bone Marrow Lesions (BML) Bone Marrow Edema (BME), Pain and Loss of Cartilage (OA) PRP-HA for the treatment of OA is justified by 3/The Study of Sanchez which demonstrated the superiority of PRP versus Hyaluronic Acid for knee OA Sanchez M, Anitua E, Azofra J, Aguirre JJ, Andia I. Intraarticular injection of an autologous preparation rich in growth factors for the treatment of knee OA : a retrospective cohort study. Clin Exp Rheumatol. 2008;26:910–913
  21. 21. *From September 2013 to April 2014, 71 patients (34 females and 37 males, 40 and 84/mean age 63, mean BMI 26.83), KL II (33 patients) and KL III (38 patients) *Failure to Classical Visco-Supplementation *3 Injections by patellar way (US) with CM were done at Day 0, Month 2 and Month 6 and evaluated at these three time-points by the Womac scale and at a final follow-up at Month 9 Multicenter Trial of CM for the treatment of Knee OA (20 patients from Medipole Garonne included)
  22. 22. WOMAC Pain at Day 0, Month 2, Month 6 & Month 9 (Multicenter Trial) Pain was gradually decreasing after each injection PRP-HA is effective when Classical Visco-Supplementation failed
  23. 23. In November 2016 Approximately 3 years after the OA study in Medipole Garonne We reviewed in consultation half of patients (no news of the other half) with a satisfactory functionality, and no prosthetic device These patients asked us a new injection So we can confirm the durability of efficiency with CM intra- articular injection In comparison with a simple visco-supplementation (6 months in literature)
  24. 24. Woman 40 yo, overweight, KL III, internal pain 4/10 MRI at one month, pain 0/10 Obvious decrease of the hypersignal of medial femoral condyle (BME) Other KL III, important decrease of BME and pain at one month after CM
  25. 25. « Menisc-arthritis » 5 months after CM Total resolution of BME (white area of BME has disappeared) Meniscal edema also decrease before after
  26. 26. III/Post-Traumatic OA (“osteo-chondritis”)  with focal loss of superficial cartilage and  Bone Marrow Edema  Knee PTOA with BME of medial femoral condyle and superficial cartilage defect  (osteochondritis). Frontal plane (top) and axial plane (bottom) with a target sign Edema and Pain  highly decreased after US-guided PRP-HA at one month.
  27. 27. Patellar cartilage is quite normal after CM injected under the patella Traumatic osteochondritis of patella : edema  of superficial cartilage and cartilaginous tear before CM
  28. 28. Ballet Dancer (Capitole of Toulouse)  Lateral epicondylitis and Traumatic  Osteochondritis of radial head Pain has really  decreased after one  simple PRP infiltration  for tendonitis and two  CM of elbow joint
  29. 29. *The BME Pattern is a non-specific finding  which could be found  out of Traumatic Bone Bruise and out of Osteo-Arthritis *BME = Pain = MRI Bio Marker of BML = White MRI hypersignal *With CM we are using the « Anticatabolic Effect » of PRP against BME and algodystrophy  by creating a Positive metabolic balance IV/Bone Marrow Lesions with Bone Marrow Edema Algoneurodystrophy     Osteonecrosis    and Stress Fractures US guided sub patellar injection and MRI control of Edema
  30. 30. Knee Algoneurodystrophy after ligamentoplasty (before CM) :  pain 6/10, lateral femoral condyle BME, small medial meniscal tear  Knee Algoneurodystrophy 5 weeks after CM :  pain 1/10, BME 0, articular collection
  31. 31. Knee Algoneurodystrophy 3 months after trauma  (partial lesion of ACL)  and 2 months after CM No tibial trabecular bone edema, no ACL edema, no pain  1 2
  32. 32. Medial femoral edema with secondary necrosis to OA  Great decreasing of « white » lesion (BME) after CM
  33. 33. Traumatic edema of  cotyle and  femoral head Labral tear Resolution of BME and tear after CM
  34. 34. 1/Neer’s Test with PRP-HA (Sub-acromial Joint) CTX RayUS Target V/ Tendinopathies/Tendon Sheath Disease /Bursitis (effusion, synovitis) UltraSonographic Guidance+++ Into sub-acromial space and  Bursa
  35. 35. US guided PRP-HA Acromio-clavicular way (needle tract) Neer’s Test with CM  for Sub-acromial Conflict (impigement syndrome)
  36. 36. US guided PRP-HA : Sub-acromial way (needle tract) Sub-acromial Conflict and supra-spinatus tendon tear Diffusion of PRP  (hyperechogenic) into the  tendon tear and into  subdeltoid bursa
  37. 37. Disorganization of Fibers, change of the Matrix and Tenocytes Focus on Tendinopathy Remarques Générales sur « l’Inflammation » Il ne faut pas confondre l’hypervascularisation « pathologique » avec des néo-vaisseaux « dysplasiques », une hyperhémie et une production de fluide et de cytokines pro-inflammatoires Avec l’hypervascularisation « thérapeutique » qui apporte des cytokines anti- inflammatoires et qui précède la cicatrisation 2/Tendinopathies/Tendon Sheath Diseases and other « Bursitis »
  38. 38. Tendon Sheath : Tibialis Posterior Tendonitis with fluid collection Before injection of US-guided PRP-HA along tendon sheath and tendon After injection of PRP-HA : anti-inflammatory effect with No fluid collection
  39. 39. Hip Bursitis : US-guided PRP-HA between Medius Gluteus Tendon and Trochanter major
  40. 40. Indications of PRP-HA 1/US guided PRP-HA can complete or replace Classical VS : *Limited action of HA alone (5 months) *PRP-HA 12 to 24 months *Accurate injection into the joint under US control 2/PRP-HA is better for diabetic patients+++ 3/PRP-HA is a good complement to surgery Post-operative recovery is better after PRP-HA (healing, natural antalgic, anti-inflammatory and bacteriostatic effects) 4/Better results are for the Knee 5/Good results of PRP-HA for tendonitis with fluid collections of synovial sheaths and Bursitis in Sub-acromial Conflict
  41. 41. • Meniscal Injuries : Grade II and III stable meniscal degenerative lesion in a stable knee; complement to surgery for unstable meniscal tear (bucket handle or meniscus flap tear), alternative for surgery of meniscal cyst • Kellgren and Lawrence Grade II and III Knee OA; but also Grade IV with extensive BME especially if surgery is refused by the patient • Tönnis I and II degenerative Hip OA • Post-Traumatic OA with BME and edematous lesions of superficial cartilage • BML with BME (outside OA) as algoneurodystrophy, osteonecrosis with edema or stress fractures, and all stable damages of fibro-cartilage in any location (mainly for knee, hip and shoulder). • New concepts include the double injection of CM for bilateral knee OA but also the use of combination therapy with simple PRP for tendon, ligament or enthese and i-a injection of CM for femoro-patellar and sub- acromial joint, forefoot, wrist and pubic symphysis conflicts Indications of PRP-HA
  42. 42. *Determining the best frequency for administering PRP-HA in the preventive treatment of OA is still unresolved ! *The purpose is to maintain a good clinical result for pain beyond one year and to delete surgical planning! One PRP-HA injection each year for sportsmen or a course of one PRP-HA every two months or 3 to 5 iterative i-a injections ? *PRP-HA has the potential to reduce pain more effectively than Classical Visco-Supplementation, and to prevent or at least to slow the progression of meniscal lesions and OA Conclusions (1)
  43. 43. *Protection of fibro-cartilaginous structures is clearly coupled with the protection of articular cartilage *We cannot ignore the fact that being overweight, or having traumatic instability or distortions of the skeleton disadvantages the therapeutic benefits of any treatment *Preventive treatment is extremely important regarding pain, functional limitation and cost of public health Conclusions (2) Early Screening (bio-markers+++, MRI) + Early Treatment = Prevention and Efficiency
  44. 44. Combination Therapy is a New and ORIGINAL CONCEPT ! Double Joint with CM (knees) or Joint with CM + tendon or ligament with PRP
  45. 45. *patellar instability and cartilaginous lesions : Infiltration of patellar retinaculum by PRP +Infiltration of the patellar joint by CM *patellar tendon by PRP and patellar joint by CM *knee sprain : Medial Collateral Ligament by PRP +Joint and medial meniscus by CM *ankle sprain : anterior talo-fibular ligament by PRP +Joint for osteochondral defect by CM (talar dome injury) *Morton neuroma by PRP + metatarsophalangeal joint by CM US guided CM under patella and PRP infiltration near to patellar retinaculum
  46. 46. PRP-HA is a good complement to surgery An association of techniques (HA + PRP + MSCs) will be more successful than a single isolated technique if we want to make of a real cartilage and not only a fibro- cartilage
  47. 47. Abstract  The PRP-HA protocol used one to three injections of a mix of PRP and HA with ultrasound  guidance, for the treatment of grade II and III stable meniscal tears, grade II and III osteoarthritis  of the knee, bone marrow lesions of the knee with edema, and for tendonitis with fluid  collections of synovial sheaths.  Tools used for the follow-up were: IKDC subjective knee score, WOMAC scale, MRI and  Ultrasound.  Meniscal tears: significant improvement in the IKDC score one year after only one injection  (7.96 vs 4.20).  Osteoarthritis:  significant difference in the WOMAC pain scale at Month 9 compared with Day  0 (1.89 vs 5.75).  Bone marrow lesions : decrease of pain (mean IKDC score from 8 to 4) correlated with a  reduction of edema.  PRP-HA appears to be efficient for the treatment of Knee Articular Disorders, including  reduction of pain for meniscal tears, osteoarthritis and bone marrow lesions.  PRP-HA seems to be more effective than visco-supplementation and can probably replace it.  What is unknown: the best frequency for injections, and whether it can supplant surgical  planning by the means of a preventive treatment for OA.  Ultrasound guidance is the best modality for injection and MRI for edema assessment.
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