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

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. 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. 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. Medipole Garonne (2012/8 till 2017/3) : 1771 PRP-HA (CM)

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. •« 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. 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. 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. 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. 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. 3 cases of UltraSonographic Meniscal Wall Infiltration
1/Meniscal wall
Medial meniscus
2/Meniscal wall
Lateral meniscus

12. 3/Lateral Meniscal Cyst : drilling then evacuation of the cyst
by « meniscal wall » way and PRP injection (CM)

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. Grade II peripheral meniscal tear before PRP treatment
MRI : Grade II meniscal tear has almost disappeared after treatment

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. 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. 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. 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. 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. 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. *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. 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. 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. 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. « Menisc-arthritis » 5 months after CM
Total resolution of BME
(white area of BME has disappeared)
Meniscal edema also decrease
before after

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. 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. 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. *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. 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. 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. Medial femoral edema with secondary necrosis to OA
Great decreasing of « white » lesion (BME) after CM

33. Traumatic edema of
cotyle and
femoral head
Labral tear
Resolution of BME and tear after CM

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. US guided PRP-HA
Acromio-clavicular way
(needle tract)
Neer’s Test with CM
for Sub-acromial Conflict (impigement syndrome)

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. 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. 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. Hip Bursitis : US-guided PRP-HA
between Medius Gluteus Tendon and Trochanter major

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. • 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. *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. *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. Combination Therapy is a New and
ORIGINAL CONCEPT !
Double Joint with CM (knees) or
Joint with CM + tendon or ligament with PRP

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. 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. 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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