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Use of PRP-HA for the Treatment of Articular and Peri-Articular Diseases By UltraSonographic Guidance


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11ème congrès de la Société Marocaine d’Arthroscopie
03-04 Février 2017 à Marrakech
Sports Clinic Medipole Garonne
Toulouse France

Published in: Health & Medicine
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Use of PRP-HA for the Treatment of Articular and Peri-Articular Diseases By UltraSonographic Guidance

  1. 1. Ph ADAM, MD Sports Clinic Medipole Garonne Toulouse France Use of PRP-HA (Cellular MatrixTM ) for the Treatment of Articular and Peri-Articular Diseases By UltraSonographic Guidance 11ème congrès de la Société Marocaine d’Arthroscopie 03-04 Février 2017 à Marrakech
  2. 2. CMTM is the « All-in-one » Therapeutic Injection with a mix of PRP-HA 1/Into the Articular Cavities (Knee and Other Joints) : *US Synovial Cavity approach (Arthritis) to detect an effusion (arthrocentesis for a dry joint+++ before CMTM ) *US Meniscal approach (or other fibro-cartilages) 2/and Outside of the Joints : Direct US access to Synovial Sheaths of Tendons and Synovial Bursae
  3. 3. Medipole Garonne (8/2012 till 9/2016) : 1562PRP-HA procedures PRP-HA
  4. 4. 1/Association PRP-HA (Cellular MatrixTM Regen Lab® ) is nor a Placebo neither a Visco-Supplementation improved by PRP ! 2/PRP (GF) produce antalgic and anti-inflammatory effect increase collagen synthesis and endogenous HA production 3/PRP-HA (CMTM ) is more efficient than PRP only by synergistic anabolic actions of HA and PRP
  5. 5. •L’effet « Visco » n’est pas celui recherché •C’est essentiellement l’effet biologique qui nous intéresse •La préparation de PRP en présence d’HA, permet de former un réseau biologique dans lequel les plaquettes sont dispersées •La fibrine interagit avec l’HA et forme un réseau à grandes mailles •Ce réseau est propice à la migration et à la division cellulaire » Why the association of Growth Factors (« PRP » « 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
  6. 6. Our Protocol for PRP-HA is codified but simple 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
  7. 7. 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
  8. 8. *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 (meniscal wall+++) and by impregnation (joint) Images of Meniscal anatomy by cortesy of Mikel Sanchez R R R W WW
  9. 9. Knee Joint : UltraSonographic approach Before injection After PRP injection perimeniscal Sub-patellar Perimeniscal needle US control
  10. 10. 1/ We need a direct injection of PRP-HA the closest possible to the meniscal lesion and to cartilage (peripheral cleft/cyst/big bulging meniscus, early arthritis) 2/ Our purpose is to reduce meniscal tear both by the vascular side (wall, RR and RW areas) and by the articular side (grade III open tear, WW area) Needle into the bulging meniscus through the meniscal wall
  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 (CMTM )
  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 CMTM 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 (aged between 23 and 84 years, mean age 49, gender ratio: 24% females vs 75% males) suffering from Grade II or III (80% grade III) stable horizontal lesion (85% medial meniscus, 15% lateral meniscus, RR or RW meniscal area) were treated with only one i-a injection of CMTM
  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-PRP 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 CMTM 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 Cellular Matrix 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. Now, 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 CMTM 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 CMTM
  25. 25. 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.
  26. 26. 1/The BME Pattern is a non-specific finding which could be found out of Traumatic Bone Bruise and out of Osteo-Arthritis 2/We are using the « Anticatabolic Effect » of PRP-HA against BME and algodystrophy IV/Bone Marrow Lesions with Bone Marrow Edema Algoneurodystrophy Osteonecrosis and Stress Fractures US guided sub patellar injection but MRI control of Edema
  27. 27. Knee Algoneurodystrophy after ligamentoplasty (before CMTM ) : pain 6/10, lateral femoral condyle BME, small medial meniscal tear Knee Algoneurodystrophy 5 weeks after CMTM : pain 1/10, BME 0, articular collection
  28. 28. Neer’s Test with PRP CTX RayUS Target V/ PRP-HA (CMTM ) for Sub-acromial Conflict Tendon Sheaths and Bursae UltraSonographic Guidance+++
  29. 29. US guided PRP-HA (CMTM ) 1/Acromio-clavicular way (needle tract) Neer’s Test with CMTM for Sub-acromial Conflict (impigement syndrome)
  30. 30. US guided PRP-HA 2/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
  31. 31. Tendon Sheath : Tibialis Posterior Tendonitis with fluid collection Before injection of US-guided PRP-HA After injection of PRP-HA No fluid collection
  32. 32. Hip Bursitis : US-guided PRP-HA between Medius Gluteus Tendon and Trochanter major
  33. 33. Indications of PRP-HA for all the joints : Super PRP ! 1/US guided PRP-HA can complete or replace classical VS : *Limited action of HA alone (5 months) *PRP-HA 12 to 24 months *HA is sometimes injected outside of the joint without US control (shoulder, forefoot, wrist, pubic joint…) 2/PRP-HA is better than for diabetic patients+++ 3/PRP-HA is a good complement to surgery Post-operative recovery is better after PRP-HA (healing, natural antalgic and anti-inflammatory effects, bacteriostatic) 4/Better results for the Knee then Hip and other
  34. 34. *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)
  35. 35. *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
  36. 36. 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