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

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. 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. Medipole Garonne (8/2012 till 9/2016) : 1562PRP-HA procedures
PRP-HA

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. •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. 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. 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. *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. Knee Joint : UltraSonographic approach
Before
injection
After
PRP
injection
perimeniscal
Sub-patellar
Perimeniscal needle
US control

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. 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 (CMTM
)

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. 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 (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. 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-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. *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. 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. 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. 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. 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. 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. 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. Neer’s Test with PRP
CTX RayUS Target
V/ PRP-HA (CMTM
) for Sub-acromial Conflict
Tendon Sheaths and Bursae
UltraSonographic
Guidance+++

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

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. Tendon Sheath : Tibialis Posterior Tendonitis with fluid collection
Before injection of US-guided PRP-HA
After injection of PRP-HA No fluid collection

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

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. *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. *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. 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