All-in-one injection of HA and PRP

1. Cellular MatrixTM
all-in-one i-a injection of HA and PRP
for Fibro-cartilaginous tears
Osteo-Arthritis and Bone Marrow Lesions
Ph ADAM, MD
Sports Clinic Medipole
Garonne
Toulouse France
Elite Sports
Rehabilitation
Conference
London 15th June
2016
« Visco-PRP »
by
Cellular MatrixTM

2. Visco-PRP is the « All-in-one »
Therapeutic Injection
with a mix of Hyaluronic Acid and
Platelet Rich Plasma (CMTM
)
1/Into the Articular Cavities (I-A)
but also !!!
2/Outside of the Joints
Into Synovial Sheaths of Tendons
and Synovial Bursae (P-A)

3. Medipole Garonne (august 2012 till march 2016) : 1521procedures

4. The largest age group was between 41 and 60 years
(62%) with a relatively small group aged less than
21 years (1%)
92,8% Visco-PRP for lower limb : 83% Knee
7,2% for upper limb
Sex ratio: 36% females vs 64% males

5. 4 objectives : protect Fibro-Cartilage and Cartilage
reduce Bone Marrow Edema and Synovial Inflammation
3 main targets : cartilaginous surface, fibro-cartilage and
synovial wall (Joint or Sheath or Bursae)
1 effective tool : « Injection of HA+PRP (CMTM
) is more
successful than HA alone or PRP alone by the way of a
synergistic anabolic action on cartilage regeneration
and an anti-inflammatory effect »

6. So we can create a Positive Metabolic Balance
by the association of anticatabolic effect on BME
and anabolic enhancement on Chondrogenesis

7. The use of PRP show an impact on Chondrogenic Differentiation
Migration and Proliferation of Mesenchymal Progenitor cells

8. Our Protocol 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/Visco-PRP is a very short procedure (≈20 mn) with blood sample,
centrifugation and injection in the same room (US or CT), and Meopa inhalation if
necessary
3/Clinical and Imaging control after at 5 weeks + 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

9. HOW To Use Medical Device and Prepare CELLULAR MATRIXTM
?
1/ Blood puncture 2/ Centrifugation : 5 mn / 1500g
3/ Turning round PRP & HA to obtain & homogenize the coktail
After withdrawal
of full blood
After centrifugation
No red cells No neutrophils
After
homogenization
HA
PRP
Sampling before
injection of
*3 to 6 ml PRP +
2 ml HA
= 5 to 8 ml
Regenlab provides us two cencentrations for HA (non cross linked, 2ml)
CM 2 : 20 mg/ml (40 mg) or CM 1,5 : 15 mg/ml (30 mg)

10. Visco-PRP with high concentration of HA
(CMTM
ACP HA, 20 mg/ml, CM2)
For Big Joints (Knee+++, Hip, Ankle, Shoulder, Elbow)
Fibro-Cartilaginous Tears Osteo-Arthritis
Osteo-Chondritis Bone Marrow Lesions
Sprain (Ankle)

11. I/Grade II and III (Stoller, MRI) stable degenerative
meniscal tears in a stable knee
+ “big” painful meniscus (para and intra-meniscal cyst)
Meniscal shear forces A stable knee is needed for a good result

12. We are using both « Meniscal Wall Infiltration » and
I-A infiltration by US approach”
1/ We need a direct injection of HA + PRP
the closest possible to the meniscal lesion (cleft, cyst, big bulging round meniscus)
2/ Our purpose is to reduce meniscal tear
Both by the vascular side (wall, RR) and
the articular side (grade III open tear, WW, joint)
Needle into
the bulging
meniscus
through the
meniscal
wall

13. Grade III meniscal tear and cyst Initial big functional disability, pain 8/10, woman 23 yo
Intra and extra meniscal cyst is decreasing, wall edema also (hypersignal decrease) :
stabilization of the meniscal tear after CMTM
Meniscal wall lesion is the area with increased (white) signal
3 months after CMTM
walk normally, pain 0/10

14. Grade II meniscal tear before and after Visco-PRP (5 weeks)
Grade II meniscal tear has almost disappeared after Visco-PRP

15. Rugbyman 21 years old (hooker)
Partial Meniscectomy for meniscal tear
(anterior horn of lateral meniscus) but post-operative pain
First MRI 2014 December
*Lateral tibial plate edema (Bone Marrow Edema)

16. Second MRI 2015 February : One month after first Visco-PRP (CMTM
)
Decreasing edema and pain
Sharper edges for lateral meniscus

17. 10 months without pain
then discomfort again
in rugby practice
Second Visco-PRP 2016
January
and Third MRI 2016 April
No pain No edema
Lateral meniscus quite
normal !
Scar (neo-meniscus)
instead of
anterior horn ?
No arthritis
No chondropathy
Ok for Rugby
IRM 1
IRM 2
IRM 3

18. Bulging Meniscus (posterior horn)
Dancer woman 33 years old
Postero-medial pain of knee without trauma, normal plain X-ray
Ultrasonography : bulging medial meniscus
First MRI 2016 March : cystic degenerative medial meniscus (« big white »)

19. Flat Meniscus
Second MRI 2016 April *One month after Visco-PRP
Cystic appearance decrease (partial collapse) and pain
Dance again with high-heeled shoes

20. May be a new entity for the US-guided treatment ?
The « big bulging round meniscus » (not discoid)
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

21. 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
2/The IKDC subjective knee score (“well-being” scale between 0
and 10) evaluated the reliability, validity, and responsiveness to the
Visco-PRP treatment
First Meniscal Study in Medipole Garonne (material)

22. 1/For grade II and III degenerative meniscal tears there was a
significant improvement in the IKDC subjective score one
year after the beginning of Visco-PRP treatment,
with a mean score of 7,96 (range 5 to 10/10) compared to 4.20
(range 0 to 6/10) before
2/A follow-up study at 2 years in August 2015 found 52% of
subjects with a long-term improvement after only one injection
3/So we can confirm the efficiency of Visco-PRP
First Meniscal Study in Medipole Garonne (results)

23. II/Kellgren and Lawrence (X-Ray)
Moderate Grade II and III
Knee Osteo-Arthritis

24. 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)
2/MRI is the better Bio Marker for articular lesions and specially BME
3/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)
Visco-PRP for the treatment of OA is justified by

25. 4/The Study of Sanchez which demonstrated the superiority of PRP
versus Hyaluronic Acid for knee OA
« In a cohort of 30 patients comparing injections of PRP with
hyaluronic acid (HA) in the management of OA, the success rate for
the pain subscale reached 33.4% for the PRP group compared with
only 10% for the HA group (p = 0.004) »
*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
Visco-PRP for the treatment of OA is justified by

26. *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 with
HA only in the previous 3 months, and not taking analgesics or
NSAIDs or anti-OA in the previous 3 months
* If effusion : arthrocentesis before i-a Visco-PRP
We need a dry joint !
*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)

27. *At month 9, 94.4% of the treated patients were considered responders
to treatment based on the OMERACT-OARSI criteria
*There was a significant (p<0,05) difference in the WOMAC pain scale
at Month 9 compared with Day 0 (mean values 1.89 vs 5.75,
respectively). Difference in WOMAC pain scale was also significant
(p<0,05) at month 2 vs baseline following 1 injection (3.62 vs 5.75) and
at month 6 vs month 2 following the second injection (2.49 vs 3.62)
*For MG 20 patients : M9 2,45 vs D0 5,65
*No severe adverse events were reported
RESULTS

28. WOMAC Pain at Day 0, Month 2, Month 6 & Month 9
(Multicenter Trial)
Pain was gradually decreasing after each injection
Visco-PRP is effective when Classical Visco-Supplementation failed

29. 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

30. « Menisc-arthritis » 5 months after CM Total resolution of BME
before after

31. III/Tönnis I and II (X-Ray) Moderate degenerative Hip OA
with Dysplasia, Impigement and Labral lesions

32. Cohort of Patients
• 13 « young » patients : unilateral osteo-arthritis, failure of
NSAIDs and classic visco-supplementation
• 2 Visco-PRP (2 months interval), clinical follow up (3
Oxford hip score)
• 22 to 60 yo (mean age 42,8), 6 men (ma 38,7), 7 women (ma 46,3)
• Group 1 : 7 femoro-acetabular impingement syndrome with labral
lesion (3 cam, 2 pincer, 2 mixt) ; 5/7 injected after surgery and 2/7
without surgery
• Group 2 : 6 without impingement (dysplasia, degenerative)
• 6/13 X Ray Tönnis 1 (mild OA) , 7/13 Tönnis 2 (moderate OA)
• One 14th
separate case : aerofight, cam, 18 years old, 1 injection, very
good result, canceled surgery

33. Grading by Oxford Hip Score
is the reference for the follow-up

34. 1/Aerofight, W 18 yo
Oxford 16 : 2014 February, labral cavitation, scheduled surgery

35. 2/Aerofight, W 18 yo
Only one Visco-PRP : Oxford 37, 2014 June, canceled surgery !

36. 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
oedema
Labral tear
No oedema

37. Rugby player, M 22 yo, cam surgery
Tönnis 1, labral cavitation, oxford 36/44/48 after 2 Visco-PRP
CT scanner before surgery : Bump et Pit lesion (cavity), labral
cavitation

38. Woman 51 yo, no impigement, Tönnis II X-Ray grade
Oxford score 38/44/47, low pain and good function after 2 Visco-PRP

39. Conclusions for Hip Study
1/Visco-PRP (Cellular MatrixTM
) was efficient
for the treatment of

40. IV/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 Visco-PRP at one month.

41. Patellar cartilage is quite normal after CMTM
injected under the patella
Traumatic osteochondritis of patella : edema
of superficial cartilage and cartilaginous tear

42. 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
Visco-PRP of
elbow joint

43. Traumatic osteochondritis of
femoral head
(fitness teacher) : centimetric defect
at the outer surface of cartilage

44. 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 Visco-PRP against
BME and algodystrophy
V/Bone Marrow Lesions with Bone Marrow Edema
Algoneurodystrophy Osteonecrosis and Stress Fractures

45. 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

46. Knee Algoneurodystrophy 3 months after trauma
(partial lesion of ACL) and 2 months after CMTM
No tibial trabecular bone edema, no ACL edema, no pain

47. Medial femoral condyle OsteoNecrosis and OA
BME before Visco-PRP and 5 weeks after Visco-PRP, no BME

48. Big Joints : Indications of Visco-PRP
(Cellular MatrixTM
) : Super Visco ?
*Visco-PRP can complete or replace other infiltrations
(HA alone +/- NSAIDs) after failure of classical procedures,
and for diabetic patients+++ (no risk with PRP vs NSAIDs)
*Visco-PRP is a good complement to surgery
for improving healing : microfracturing, shaving
but also microdrilling with CSM grafts
*Post-operative recovery is better after Visco-PRP (natural antalgic and
anti-inflammatory effects + bacteriostatic)
*Better results of Visco-PRP are for the Knee (FT joint)

49. Big Joints : Indications of Visco-PRP
(Cellular MatrixTM
)
*Visco-PRP is efficient for stable fibro-cartilaginous damages
Meniscus of the knee
Labrum of the Hip
Labrum of the Gleno-Humeral Joint
*For Post-Traumatic Osteochondritis and Bone Marrow Lesions

50. Visco-PRP for isolated labral tear of shoulder
(14 yo, soccer)
No pain No tear visible
on MRI 3D millimetric
sequence at 2 months

51. Visco-PRP with low concentration of HA
(CMTM
BCT HA, 15 mg/ml, CM 1,5)
for Small Joints (forefoot, hindfoot, wrist, hand)
Tendon Sheaths and Peri-articular Bursae
1/Degenerative (and Inflammatory ?) Osteo-Arthritis
2/Sub-Acromial Conflict
(rotator cuff tears and sub-acromial bursa)
3/Tendonitis/Teno-Synovitis (fluid production by synovium)
4/Other Bursitis (hip, knee)

52. CT-guided Visco-PRP of Sub-talar PTOA
Very good result after three years of failure for corticosteroid infiltrations and classical visco
I/Visco-PRP for Small Joints

53. Woman 55 yo, Morton’s neuroma + plantar plate lesion (meniscus of the foot)
Pain 7/10, 2 simultaneous injections : simple PRP for Morton +
US-guided Visco-PRP into the second metatarso-phalangeal joint

54. Five weeks after treatment, pain 2/10, plantar plate
improvement, size of neuroma decrease

55. Antero-lateral tissular conflict (ankle sprain sequelae)
With a painful hypervascular Synovial I-A Scar

56. II/Visco-PRP (1,5) for Sub-acromial Conflict
Tendon Sheaths and Bursae

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

58. US guided Visco-PRP
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

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

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

61. Knee Bursitis : Tensor of the Fascia lata, Pes Anserinus
TFL before and after PRP Pes Anserinus Bursitis before
and after draining
Pes Anserinus Bursitis
Tibial Exostosis

62. *Determining the best frequency for administering Visco-
PRP 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 avoid or delete surgical planning!
One Visco-PRP injection each year for sportsmen
or a course of one Visco-PRP every two months
or 3 to 5 iterative i-a injections ?
*Visco-PRP 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)

63. *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

64. Combination Therapy is a New Concept :
« Visco-PRP into the Joint + PRP out of the Joint »
to improve the clinical performance by
accumulating the profits of superficial and deep ways !
*patellar instability : patellar retinaculum by
PRP + patellar joint by Visco-PRP
*patellar tendon by PRP + patellar joint by
Visco-PRP
*meniscal lesion by direct PRP « out » through
meniscal wall (US-guided) and Visco-PRP into
the joint (under patella)
*knee sprain : Medial Collateral Ligament by
PRP + Joint and medial meniscus by Visco-PRP
*ankle sprain : anterior talo-fibular ligament by
PRP +Joint for talar dome injury by Visco-PRP
Conclusions (3)

65. Tibial and Femoral CSM Grafts by microdrilling
(by cortesy of Michel Assor) Kellgren IV knee arthritis
Completed at 2 months by Visco-PRP
because of permanent pain
Resolution of pain after 2 Visco-PRP
Association of HA, PRP and MSCs (Biological Synergy) ?

66. The Future ? Potential benefits of utilizing chondroprogenitors
In cell-based cartilage therapy
(Chathuraka T. Jayasuriya and Qian Chen, Connect Tissue Res. 2015; 56(4) 265-271