UTC. a novel approach for imaging of. Achilles and patellar tendinopathy

Transcription

1 UTC a novel approach for imaging of Achilles and patellar tendinopathy Hans T. M. Van Schie PhD UTC Imaging, Netherlands Ladies and Gentlemen, it is a great honor for me having the opportunity to tell you something about UTC imaging, an innovative technique for diagnosis, therapy and monitoring of Achilles and patellar tendinopathy. 1

2 What is UTC? = Ultrasound Tissue Characterization ~ visualizes & quantifies 3-D Tendon Integrity ~ discriminates various pathological stages ~ highly reproducible UTC is our abbreviation for Ultrasound Tissue Characterisation. This technique visualizes and quantifies 3-D tendon integrity. UTC discriminates a variety of pathological tissue types 2

3 Tendinopathy chronic pain, swelling & loss of function intra-tendinous disintegration due to tendinosis partial ruptures surrounding paratenonitis 3 As you know, tendinopathy stands for chronic pain, swelling and loss of function. These clinical symptoms may be caused by # tendinosis # and/or partial ruptures, # and/or paratenonitis.

4 Tendinosis, No Uniform Pathology! partial rupture haematoma fibro-proliferation hyper-cellularity fibrosis, a-cellularity vascular sprouts necrosis cell-death amorphous degeneration paratenonitis mineraloid Microscopy of tendinotic tendons shows multiple appearances. # You may find partial ruptures and haematoma, # or fibro-proliferation with hyper-cellularity and increased cellmetabolism. # or, on the other hand, extensive disintegration with a-cellularity and vascular sprouts # or focal degeneration with cell-death and necrosis. # or, amorphous mucoid, fibro-myxoid and fatty degeneration # at endstage, degeneration may lead even to calcification. So, no uniform pathology at all! 4

5 Tendinopathy, No Uniform Pathology! inconsistent results of regenerative therapies! regenerative therapy regenerate all stages? prognosis varies with type of pathology! => therapy based on tissue type! => exercise adapted to stage of integrity! 5 Even our smartest therapy suffers inconsistent results, raising questions like # do regenerative therapies really regenerate all tissue types, and # does prognosis vary with type of pathology In my opinion # treatment protocols have to be based on tissue type, and # during rehabilitation, exercise levels should be adapted to stage of integrity

6 Therefore UTC! standardized scanning & analysis visualizes & quantifies 3-D tendon integrity UTC aims at: monitoring exercise effects early detection of matrix degradation staging of lesion targeted therapy guided rehabilitation UTC is based on standardized scanning and analysis. In contrast to conventional ultrasonography, UTC is highly reproducible which allows # monitoring of exercise effects # early detection of matrix degradation # staging of the lesion # targeted therapy # and guided rehabilitation 6

7 UTC configuration standardized scanning & foot-position motor-drive moves 7-12 MHz transducer transverse scans collected every 0.2 mm real-time storage in laptop scan over 12 cm takes < 60 sec. 7 This is the complete UTC configuration, a portable modality completely different from conventional ultrasonography Foot position and scanning are standardized. The ultrasound transducer is fixed in a tracking device that moves automatically along the tendon by means of a motor drive. Transverse images are collected at regular distances of 0.2 mm and stored real-time in a laptop computer. Scanning over 12 cm takes less than 60 seconds.

8 Tomographic & 3-D Visualization proximal proximal ü transversal ü sagittal ü coronal ü 3-D coronal surgeon s view into lesion mineraloid (arrow) 8 By piling-up (and compounding) all successive transverse images, a 3 dimensional block is created, representing a tendon section with a length of 12 cm. Tendons can be visualized tomographically in 3 planes of view and in 3-D Please notice that the 3-dimensional coronal image provides an inward view into the lesion and visualizes perfectly the integrity and continuity of fibres and fasciculi.

9 Tomographic & 3-D Visualization proximal proximal ü transversal ü sagittal ü coronal ü 3-D coronal surgeon s view into lesion mineraloid (arrow) 8 By piling-up (and compounding) all successive transverse images, a 3 dimensional block is created, representing a tendon section with a length of 12 cm. Tendons can be visualized tomographically in 3 planes of view and in 3-D Please notice that the 3-dimensional coronal image provides an inward view into the lesion and visualizes perfectly the integrity and continuity of fibres and fasciculi.

10 Tissue Characterization Echo-Types I. intact, aligned bundle, Ø 0.38 mm II. III. IV. discontinuous, wavy bundle, Ø 0.38 mm mainly fibrillar, Ø << 0.38 mm mainly cellular and fluid, Ø <<< 0.38 mm 9 Even more important than visualization is tissue characterization and quantification of integrity. Based on dynamics of echopatterns, UTC algorithms can discriminate 4 different echo-types, namely + type I, generated by intact and aligned fibres and fasciculi, colored green + type II, generated by discontinuous or wavy fibres and fasciculi, colored blue + type III, related mainly to smaller fibrils, colored red, and + type IV, related mainly to amorphous tissue with cells and fluid, colored black. Please notice that echotypes I and II are generated by reflections from larger structures, while III and IV are interfering echoes from smaller entities with a size below the limits of resolution.

11 Quantification of Integrity NORMAL I intact bundles (green): % II discontinuous (blue): % III fibrillar (red) IV cellular & fluid (black) < 5 % => intact matrix inter- & intra-observer reproducibility 0.92! In this way integrity can be quantified # normal tendons have at least 80 percent intact and aligned tendon bundles, generating green echoes, and # less than 15 percent discontinous or waving tendon bundles, generating blue echoes # please notice, less than 5 percent red and black echoes, thus barely loose fibrillar and cellular tissue or fluid 10

12 Tendinopathic Iceberg symptoms only tips of iceberg! no chance for complete repair! manageable degeneration a-symptomatic during months, years! advanced degeneration less favourable! => early detection of degeneration is crucial! 11 We are becoming more and more aware that clinical symptoms are frequently only the tip of the iceberg and disintegration is going on for months or even years before symptoms become manifest. UTC is extremely sensitive to detect effects of aging and degeneration. Bottom left is an Achilles tendon in young mature people. Degradation starts mainly postero-medially, already from approximately thirty years of age. Disintegration gradually spreads through the entire cross-section, ultimately leading to clinical symptoms due to advanced fibrosis, partial ruptures and degeneration. When it comes to a rupture, cases with underlying degeneration have by far the worst prognosis.

13 Evaluation of Regenerative Therapy equine model standardized central-core lesion treatment: PRP, MSC s UTC: 0, 1, 2, 3, 5, 8, 12, 18, 24 w. Please allow me a brief excursion to the horse. UTC is used for staging and objective evaluation of regenerative therapies, e.g. with platelet-rich plasma or with stem cells. Standardized lesions were created in the superficial flexor tendons of both front limbs. In these experiments, one limb received treatment while the contralateral limb was placebo-treated with the same volume sterile saline. Subsequently healing was monitored by means of UTC during 24 weeks. 12

14 Evaluation of Regenerative Therapy treatment: PRP or MSC s placebo-control: NaCl 0.9% 13 In these experiments, one limb received treatment while the contralateral limb was placebo-treated with the same volume sterile saline.

15 Staging & Monitoring of Repair initially extension from D 35 fibrillogenesis from D84 organization During repair, various stages of integrity can be discriminated and the excellent reproducibility of UTC offers the opportunity to monitor repair processes. # Till Day 35 the lesion is extending which is a normal phenomenon during early stages of healing. # At Day 35 the lesion contains already more red than black echoes indicating fibrillogenesis. # At Day 84 the lesion has filled in with blue and green echoes. This means early bundles that are not yet aligned. # At Day 126 bundles are more organized, thus less blue and more green echoes.

16 Staging of Repair Green = intact, aligned bundle Blue = discontinuous bundle Red = mainly fibrillar Black = mainly cells and fluid inflammation & demarcation fibrillogenesis organization & bundle formation remodeling This schedule was developed for staging of repair. * during INFLAMMATION and demarcation of the lesion, there are mainly black echoes, thus haematoma and exsudate * during FIBRILLOGENESIS, there is a decrease of black echoes and an increase of red ones, indicative for the formation of a fibrillar matrix. * during ORGANIZATION & BUNDLE FORMATION, green and blue echoes do increase. At the same time, red and black echoes decrease sharply, indicating the organisation of fibrils into tendon bundles. * during the REMODELING stage, a sharp drop of blue echoes can be observed, thus less integer tendon bundels are remodelled into intact and aligned bundles, colored green. 15

17 Objective Evaluation Effects of PRP ü less inflammation ü increased, fibrillogenesis ü early bundle formation ü advanced remodeling PRP: solid line, placebo: dotted line 16 As UTC is both standardized and quantitative it allows the objective evaluation of therapeutic interventions. For instance, the effects of PRP were compared with those of placebo treatment with the same volume of sterile saline injected in lesions in both front-limbs. Intra-vital UTC-monitoring at several time-points during tendon healing offers great benefits compared to single postmortem investigation of experimental animals! First of all, it can safe lifes! Furthermore, besides evaluation at end-stage UTC-monitoring also provides utmost important information at various stages of repair. These graphs visualize significant differences (marked by asterisk) between PRP and saline injected lesions at several stages of repair(prp in solid lines, Saline in dotted lines). In PRP treated tendons 1. from 1 week post-treatment a significant decrease of echotype IV, thus less amorhous tissue with cells and free fluid, exsudate and/or haematoma. This is indicative for an anti-inflammatory effect. 2. from week 1 till 8 a significant increase of echotype III, thus increase

18 Monitoring of Therapy eccentric exercise rest injection PRP resume training from 4 w. increasing exercise from 12 w. after PRP Back to humans. This is an example of monitoring of regenerative processes in case of mid-portion tendinosis plus a sagittal rupture. Initially a significant worsening during 16 weeks of eccentric exercises. Please notice the extensive area with red echoes, indicative for fibrillar disintegration. Subsequently, sports activities were stopped during 24 weeks resulting in some improvement. However, as soon as training was resumed the condition of the tendon worsened again. Than, this tendon was treated with injections of platelet-rich plasma and starting from 4 weeks post-treatment exercise was gradually increased. Please do not understand me wrong, I do not dare to say that eccentric exercise is bad and PRP is a cure-all. But, it appeared that UTC allows * objective monitoring of repair and * the design the most appropriate rehabilitation program. 17

19 UTC-guided ESWT elite decathlon athlete, protracted complaints > 12 m. localized rupture musculo-tendinous junction 18 UTC is also used for targeted shockwave-treatments, electrohydraulically generated. This is a rupture in a professional athlete with complaints during more than one year. On MRI no relevant observations but on UTC we found a small rupture, hidden deep on the anterior side where the soleus merges with the gastrocnemius tendon.

20 UTC-guided ESWT ESWT: once, 1000, E3, 3 cm, from medial Outcome: light exercise from 4 w. 50% function at 12 w. full recovery at 20 w. 19 The tendon was treated once with only 1000 shocks, exclusively from the medial side over a length of 3 cm. At 4 weeks light exercise was resumed and at 6 weeks UTC showed that the lesion had filled in already with good quality of repair. Exercise was increased stepwise, guided by means of regular UTC. And at 20 weeks functional capacities were fully recovered.

21 UTC-guided ESWT targeted treatments! guided rehab! => excellent results (>80%) minimal amount treatments (av. 1.5) interval 6-8 weeks => fibrotic (blue) or fibrillar (red) have better prognosis than amorphous (black)! => strong relationship UTC and function! 20 Overall, our patients received only 1.5 shockwave treatments and afterwards UTC-guided rehabilitation. In more than 80 % we reached recovery but prognosis varied with tissue type. And, there appeared to be a strong relationship between functional capacity and improvement on UTC (except of those patients with amorphous degeneration).

22 UTC-guided Surgery surgical debridement guided by UTC => less invasive, facilitates scopic surgery matching of per-operative tissue with UTC => validation of tissue characterization monitoring repair => design rehabilitation program UTC is also used for surgery, # for reconstruction of extensive ruptures, and # for debridement of tendinosis. 21 # we do scan pre-surgery, aiming at effective and minimally-invasive surgery. # we harvest per-operatively tissue samples in order to check our tissue characterization, and # we monitor tendon repair in order to design the best rehabilitation program.

23 Traumatic Rupture extensive Achilles tendon rupture, after single macrotrauma 22 This is a nice example of tomographic visualization and tissue characterization after single macrotrauma. A completely normal Achilles tendon, except of the extensive rupture just proximally of the Calcaneus. The dimensions of the lesion are best visualized in the 3 D coronal image. This athlete was monitored for 9 months and came to full recovery, even becoming a world champion.

24 Pre-Surgery UTC Achilles tendon 23 This is the complete UTC volume of a partially-ruptured Achilles tendon. The tendon can be viewed sliding in all tomographic planes and in 3-D. Abnormalities can not be missed. It provides an inward view for localization and evaluation of pathologies and this information is crucial for targeted and minimal invasive interventions. At the rupture site, an enormous increase of red and black echoes can be seen. But, there is also a significant increase of blue ones. Persistent blue type II echoes are indicative for fibrosis which means that this rupture is not a primary trauma but a relapse based on underlying fibrosis. Towards the insertion on the calcaneal bone the tendon is becoming more and more normal.

25 Monitoring Rupture Repair 1.5 months 3 months 6 months 9 months fibrillogenesis : mostly fluid, cells & fibrils bundle formation : decrease of fluid, cells & fibrils increase of bundles remodeling : bundles wavy, incontinuous sharp transitions repair : continuous bundles less sharp transitions This is an example of staging during rehabilitation after 1.5 months post-surgery, mostly red and black echoes, indicative for the fibrillogenesis 3 months, green and blue echoes can be seen, indicative for early stages of bundle formation and 6 months post-surgery, the green echoes are starting to exceed the blue ones, indicative for remodeling. However, sharp transitions can be observed along the lines in the graphs, thus inhomogenous repair 9 months, the red and black echoes have further decreased. Furthermore, there are less sharp transitions, thus more homogenous repair tissue. However, blue echoes are still far to high for 9 months after surgery, indicative for delayed remodeling and formation of fibrotic tissue. 24

26 Monitoring Rupture coronal coronal view in UTC visualizes: continuity of tendon bundles in lines of stress outline of paratenon coronal view through center-core predicts functional capacity and prognosis! 25 After surgical co-aptation of a serious rupture, a coronal view through the center-core visualizes the formation of collagen bundles and their organization in the lines of stress. This information provides feedback to the sports physician and physio and there appears to be a close relationship with functional capacity during rehabilitation.

27 Monitoring Scraping September 2011 June 2011 Achilles tendon scopic removal peritendinous nerves, vascular sprouts, and/ or plantaris => immediate relief of pain absence of PAIN not necessarily indicates improved INTEGRITY => tissue repair takes longer (9 months) OBJECTIVE INFORMATION ABOUT INTEGRITY MAY BE VITAL! 26 A new surgical approach for Achilles and Patella tendinopathy is the peritendinous scopic scraping technique. This case is a professional soccer player suffering Achilles tendinopathy where ingrowing vascular sprouts and nerves, and sometimes also the invaginated plantaris are removed. This technique, due to denervation, frequently results in immediate relief but less pain does not necessarily indicate improved integrity. Tissue repair took 9 months. In the meantime objective information about integrity may be vital.

28 Scraping Patella tendon absence of PAIN not necessarily indicates improved INTEGRITY OBJECTIVE INFORMATION ABOUT INTEGRITY MAY BE VITAL! 27 A new surgical approach for tendinopathy is the peritendinous scopic scraping technique. This case is a professional soccer player suffering patella tendinopathy where infra-patellar vascular sprouts and nerves are removed. This denervation frequently results in relief of complaints but less pain does not necessarily indicate improved integrity of the patella tendon. Images show both tendons and it is clearly visible that the left one is still significantly disorganised. In these cases objective information about integrity may be vital.

29 Pro-Active SportsMedicine Achilles, patella, quadriceps, hamstrings bi-weekly check-up s, aiming at: early detection of matrix changes injury-prevention guided rehabilitation amongst others in: Australia: AFL NL: premier league soccer and Olympic teams Even more important than smart therapies is the prevention of injuries. Since it s introduction UTC is also used for top-athletes in Australia, UK and the Netherlands. UTC check-up are made on a regular basis, even bi-weekly. 28

30 3-D Visualization of Patellar Tendon This is the complete UTC volume of a disintegrated patella tendon. The tendon can be viewed sliding in all tomographic planes and in 3-D. Abnormalities can not be missed. It provides an inward view for localization and evaluation of pathologies and this information is crucial for targeted and minimal invasive interventions. Clearly visible is that the distal insertion and the mid-portion are normal. The proximal part, especially around the insertion on the inferior patella pole is abnormal. 29

31 Monitoring of Exercise professional athlete PT check-up few days slight swelling & tenderness eccentric exercise + UTCguidance => within weeks: improved integrity! => stayed sound during entire season! UTC is also used for rehabilitation. Most cases don t improve with rest but with physical stimulation, in other words guided exercise. For instance, this is a nice example of patellar tendinopathy. To the left the scans at 3 levels, from proximal towards distal of the patellar tendon prior to the start of exercise. And, to the right the scans after only a few weeks UTC-guided exercise, showing already a significant improvement of integrity. 30

32 Early Detection AT: reactive stage after heavy exercise => matrix swelling & reactive remodeling ~ frequently a-symptomatic, No Pain! ~ not detected in conventional US image! ~ UTC detects matrix changes! 31 Another application of UTC is the regular check-up, sometimes even biweekly, in athletes, aiming at injury prevention. These are transverse images of an Achilles tendon after heavy competition. No clinical symptoms and on grayscale no abnormalities. However, on the corresponding UTC-processed image a localized spot, mainly blue which is indicative for matrix swelling and remodeling. These changes may be reversible with adjusted exercise.

33 Early Detection AT routine check-up: no clinical symptoms, NO PAIN! => advice: reduce exercise however, athlete continued high-impact training 2 weeks later: symptoms & rupture!!! UTC detects matrix changes before symptoms => can be used to prevent injuries!!! But outcome is not always that good. This player showed at regular check-up a localized remodeling, seen as a blue spot in the center of the Achilles tendon. Without any clinical symptoms. These changes had not been observed on a previous check-up some weeks earlier and it was decided to prescribe reduced exercise. Despite this advice, the athlete continued high-impact training. And, regretfully for him, he came back 2 weeks later with a fullydeveloped partial rupture. This was one of those cases that convinced us of the possibilities to predict tendon injury. 32

34 portable standardized & highly reproducible 3-D visualisation & tissue characterisation early detection overstraining & degeneration precise diagnosis & prognostication targeted & minimally-invasive treatments objective evaluation & monitoring of therapy guided rehabilitation So, interventions for tendinopathy can be monitored indeed! And for those who are prepared to think ProActive instead of ReActive, UTC may facilitate the design of exercise programs to prevent or rehabilitate tendon injuries. 33 Thank you for your attention.

35 portable standardized & highly reproducible 3-D visualisation & tissue characterisation early detection overstraining & degeneration precise diagnosis & prognostication targeted & minimally-invasive treatments objective evaluation & monitoring of therapy guided rehabilitation So, interventions for tendinopathy can be monitored indeed! And for those who are prepared to think ProActive instead of ReActive, UTC may facilitate the design of exercise programs to prevent or rehabilitate tendon injuries. 33 Thank you for your attention.