US guided injection of highly concentrated PRP in chronic refractary tendinopathies: preliminary results

Transcription

1 US guided injection of highly concentrated PRP in chronic refractary tendinopathies: preliminary results Poster No.: C-0795 Congress: ECR 2012 Type: Scientific Paper Authors: A. De Marchi, S. Pozza, E. C. Cenna, F. Rosso, C. Faletti; Torino/ IT Keywords: Musculoskeletal soft tissue, Ultrasound, Ultrasound-Colour Doppler, MR, Trauma DOI: /ecr2012/C-0795 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Purpose Chronic tendinopathies are difficult to treat and often they don't respond to the treatment. Other studies demonstrated that Platelet Rich Plasma (PRP) is able to start a reparative process. However, clinical efficacy was not correlated with the platelets concentration, which largely depend on the manufactorer's equipment. It has not been studied if too great platelet concentration would have paradoxical effects. Our purpose is to correlate the efficacy of three injections of autologous highly concentrated platelets rich plasma (hcprp) with 6 millions +/- 2 millions platelets each injection, with imaging modification and clinical results in chronic refractory tendinopathies. Images for this section: Page 2 of 17

3 Fig. 1: Sagittal STIR image showing a severe tendinopathy of the Achille's tendon as manifested by fusiform thickening, contour's irregolarity and intratendinous large split. Page 3 of 17

4 Methods and Materials Inclusion criterias: chronic refractory tendinopathy (jumper's knee, tennis elbow, Achilles tendinopathy) which did not respond to conservative treatment in patients engaged in amatorial sports. Exclusion criterias: sistematic disorders such as diabetes, cardiovascular diseases, infection, immunodepression. 6 PRP preparation and injection: three injections of hcprp (1.5 x 10 µl) were performed under US guidance at 15 days distance. US guidance can be used free-hand or with the dedicated device. Casuistry: We treated 11 patients, 9 male and 2 female, age 18-65, mean age 43.2 years (SD +/- 14.3); 5 Achilles tendinopathies, 5 jumper's knee and 1 tennis elbow. Method of study: all patients were studied before and at 6 months post-treatment by US, DopplerUS, CEUS (Contrast Enhanced US ) and MRI. Physical exam and clinical evaluation were registered according to international scale (activity level by Tegner scale; index of osteoarthritis by Womac; pain by VAS; emotional intelligence by EQ test) at preand post-treatment evaluation. Statistical methods: Differences between clinical evaluations (VAS, TEGNER, WOMAC and EQ) were calculated using t-test and p value<0.05 was considered statistically meaningful. Besides imaging evaluations were confronted using percentage difference. Images for this section: Page 4 of 17

5 Fig. 2: Table of clinical and imaging evaluation Page 5 of 17

6 Fig. 3: Our autologous PRP preparation: one of the three unit of 4.5 ml obtained after 120 ml venous blood sample. Page 6 of 17

7 Fig. 4: Achille's tendon US-guided injection with device Page 7 of 17

8 Fig. 5: Jumper's knee US guided injection with device Page 8 of 17

9 Fig. 6: Longitudinal US showing guided needle placement in tennis elbow prior to PRP's injection Page 9 of 17

10 Results No complications related to the injection or severe adverse events were observed. Three patients underwent surgical treatment at 7 months post-injection without imaging control. Before the treatment, the basal US aspect of pathologic area was: in 8 cases hypoechoic, in 2 cases hyperechoic and in the last one hypo-anechoic. Edges were irregular in 8 cases and regular in 3 cases. Tendon morphology was regular in 1 case, in 10 cases irregular, in 4 of which spindle-shaped; microcalcifications were detectable in 6 cases. At PD exams, vascular spot were observed in 8 cases and absent in the last 3; in 6 cases CEUS demonstrated a very rich vascularisation, whereas in 3 cases was poorer and in 1 case absent. At MRI, bone oedema was present in 3 cases and tendon's signal alteration was detectable in 5 cases; in the last 3 cases the tendons were thicker than normal with normal signal. Before the treatment, the average clinical evaluation was: WOMAC score 22.4 (SD +/-11.1), TEGNER score 4.3 (SD +/-2.1), VAS score 26.4 (SD +/- 14.6), EQ score 8 (SD +/- 1.4). 6 months after the treatment, the basal US of pathologic area was: in 4 cases hypoechoic, in 1 hyperechoic and 2 case hypoanechoic. The last 4 cases have normal basal US morphology. Edges were irregular in 5 cases and regular in last 6 cases. Tendon morphology was irregular in 3 cases, in 1 of which fusiform; the last 8 cases had normal regular morphology and 1 case had microcalcifications. At PD exams in 6 cases there were many vascular spot; in 2 cases of wich CEUS demonstrated a very rich vascularisation, whereas in 4 cases was poorer and the last 5 cases absent. At MRI bone oedema was present in 2 case, but in reduction in comparison to pre-treatment, and signs of tendon's signal alteration was detectable in 1 case, but also in this case in reduction. At 6 months post-treatment, the average clinical evaluation was: WOMAC score 8.7 (SD +/-7.7), TEGNER score 4.6 (SD +/-3), VAS score 80 (SD +/-14.4) and EQ score 7 (SD +/- 2.4). Images for this section: Page 10 of 17

11 Fig. 7: Sagittal US pre-treatment of a tennis elbow. Us image on the left; CEUS (on the right)shows increasing doppler flow in the fibers on the tendon. Page 11 of 17

12 Fig. 8: Pre-treatment coronal STIR MRI of tennis elbow shows a non-homogeneous signal in the tendon and bone oedema. Page 12 of 17

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14 Fig. 9: Post-treatment coronal STIR MRI of tennis elbow shows a healed chronic tear. Fig. 10: Clinical results (VAS scale 0 worst, 100 better) Page 14 of 17

15 Conclusion Improvement in TEGNER score was not statistically significant (p=0.675), but all the patients play amatorial sports, so this result can have been expected. Besides also improvement in EQ average score was not statistically meaningful (p=0.502). On contrary differences between WOMAC and VAS average score was statistically significance (respectively p= and p=0.0009). At basal US there was a reduction of all pathologic aspect: 50% in hypoechoic structure, 38% in irregular edges, 70% in irregular morphology and 85% in microcalcifications. At PD exams we have a reduction of 25% of vascularisation; at MRI we have 33% of oedema's reduction. In conclusion the precise injections in the pathologic area under US guided procedure and the hcprp are the focal points in this study. Thanks also to this, imaging and clinical preliminary results are encouraging. It could be useful to improve the casuistry in order to obtain more significant results. Images for this section: Fig. 11: Sagittal US pre-treatment in jumper's knee shows increased doppler flow in the tendon. Page 15 of 17

16 Fig. 12: Sagittal US post-treatment in jumper's knee shows a significance reduction in doppler flow. Page 16 of 17

17 References 1. Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Corr Rev Musculoskeletal Med 2008;1: Filaro G, Kin E, Della Villa S, Vincentelli F, Fornasari PM, Marcacci M. Use of plateletrich plasma for the treatment of refractory jumper's knee. SICOT Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with bufferede plateletrich plasma. Am J Sports Med 2006;10(10): Edwards SGH, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. Am J Hand Surg 2003;28(2): Connel DA, Ali KE, Ahmad M et al. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol 2006; 35: Pietrzac W, Eppley B. Scientific foundations plateled rich plasma: biology and new technology. J Craniofac Surg. 2005;16(6): Personal Information Page 17 of 17