17 th Annual Scientific Meeting of ECVS! Basel, July ! 44278
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1 !! 17 th Annual Scientific Meeting of ECVS!! Basel, July !
2 Intralesional injection of platelet-rich plasma followed by controlled exercise for treatment of midbody suspensory ligament desmitis in Standarbred racehorses J Am Vet Med Assoc. May 15; 232 (10): , 2008! M Waselau, Dr.med.vet., MS 1, ; WW Sutter, DVM, MS, DACVS 1,* ; " RL Genovese,VMD 2 ; AL Bertone, DVM, PhD, DACVS 1 " 1 Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, OH; 2 Randall Veterinary Hospital, Cleveland, OH;!! Dr. Waselau s current address is University of Zurich, Switzerland; * Dr. Sutter s current address is Ocala Equine Hospital, Ocala, FL!
3 INTRODUCTION! SDFT/SL injuries! Most common musculoskeletal injury! 46% of all MS injuries 1! Racing TB/STB:! Midbody Susp. Lig. Desmitis (MSD)! Different from proximal lesions! Acute & career limiting 2! Particular problems:! High energy injuries, low blood supply! Low potential for regeneration! 1 Williams, JB et.al. EVJ 33:5, , 2001! 2 Ross, MW in Proceedings 16th ACVS Meeting, , 2006!
4 INTRODUCTION " " "- Management Options-! CONSERVATIVE:! Stall rest, exercise programs! Medication ( + /- intralesional)! SURGICAL:! Splitting! Acute ( + /- chronic)! Delayed or inefficient healing!regardless of treatment! Adjunctive therapy?! Growth factors or PRP for SDFT 1! Reports for SL are lacking!!!!!!! 1 Schnabel LV et.al. J Orthop Res, Feb;25(2): , 2007!
5 INTRODUCTION!!!- Platelet-Rich Plasma -" Supraphysiologic
6 INTRODUCTION!!!- Platelet-Rich Plasma -! Source of growth factors (α-granules) 1! High levels! PDGF, TGF-ß! Lower levels! IGF-1, EGF, VEGF, TGF-α! Degranulation upon activation! Centrifugation! CaCl 2, thrombin 2! Exogen immediate! Endogen slow! Platelets and ligament healing?! Anabolic effect + stimulus for angiogenesis 3! Achilles tendon repair 4,5! 1 Eppley BL et.al. Plast Reconstr Surg. Nov;114(6): , 2004! Enhancement tendon repair 6,7! 2 Everts PA et.al. Growth Factors Sep;24(3): , Anitua E et.al. J Orthop Res 23: , 2005! 4 Aspenberg P, Acta Orth Scan 75:93-99, 2004! 5 Sanchez M et al:. Am J Sports Med , 2007! 6 de Mos M et.al. Am J Sports Med June; 36(6): , 2008! 7 Schnabel LV et.al. J Orthop Res, Feb;25(2): , 2007!
7 INTRODUCTION!!!- Platelet-Rich Plasma -" Human medicine:! Oromaxillofacial, plastic 1, orthop. & spinal Sx 2! Accelerates bone, skin graft, tendon & tissue regeneration!! Veterinary medicine:! Wound healing acceleration 3! SL fibroblasts exposed in vitro increased COMP 4! Tendon cultures increased COL1A1, COL3A1, COMP 5! Humane systems can be used to enrich equine platelets 6! The Ohio State since 2003 ( 215 horses)! More clinical studies needed! 1 Marx RE et.al. Oral Surg Med Path Radiol Endod 85: , 1998! 2 Kasolis JD et.al. J Periodontol 71: , 2000! 3 Carter CA, Exp Mol Pathol, Jun;74(3): , 2003! 4 Smith JJ et.al. Vet Comp Orthop Traumatol 19:43-47, 2006! 5 Schnabel LV et.al. J Orthop Res, Feb;25(2): , 2007! 6 Sutter WW et.al. AJVR 65: , 2004!
8 PURPOSE! Describe 3 year racing performance of Standardbreds with MSD treated by! a single platelet-rich plasma injection!! compared to!! a cohort population of Standardbreds matched in age, gender and racing status based upon earnings per start.!
9 HYPOTHESIS! Intralesional PRP-Injection:! Is safe,! May support suspensory ligament healing! And will, in combination with a controlled exercise program, allow horses to successfully return to racing!! With a performance curve characteristic for a normal, aging racing horse.!
10 MATERIALS & METHODS " " "- Nonrandomized clinical trial -" Case Group!! Racing Standardbreds 1! Moderate-severe MSD! Single PRP-Injection! Recorded age, gender, racing status! Comparison Group! Racing Standardbreds 2! No MSD! No PRP! Matched in age, gender,racing status! Outcome of treatment compared to a comparison group! 1 Medical records, sequentially admitted to OSU! 2 United States Trotting Association!
11 MATERIALS & METHODS " " "- Criteria for Case Selection -" Medical records for MSD reviewed! Moderate-severe MSD! Inability to race due to MSD! Age, gender, limb, time since injury, platelet counts before/after enrichment, current racing status, results of ultrasonography!! Ultrasonographic exam:! Transverse & longitudinal! Entire Zone (2A + 2B) with CSA 15%! Considered as moderate to severe lesions! Echogenicity & Fiber arrangement ( Grade 3 * ) 1! * Scores 0=none; 1=minimal; 2=mild; 3=moderate; 4=severe! 1 Bertone, AL et.al. J Biomed Mater Res; 84: , 2008!
12 MATERIALS & METHODS " " "- Comparison Group Selection -" Retrospectively selected:! From electronic database 1! Same source as for MSD-Horses! Racing:! Within same dates as MSD-Horses! Earnings/start:! Within one SD unit of the mean earnings/start for the MSD-Horses!! Statistically not different (p<0.05)! 1 United States Trotting Association;
13 MATERIALS & METHODS " " "- PRP-Preparation -" SECQUIRE System:! C Sterile, commercially available system! Aseptic patient side collection of whole blood! Filled in anticoagulant bag! 50ml gently injected into four specifically designed blood tubes! Multiple 3500r/min to process!
14 After 1 st centrifugation, all but 3ml of packed red cell blood layer is removed via blood port! Secquire Blood Port After 2 nd centrifugation, platelet poor plasma is removed via plasma port leaving 5ml of final product! Plasma Port Remainder is plateletrich plasma drawn up through the blood port!
15 MATERIALS & METHODS " " "- Intralesional PRP-Injection -" Sedation, high palmar/plantar nerve block! 1.5-inch, 20-gauge needles; applicator set + lure lock! Single handed, simultaneous injection (Ratio RPR : Thrombin =11:1)! US-guided, percutaneous, aseptic injection! Every 2-4 cm throughout entire length of lesion! ~ 3 ml or PRP leaked out!
16 MATERIALS & METHODS " " "- Aftercare -" Distal limb bandage! Protection, removed after 2 weeks! Daily/EOD monitoring of injection sites! Hospitalization! Observation for 3 days! Medication! No NSAIDʼs for 7 days! Possible interaction with platelets?! Exercise protocol! Controlled exercise program recommended! Modification based upon healing!
17 MATERIALS & METHODS " " "- Exercise Protocol -" Time 1! Nature and Duration of Exercise 2! 0-14 days (2 weeks)! Stall rest!! days (4 weeks)! Walk in hand 15 min, 1x/day! days (8 weeks)! Walk in hand 30 min, 1x/day! days (12 weeks)! Walk in bike for 30 minutes, 1x/day! days (16 weeks)! Any type of jogging! days (20 weeks)! Jogging + training miles under 2:20min! days (24 weeks)! Racing! 1 Time after intralesional PRP-Injection; 2 Shortened or lengthened upon progression of healing!
18 MATERIALS & METHODS " " "- Serial Evaluation -! Progression of healing! Clinical and ultrasonography! " " " " - Racing Performance Outcomes -! Race records reviewed for MSD + comparison group 1! Year before injury! # Starts, # Earnings, # Earnings/start! 3 consecutive years after returning! Time to 1 st race! # Starts, # Earnings, # Earnings/start! Fore vs. Hind limb! Comparison to comparison group! 1 United States Trotting Association;
19 MATERIALS & METHODS " " "- Statistical Analyses -" Serial objective data! 2-factor ANOVA (time, treatment) for racing performance between case and comparison cohorts across time! Least significant difference (LSD) post hoc test to compare both 1, yrs of racing! Objective data:! 1 factor ANOVA (time)! Starts, earnings, earnings/start! Before and at 1 year time points after PRP-Injection! Paired t-test for platelet concentration! Differences considered p< 0.05!
20 RESULTS!!!- MSD-Horses -! 9 Standardbreds met inclusion criteria! 3.3 years (2-5 years), 8 Geldings, 1 Stallion! 5 fore limbs, 4 hindlimbs! Prior treatment! 7 wks (1-28 wks) of stall rest! Ultrasonography! Cross-sectional area: 35% (17-66%) of Zone 2A+B! Fiber alignment score: 3.22 (3-4)! Echogenicity score: 3.66 (3-4)!
21 RESULTS!!!- PRP-Processing & Injection -! Processing! Successful enrichement! Mean = 900% (p< 0.02)! 1,370,000/µl;SEM= 456,853! Injection! Technically easy! Minimal leakage around needles! Volume (10.7ml, 7-12 ml)! Clinical evaluation! No adverse reaction, lameness or swelling!
22 RESULTS!!!- Return to Racing for MSD * -" *All cohort horses raced! Recovery period! Median = 32wks (26-68wks)! At least 6 starts! Rates! First year:!89%!(8/9)! 18 (range 6-37)! Second year:!100%!(9/9)! 22 (range 3-26)! Third year:!56%!(5/9)! 9 (range 9-25)! Compared to year before! Fewer starts in 1 st + 3 rd yr (p<0.03)!
23 RESULTS!!!- Total Starts -! MSD horses! Fewer starts in general! 3 rd year significantly less!! Comparison horses:! Number of starts declined as well! 3 rd year significantly more!
24 RESULTS " " "- Total Earnings -! MSD horses! Higher earnings the year before injury! MSD and Comparison horses! No statistical difference between groups!
25 RESULTS " " "- Earnings / Start -! MSD horses! Significantly less 1 st + 3 rd year after PRP-Injection compared to year before! MSD and Comparison horses! Significantly less 1 st year after PRP-Injection only!!(p<0.05)!
26 RESULTS " " "- Fore vs Hind Limb? -! Outcome parameters:! Statistically no difference in MSD horses between! forelimb (n=5) and! hindlimbs (n=4)!
27 DISCUSSION " " "- Platelet-Rich Plasma -! First report on clinical use of PRP for equine MSD! PRP-Kit! Safe, reliable, practical, standardized processing! Effective platelet enrichment! < 2 to > 8.5-fold concentration ratios reported 1! 1,000,000 plt./ µl per 6ml considered as standard! Thrombin for degranulation! Required? Bovine? Potential reactions?! Alternatives?! 10% CaCl 2 1, soluble type I collagen 2! Thrombin receptor agonist peptide 3! Batroxobin 4 slow release without rapid activation! 1 Marx RE J Oral Maxillofac Surg ;62: , 2004!! 3 Landesberg R et.al. J Oral Maxillofac Surg, Apr;63(4): , 2005! 2 Fufa D et.al. J Oral Maxillofac Surg, Apr;66(4): , 2008! 4 Mazzucco L et.al. Vox Sang., Apr;94(3): , 2008!
28 DISCUSSION " " "- Intralesional Injections -! Advantages! Direct delivery without systemic side effects! Practical needle application! No adverse reactions observed! Disadvantages! Needle tracks? 1! $$$??! Treatment schedule! Multiple treatments required?! Optimum time to inject?! 1 Smith, RKW Equine vet. Educ.; 20(7), 392, 2008!
29 DISCUSSION " " "- Race Record Review -! Well-accepted method! Other performance limiting factors! Fully considered?! Comparison group minimized this variability! Matched in age, gender, racing status!! Indicate that:! Return to racing for 3 consecutive years! Sustained race career after clinical use of PRP! Performance curve consistent with aging race horse!
30 DISCUSSION!!!- Comparison to Other Studies -! Difficult! Lack of reports on intralesional Tx of MSD! Career limiting, retired for economic reasons! Our report! 100% return, least 6 starts! Higher than previous studies after! Intralesional Tx bone marrow or bioscaffold (82-84%) 1,2! No consistency! Location, extent, severity, follow-up variable! Limitations! Small number; however, consistency! 1 Herthel DJ: Enhanced suspensory ligament healing in 100 horses by stem cells and other bone marrow components in Proc. AAEP 2001! 2 Mitchell RD: Treatment of tendon and ligament injuries with UMB Powder (A Cell-Vet.), in Proc. ACVS 2004!
31 CONCLUSIONS! Intralesional PRP-Injections! Appear to be easy and safe!! PRP + controlled exercise program! Return to racing least 3 consecutive years! Performance consistent with a normal, aging race horse! Exact contribution of each component difficult to determine!! PRP may! Provide growth factors! that encourage ligament healing similar to tendon healing! Represent an alternative/adjunctive for MSD!
32 CONCLUSIONS!! Further studies needed! To clearly prove efficacy! Create defect!!! PRP + Exercise vs. Exercise only! Biochemistry + Histology of healing tissue! Long-term with greater patient material!! In combination with stem cells?! Enhances their proliferation!! Other systems?! More effective/less expensive?! DePuy Symphony, Biomet GPS TM! HARVEST TM Smart PReP 2 APC + TM! Find your system!!
33 QUESTIONS?! Galbreath Equine Trauma Center, The Ohio State University" Acknowledgments!! Suzanne L. Huck for techincal assistance and subsequent data collection.!
34
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