tissue, Interventional non-vascular /ecr2014/C-1241

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1 Effectiveness of Ultrasound-guided Platelet Rich Plasma (PRP) injections after needle tenotomy in the treatment of chronic tendinopathies : A prospective study. Poster No.: C-1241 Congress: ECR 2014 Type: Scientific Exhibit Authors: J.-C. Brichaux; Bayonne/FR Keywords: Inflammation, Athletic injuries, Treatment effects, UltrasoundColour Doppler, Musculoskeletal system, Musculoskeletal soft tissue, Interventional non-vascular DOI: /ecr2014/C-1241 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 12

2 Aims and objectives Prospective Evaluation of the effectiveness of Ultrasound(US)-guided needle tenotomy followed by an autologous platelet-rich plasma (PRP) injection in reducing pain and functional improvement for chronictendinopathy. Methods and materials Patients : 50 consecutive US-guided PRP injections after needle fenestration were performed for tendinopathy between January 2013 and november Inclusion criteria : Presence of lateral or medial epicondylitis, Achilles tendinopathy or Plantar Fasciitis with pain at palpation and during physical activity for at least three months and UTZ or magnetic resonance imaging (MRI) evidence of tendon degeneration. All patients had previously non satisfactory outcome with other conservative treatments (NSAIDs, US shock waves, local administration of corticosteroids). Exclusion criteria : Systemic disease (e.g diabetes, rheumatoid arthritis, coagulopathy, severe cardiovascular disease, infection, immunosuppression), intake of NSAIDs less than 28 days before the procedure. Clinical evaluation : By the same Orthopaedic surgeon or Sport medicine physician using the Visual Analogue Scores (VAS) scale which assessed pain and activity level. Clinical evaluation was performed in all cases : - Before treatment-after PRP and needle fenestration procedure at 4, 10 and 24 weeks using the same criteria. Page 2 of 12

3 - At the 6 month follow-up evaluation, overall satisfaction with the treatment was asked using a semi-quantitative scale (poor, intermediate, good, excellent). Ultrasound and Color Doppler evaluation : All studies were performed by one single experienced musculoskeletal radiologist using an IU22 Matrix scanner (Philips Healthcare) with various high-resolution transducers and frequencies depending on the specific tendon location (17-5 MHz). For each procedure, following parameters were recorded : - US data : Tendon thickness (compared to the contralateral normal tendon), presence or absence of hypo echoic area or fibrillar disruption or tear or calcification. - Color Doppler Flow Imaging data : area of hypervascularisation?. PRP preparation and injection procedure : All PRP were performed using the SmartPReP 2 APC+ 30 and 60 procedure packs (Harvest Technologies Terumo). 30 to 50 ml of blood was spun down using a centrifuge (after anticoagulation) and red cells were separated and removed. Residual plasma and buffy coat layer were then processed to yield approximately 3.5 to 6 ml of PRP. Sonography of the tendon was carried out before the injection to target the specific site for PRP injection. After skin disinfection and subcutaneous administration of local anesthesia (5 ml of 1% lidocaine), a 21Gauge needle fenestration of the tendon was performed under US guidance. PRP injectate was then injected in the center of the lesion under US guidance with both controlled axial and longitudinal images. Images for this section: Page 3 of 12

4 Fig. 1: Severe lateral epicondylitis in a 35 y.o man: Longitudinal US images at the origin of the common extensor tendon Pre therapeutic study: - Markedly hypoechoic area with fibrillar disruption - Large tendon tear in the center of the origin of the tendon Fig. 2: 10 weeks follow-up study after PRP and needle fenestration: - Decrease of tendon thickness and hypoechoic area - Improvement of fibrillar organisation - Disappearance of tendon tear Page 4 of 12

5 Results The initial population consisted of 50 patients (27 males and 23 females) aged 22 to 78. The cohort of patients was divided in 4 groups depending of the initial tendinopathy. Group 1 : Lateral Epicondylitis (n=28) Group 2 : Medial Epicondylitis (n=4) Group 3 : Achilles tendinopathy (n=6) Group 4 : Plantar Fasciitis (n=12) None patient had clinical complications Visual Analogic Score items for patients with tendinitis VAS PreTest mean PostTest W10 mean PostTest W24 mean Lateral Epicondylitis Medial Epicondylitis Achilles Tendinopathy Plantar Fasciitis Results : Group 1 (Lateral epicondylitis) n=28 - VAS score (mean) : Before treatment 8.1 to 2.7 at 10 weeks follow-up At 6 months : 25/28 were satisfied (excellent or good results) on the semiquantitative scale.. Poor n=1 / Intermediate n=2 / Good n=20 / Excellent n=5. 89% of all patients have clinical improvement - Among the group of 3 patients with poor or intermediate results, a second PRP injection has been performed Page 5 of 12

6 - Two of them experienced clinical benefit with a decrease of the VAS score from 4,8 to 3 at 3 months. - No results at 6 months were available at the time of publication and were excluded from the study. Results : Group 2 (Medial epicondylitis) n=4 - VAS score (mean) Before treatment 8.5 to 4 at 10 weeks follow-up At 6 months : 3 out of 4 patients were satisfied on the semi quantitative scale. Poor n=0 / Intermediate n=1 / Good n=2 / Excellent n=1. Too small number of patients to be significant Results : Group 3 (Achilles tendinopathy) n=6 - VAS score (mean) Before treatment 7.8 to 1.5 at 10 weeks follow-up At 6 months : 5 out of 6 patients were satisfied on the semi quantitative scale. Poor n=0 / Intermediate n=1 / Good n=3 / Excellent n=2. Clinical improvement and functional recovery at 6 months in 83% of the patients Results : Group 4 (Plantar Fasciitis) n=12 - VAS score (mean) Before treatment 8.9 to 3.2 at 10 weeks follow-up At 6 months : 8 out of 12 patients were satisfied on the semi quantitative scale. Poor n=2 / Intermediate n=2 / Good n=6 / Excellent n=2 Page 6 of 12

7 - Among the group of 4 patients with poor or intermediate results, a second PRP infiltration has been achieved. - Three of them (with poor and intermediate results) had clinical benefits with a decrease of the VAS score from 7, 6 and 4 respectively to 2, 3 and 3 at 3 months. - No results at 6 months are available and therefore are not included in these results - One of them was operated Discussion : - PRP was used first in oral and maxillofacial surgery but became more used for a wide variety of orthopedic procedures. - The goal is to stimulate and promote healing processes by placing higher than normal concentrations of autologous platelets and growth factors at the site of tendon damage. - The popularity of PRP have especially increased after receiving media attention for its use in professional athletes whose accelerated healing and return on the field was credited to PRP treatment. - Radiologists, especially those offering musculoskeletal ultrasound services in collaboration with sports medicine physicians and orthopaedic surgeons significantly increased the number of US-guided treatments for chronic tendinopathies, ligamentous or muscle injuries using PRP injections. - Tendinosis is due to repetitive stress, overuse, degeneration, which lead to painful conditions affecting the quality of live, impairing mobility. - Tendinitis is a inappropriate response occurring when breakdown of collagen fibers exceeds the rate of repair with collagen degeneration and fiber disorganization. There is hypercellularity, scattered vascular and neural ingrowth associated or not with paratendinopathy where an inflammatory process can affect the synovial tendon sheath or adventitial paratendon, but no histopathologic evidence of inflammatory cells. - Tendon healing is a slow process, and the resolution of symptoms precedes the end of healing process. Early return to full activity may lead to a progressive tendinosis. Page 7 of 12

8 - No consensus about best treatment exists and no conventional therapy directly addresses the underlying pathophysiology of degenerative tissue. - Eccentric-loading physical therapy is widely employed, despite the small number of high-quality research to support the clinical effectiveness of physiotherapy over other treatments. - Many injection therapies have been employed for chronic tendinopathies and dry needling is based like PRP injection or shock waves on the same principle that haemorrhage releases growth factors that initiate the healing response and disrupt the cycle of tendinopathy. - US guidance ensure precise needle placement as well as real-time visualization of needle fenestration, in the targeted area and allow correct PRP injectate distribution. - Our results like other studies involving ultrasound have reported a decrease in thickness, normalization of the hypoechogenic portions of the tendon after treatment and disappearance of tendon tear. - In lateral and medial epicondylitis, recent randomized studies of clinical outcome have demonstrated a significant difference in quality of life and pain scores as well as improved functional scores favoring the Harvest PRP injections groups in comparison with other types of injections (steroids injections). - Corticosteroid injections in tennis elbow may reduce pain in the short-term but delay long-term recovery suggesting that progressive healing may be responsible for clinical improvement in the PRP subjects. - Chronic Achilles tendinopathy is also due to overuse and characterized by degeneration process, and abnormal tissue repair affecting athletes and middle-aged individuals leading up to 25-45% of patients requiring surgery. PRP injections may be a minimally invasive option therapy in these cases. - Two recent meta-analyses of different injection therapies for tendinopathy both concluded that all treatments have promising effects, with the exception of steroids, which often showed relapse of symptoms in the long term. Page 8 of 12

9 - The group of our patients with Achilles tendinopathy have demonstrated a real improvement of pain score and functional levels. - Plantar fasciitis is a musculoskeletal disorder affecting the fascial enthesis and is the most common cause of inferior heelpain.the degenerative features are comparable to tennis elbow, Achilles tendinosis and there is no uniformly effective treatment of plantarfasciitis. Traditional conservative treatments (orthoses,nonsteroidal anti-inflammatory drugs, steroid injections) have a poor supportive clinical evidence. - Patients with poor improvement with conservative management may be candidates for PRP therapy. - Numerous studies have reported the clinical improvement after PRP injection using pain scores and semi-quantitative satisfaction scores. They also noted that ultrasonographydemonstrated significant changes in the plantar fascia at the end of the follow-up period. - Clinical research have to develop a standard PRP concentration, dose, and composition to clarify the current mixed results found in the literature. - In addition, developing a standard post-procedure protocol that involves short-term immobilization and appropriate rehabilitation would be important to promote the healing effects of PRP. - The limitations of this study is the relatively small number of patients, lack of randomized trial and the relatively short term of the follow-up. Images for this section: Page 9 of 12

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11 Conclusion - Our preliminary results are promising in lateral epicondylitis, Achilles tendinopathy and plantar fasciitis and lead to conclude that PRP injection under US guidance and after needle fenestration, significantly improves pain scores and functional outcome. - Ultrasound guidance in combination with needle fenestration enables direct targeting of the specific lesion and than increases the accuracy of the procedure. - Platelet-rich plasma US-guided injection is a safe procedure with no complications. - Ultrasound is helpful to manage the follow-up, demonstrating the remodeling of the tendinosis area in correlation to the healing process and the clinical improvement. Personal information The authors do not have and have not within the past 12 months had a financial interest or other relationship with a commercial organization that may have an interest in the content of this exhibit. References - Bernuzzi G et al. Use of platelet-rich plasma in the care of sports injuries: our experience with ultrasound-guided injection. Blood transfus. 2013; 3: Campbell R S et al. Radiological interventions for soft tissus injuries in sport. Bjr 2012; 85: Chiavaras MM et al. Ultrasound-guided tendon fenestration. Semin MusculoSkelet Radiol.Semin 2013; 17: De Vos RJ. Et al. Platelet-rich Plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010; 303: Page 11 of 12

12 - Ferrero G et al. Ultrasound-guided injection of platelet-rich plasma in chronic Achilles and patellar tendinopathy. Journal of Ultrasound 2012; 5: Finnoff JT et al. Treatment of chronic tendinopathy with ultrasound-guided needle tenotomy and platelet-rich plasma injection. PM R. 2011; 3(10): Halpern B.et al. The Role of Platelet-Rich Plasma in Inducing Musculoskeletal Tissue Healing. HSSJ 2012; 8: Harmon K.G. et al. The use of platelet-rich plasma in the nonsurgical management of sports injuries: hype or hope? Hematology2013; Hayter C et al. Injuries of the Elbow and the Current Treatment of tendon Disease. AJR 2012; 199: Kumar V et al. The Treatment of intractable plantar fasciitis with platelet-rich plasma injection. Foot 2013; 23 Jun-Sep: Lee KS et al. Musculoskeletal Applications of Platelet-Rich Plasma: Fad or Future? AJR 2011; 196: Loftus M. et al. Retrospective Analysis of Postinjection Ultrasound Imaging After Platelet-Rich Plasma or Autologous Blood: Observational review of Anatomic Distribution of Injected Material. AJR 2012; 199: Mishra K. et al. Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow: A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients. Am J Sports Med 2013;10:1-9 - Ragab EM et al. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012; 132: Ryan M. et al. Favorable Outcomes After Sonographically Guided Intratendinous Injection of Hyerosmolar dextrose for Chronic Insertional and midportion Achilles Tendinosis. AJR 2010; 194: Shiple B.J. How effective are injection treatments for lateral epicondylitis? Clin J Sport Med. 2013; 23: Titchener AG et al. Corticosteroid and platelet-rich plasma injection therapy in tennis elbow (lateral epicondylalgia): a survey of current UK specialist practice and a call for clinical guidelines. B J Sports Med 2013; : Vetrano M. et al. Platelet-Rich Plasma Versus Focused Shock Waves in the Treatment of Jumper's knee in Athletes. Am J Sports Med 2013; 41: Page 12 of 12