prp icl 16 - case presentation isakos 2013

Cell Therapy in Orthopedic and Cartilage Healing - New Frontiers

Rogerio Teixeira da Silva, MD. PhDChairman - NEO Orthopedic Sports MedicineSamaritano Hospital - São Paulo, BrazilDirector - Brazilian Orthopedic Society for Sports Medicine

Toronto, May 14th 2013

www.neo.org.br

http://docroger.blogspot.com

The Biological EraPLATELET RICH PLASMA / STEM CELL / TISSUE ENGINEERING

Cartilage Healing Example

1. Good environment

Scaffold / Clot

2. Good stem cell

Chondroblasts

3. Growth factors

PDGF, TGF beta

THE NEEDS FOR SUCCESSFUL TREATMENT

Case Report - Pro Tennis Knee Injury

23 yo, female, rk 1 in Brazil, rk 150 WTA in 2010

Partial lateral meniscectomy 7 months before

Pain + swelling after practice

Didn’t return to competitions after the prior surgery

Physical exam: effusion + pain at the lateral side

MRI - Chondral damage LFC grade 3-4

O QuickTime™ e umxvid descompressor

são necessários para ver esta imagem.

Case Report - Pro Tennis Knee Injury

Drilling + PRP

O QuickTime™ e umxvid descompressor

são necessários para ver esta imagem.

O QuickTime™ e umxvid descompressor

são necessários para ver esta imagem.

Drilling + PRP

O QuickTime™ e umxvid descompressor

são necessários para ver esta imagem.

Drilling + PRP

Aquiles TendinopathyPRP therapy for chronic tendon pathology for the aquiles tendon

Clinical EvidencePRP not better than placebo

Achilles tendinopaty with NO rupture (LE 1, PRCT)

2 groups (27 pts each) - ONLY tendon thickening

PRP (GPS II, Biomet®) vs Saline / Eccentric Training)

OBS: EXCLUDED PARTIAL RUPTURES

Clinical EvidencePartial Rupture - Aquiles (2011) - level 4

Clinical case

MC, 42 YO, AMATEUR TENNIS

RUPTURE - ACUTE

Male, 45 yo - Jan 2011

August 2011(7 months) Courtesy: JL Runco

Soccer, male, 47 yo - October 2006 - complete rupture

January 2007(3 months)

Courtesy: JL Runco

Tennis elbowPRP therapy for chronic tendon pathology around the elbow joint

Clinical Case 1 (amateur)FMC, 44 yo, male, elbow pain 8 mponths (PT + SWT without resolution of the pain)

Proposed treatment - US guided PRP injection (2ml) / non activated / tendon dry needling

4 WEEKS POS PRPNO SYMPTONS

Clinical Case 1 (amateur)

RTP AFTER6 WEEKS

2 year follow-up MRIA - MRI before treatment

(coronal, T2 fat)B - 2 year FU MRI(coronal, T2 fat)

RCCA, 66 yo, male, tennis player (8hs/week), pain at the R elbow during the last 2 years (PT 65 sections / acupunture)

Partial rupture 1,2cm (ERC tendon)

Clinical Case 2 (amateur)

5 WEEKS - PAIN VAS = 2

PRP injection (2.5ml) guided by US

PT after 5 days

Clinical Case 2 (amateur)

Rotator CuffUse of PRP injection for the treatment of RC patology (partial tears (articular) / tendinopathy

Clinical case - RC partial tear

RBF, 65 yo, male, amateur tennis player, R shoulder pain last 3 years (PT / acupunture / 2 CE infiltration)

Partial tear 1,0cm (PASTA)

Infiltration of 2.5ml of PRP - non activated

O QuickTime™ e umDVCPRO50 - NTSC descompressor

são necessários para ver esta imagem.

Clinical case - RC partial tear

Pain (moderate) during the first 3 days (analgesic drug for this period)

Pain decreased progressively

2 weeks FU: it is possible to sleep without pain

6 WEEKS - POSTNO PAIN

US showing no doppler active sites with healing

Clinical case - RC partial tear

Caso Clínico - MR (amador)

6 WEEKS - POSTNO PAIN

Muscle rupturePRP treatment for partial and complete muscle ruptures

Clinical Case - Tennis leg

FF, 44yo, male, business man, amateur tennis player

Pain at the R calf when running to the net (4 hours ago)

Muscle rupture (g.3) medial gastroc. (5 cm)

D D E D E

PRP injection guided by US (48 hours after the injury)

6ml (total)

O QuickTime™ e umMicrosoft Video 1 descompressor

são necessários para ver esta imagem.

Clinical Case - Tennis leg

Return to tennis = 3 weeks (no pain 1 week after the injection)

FU (2 years and 6 months) = normal

US (CONTROL) = 4 WEEKS

Clinical Case - Tennis leg

Knee OsteoarthitisPRP treatment for mild to moderate OA of the knee

Evidence - Level 2

Spakova et al, Am J Phys Med Rehabil 2012; 91: 411-17

Conclusions: Our preliminary findings support the application of autologous PRP as an effective and safe method in the treatment of the initial stages of knee osteoarthritis. Further studies are needed to confirm these results and to investigate the persistence of the beneficial effects observedLevel of Evidence: Level II, cohort prospective study

120 patients / HA vs PRP (up to 6 months follow-up)

Spakova � T, Rosocha J, Lacko M, Harvanova � D, Gharaibeh A: Treatment of knee joint osteoarthritis with autologous platelet-rich

plasma in comparison with hyaluronic acid. Am J Phys Med Rehabil 2012; 91:411-417.

Evidence - Level 1

Sanchez et al, Arthroscopy 2012; 28(8): 1070-78

Conclusions: Plasma rich in growth factors showed superior short-term results when compared with HA in a randomized controlled trial, with a comparable safety profile, in alleviating symptoms of mild to moderate osteoarthritis of the knee. Level of Evidence: Level I, randomized controlled multi-center trial

176 patients / RCT HA vs PRP (up to 24 weeks of follow-up)

Evidence - Level 1

Sanchez et al, Arthroscopy 2012; 28(8): 1070-78

Personal Experience

5 years - 365 cases (in protocols - RC, Achilles, Elbow, Patella, Muscle,

Chondral injury - knee)

- more than 6 months of pain, chronic, more than 2 treatments without

success, indication for surgery

* Tennis elbow paper: 78 cases - minimum FU of 1 year (clinical)

- 75,6% of the patients (59) return to play tennis (same level)

- average = RTP after 8 weeks and 3 days (5 to 16 weeks)

- Failure:

*Surgery on 8 patients (10,25%)

* Lost to FU or stop to play tennis = 11 (14,15%)

Adult Mesenquimal Stem Cell

New treatment, with old concepts = restore cartilage cells

- fat = a good source for harvesting the stem cell

- Lipoaspirate samples = perfect for culture (protocol = Baptista et al, 2009)

Adipose Mesenquimal Stem Cell

New treatment, with old concepts = restore cartilage cells

- fat = a good source for harvesting the stem cell

- Lipoaspirate samples = perfect for culture (protocol = Baptista et al, 2009)

Stem Cell - Tendons

Carvalho AM et al, 2011

Protocol - Chondral Injury (Knee)

Example of a grade III medial femural condyle chondral injury

- Arthroscopy + microfracture

- Harvesting - 150ml lipoaspirate (abdominal region)

- Sent to the lab for culture (air transportation)

- 4 to 6 weeks: cells are good for implantation

- Injection of 2 x 106 cells / 3 applications / 2 weeks intervals

Protocol - Harvesting Kit

FAT RECIPIENT(FOR STEM CELL)

BLOOD TUBES (4)(FOR PRP / TEST)

Protocol - Lipoaspirate

Protocol - Lipoaspirate

Protocol - Harvesting Kit

Stem Cell Injection + PRP

MISHRA ET AL, 2009

Stem Cell Injection + HA

SAW ET AL, ARTHROSCOPY PREVIEW 2013

Conclusions: After arthroscopic subchondral drilling into grade 3 and 4 chondral lesions,

postoperative intra-articular injections of autologous PBSC in combination with HA resulted in

an improvement of the quality of articular cartilage repair over the same treatment without

PBSC, as shown by histologic and MRI evaluation.

Level of Evidence: Level II, randomized controlled trial (RCT).

50 patients / Chondral injuries of the knee / Drilling + PBSC injections and/or HA

Stem Cell Injection + HA

SAW ET AL, ARTHROSCOPY PREVIEW 2013

18 MONTHS (PO)

The results can be promising

AT, 57 yo, male, runner (amateur), pain at the R ankle during the last 3 years

- Ankle arthroscopy 2 year ago: didn’t return to run after 1 year PO (still felt

pain for run / walk + swelling)

- THERAPY: Arthroscopy + microfracture + PRP + Stem Cell (patient

consent - initial study for protocol) - Able to run (12 km / week) = 6 months

6 MONTHSPRP + STEM

CELL

But...we need more research

Clinical protocols - 9 cases until now

(Chondral injury 6 - knee and ankle / OA 3)

- FU = 6 months

- Good results to control pain

- It seems that the coverage of the cartilage

defect is better (MRI view)

BUT = we need to WAIT to confirm our

HYPOTESIS

To PRP or NOT PRP = that’s the question

For me it is AN OPTION of TREATMENT

MEDICINE

“The science of transient solutions”...let’s see it in the future

Don’t believe in miracles in your life

PRP in my hands:

- helped me to solve some chronic tennis elbow

- help some patients that didn’t want to operate

(aquiles and elbow tendinopathy)

- help my PT team for pain control during rehab

(rotator cuff tendinopathy)

- stimulated myself to study biology

Rogerio Teixeira da Silva, MD, PhD

Orthopedic and Sports MedicineSao Paulo, Brazil

rgtsilva67@me.com

www.neoesporte.com