prp icl 16 - case presentation isakos 2013
DESCRIPTION
Lecture presented at the 9th Biannual Meeting, Toronto, Canada, May 14th 2013TRANSCRIPT
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
www.neoesporte.com