Injections Intra-Articulaires « Single Shot »Injections Intra-Articulaires « Single Shot »de Facteurs de Croissance et de Facteurs de Croissance et

d’Acide Hyaluroniqued’Acide Hyaluronique

Concept de « VISCO-PRP » (AH + PRP)Concept de « VISCO-PRP » (AH + PRP)Philippe ADAM Michel NOAT Olivier MAY

Clinique Médipole Garonne (novembre 2014)

1/Collagen Synthesis (cartilage, fibro-cartilage)

2/Growth/migration/recruitment of Cells

3/Neo-angiogenesis (péricytes, MSC)

4/Protein Matrix

Growth Factors Effects (platelets,wbc) « Tissue Healing is boosted »

PRP riche PRP riche en facteurs de en facteurs de croissance croissance

2014- SV © Regen Lab Données issues de Borrione et al Am J Med Rehabil 2010;89:854-861

TGF-beta

Transforming Growth Factor β

Stimule la prolifération cellulaireFavorise la production de matrice extracellulaire (collagene I & III)Stimule l’ angiogenèse

PDGF-AB

Platelet-Derived Growth Factor

Stimule la prolifération cellulaireStimule le chimiotaxisme des fibroblastes

bFGF Basic Fibroblast Growth FactorStimule la prolifération des

fibroblastes

VEGF Vascular Endothelial Growth

FactorStimule la prolifération et la migration des cellules endothéliales, angiogenèse

EGF Epidermal Growth Factor

Stimule l’ angiogenèseContrôle le renouvellement de la matrice extracellulaireStimule la migration et la prolifération des fibroblastes

IGF (plasma)

Insulin-like Growth Factor

Stimule la prolifération cellulaireFavorise la synthèse de collagene et de matrice extracellulaire, remodelageStimule la migration des fibroblastes

Intérêt Visco-PRPLe PRP a un effet anti-inflammatoire naturel (secrétion de cytokines

anti-inflammatoires)

PRP : « le corticoide sans les inconvénients »

Il a de fait un effet antalgique

On connaît aussi son effet antibiotique

L’article de Sundman et l’expérience pratique de 3 ans de recul démontrent que l’association thérapeutique AH exogène + PRP autologue est très intéressante par effet de sommation (douleur, fonction)

Le PRP favorise par ailleurs la synthèse d’AH endogène

HOW TO PREPARE PRP-HA CELLULAR MATRIX ? THE STEPS : Very fast Procedure !

1/Blood puncture2/Centrifugation : 5 mn / 3500

3/Turning round PRP & HA to obtain & homogenize the cocktail (≥4 cc)

After withdrawal of full blood

After centrifugation

After homogenization

HA

PRP

CELLULAR MATRIX (PRP-HA, class III material device)

Sampling before injection4 cc (2 ml PRP + 2 ml non cross linked HA)

Comparaison des Kits de prélèvement

Les Méchants GB

Et les Bons GB

Et les Bons GB

L’élément majeur est la pauvreté en Neutrophiles

des produits Regenlab (efficacité/disparité littérature)

Mode Opératoire de l’Injection Articulaire : CT ou RX ou US (analgésie, MEOPA)

CT ou RX : bulle d’air, voie postéro-médiale ou latérale selon siège méniscarthrose genou, voie sous-rotulienne, voie antérieure hanche/cheville/épaule, coude….poignet….rachis….

Il faut être dans l’articulation et prés de la lésion !

Les cibles de la Visco-PRP

1/Lésions méniscales stables stade II et III sur genou stableMénisques suturés à risque, Kystes méniscaux

(Ph ADAM, M Noat, Biobridge Venise, Septembre 2013)Kyste méniscal

Classification IRM

*Peripheral Vascularity seem to play an important role in meniscal healing*But deep meniscus is also soaking into the joint fluid !*Therefore growth factors can impact meniscal healing by stimulation of vascular proliferation and by impregnation

R R R W WW

Results and Profits of « PRP therapy »for meniscal lesions

* Positives : 92% for group 1 (grade III, meniscal cyst : 116/126)

Clinical aspect : Constant antalgic effect of PRP (anti inflammatory effect of growth factors), better joint ability

Imaging aspect : reduced inflammation of the joint , decrease or stabilization of meniscal lesion (cyst, cleft)

Failures (10/126) are owed to a bad evaluation of lesional stability(a good diagnosis by imaging is essential+++)

* Positives : 100% for group 2. We can improve the rate success for meniscal suture

Remote Evaluation of the Efficiency

Anterior horn cyst of LM january 2013

Anterior horn cyst of LM may 2013

Meniscal Lesions : Clinical Cases

LM before and after suture completed by PRP injection (bucket handle) : no scar is visible !

before

after

1/Big functional disability, pain 4/10, 64 years old 2/walk normally, pain 0/10

After PRP : Inflammation Decrease

(paratibial fluid collection)

Improved medial meniscal structure

Before PRP After PRP

Cleft and Cyst of MM (ultrasonography)One month after PRP

Running, postural internal pain (6/10) Grade III lesion of MM (before PRP)

At one month : decreasing pain (0/10) decreasing size and intensity of meniscal cleft

Dr JLRenevier Hôpital de Meulan

Dr Jean-François MARC 42300 Roanne

Dr Philippe ADAM Médipôle Garonne 31100 Toulouse

Dr Jacques LE COZ 75014 Paris

Dr Ivan PROTHOY Polyclinique des Alpes du Sud 0500 Gap

Pr Nicolas SANS Hôpital Purpan Place du Dr BaylacTSA 40031 31059 Toulouse

Biobridge Venise Septembre 2014

Les cibles de la Visco-PRP

2/Arthrose du genou : stades non chirurgicaux, nombreux échecs de la visco simple

Si nécessaire assécher l’articulation avant (ponction + corticoides)

RESULTS

RESULTS*87.3% improved after the study patients

*There is a significant difference in the average WOMAC A1 before the start of treatment and pain 36 weeks after starting treatment

*This difference was also significant between the first and the second injection and between the second and third injection. *There is no significant difference in pain scores as the radiological grade (II-III) *No significant side effects reported.

Partial meniscectomy / Arthritis (woman 52 yo) /axial plane

May 2013 pain 8/10

August 2013 pain 0/10

« Méniscarthrose »

Woman 40 yo, overweight, internal pain 4/10 MRI at one month, pain 0/10

Obvious decrease of the oedema of the

internal condyle

Slight modification of the signal of medial

meniscus

Le marqueur de la douleur c’est l’œdème

en IRM

Dysplasia and/or Impingement

If impingement : Cam effect/Pincer effect/ or Mixt

Cartilaginous +/- fibro-cartilaginous labral lesions

Sport Practice

Surgery before CM injection for impigement

Failure of NSAIDs and classic visco-supplementation

Les cibles de la Visco-PRP

3/Arthrose de hanche : conflits, complémentaire ou alternative à la chirurgie (labrum)

Oxford Score : Synthesis

Mean score before injection is 30 (moderate)

Mean score after two injections is 37,6 (mild) : 25% increase

6/13 have satisfactory joint function (46%) after 2 injections

No side effects after CM injection

Good progress and improvement specially for patients with impigement (37% versus 17% for other group)

Separated case 14 (cam) : before 16 (severe), and after one CM injection 37 (mild, over 50%)

Conclusions of the study

Case 1 : soccer player, M 43 yo, no impigement, Tönnis 2, oxford 31/34/41 (32% improvement)

French XV International Rugby Player : Traumatic lesion of labrum (acetabular tear/oedema), AH only no result, PRP at one month rapidly

permit decreasing of pain, normal function, with no recurrence over one year

oedema

Labral tear

No oedema

Labral and Meniscal Treatment by Visco-PRP is the Same fight !

1/ Preventive Labral Treatment is so efficient as meniscal

2/ Hip Labral-Arthritis = Knee Meniscal-Arthritis

3/Save labrum = Protect hip and slow down arthritis

Detection of pre-arthritis and Preventive Treatment are the Goal in the Young !

1/ Corrective surgery to avoid prosthetic device

2/ 40% arthritis (hip) under 50 yo considered as « idiopathic » : Not detected Impigement ?

3/ Visco-PRP (HA + PRP) complete corrective surgery

Which is the new deal for Degenerative Arthritis ?

Early Screening(bio-markers+++)

+ Early Treatment

= Prevention and Efficiency

Visco-PRP Surgery