ultrasound-guided regenerative medicine procedures: pandora or panacea ken mautner, md director,...
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Ultrasound-guided Regenerative Medicine Procedures:Pandora or Panacea
Ken Mautner, MDDirector, Primary Care Sports MedicineEmory Sports Medicine
Goal of talk “I would like you to talk about stem
cells and PRP, the evidence for them in tendons and joints, and why ultrasound guidance is important”
Jon Finnoff, DO
Do it less than 20 minutes !
Outline Ultrasound guidance for regenerative
medicine procedures Dangers of steroids in treating tendinopathy Regenerative injections for recalcitrant
tendons Needle Tenotomy PRP Stem cells
Regenerative Medicine for Cartilage/OA (knee) 1-2:30 pm today!
Is ultrasound guidance needed for regenerative medicine procedures ?
Accuracy
Efficacy
Cost-effectiveness
Reactive vs
Degenerative Tendon
What is ideal way to treat tendinopathy?
“Old School” Treatments Rest Ice Immobilization NSAIDS Physical Therapy/ biomechanics Possible corticosteroid Injection (CSI) RTP when pain free/ functional
But is tissue healed? If symptoms persist
Surgery
LACK OF EVIDENCE FOR TRADITIONAL TREATMENTS
Lancet, 2010
Lancet, 2010
JAMA, 2013
What is ideal wayto treat tendinopathy?
Evolving algorithm -- “New School” Pathology specific conservative treatments
NSAIDS If inflammatory Mechanotransduction for tendinosis
Eccentrics exercises IASTM/ CFM/ART Nitric Oxide ESWT
Regenerative intervention Percutaneous needle tenotomy (PNT) High Volume Injection (HVIGI) Scraping PRP TENEX (FAST) ADSC +/- PRP BMAC
TIMING OF INTERVENTION AND TYPE OF INTERVENTION HAS NOT BEEN FIGURED OUT
Percutaneous Needle Tenotomy (PNT) and
Platelet Rich Plasma (PRP)
PNT (needle tenotomy) for lateral epicondylosis
McShane et al, Journal of Ultrasound Med. 2006
Ultrasound guided PNT with steroid for chronic lat. epicondylitis Failed conservative tx
58 pts-- avg f/u 28 mo. 80 % Good or
Excellent Outcome 85% would refer friend
or family for procedure
McShane et al, Journal of Ultrasound Med 2008
Ultrasound guided PNT without steroid for chronic lat. Epicondylitis Failed conservative tx
57 pts --avg f/u 22 mo. 92% Good or
Excellent Outcome 90% would refer friend
or close relative for procedure
PRP for chronic lateral epicondylosis
140 pts evaluated for lateral epicondylosis 20 had refractory pain an avg. of 15 months later
15 in treatment group, 5 in bupivicaine control group
Intervention– Injection w/ autologous PRP once into common
extensor tendon followed by gradual increase in rehab program through 4 weeks after which full activity allowed
Outcome– A 46%, 60% and 81% improvement in VAS pain scores
at 1, 2 and 6 months respectively in tx group– 3/5 in bupivicaine group withdrew/ sought other tx– At final F/U (12-38 months) 93% pain free (<10/100
VAS)– No complications, no one got worse
AJSM, 2006
Pts age 16-70 (avg 48 yrs) Greater than 6 months of pain (avg 36 months) Diagnosed by clinical exam plus MRI or
diagnostic US Failed conventional treatments
Medications Bracing Stretching Strengthening CFM Modalities
PRP done under US guidance
PMR journal, 2013
Data of PRP procedures
325 patients with isolated tendinopathy sent questionnaire
Eliminated all non tendons and regional PRP treatments
180 responded (55%) All retrospective data analyzed with following
questions: Overall improvement
Not at all, slightly, moderately, mostly, completely VAS score –pre and post Overall satisfaction Nirchl phase scale
Distribution of Tendons Lateral Epicondyle 30Patella Tendon 27Achilles 27Rotator Cuff 21 Hamstring 17 Gluteus Medius 16 Medial Epicondyle 11 Plantar Fascia 9 13 other tendons <5 each
Improvement
82% reported moderate to complete improvement
– 50%- 100% relief of symptoms70 % reported mostly to complete improvement
-- 75-100% relief of symptoms
Pain Score pre and post PRP
➤ 74% Reduction in VAS
7.3
2.1
Why are we still debating if orthobiologics works?
Need to define what we are injecting ? Platelet counts
MSC counts Leukocyte +/ -
Differential RBC +/ RBC – Autologous/ Allogenic
Need to define the procedure US guidance Needle tenotomy?
Rehabilitation methods Immobilization ? Timing of eccentrics
Do different body regions require different formulas ?
Slide from 2011
____________________________1 If WBC are present (+) the % of neutrophils should also be reported.2 The method of exogenous activation should be reported.
April, 2015
• 80 patients randomized
• PRP vs Placebo• ACP vs saline
• 2 injections 5 days apart• 5 days after injury
• End point was RTP• No difference• Average 42 days
2014, Reurink
RehabilitationL+ PRP
42 days vs 26 days
Why the difference ?
MY TAKE:L+ PRP may reduce recovery from acute hamstring muscle injury
Is it the Needle?
AJSM, 2013
PRP vs PNT for RTC pathology
DBRCT comparing 2 PNT vs 2 PRP injections under US guidance for RTC tendinosis or small, partial tear
Measured results using Shoulder Pain and Disability Index
Clinical Rehabiliation, 2012
60 patients randomized to US- guided injection of PRP vs no injection on POD 7, 14
Outcomes tracked through 16 wks MRI done at 16 wks RESULTS:
PRP did NOT improve early fxnl recovery, ROM, or strength
NO difference in structural integrity at 16 wks. Did not look at long term outcomes….
AJSM, 2015
Stem cells for Tendinopathy
April, 2015
Stem Cells for soft tissue
Surprisingly few clinical studies examining stem cells use for soft tissue injuries Many more studies looking at cartilage Soft tissue studies predominantly
involve PRP Early clinical studies promising but
much more work needed in the area.
46 pts, 60 patellar tendons
Dermal fibroblasts Cultured for 4 wks
Injected in autologous plasma
US guidance usedCompared to autologous
plasma only
AJSM, 2011
• Is it worth it?• High cost• Lag time (4
wks)• Regulatory
issues
45 patients in received BMC during single-row arthroscopic RTC repair 51,000 MSC +/- 25,000
45 age matched controls Up to 10 years follow up with MRI imaging RESULTS:
6 mo 100% of MSC group healed 67% of control group healed
10 years 87% of MSC group with intact RTC 44% of control group
Results most correlated with MSC concentration
Conclusions Needle tenotomy is effective for tendinosis
US guidance will improve accuracy Tenotomy helpful no matter the injectate
Saline, WB, ACP, PRP, Stem Cells PRP may have better results than needling
alone Unsure if related to pathology (tendinosis vs tear)
Stem cells may have better results than PRP/ needling No head to head studies Is it worth the cost and increased risk to perform
this procedure for tendons ? I rarely utilize stem cells as a first line treatment
for recalcitrant tendinopathy