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advances in in-season care of the mcl sprain

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advances in in-season care of the mcl sprain

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    1. Autologous Conditioned Plasma in the Treatment of Sports Injuries Ariko Iso, MA, ATC Pittsburgh Steelers

    3. Biologics in Sports Medicine? Platelet rich therapies present significant opportunities as well as significant questions about appropriate clinical applications for this developing therapy & the legality of its use in professional sports ( OK in NFL & NCAA) WADA a different story A clear understanding of the repair response & the variables that may affect the effectiveness of ACP therapy is necessary to make informed clinical judgments on its use

    4. Platelet Rich Therapy Introduction Platelet rich therapies contain “HEALING” (growth) factors that accelerate the biologic processes necessary for repair of soft tissues following acute traumatic & overuse injuries Methods to deliver high doses of GF to injured tissue Platelet rich plasma (PRP) Autologous Condition Plasma (ACP) Both have in common a reliance on growth factor release from platelets

    5. Platelet Rich Therapy Introduction Most musculoskeletal injuries involve anatomic areas with minimal blood flow & low cell turnover rate Joint spaces, ligaments & cartilage have a naturally limited blood supply Muscle & tendons commonly experience decreased local blood flow following injury This imbalance of growth factor supply & demand hinders the regenerative process

    6. Ortho Biologics Platelet rich therapies allow for an opportunity to utilize the body’s own Healing (growth) Factors to improve the quality & speed of recovery from an injury.

    7. What was the turning point ? Hx: January 18, 2009 Pro Bowl wide receiver sustained a valgus stress to his right knee during the AFC Championship game Diagnosis Grade 2 MCL Sprain

    8. Case #1 MRI Findings MRI performed 1/20/09 Medial retinacular & grade II MCL tear Reported medial knee discomfort, FAROM, excellent quad sets Treatment: ACP #1 Game Ready Grade II MCL Tear

    9. Case #1 1/21/09 Reported no changes from yesterday Fitted for hinge brace Treatment: US 3MHz 20% Bike SLR #5 Game Ready Hybresis

    10. Case #1 1/23/09 Noted some improvement FAROM, Excellent Quad sets, decreased discomfort and echymosis Treatment: US 3MHz 50% Eliptical, Stair Master SLR #7.5 Game Ready Hybresis

    11. Case #1 1/26/09 ACP #2 Travel to Tampa Continue treatment and rehab Participate Super Bowl Functions 1/28/09 Noted improvement Denies pain or dysfunction

    12. Case #1 2/01/09 Pt denied knee pain Pt was cleared for practice at 10 days Pt returned to play 14 days after initial injury Tells Media in front of a national audience he had ACP which allowed him to play

    13. Healing Cascade Made Easy

    14. What Are Platelets? Fragments of cells originating from bone marrow that live between 5-9 days They contain growth factors & other molecules to control wound healing and homeostasis (clotting) When activated they release growth factors when they come in contact with damaged tissue (collagen) Platelet Activation

    15. How do GF work ?

    16. Basic Biology of GFs GF are proteins secreted by many different body tissues: connective tissue fibroblasts FGF, stem cells G-CSF, white cells cytokines, platelets PDGF VEGF, TGF, EGF, FGF also solid organs liver IGF1 All have a short half life with rapid disappearance Their effects are confined to the site of delivery GF are stored in the alpha granules of the platelets Platelets are the 1st to arrive at the injury site and they mediate the healing response This is why platelets are used as the delivery tool for GFs

    17. What is in ACP ? Platelet derived Activation leads to a-granule release a-granules contain: IGF-1 TGF-ß1 VEGF PDGF bFGF EGF Plasma derived-HGF,IGF-1 Minimal WBCs

    18. Important Growth Factors

    19. What Are Growth Factors? Proteins found in the body that assist in the healing and formation of hard and soft tissues. Functions: Promote cell migration/proliferation Promote collagen formation Stimulate angiogenesis Modulate matrix formation

    20. Growth Factors & Soft Tissue Healing: the literature Kurtz CA et al IGF-1 accelerates functional recovery from Achilles tendon injury in a rat model. Am J Sports Med 1999; 27(3): 363-9. 25 µg IGF-1 in methylcellulose gel carrier to transected rat Achilles tendons Restored function and reduced inflammation from 24 hours up to 15 days

    21. Growth Factors & Soft Tissue Healing Hildebrand KA et al. The Effects of PDGF-BB on Healing of the Rabbit MCL. Am J Sports Med 1998; 26(4): 549-54. Applied low and high doses of PDGF in fibrin sealant to ruptured rabbit MCLs, sham-operated knees in same animals as controls After 6 weeks, higher ultimate load of femur-MCL-tibia construct for high dose PDGF compared to low dose and fibrin sealant alone

    22. Growth Factors & Soft Tissue Healing PRP applied to ruptured Achilles tendons of a professional basketball & professional football players in conjunction with operative repair led to earlier return to play in 14 weeks Sanchez et al

    23. Growth Factors & Soft Tissue Healing PRP in the treatment of chronic elbow tendinosis resulted in: 60% pain improvement vs 16% in controls at 8 wks 2 year follow-up, PRP treated patients showed 93% improvement in pain, & 94% return to sport/work Mishra et al Am J Sports Med 2006;34

    24. Growth Factors & Soft Tissue Healing In ACP treated human muscle strain injury, there was complete versus partial regression of subjectively assessed MRI findings in ACP treated patients ACP treated patients RTS at a mean of 16.6 vs. 22.3 days in controls Wright-Carpenter et al, Int J Sports Med 2004 Wright-Carpenter et. al. reported:Wright-Carpenter et. al. reported:

    25. Biologics in Sports Medicine Has primarily focused on improving platelet/plasma delivery to areas of injury Practical challenges to use of biologics in sports medicine applications Cost containment Added time to the procedure Regulatory control Cost and time for development Quantifying results

    26. Lets look at the issues Practical challenges to use of biologics in sports medicine applications Cost containment - 150 dollars/syringe vs 600-800 PRP Added time to the procedure - 10 mins vs. 20 mins PRP Regulatory control - FDA approved for surgical sites Cost & time for development - done Quantifying results – many animal studies, human early but good with many centers now involved

    27. What are our options

    28. Platelet Rich Plasma Methodology first developed by Marx PRP The therapeutic outcome of a technique involving centrifugation of autologous blood which allows the extraction of plasma which contains a high concentration of platelets Additives Requires addition of an anticoagulant – Dextrose A, in order to prevent platelet activation prior to its use. Platelets are activated at the time of injection with the addition of Ca and Thrombin.

    29. PRP – How Does it Work? 2 Centrifugations 1st separates RBCs/WBCs from Platelets/Plasma 2nd separates Platelet Rich Plasma (PRP) from Platelet Poor Plasma (PPP) Still has White cells

    30. Platelet Rich Plasma PRP extract injected into damaged tissue Platelets begin secretion of growth factors within 10 min, 95% growth factors released within 1 hour Platelets are viable for 7 days and continue release of growth factors into tissue

    31. Our Answer is ACP by Arthrex Autologous Conditioned Plasma An easy to use double syringe system to concentrate platelets using a centrifuge We want the yellow plasma layer on top, not the red and white blood cells on the bottom Increased concentration of platelets & growth factors in the yellow plasma layer can alter the healing process QuestionQuestion

    32. What Does ACP Look Like?

    33. ACP VS PRP

    34. ACP vs PRP ACP advantages include: Easy to use system PRP system often require rep-support due to its complicated process Quick procedure time Double centrifugation process for PRP more than doubles procedure time Inexpensive PRP devices & syringes cost >2-6x as much as ACP equivalents Minimal required blood volume PRP systems require 60-120cc blood, ACP requires 10cc Has no additives Reduced level of RBC and WBCs Similar GF concentration to other systems

    35. HOW ACP is MADE

    36. Potential Risks of Using Growth Factors in Sports Medicine

    37. Potential Complications Fibrosis TGF-B1 regulates balance between regeneration & fibrosis Infection same as any injection Carcinogenesis Growth factors act on cell surface receptors, do not enter the cell, and do not cause DNA mutation Systemic effect on serum growth factor levels IGF-1 (HGH) too short a half life, isoformIGF-1Ea in PRP not responsible for muscle hypertrophy(IGF-1Ec &MGF), doses of IGF-1 are subtherapeutic in terms of anabolic action by a factor of 500 ( 300 ng vs. 160 ug) WADA does not get this YET Question on last paragraphQuestion on last paragraph

    38. Therapy vs Doping:IGF-1 content of PRP The unbound IGF-1 has too short a half-life to be able to exert systemic effects (10 min vs 16 hours) Isoform IGF-1Ea found in PRP is not the isoform principally responsible for skeletal muscle hypertrophy (IGF-1EC/MGF) Doses of IGF-1 in PRP are sub-therapeutic in terms of producing systemic anabolic actions by a factor of 500 (300ng vs 160 ug)

    39. How can biologics treat these injuries?

    40. Clinical Applications for Platelet Rich Therapies

    41. Clinical Applications for Platelet Rich Therapies

    42. Evaluated Methods of Concentrating Platelets Arthrex Double-Syringe® Autologous Conditioned Plasma (ACP) 10 cc blood/yield = 3cc product Biomet GPS® II Platelet Concentrate System 27cc blood/yield = 3cc product Musculoskeletal Transplant Foundation CASCADE® Autologous Platelet System 9cc blood/yield = 2cc product Platelet Rich Plasma (PRP) – Literature Based Platelet Concentration Method 10cc blood/yield = 1.5 cc product

    43. Platelet Concentrations

    45. Why with a 4 fold increase in platelets is there no difference in tendon growth?

    46. Platelet to White Blood Cell Ratio

    47. WHY ? It is all about the ratio of Platelets to WBCs in the solution 2000 (platelets) to 1 (WBC) appears to be the correct ratio What is the ratio in ACP? 2000 to 1 That is why even though you have more platelets in other preparations you do not get an additive effect on cell proliferation

    48. Effects of Leukocytes (WBC) on PRP Effectiveness Contaminating WBCs contribute to the overall GF content of PRP.2,3 WBCs are believed to be contaminants in PRP.2 The # of WBCs in PRP critically effects the production of destructive lysosomes & cytokines in PRP.1 Little is known about in vivo effects of contaminating WBCs in PRP & their specific cytokine & GF content.2

    49. HOW WE USE ACP Performed in Team Physician’s Office Draw 10 ml of blood without ACD-A (less pain with injection) Use 3-5 ml of platelet extract for injection Direct injection at site of injury (blind) Digital MRIs, CT guided or Ultrasound for localization Typically 2 to 3 injections between 5-7 days apart

    50. STEELERS ACP USE

    51. Case Example # 2 Date of Injury 8/22/09 History 23 year old, professional NFL quarterback Right hand dominant Mechanism of Injury: tackled & landed on right shoulder

    52. Case #2 Diagnostic Studies (8/23/09) Demonstrate Grade III AC separation Plan Ice applied to shoulder Pt placed into a sling for comfort

    53. Case #2 8/24

    54. Case # 2 8/25/09 50 hours after initial injury Athlete received 1st of 3 ACP Injections to right AC joint

    55. Case #2 8/25/09 Training Room Clinic Hour He is doing well with minimum discomfort Long discussion regarding Dos and Don’ts With his position and the degree of sprain, although he is exceptionally doing well at this time, we will progress slowly. Focus on passive ROM rehab

    56. Case # 2 Patient returns 1 week later and reports no pain with shoulder ROM Examination Mild tenderness at AC joint No pain with shoulder ROM Plan Patient given 2nd ACP injection Patient slowly progressed to throwing

    57. Case # 2

    58. Case Example # 3 History 27 year old NFL running back c/o pain & a “pop” sensation in hamstring Unable to return to play due to pain & difficulty running Date of Injury: 8/6/09 Examination Non antalgic gait (+) pain with resistive hamstring strength @ 45 degrees Good knee ROM (-) Plank Test

    59. Case #3 Diagnostic Studies Grade II hamstring strain Plan Athlete given ACP injection under sterile conditions to hamstring 24hours after injury

    60. Case # 3 8/13/09 Athlete returns for second ACP injection Reports decrease in pain Examination + pain with hamstring manual muscle testing @ 45 degrees

    61. Case # 3 Athlete reports he is improving but not yet at 100% Examination No pain at 10, 45 or 90 degrees (-) Plank test Plan Athlete given 3rd ACP injection under sterile conditions 8/20/09)

    62. Case # 3 Summary Date of Injury: 8/6/09 Athlete reports significant improvement in hamstring strength 20 days after injury Examination 5/5 hamstring strength No pain at 10, 45, or 90 degrees Plan Athlete allowed to return to practice/games

    63. Case Example # 4 History Date of Injury: 8/05/09 26 years old NFL WR experienced “grab” while he was accelerating out of a break running pass route Examination 4/5 hamstring strength Drag 7/10 No deformity, mass edema or echymosis MMT: deferred due to pain

    64. Case # 4 8/6 09 MRI was performed Biceps Femoral middle distal 1/3 Grade II strain First ACP treatment Rest and Ice

    65. Case # 4 8/7/09 Noted pain with normal daily activities No obvious edema, echymosis Decreased PROM by 20% MMT 5-/5 at knee flexion 90 deg. 4/5 at knee flexion 30 deg. Treatment: Bike Standing ham curl Bridging Walk forward and backward on the field Game Ready

    66. Case # 4 8/11/09 Second ACP injection Rest and ice, resume rehab on 8/12 8/12 09 PROM hip flexion decreased by 10-15 % MMT: 5/5 90 deg. hip flexion, 4/5 4/5 hip flexion Bike Lower body lifting Striders and agility drills during practice

    67. Case # 4 8/15/09 Participate practice (individual portion) Denies soreness from previous day rehab Continue lift and treatment 8/16/09 Participate full practice as pain allows 8/27/09 Injury closed

    68. SUMMARY Ageing: the bodies repair system slows Early studies show ACP can alter it Basically, kick start the healing process Follows KISS Principle This is the evolution from surgical to biologic repair Amount, frequency & quantity of growth factors are being investigated

    69. Conclusion The use of ACP promises to become a powerful therapeutic modality for use in muscle, tendon, bone & ligament injury This technology is still in its infancy with respect to musculoskeletal injuries & further studies to characterize its potential role on improving healing are now ongoing

    70. Thank You

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