Ultrasound-guided PRP injections in tendinopathy
treatment.
Poster No.:
C-0439
Congress:
ECR 2017
Type:
Educational Exhibit
Authors:
C. Morandeira, J. L. Del Cura Rodríguez, R. Zabala Landa, N.
Nates Uribe, I. Korta; Bilbao/ES
Keywords:
Athletic injuries, Technical aspects, Diagnostic procedure,
Ultrasound, Musculoskeletal system, Interventional non-vascular
DOI:
10.1594/ecr2017/C-0439
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Page 1 of 20
Learning objectives
The aim of this study is to review the role of Platelet-Rich Plasma (PRP) in tendinopathy
therapy.
Background
Tendons are subjected to high mechanical forces due to their function in movements and
transmitting muscular forces between bones and muscles (1, 3).Therefore, tendinopathy
has a high prevalence, especially in Achilles, rotator cuff, patellar and forearm extensor
tendons because of their overuse (2). The tendinopathy changes that occur in these
patients are discontinuous, disorganized and hyper vascular collagen fibbers that can be
seen in echography imaging (1, 3).
Ultrasound-guided PRP´s injection is an emerging treatment in these patients because
it contains bioactive factors, such as growth factors (TGF-B, HGF…), proteins (albumin,
globulins, fibrinogen…) and cells (leukocytes, neutrophils, and monocytes) that influence
in tendon healing (1-3). In laboratory studies, PRP permits tenocytes proliferation and
differentiation and has anabolic, anti-inflammatory and antibiotics effects (5). In animal
and human studies, it enables to activate, modulate and optimize the healing process.
Consequently, tendon tissue recovery is shorter and more efficient.
Up to now, a number of studies have been published demonstrating its efficacy.
Nevertheless, there are no high quality and big-scale studies. The main biases of
discussion are the type of tendon and the severity of the tendinopathy that should be
treated. In addition to this, differences in the elaboration of PRP make the results very
variable, thus making the treatment a matter of discussion.
Findings and procedure details
Procedure details:
To obtain PRP we use TriCell system (Tricell Plasma Products Apire Medical products).
First of all, we obtain approximately 27 ml of peripheral blood from the arm of the patient
by venepuncture using a sterile technique In women, 3ml more are dawned due to their
lower plasma volume and haematocrit.
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Next, the blood is mixed with 3 ml of ACD-A anti-coagulant.
Then, the mixture obtained is introduced in the first of a 3-chamber device and centrifuged
twice at 3200 rpm ( Fig. 2 on page 8 ). The first centrifugation takes 4 minutes and
it´s objective is to separate patient´s blood in 3 layers that are from top to bottom due to
their weight ( Fig. 3 on page 9 ):
•
•
•
Plasma
Buffy coat containing platelets
Leukocytes and red-blood cells
We use PRP technique, thus we include plasma and the entire buffy coat containing
platelets in the second plasma chamber ( Fig. 3 on page 9 ). To do this, we close
leucocytes and red blood cells chamber and the device is centrifuged for the second time
upside-down during 2 minutes. Nevertheless there are other techniques such as PCP
(platelet conditioned plasma) where only a small portion of the buffy coat is mixed with
the plasma chamber) and PLC (platelet lite concentrate) where a minimal portion of the
buffy coat is united to the plasma chamber).
rd
After this, approximately 2 or 3 ml of PRP are obtained in the 3 chamber and this fluid
is extracted from the device. This PRP is activated with 1 ml of CaCl.
Finally, we use ultrasound to target the areas where the tendinopathy changes are more
evident and we inject the activated PRP in these areas using US-guidance ( Fig. 3 on
page 9 ).
We advise the patients not to carry out any exercise that involve the treated tendons for
three weeks and no anti-inflammatory drugs are prescribed.
Findings and indications:
The therapy objective is to accelerate the tendinopathy´s cure and consequently reduce
pain and restore early the tendon´s function. We have used it to treat tendinopathy, but
also partial tears in Achilles tendon, shoulder, elbow, knee and ankle and hip pain:
Achilles tendon:
Page 3 of 20
Published studies indicate that PRP injections in Achilles tendon are a good treatment
for tendinopathy (1-4). They permit clinical and radiological improvement (3, 4), mainly
when the disease is treated in an early stage (1, 2).
We performed 43 PRP- infiltrations in 24 patients.
The main echographic findings in these patients were thickening and lost of normal
fibrillar structure in distal region of the tendon, associated with enthesophytes and
neovascularity in Doppler-study. In addition to this, the most advanced cases also
presented hiperechogenicity in Kager´s fat and pre- Achilles bursa distension ( Fig. 4 on
page 6 ).
6 of the patients had a complete resolution of the pain and 17 of them had partial
resolution of it.
Nevertheless, one patient was complicated with a complete rupture of the tendon one
week after the procedure and needed surgical reparation ( Fig. 5 on page 6 and Fig.
6 on page 7 ).
Shoulder:
The efficacy of the procedure in the rotator cruff tendons remains contradictory; there
are studies with high standard of proof (3, 6) but there are also other studies that insure
the opposite (3).
We infiltrate 23 patients in 37 procedures, 34 were done in the supraspinatus tendon and
3 in the subacromial bursa.
Ultrasound exploration of supraespinous tendon was performed with the arm extended
or internally rotated. It showed inhomogeneous echotexture of supraspinatus tendon
near it´s insertion, where a cortical irregularity of the insertional area was depicted.
Furthermore, focal hipoechogenicities due to tears were demonstrated as well as
subacromial bursa distensions. Moreover, some patients described calcific tendinosis
with focal hiperechogenic mass with acoustic shadowing inside the tendon ( Fig. 7 on
page 10 and Fig. 8 on page 11 ).
The result was a partial response to the pain in 20 patients presented and no response
in 3 cases.
Elbow epicondylitis:
Page 4 of 20
Only a small number of series are found in the literature; thus the support PRP treatment
in epicondylitis (3).
Technique was executed 9 times in 5 patients.
Diagnostic findings of epicondylitis were diffuse tendon thickening of common extensor
tendon associated with lost of normal fibrillar structure, mainly in the deeper fibbers,
and intrasustance hyperaemia. Highly- developed findings were partial tears or complete
avulsion defined as linear hipoechogenicity and radical collateral ligament injury ( Fig. 9
on page 12 ).
Finally, 4 patients presented partial pain response and 1 had no response.
Knee:
According to the patellar tendinopathies, publiseg studies are favourable (2, 3).
Nevertheless, some of them advice associated physiotherapy to improve pain (3)
17 procedures were performed in 7 cases
Patients presented thickening of patellar tendon and hiperechogenicity and high Doppler
signal in Hoffa´s fat ( Fig. 10 on page 13 ).
Partial resolution of the pain was obtained in all the patients.
Others:
Furthermore, in also use it in special occasions such as:
•
•
•
•
Achondroplasic woman with important degenerative changes in both hips,
with no response to treatment ( Fig. 11 on page 14 ).
Young athletic women with important pubis symphysitis with partial response
to the pain ( Fig. 12 on page 15 ).
Young athletic man with an ankle sprain, with very good result in tendon
healing ( Fig. 13 on page 16 ).
Posterior tibial and peroneal nerve in a patient with nerve entrapment after
tibial pilon fracture with partial response to the symptoms ( Fig. 14 on page
17 ).
Page 5 of 20
PRP injections are a safe technique, with no adverse effects known. We only had one
complication. It is a low invasive procedure, easy to use, painless and has a relatively
low cost.
Images for this section:
Fig. 4: Achilles tendon
© - Bilbao/ES
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Fig. 5: Achilles tendon complication
© - Bilbao/ES
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Fig. 6: Achilles tendon complication
© - Bilbao/ES
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Fig. 2: PRP technique details
© - Bilbao/ES
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Fig. 3: PRP technique details
© - Bilbao/ES
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Fig. 7: Rotator cuff
© - Bilbao/ES
Page 11 of 20
Fig. 8: Rotator cuff
© - Bilbao/ES
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Fig. 9: Elbow epicondylitis
© - Bilbao/ES
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Fig. 10: Patellar tendon
© - Bilbao/ES
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Fig. 11: Hip
© - Bilbao/ES
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Fig. 12: Pubis symphysitis
© - Bilbao/ES
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Fig. 13: Deltoid ligament
© - Bilbao/ES
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Fig. 14: Ankle nerves
© - Bilbao/ES
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Conclusion
PRP ultrasound-guided injection is a promising technique for tendinopathy treatment.
Randomised controlled scientific studies are needed to generalize results.
Images for this section:
Fig. 15: Conclusion
© - Bilbao/ES
Page 19 of 20
Personal information
Clara Morandeira Arrizabalaga
Hospital Universitario Basurto
[email protected]
References
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