D’Apote Giulia, Conti Linda, Lullini Giada, Sforza Teresa TRATTAMENTO DELLA TENDINOPATIA DELL'ACHILLEO CON APPROCCIO RIABILITATIVO INTEGRATO D’Apote Giulia, Conti Linda, Lullini Giada, Sforza Teresa ISTITUTO ORTOPEDICO RIZZOLI

THE REPAIR RESPONSE OF MUSCULOSKELETAL TISSUES GENERALLY STARTS WITH THE FORMATION OF A BLOOD CLOT AND DEGRANULATION OF PLATELETS, WHICH RELEASES GROWTH FACTORS AND CYTOKINES AT THE SITE REPAIR MECHANISM

GROW FACTORS MANY OF THESE FACTORS HAVE BEEN SHOWN TO ENHANCE ONE OR MORE PHASES OF TISSUE REPAIR AND OSTEOGENESIS PDGF, EGF, AND FGF-2 HAVE BEEN SHOWN TO STIMULATE PROLIFERATION OF OSTEOBLASTIC PROGENITORS TGF-B INCREASES MATRIX SYNTHESIS (EG, TYPE I COLLAGEN) IN VITRO AND IN VIVO ANGIOGENIC FACTORS, INCLUDING VEGF AND FGF-2, CAN POTENTIALLY ENHANCE EARLY ANGIOGENESIS AND REVASCULARIZATION, AS SUGGESTED BY A RECENT STUDY EXAMINING BLOOD VESSEL FORMATION IN LARGE SEGMENTAL DEFECTS IN THE TIBIAS OF RATS TREATED WITH PLATELET-RICH PLASMA (PRP)

PLATELET RICH PLASMA (PRP) PLATELET RICH PLASMA (PRP) HAS BEEN DEFINED AS A VOLUME OF PLASMA THAT HAS A PLATELETS CONCENTRATION ABOVE PHYSIOLOGIC LEVEL RECENT STUDIES HAVE ESTABLISHED PRP PROMOTES ACCELERATION OF WOUND REPAIR BY MEANS OF GROWTH FACTORS PRESENT IN THE PLATELETS, WHICH ARE THE UNIVERSAL INITIATORS OF HEALING PROCESS ( Anitua et al. Journal Orthopaedic Research 2005 )

Am J Sports Med. 2006 Nov;34(11):1774-8 PRP APPLICATIONS ORTHOPEDICS SPORTS MEDICINE DENTISTRY DERMATOLOGY OPHTALMOLOGY PLASTIC SURGERY TENDINOPATHIES EPICONDILITIS Am J Sports Med. 2006 Nov;34(11):1774-8 Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Mishra A, Pavelko T.

TENDINOPATHIES ACHILLE S PATELLAR T. PLANTAR FASCITIS

JOINTS KNEE ANKLE

PATHOLOGICAL CLASSIFICATION STAGE 1 PERITENDINITIS PERITENDINITIS AND TENDINOSIS STAGE 2 STAGE 3 TENDINOSIS ( Puddu 1976 )

CLINICAL CLASSIFICATION EFFECTIVENESS OF THE CONSERVATIVE TREATMENT SYMPTOMS DURATION EFFECTIVENESS OF THE CONSERVATIVE TREATMENT ACUTE < 2 WEEKS SUB – ACUTE 3 – 6 WEEKS CHRONIC > 6 WEEKS

INTRINSIC FACTORS HYPER SUPINATION HYPER PRONATION CAVUS FOOT

CONDITIONING THE BIOMECHANICS MAY PRODUCE TENDINOPATHIES INTRINSIC FACTORS MALALLIGNMENTS CONDITIONING THE BIOMECHANICS MAY PRODUCE TENDINOPATHIES

CONSERVATIVE TREATMENT REST DRUGS PHYSICAL THERAPY ORTHOTICS DEVICES STRETCHING BANDAGE WEIGHTBEARING REDUCTION WALKER BOOTS GROWTH FACTOR INFILTRATIONS

20 Patients non professional athletes MATERIALS AND METHOD The study was performed at the RIZZOLI ORTHOPAEDIC INSTITUTE in Bologna 20 Patients non professional athletes 18 MEN 2 WOMEN MEAN AGE AVERAGE WEIGHT AVERAGE HEIGHT 36 years 73 kg 1.75 m

INCLUSION CRITERIA EXCLUSION CRITERIA ACHILLES TENDINOPATHY GRADE 2-3 PUDDU CLASSIFICATION PATIENTS WITH ACHILLES PAIN MORE THAN 6 MONTH INCREASE IN THICKNESS OF THE ACHILLES TENDON NO DEFORMITY EXCLUSION CRITERIA - SOFT TISSUES INFECTIONS - HEMATOLOGIC TUMOR OR PLATELETS FUNCTION OR COUNT DEFECTS - CARDIOVASCULAR DESEASES - RA, SJOGREN SYNDROME - SIMULTANEOUS TREATMENT WITH CORTICOSTEROID INJECTIONS

AOFAS clinical score and VAS pain score: - Time 0: before treatment MATERIALS AND METHOD AOFAS clinical score and VAS pain score: - Time 0: before treatment - Time 3: 3 months after treatment - Time 6: 6 months after treatment A study of the tendon using MRI pre-treatment and at 3 months follow up was performed.

MATERIALS AND METHOD A statistical analysis was conducted to assess the improvement after treatment at different follow-up by: - "Paired test with Bonferroni correction for multiple comparison" - "Paired Wilcoxon non-parametric test with Bonferroni correction for multiple comparison"

PREPARATION BLOOD CENTER 150 ml OF BLOOD COLLECTED FROM A PERIPHERAL VEIN OF THE PATIENT Double venous blood centrifugation was performed with Cryofuge 6000i at 20°C: - Centrifugation n.1: 1480 rfm x 6 minutes - Centrifugation n.2: 3400 rfm x 15 minutes

CENTRIFUGATION SYSTEM Harvest System 3i System Average Platelets in 6 ml 1.5 million 1.2 million Time for Isolation 15 minutes 20 minutes

PRP PROTOCOL INTRATENDINOUS INJECTIONS 3 LATERAL AND 3 MEDIAL TO THE LESION 5mL OF PLASMA RICH IN PLATELETS + 1mL OF CALCIUM GLUCONATE 3 APPLICATIONS EVERY 15 DAYS EACH APPLICATION IS FOLLOWED BY 5 LASER ND-YAG APPLICATION AND ECCENTRIC EXERCISES EVALUATION BEFORE AND 3 MONTHS AFTER THE TREATMENT

WHY ECCENTRIC EXERCISES? ( Virchenko et al. Acta Orthopaedica 2006 ) PRP IN A GROUP OF MICE TREATED WITH BOTULINUM WITHOUT WEIGHTBEARING NO CHANGES ACCELERATE THE FIRST STEPS OF TENDON REPAIR PROCESS THE MECHANICAL LOAD IS NECESSARY INCREASE THE TENDON STRENGHT BETTER DISPOSITION OF THE COLLAGEN FIBRES DURING THE HEALING IMPROVE THE RESISTANCE TO THE MECHANICAL LOAD INCREASE RESISTANCE OF THE NEOFRMED TISSUE ( Manske et al. JBJS Am. 1984 ) (Pneumaticos et al. Foot Ankle Int. 2000)

LASER YAG THERAPY - HIGH ANTI-INFLAMMATORY EFFECT - HIGH POWER SHORT TIME APPLICATION

RESULTS TIME 0 TIME 3 TIME 6 AOFAS VAS Mean 60,42 7,42 St. Dev. 21,94 1,62 TIME 3 AOFAS VAS Mean 84,33 3,33 St. Dev. 8,91 2,23 TIME 6 AOFAS VAS Mean 84,92 2,50 St. Dev. 21,79 2,47

STATISTICAL ANALYSIS Paired Semples Test Mean difference Stand Dev 95%CI della mean difference Paired test With Bonferroni correction Paired Wilcoxon non parametric test Pair 1 AOFAS 0 AOFAS 3 23,9 -36,9 -10,9 0,01 Pair 2 AOFAS 6 -24,5 -42,5 -6,5 0,03 Pair 3 -0,6 -13,9 12,7 0,92 0,3 Pair 4 VAS 0 – VAS 3 4,1 2,5 5,6 Pair 5 VAS 0 – VAS 6 4,9 3,3 6,6 0,0001 Pair 6 VAS 3 – VAS 6 0,8 -0,7 2,4 0,27 0,1

RESULTS

RESULTS

RESULTS MRI EVALUATION BEFORE AFTER 3 MONTHS

CONCLUSIONS Statistical Analysis showed statistically significant improvements for AOFAS and VAS in the first follow-up and in the second compared to the pre-treatment. The improvements achieved in the first follow-up (3 months) and second (6 months) are not significant from a statistical point of view. Our results are very encouraging because most of the patients reported a marked decrease in pain and a functional recovery of the ankle and of the physical activity. Our patients showed a high degree of satisfaction. Up to date, the patients of this study do not need FANS drugs and restarted previous physical activities without pain.

INTRATENDINOUS INJECTION PRP INTRATENDINOUS INJECTION TENDON LESION GROW FACTORS WITH ANGIOGENETIC FACTORS LIKE VEGF AND FGF-2

Istituti Ortopedici Rizzoli Inaugurazione degli Istituti Ortopedici Rizzoli 28 giugno 1896 THANK YOU!