PRGF

@RamonCugat
Eficacia de los Tratamientos Biológicos:
Factores de Crecimiento y Células
Mesenquimales en lesiones del deporte
Barcelona, Enero 2014
MEDICINE DOCTORS
Ramon CUGAT
Xavier CUSCÓ
Pedro ÁLVAREZ
Óscar ARES
Juan Manuel BOFFA
Eduardo MAURI
Betina NISHISHINYA
Marta RIUS
Esther SALA
Roberto SEIJAS
Gilbert STEINBACHER
Montse GARCIA-BALLETBO
Ana WANG-SAEGUSA
Silvia RAMON
Josep VERGES
BTI
Eduardo De ANITUA
FISIOTERAPEUTAS
Ferran VIDIELLA
Miguel Ángel PÉREZ
Miguel MARÍN
M Ángeles ENGUITA
Elena MORALES
Rosa TEIXIDÓ
Rafa ALCOVER
Nieves LAMA
Xavier ÁLVAREZ
Juan Carlos ALEMANY
Montserrat VERGÉS
Joan BOSCH
Nahor GARCÍA
Lorena PAHINO
Ixchel MONTSERRAT
VETERINARY DOCTORS
.- IVOT:
Alex TARRAGÓ
Ángel DURAN
Diego LÓPEZ
Javier TOTUSAUS
.- Universidad CEU-UCH de Valencia:
José Mª CARRILLO
Joaquín SOPENA
Mónica RUBIO
Mariluz ORTIZ
Mireia GARCIA
Belén CUERVO
Deborah CHICARRO
Elena DAMIÁ
.- Universidad de Murcia:
José Joaquín CERÓN
Asta TVARIJONAVICIUTE
.- Universidad de Córdoba:
Juan Manuel DOMÍNGUEZ
Andrés FERNÁNDEZ
Mª del Mar GRANADOS
Rafael GÓMEZ
Rocío NAVARRETE
Juan MORGAZ
Setefilla QUIRÓS
Raúl ROMERO
Francisco Javier FUNES
Pilar MUÑOZ
María RODRÍGUEZ
.-Universidad de Las Palmas de Gran Canaria:
José VILAR
Manuel MORALES
.-Universidad Católica de Valencia:
Iván SERRA
Carme SOLER
PRGF - Endoret
Regenerative Medicine
3-Dimensional
Matrix
Cells
Signaling Molecules
PRGF - Endoret
Repair and Regeneration
Tissue response (time)
Haemostasia
Inflammation
Angiogenesis
Cell proliferation
ECM
migration
remodelling
Anitua E. Int J Oral Maxillofac Implants 1999;14(4):529-35.
Anitua E, Sánchez M, Orive G. Adv Drug Deliv Rev. 2010;62(7-8):741-52.
Anitua E, Sánchez M, Orive G, et al. Biomaterials 2007;28:4551-4560
Cugat R, Garcia-Balletbo M. Eur Musc Rev 2010;32-35
PRGF - Endoret
Are all the PRPs the same?
Biomet GPS
Harvest/SmartPrep2/BMACDepuy/
Symphony II
Sorin Angel/Arteriocyte Medical
(Magellan:Medtronic, Minneapolis,MN)
Buffy coat product: concentrated
platelets + white blood cells + fractions
& minimal amount of red blood cells
Genesis CS
Choukroun’s PRF
Leucocytes & platelet rich fibrin
concentrates of platelets, leucocytes
through siphoning device
Autogel System/Smart PReP
Platelet in plasma suspension with minimum
white blood cells & low concentration of platelets
Electa/Haemonetics/CATS/BRAT
Platelet concentrate only
Cascade PRFM fibrinet system
Platelet-rich fibrin membrane
Secquire/Arthrex ACP
Manual aspiration of platelet & plasma after
centrifuging
Vivostat
Platelet-rich fibrin & Fibrin sealant without
platelet
Caption
Concentrated platelets without plasma
BTI. Biotechnology Institute
Platelets & plasma
Formulas obtained with PRGF-Endoret®
.-PRGF-Endoret® Liquid not
Activated=Fraction 1, Poor or
Superior + Fraction 2, Rich or Next to
the buffy coat
Yellowish liquid obtained after centrifugation:
Plasma with Plasmatic Growth Factors &
Platelets intact
.-PRGF-Endoret®Liquid Activated
It is generally fraction 2=Plasma with 2-2’5 times
the peripheral blood platelet concentration +
5%CaCl2
.- PRGF-Endoret® Coagulant/Clot
(Fraction 2)
It is PRGF-Endoret® Liquid (Fraction 2)
Activated & Coagulated
Alternative Version: PRGF-Endoret® Coagulant +
biological material or inorganic
.-PRGF-Endoret® Fibrin Membrane
(Fraction 1)
It is Liquid PRGF-Endoret® (Fraction 1)
Activated & Coagulated “Ex Vivo”
Plasma with concentration of platelets similar to
those of peripheral blood without red or white
cells
.-PRGF-Endoret® Supernatant
Transparent yellowish liquid that bathes the
white fibrin membrane. It is a liquid preparation
with a high content of cellular signals
PRGF - Endoret
Tissue repair: biological processes
Anti-Angiogenic
Factors
Pro-Angiogenic
Factors
Thrombospondin 1
Vascular Endothelial
Growth Factor
Platelet Factor 4
Angiostatin
Fibroblast Growth
Factor
Endostatin
Angiopoietin-1
Tissue inhibitors of
metalloproteinases
Platelet-Derived
Growth Factor
Epidermal Growth
Factor
Endoret
Insulin-Like Growth
Factor-1
Heparanase
Stromal Cell-Derived
Factor-1
Stellos K et al. Platelets in regeneration. Semin Thromb Hemost 2010. 36: 175-84
Sphigosine
Phosphate
Bone
Percutaneous Infiltration
In clot/coagulant form with bone graft
6 months post-op
3 months post-op
References
1. Nonunions treated with autologous preparation rich in
growth factors. Sanchez M, Anitua E, Cugat R, Azofra
J, Guadilla J, Seijas R & Andia I. J Orthop Trauma
2009 Jan 23(1):52-59. PMID: 19104304
2. Delayed union of the clavicle treated with plasma rich
in growth factor. Seijas R, Santana-Suárez Y, GarcíaBalletbó M, Cuscó X, Ares O & Cugat R. Acta
Orthopedica Belgica 2010, 76(5), 689-693 PMID:
21138228
3. Growth Factors: Application in Orthopaedic Surgery
and Trauma. Garcia-Balletbo M & Cugat R. In: Doral
MN et al. (Eds.) Sports Injuries DOI: 10.1007/978-3642-15630-4_116,© Springer-Verlag Berlin Heidelberg
2012
References
FERNÁNDEZ-SARMIENTO JA. “Effect of the Implementation of
PRGF® in Tendon Healing. Experimental Study in an Achilles
Tendon Rupture Model”. DOCTORAL THESIS. Universidad de
Cordoba.
.- DOMÍNGUEZ JM, FERNÁNDEZ-SARMIENTO JA, GRANADOS MM, MORGAZ J,
NAVARRETE R, CARRILLO JM, RUBIO M, GARCÍA-BALLETBÓ M, CUGAT R, MONTERDE
J, BLANCO A. Ultrastructural study of the healing process in tenotomized achilles
tendons treated with plasma rich in growth factors in sheep. Osteoarthritis and Cartilage.
20; Supplement 1, April 2012, S250-S251. ISSN: 1063-4584. Impact Factor: 3.953.
.- FERNÁNDEZ-SARMIENTO JA, DOMÍNGUEZ JM, GRANADOS MM, MARTÍN DE LAS
MULAS M, MILLAN Y, GARCÍA-BALLETBÓ M. Histological Study of the Influence of
Plasma Rich in Growth Factors (PRGF) in a Model of Tenotomized Achilles Tendon in
Sheep. KSSTA. 20, Supplement 1, May 2012, S349. ISSN: 0942-2056. Impact Factor:
1.857.
.- FERNÁNDEZ-SARMIENTO JA, DOMÍNGUEZ JM, GRANADOS MM, MORGAZ J,
NAVARRETE R, CARRILLO JM, GÓMEZ-VILLAMANDOS RJ, MUÑOZ-RASCÓN P, MARTÍN
DE LAS MULAS J, MILLÁN Y, GARCÍA-BALLETBÓ M & CUGAT R. Histological Study of
the Influence of Plasma Rich in Growth Factors (PRGF) on the Healing of Divided Achilles
Tendons in Sheep. JBJS 2013, Am95: 246-55. Impact Factor: 3.234
Conclusions
1)
2)
3)
PRGF® injections produced no detectable adverse
effect on tendon healing and general health of
animals.
Tendons treated with PRGF® showed an
improvement in the tendon healing process both at
4 and at 8 weeks in the Achilles tendon rupture
experimental model in the study.
PRGF® injections produced a better
organization of collagen fibres and less intense
inflammation than infiltration with saline.
Muscle
Medial Third of the Rectus Femoris Injury
Injury: 10 September 06
PRGF® injection: 13 September 06
Gastrocnemius Injury
CASE 5
Vastus
Lateralis
*
*
Vastus Intermedius
Vastus
Lateralis
Vastus Intermedius
11 days
Randomised Studies
SEIJAS R, CUSCÓ X, ARES O, ÁLVAREZ P, SERRA IC & CUGAT R.
RPRGF Application at Donor Site Decreases Knee Pain in Bone Tendon
Bone ACL Reconstruction. (Pending Publication)
SEIJAS R, RIUS M, ARES O, GARCÍA-BALLETBÓ M, SERRA IC & CUGAT
R. Healing of donor site in BTB ACL Reconstruction accelerated with
Plasma Rich in Growth Factors (PRGF): a randomized clinical trial. KSSTA
2013 Nov 17
LIGAMENT ACL Surgical Reconstruction
Study on the maturity of B-PT-B autograft and donor site
Patient No.
98
Age Range
18-65
Patient No. Group A
(Surgery + PRGF®)
49
Patient No. Group B
(Surgery)
49
Inclusion Criteria
First Surgery on injured knee
Informed Consent
Total Rupture requiring ACL reconstruction
Follow Trial Controls
No previous PRGF® treatment
No Contraindications
Surgical Technique
Arthroscopic ACL Anatomical Reconstruction using
Single Bundle Autograft B-PT-B AM Portal
Seijas R, Ares O, Catala J, Alvarez-Diaz P, Cusco X & Cugat R Magnetic Resonance imaging evaluation of patellar tendon graft remodelling after
ACL reconstruction with or without platelet-rich plasma 2013
16% Anterior knee pain related exclusively to this surgery
Weiss RA, Re LP, Rintz KG. Incidence of anterior knee pain after treatment for anterior cruciate ligament
rupture. Arthroscopy 1993;9;366
Shelbourne KD, Trumper RV. Preventing anterior knee pain after anterior cruciate ligament
reconstruction. Am J Sports Med. 1997 Jan-Feb;25(1):41-7
Seijas R, Ares O, Catala J, Alvarez-Diaz P, Cusco X & Cugat R Magnetic Resonance imaging evaluation of patellar tendon graft remodelling after
ACL reconstruction with or without platelet-rich plasma 2013
A
B
C
Patellar Donor Site Maturation
A
D
Open
B Closed less 50%
C Closed more 50%
D Closed
Seijas R Estudio de Evaluación de la Cicatrización en Ligamentoplastia de Ligamento Cruzado Anterior de Rodilla 2013
Patellar Donor Site Maturation
Results: Time to Full Maturity
PRGF group shows
earlier donor site
regeneration with
statistically significant
differences at 4 month
follow-up. No
statistically significant
differences were found
within tendinous
maturation and
regeneration both during
first months and beyond
6th month.
Seijas R Estudio de Evaluación de la Cicatrización en Ligamentoplastia de Ligamento Cruzado Anterior de Rodilla 2013
Patellar Donor Site Maturation
Results: Pain
PRGF® decreases pain during first months
PRGF group presents
less pain at the donor
site, with statistically
significant differences
during the first 4
months of follow-up,
with a strong trend
towards 6th month
although without
statistical significance
Seijas R Estudio de Evaluación de la Cicatrización en Ligamentoplastia de Ligamento Cruzado Anterior de Rodilla 2013
Results
Graft Maturity
1
Hypointense
2
Mildly
Hyperintense
3
Moderately
Hyperintense
4
Severely
Hyperintense
5
Diffusely
Hyperintense
Seijas R, Ares O, Catala J, Alvarez-Diaz P, Cusco X & Cugat R Magnetic Resonance imaging evaluation of patellar tendon graft remodelling after
ACL reconstruction with or without platelet-rich plasma 2013
Graft Maturity
Results: MRI Assessment
1
Hypointense
2
Mildly
Hyperintense
3
Moderately
Hyperintense
4
Severely
Hyperintense
5
Diffusely
Hyperintense
4 Months
P Value
0.003
PRGF®
4
6
20
12
7
Non PRGF®
7
19
12
9
2
6 Months
0.0001
PRGF®
1
2
9
15
22
Non PRGF®
6
11
15
14
3
12 Months
0.354
PRGF®
0
1
1
13
34
Non PRGF®
0
2
2
15
30
4 Months
PRGF® group: Statistically Significant Differences with more cases in more advanced
stages of maturation (p=0.003)
6 Months
Statistically Significant Differences between groups. PRGF® group showing greater
number of cases in more advanced stages of maturation (p=0.0001)
12 Months
Both groups showed complete maturation in almost all patients (p=0.354)
Seijas R, Ares O, Catala J, Alvarez-Diaz P, Cusco X & Cugat R Magnetic Resonance imaging evaluation of patellar tendon graft remodelling
after ACL reconstruction with or without platelet-rich plasma 2013
Patellar Donor Site & Graft Maturation
Results
1) PRGF group shows earlier donor site regeneration with statistically
significant differences at 4 month follow-up. No statistically significant
differences were found within tendinous maturation and regeneration both
during first months and beyond 6th month
2) PRGF group presents less pain at the donor site, with statistically significant
differences during the first 4 months of follow-up, with a strong trend towards
6th month although without statistical significance
3) PRGF group did not show differences in terms of functional return; in
general quality of life index, as well as in specific, sports return or objective
parameters such as KT-1000 or maturation grades of the graft measured with
MRI
4) More patients in the PRGF group attained higher stages of remodelling at
month 4 (p=0.003), month 6 (p=0.0001), and month 12 (p=0.354)
5) PRGF and control groups did not differ significantly in terms of age,
comorbidities, sex, height, weight, and postoperative swelling and
complications
Seijas R, Ares O, Catala J, Alvarez-Diaz P, Cusco X & Cugat R Magnetic Resonance imaging evaluation of patellar tendon graft remodelling after ACL reconstruction with or
without platelet-rich plasma 2013
Knee Dislocation. PRGF Treatment
Knee Dislocation
BPTB Graft Revision
7 Weeks post-Surgery
BPTB Graft Revision
14 Weeks post-Surgery
MCL Results
Pre - PRGF® Treatment
Post - PRGF® Treatment
References
PCB 19 w
PRP 19 w
REFERENCES:
•Cugat R, Carrillo JM, Sopena J, Tarrago A, Soler C & Serra CI.
Treatment Results of Chondral Lesions using Plasma Rich in Growth
Factors and Other Substances. Electronical Poster in ISAKOS Bi-Annual
Congress. Hollywood FL, US 2005
•Serra CI. Análisis Biomecánico e Histológico del Tejido de Reparación en
Defectos Condrales de Espesor Completo tras la Aplicación de Plasma Rico
en Plaquetas Autólogo. Estudio Experimental. Doctoral Thesis.
Universidad Cardenal Herrera CEU. Valencia, Spain 2006
•Soler MC. Análisis Macroscópico, Histólógico e Inmunohistoquímico del
Efecto del Plasma Rico en Plaquetas Autólogo en la Reparación de Defectos
Condrales en Conejo. Estudio Experimental. Doctoral Thesis. Universidad
Cardenal Herrera CEU. Valencia, Spain 2006
REFERENCES:
•CUGAT R & GARCIA M. Treatment of Chondral Lesions with Plasma-Rich Growth Factors.
Oral Presentation at the Japan Knee Society 29th Annual Meeting. Hiroshima, Japan.
2004.
•CUGAT R, CARRILLO JM, SERRA CI & SOLER C. Articular Cartilage Defects
Reconstruction by Plasma Rich Growth Factors. In Basic Science, Clinical Repair and
Reconstruction of Articular Cartilage Defects: Current Status and Prospects. Chapter 88.
Edited by Timeo. Pp:801-7. 2006.
•WANG-SAEGUSA A. Infiltración de PRGF (PRP) en OA de Rodilla. Efecto-Repercusión en la
Calidad de Vida y Función Física. Tesina para Máster en Medicina Cosmética y
Antienvejecimiento. UAB 2008.
•ZARINS B, CUGAT R & GARCIA-BALLETBO M. Platelet-Rich Plasma (PRP)-Potential
Orthopaedic Applications of Autologous Preparations Rich in Growth Factors (PRGF). Hvd
Ortho J. 2009.
•WANG-SAEGUSA A, CUGAT R, ARES O, SEIJAS R, CUSCO X & GARCIA-BALLETBO M.
Infiltration of plasma rich in growth factors for osteoarthritis of the knee short-term effects
on function and quality of life. Arch Orthop Trauma Surg 131: 311-7. 2010.
•ARES O & CUGAT R. Biological Repair of Knee Injuries in Soccer Players. Techniques
Knee Surg. 9: 132-8. 2010.
•CUGAT R & GARCIA-BALLETBO M. Growth Factors a brief review. Musculoskeletal Rev
5: 32-5. 2010
Cartilage
CULTIVATED ADULT STEM CELLS
MESENCHYMAL
STEM CELLSADIPOSE TISSUE
• chondrocytes
• osteocytes
• adipocytes
• myocytes
• fibroblasts
http://krlosmundovitalkrlos.blogspot.com/2011/02/celulas-madre-iiparte-embrionarias-y.html
MATERIALS & METHODS
ANIMAL MODEL
Animal Specie:
Canis familiaris
Number of
animals: 17
Type of study:
Prospective
Multicentric
Clinical Study
Study groups: 2
Joints Studied:
- Coxo-femoral joint (Hip)
-Synovial hinge joint (Elbow)
-Femoro-tibial-fibular (Knee)
Vilar JM, Morales M, Santana A, Spinella G, Rubio M, Cuervo B, Cugat R & Carrillo JM.
Controlled, blinded force platform analysis of the effect of intraarticular injections of
autologous adypose-derived mesenchymal stem cells associated to PRGF-Endoret in
osteoarthritic dogs. BMC Veterinary Research. 2013. 9: 131-6
Results
PRGF
ADMSC + PRGF
Improvement Articular Mobility
+
+
Improvement Functional Limitation
(Quality of Life)
+
+
VAS owner: Pain decrease
+
+
VAS Veteranarian: Pain decrease
+
+
Owner satisfaction: Decrease Degree
of Lameness
+
+
Conclusions
PRGF & ADMSC + PRGF improve articular function
At 6 months differences between the 2 groups do not exist
Differences more long term
Conclusions
The application of plasma rich in growth factors (PRGF®Endoret) in bone fractures, delayed unions and nonunions
should be seen as beneficial in the acceleration of the
healing process
Tendons treated with PRGF®-Endoret showed an
improvement in the healing process
PRGF®-Endoret injections produced a better organization
of collagen fibres and less intense inflammation
PRGF®-Endoret in ACL Injuries, accelarate healing &
decrease pain
GFs obtain hyaline-like cartilage
Muscle hypertrophy does not occur locally or systemically
after local injection of PRGF®-Endoret
Conclusions
GFs + Cells + Scaffolds + Enviroment = Good Setting
ADRCs express growth factors in response to the environment around
them
 Growth factors express change as the environment changes and
promote healing through transient modulation of:
 Angiogenesis
 Chemotaxis
 Cell proliferation & Differentiation
 Synthesis of ECM
We still have a long way to go but regeneration is the path to
follow
@RamonCugat
www.artroscopiagc.es
www.fundaciongarciacugat.org
www.bioregeneracion.com