1. 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

2. 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

3. 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)

4. 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 )

5. 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 Nov;34(11):1774-8
Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.
Mishra A, Pavelko T.

6. TENDINOPATHIES
ACHILLE S
PATELLAR T.
PLANTAR FASCITIS

7. JOINTS
KNEE
ANKLE

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

9. 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

10. INTRINSIC FACTORS
HYPER
SUPINATION
HYPER PRONATION
CAVUS FOOT

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

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

13. 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

14. 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

15. 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.

16. 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"

17. 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

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

19. 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

20. 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 )
(Pneumaticos et al. Foot Ankle Int. 2000)

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

22. 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

23. 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

24. RESULTS

25. RESULTS

26. RESULTS
MRI EVALUATION
BEFORE
AFTER 3 MONTHS

27. 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.

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

29. Istituti Ortopedici Rizzoli
Inaugurazione degli
Istituti Ortopedici Rizzoli
28 giugno 1896
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