THE CELLULAR MATRIX® REVOLUTION FOR THE TREATMENT OF GONARTHROSIS: FROM VISCOSUPPLEMENTATION WITH AH TO COMBINATION WITH PRP.
THE CELLULAR MATRIX® REVOLUTION IN THE TREATMENT OF GONARTHROSIS : FROM AH VISCOSUPPLEMENTATION TO COMBINATION WITH PRP
Philippe ADAM MD.., Radiologist at the Médipôle Garonne clinic in Toulouse.
Marine DELCROS MDRegenLab.
- Adam naturally turned to osteoarticular pathologies. He is a radiologist at the Médipôle Garonne clinic in Toulouse, a former reserve lieutenant physician (ENORSSA Libourne) and former head of clinic at the Toulouse University Hospital. A graduate in Aeronautical and Space Medicine (Toulouse-France), he is also heavily involved in sports medicine (expert for the French National Rugby League).
- Member of the SIMS (Société d'Imagerie Musculo-Squelettique) and theICRS (International Cartilage Repair Society) and founding member of the GRIIP (International Research Group on Platelet Injections), P. Adam now follows over 7,000 patients with gonarthrosis, and for several years has been interested in intra-articular, ultrasound-guided injectable products and their therapeutic combinations.
INTRODUCTION
- Intra-articular injection of hyaluronic acid (HA) has been used for years for Kellgren & Lawrence grades I to III of symptomatic gonarthrosis, thanks to the product's viscoelastic and lubricating properties.
- Platelet-rich plasma (PRP), for its part, has biological analgesic and anti-inflammatory effects, not to mention its main role in the release of growth factors, which enable the activation of chondrocytes and other mesenchymal stem cells.
- HA can also be likened to a biological network, helping growth factors to reach their receptors. It has the ability to retain PRP, thereby prolonging its effects, notably on platelet residence time and cell migration.
- The PRP-AH combination is proposed after failure of other treatments (including HA alone). It reduces cartilage catabolism and the inflammation that accompanies osteoarthritis.
- It also has a synergistic effect on chondrogenesis, as described in numerous studies. in vitro [2, 3, 4], putting forward the hypothesis of a PRP + HA combination that performs better than HA or PRP alone.
- It's not just a question of simple complementarity, but of a definite synergy, a real "add-on effect".
Indications for Cellular Matrix A-CP HA Regenlab® in symptomatic stage II and III gonarthrosis
Thus, the coupled injection of PRP-AH was tested with efficacy and safety on symptomatic stage II and III gonarthrosis patients in 2015.
- Injection of 2 mL LP-PRP + 2 mL non-cross-linked HA (Cellular Matrix A-CP HA RegenLab®) shows clinical results equivalent to intra-articular infiltration of PRP alone (4-5 mL).
- HA acts as a matrix, or network, protecting the PRP [1].
- It's more like a "super-PRP" than a "super-hyaluronic acid".
The effects of the PRP-HA combination are even greater than those of PRP or HA alone, in particular Sinovial Forte® 1.6 % [5] on pain and functionality criteria, at 3, 6, 12 months [6, 7, 8, 9]. Moreover, PRP does not alter the viscosupplementation property of HA [ ].10].
- It is important to pay close attention to PRP and hyaluronic acid combinations performed as separate injections, which are not authorized in this case.
EQUIPMENT AND METHOD
" Cellular Matrix A-CP- HA (Regenlab®)
Cellular Matrix A-CP- HA (RegenLab®) is a non-cross-linked LP-PRP + HA combination (bacterial origin concentrated to 2 %). It is a class III device.
ADAM PERFORMED 7,124 INTRA-ARTICULAR INFILTRATIONS (80 % OF GONARTHROSIS) OF CELLULAR MATRIX, BETWEEN THE END OF 2012 AND THE END OF 2023, IN PATIENTS WITH SYMPTOMATIC GONARTHROSIS, BILANTES ON IMAGING (RADIOGRAPHY BEING A MAJOR ELEMENT).
- Cellular Matrix® is reserved for large joints, while smaller joints benefit from PRP
- For the most part, patients come to us after other therapies have failed, including correction of contributing factors, cortisone infiltration and, above all, visco-supplementation, for which the notion of "escape" must be emphasized.
- This raises the question of whether Cellular Matrix should be indicated as a first-line treatment, in order to avoid these failures and achieve a faster, more cost-effective long-term result.
- Adam recommends maintaining a close relationship with patients, exchanging e-mails with them throughout the follow-up period, and standardizing procedures: a follow-up at 6 weeks and then at 3 months, is always combined with rehabilitation advice. Patients are also informed in advance with flyers explaining the products, their effects and the application process.
TECHNICAL
Infiltration is performed after ultrasound examination of a non-congestive knee, using a lateral approach. As head of the Pain Management Group for GRIIP, Adam urges puncture prior to infiltration, in the case of a congestive knee (or the presence of a popliteal cyst).
Based on this experience, he favors a single Cellular Matrix® infiltration, with a second infiltration at 6 months, 2 or 3 years, depending on results.
Managing rigorous asepsis (masks, cap, gel and sterile gloves), and of course the risk of bleeding, is an inherent part of medical practice, and is explained to the patient in consultation.
DISCUSSION
A HA concentration below 1 % showed a clear decrease in the mixture's viscoelastic properties, and no effect on chondrocyte proliferation. in vitro [10].
Molecular weight and the type of HA used are therefore very important.
Studies are underway with a combination of LP-PRP + cross-linked HA (RegenMatrix RegenLab®), compared to infiltration with Synvisc-One® or placebo (saline solution).
Another promising avenue is the combination of PRP (RegenPRP®) with an autologous thrombin preparation (RegenATS®), to form a platelet gel low in leukocytes, with the dual benefit of filling and prolonged release of growth factors.
Adam also observed astonishing results on rotator cuff and lateral epicondyle tendinopathies for the upper limb, and on posterior tibial, patellar and calcaneal tendinopathies for the lower limb.
CONCLUSION
PRP continues to deliver convincing clinical results.
We must not forget to integrate the evolution of the pathology into the reasoning and prevention of this same evolution: it is essential to treat the precursor factors of gonarthrosis.
What's more, networking is essential: from the technical sales representative to the contrast agent supplier, for example, the benefits for everyone are indisputable.
Last but not least, it's important to keep patients informed, to let medical correspondents know about the benefits of combining platelet-rich plasma and hyaluronic acid, and to pass on the message of good clinical practice.
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- Sundman EA, Cole BJ, Karas V, Della Valle C, Tetreault MW, Mohammed HO, Fortier The anti-inflammatory and matrix restorative mechanisms of platelet-rich plasma in osteoarthritis. The American journal of sports medicine. 2014;42(1):35- 41.
- Chen WH, Lo WC, Hsu WC, Wei HJ, Liu HY, Lee CH, and Synergistic anabolic actions of hyaluronic acid and platelet-rich plasma on cartilage regeneration in osteoarthritis therapy. Biomaterials. 2014;35(36):9599-607.
- Satin AM, Norelli JB, Sgaglione NA, Grande E ect of Combined Leukocyte-Poor Platelet-Rich Plasma and Hyaluronic Acid on Bone Marrow-Derived Mesenchymal Stem Cell and Chondrocyte Metabolism. Cartilage. 2021;13(2_suppl):267S- 76S.
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- Renevier JL, Marc JF, Adam P, Sans N, Le Coz J, Prothoy I. "Cellular matrix™ PRP-HA": A new treatment option with platelet-rich plasma and hyaluronic acid for patients with osteoarthritis having had an unsatisfactory clinical response to hyaluronic acid alone: Results of a pilot, multicenter French study with long-term follow-up. Int J Clin Rheumatol. 2018;13(4):230-8.
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