Post on 26-Jun-2020
A Comparison of the use of PRP Vs Hypertonic Glucose
in SIJ Incompetence.
Dr J Saunders, Sports Physician
University of Notre Dame
Sydney, Australia
Declarations of Interest
• PRP tubes of the study were supplied by Regen Labs
• Sonosite Edge ultrasound also supplied for the duration of the study
Assessment of the SIJ
• History
• Clinical examination • “clusters” more accurate (Laslett)
• Evidence based specific tests (Active Straight leg Raise, P4, Stork, tenderness over the LDSIL)
• Supplementary tests SIJ Glide (AP and Vertical arm),
FABER, Standing Flexion test, Gaenslen’s Test
• Imaging• X-Ray, CT, MRI: poor yield for mechanical function
• “Scintigraphy useless” (Lipman)
• SPECT CT, “new” technique
SPECT CT
Cusi, Saunders et al Eur J Spine 2013
Load transferOptimal Sub-optimal
Sacral nutation Sacral counter-nutation
Muscular actions across SIJ
Ligamentous apparatus
Diarthrodial joint
• Synovial portion (anterior)
• Ligamentous portion (posterior)• Long dorsal SI ligament• Posterior Interosseous
• Anterior SI ligament mechanically less relevant
• Most important is the Interosseous ligament
Management approach
• Mechanical dysfunction
a) Force closure failureWork on muscle recruiting
b) Form closure failureWork on ligaments
The Study1200 consecutive patients with a clinical diagnosis of SIJ
incompetence
A/Prof M CusiSport & Exercise Physician
Sex 64% Female (n=768)
36% Male(n=432)
Age 42 years (mean) 15-78 Range
History 88% trauma
8% Pregnancy
4% Unknown
Length of Symptoms
43 months (mean) 6 weeks to 26 years (range)
Treatment Results
Total Physio Prolo or PRP
Surgery Lost toF/U
851 665 65 18 145
78.1% 7.6% 2.1% 17%
A/Prof M Cusi Sport & Exercise Medicine Physician
Standard of care has been Hypertonic Glucose to the inter osseous ligament• When specialised physical
therapy with trunk retraining fails then ligament instability is suspected.
• Prolotherapy standard of care
• 3-6 injections required under radiological guidance.
Cusi, Saunders et al BJSM 2008
Study
• Ethics approval from University of Notre Dame Australia (App No 015002S)
• Registered with Australian and New Zealand Trials Registry (368092 )
• Case Control Study with prior patients undertaking hypertonic glucose injections (Cusi, Saunders et al BJSM 2008)
• 25 females (av age 30.75) 5 males (av age33.86)
• 3 lost to follow up ( 1 x gynaecological issue, 1 x hip injury and 1 relocated to another country)
• 2 awaiting completion 12 month post treatment
Inclusion Criteria
• Clinically Diagnosed SIJ incompetence with history, clinical tests and confirmed on SPECT CT imaging
• Failed 3 months specialised physiotherapy with emphasis on regaining neuromotor control
• Age greater than 18 years
• Ability to provide informed consent
Exclusion Criteria
• Age less than 18 years of age
• Prior pelvic fractures
• Pregnancy
• Platelet deficiency
• Inflammatory conditions
• Neoplastic disease.
Outcome Measures
• Visual Analogue Scale (VAS)
• Clinical Scores (assigned 1 when positive 0 if negative, possible maximum of 9)
• Questionnaires of function (Roland Morris, Roland Morris 24 and Quebec Back Pain Inventory)
• Comparison with BJSM study (Cusi, Saunders et al, 2010), using 20% Dextrose with CT guidance
US Guided SIJ Injection
• Prolotherapy : use of irritant to commence inflammatory response
• PRP : Platelet Rich Plasma
Saunders,J Cusi et al J. Pain and Management August 2016
Injection Technique
• Sonosite Edge (Sonosite USA)
• Technique reported in Saunders J, Cusi M et al: JSM Pain and Management Sept 2016
Saunders,J;Cusi,M et al JSM Pain & Management 2016
RESULTS
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
VAS VAS 12m
VAS
PRP
Results of PRP Injections
Clinical
Scores
VAS RM RM24 QUEBEC
PRP Baseline 7.7SD 0.82
63.1Sd 28.83
93.4Sd 59.06
9.2Sd 5.93
31.8Sd 12.89
PRP 12 months 1.3sd 1.53
12.1Sd 11.23
19.4Sd 27.91
1.4Sd 2.55
7.9Sd 11.23
P Value P=0.00 P=0.00 P=0.00 P=0.00 P=0.00
0 Months 12 Months
PRP CS Major 7.63 1.47
Glucose 6.96 2.10
-1.00
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
Clinical Scores
PRP CS Major Glucose
PRP Vs Hypertonic GlucoseHypertonic
Glucose
PRP T value p value
Patient number 19 30Mean clinical score base 7.2 7.7
Mean clinical score 12
month2.2 1.3 -4.4 P<0.05
Mean RM 24 base 13.0 9.2
Mean RM 24 @ 12
months10.5 1.4 -22.7 P<0.05
Mean RM base 146.5 93.4Mean RM 12 months 108.6 19.4 -20.7 P<0.05
Quebec base 57.7 31.8Quebec 12 month 39.5 7.9 -17.4 P<0.05
No of Injections 3 1.79
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Clin score RM24 RM/RMQ Quebec
Percentage Change 12m
Glucose Change 12m (%)
PRP Change 12m (%)
SUMMARY
• PRP (Regen BCT) is a valid treatment for treating physical therapy resistant (form closure failure) mechanical Sacroiliac Joint incompetence.
• Accurate placement of the injectate is possible with ultrasound
• It works well, with fewer injections required than hypertonic glucose.
• Long term results yield excellent recovery of normal function, decrease in pain.
Thank You For Your Attention
THANK YOU FOR YOUR ATTENTION
Psoas
Quadratus lumborum
TFL / ITBGmed + P
Adductors
Long dorso sacroiliac joint ligament
• Restricts counternutation (sacral backwards bending)
Dr Jeni Saunders MBBS FACSP
Long dorso sacroiliac joint ligament
• Restricts counternutation (sacral backwards bending)
Dr Jeni Saunders MBBS FACSP
Muscular Control
DeRosa-Porterfield
© 1998
• Intrinsic system
• Extrinsic System
Dr Jeni Saunders MBBS FACSP
Posterior Oblique Slings
Dr Jeni Saunders MBBS FACSP
Anterior Oblique Sling
Dr Jeni Saunders MBBS FACSP