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