Applications of Platelet-Rich Plasma in Musculoskeletal and Sports Medicine: An Evidence-Based Approach

The Clinical Efficacy of Platelet-Rich Plasma Injection Therapy versus Different Control Groups for Chronic Low Back Pain: A Network Meta-Analysis of Randomized Controlled Trials

Objective

Low back pain is one of the main causes of disability in the world. Although regenerative medicine may represent breakthroughs in the management of low back pain, its use remains controversial. Therefore, we conducted a meta-analysis to evaluate the clinical efficacy of platelet-rich plasma (PRP) injection therapy versus different control groups for chronic low back pain during 4 weeks, 3 months, and 6 months.

Methods

Different electronic databases were searched for randomized controlled trials up to August 2023. Mean changes from baseline in pain and Oswestry Disability Index (ODI) scores at 4 weeks, 3 months, and 6 months and standard deviations of outcome were recorded.

Results

Four articles with 154 cases were finally included in this meta-analysis. After 4 weeks, corticosteroid (CS) was the optimal treatment option for chronic low back pain in terms of improvement in pain and disability index (surface under the cumulative ranking curve [SUCRA]=71.3%, SUCRA=57.8%, respectively). After 3 months, radiofrequency (RF) emerged as the best therapy in pain (SUCRA=100%) and disability index (SUCRA=98.5%), followed by PRP (SUCRA=62.3%, SUCRA=64.3%, respectively), CS (SUCRA=24.6%, SUCRA=25.9%, respectively) and lidocaine (SUCRA=13.1%, SUCRA=11.3%, respectively). At 6 months, RF was most likely to be the best treatment in pain (SUCRA=94.9%) and disability index (SUCRA=77.3%), followed by PRP (SUCRA=71.2%, SUCRA=79.6%, respectively). However, compared with the last follow-up, there was a slight downward trend in improvement pain and disability index with RF, while PRP was still an upward trend.

Conclusion

This study demonstrated better short-term improvement of chronic low back pain with CS after 4 weeks. PRP and RF improvement effects matched, but follow-up of at least 6 months showed that PRP seemed to be more advantageous in improvement in disability indices. Considering the limitations of this study, these conclusions still need to be verified by more comparative RCTs and a longer follow-up period.

Trends in utilization, demographics, and costs of platelet-rich plasma injections: a ten-year nationwide investigation

INTRODUCTION

Platelet-Rich Plasma (PRP) has become one of the most popular biologic treatments in orthopedic surgery. Despite this, its utilization over the last decade has not been investigated.

METHODS

We conducted a search using Current Procedural Terminology codes to identify patients who received PRP injections between 2010 and 2019 using the PearlDiver database. The purpose was to 1) determine annual trends of PRP injections of the ankle, hip, knee, shoulder, and elbow for cartilaginous, tendinous, ligamentous, meniscal/labral, and miscellaneous pathologies; 2) compare baseline demographics of patients receiving these injections; and 3) analyze costs.

RESULTS

A total of 23,716 patients who received PRP injections were identified; 54.4% were female. The incidence of PRP injections was between 1.6 and 4.3 per 100,000 orthopedic patients. The most common anatomic locations targeted for PRP therapy was the knee (36.7%), followed by the shoulder/elbow (30.5%), then the ankle (19.6%) and hip (13.6%). Subgroup analysis revealed that most common use of PRP was for knee cartilaginous pathologies, followed by shoulder/elbow tendinous pathologies. The number of injections used in the knee significantly increased between 2010 and 2019 (p< 0.001), and trended toward significantly increasing in the shoulder/elbow (p = 0.055). Average annual costs for PRP injections ranged from $711.65 for ankles and $1,711.63 for hips; costs significantly changed for 3 of the 4 anatomic locations. By 2019, average PRP injection costs for each area clustered around $1000.

CONCLUSION

Between 2010 and 2019, there was an increase in usage of PRP injections in the knee (cartilaginous pathologies) and the shoulder/elbow (tendinous pathologies). PRP costs demonstrated early variability but clustered around $1000 by 2019. Further studies into drivers of prices and cost-effectiveness of PRP are needed to provide clarity into the true costs to patients and healthcare providers.

A novel treatment of clavicular nonunion: Combination with PRP, autologous bone grafting, and internal plate fixation

BACKGROUND

Nonunion is a major concern for orthopedic surgeons, particularly nonunion of the clavicle, which can cause severe pain, loss of full range of motion, poor sleep quality, and loss of strength in the affected individuals. Platelet-rich plasma (PRP), an important biological agent, is widely used in orthopedics.

OBJECTIVE

We used a combination of three techniques - the PRP technique, autologous bone grafting technique, and internal plate fixation technique - to ensure adequate internal fixation and enable a bone growth-supportive environment at the fracture site.

METHODS

The surgical approach was applied to a patient with clavicle nonunion.

RESULTS

Based on postoperative follow-up findings and intraoperative findings at the time of re-removal of the patient's implant, the prognosis at the fracture site was considered satisfactory.

CONCLUSION

We observed that the patient treated with this method had favorable clinical outcomes, and we recommend that this technique be used in patients with long-bone nonunion.

Elevated IL-1β and Comparable IL-1 Receptor Antagonist Levels Are Characteristic Features of L-PRP in Female College Athletes Compared to Male Professional Soccer Players

Autologous platelet-rich plasma (PRP) therapy has been becoming popular for the treatment of musculotendinous injuries among athletes. However, for individual and practical variations, clinical success is hardly predictable. To overcome this difficulty, we have been exploring possible criterion candidates for monitoring its clinical effectiveness. In this study, we focused on sex-based differences in young elite athletes and compared the biochemical compositions of their PRP. Leukocyte-rich PRP (L-PRP) was manually prepared from blood samples collected from male professional soccer players (mPSPs) (n = 25) and female college athletes (fCAs) (n = 36). Platelet-derived growth factor-BB (PDGF-BB), transforming-growth factor-β1 (TGFβ1), platelet factor-4 (PF4), interleukin-1β (IL-1β), and IL-1 receptor antagonist (IL-1RA) were quantified using an enzyme-linked immunosorbent assay. The levels of PDGF-BB, TGFβ1, and PF4 in L-PRP were significantly higher in mPSPs than in fCAs. Conversely, IL-1β and IL-1RA were detected at significantly and slightly higher levels, respectively, in fCAs than in mPSPs. Our findings suggest that, even though L-PRP from fCAs may have lower potential to induce cell growth and differentiation than that of mPSPs, due to the latter's higher capacity to control inflammation, it does not necessarily imply that PRP treatment in fCAs is less effective. Thus, these cytokine levels should be checked before PRP therapy.

A Preliminary Report on the Combined Effect of Intra-Articular Platelet-Rich Plasma Injections and Photobiomodulation in Canine Osteoarthritis

Osteoarthritis (OA) is highly prevalent in the canine population. Due to the multiple dimensions of the disease, a multimodal approach is usually favored by clinicians. To evaluate the combined treatment with intra-articular platelet-rich plasma (PRP) and photobiomodulation in dogs with bilateral hip OA, thirty dogs were assigned to a PRP group (PRPG, n = 10), a photobiomodulation group (PBMTG, n = 10), or a combined therapies group (PRP+PBMTG, n = 10). The PRPG received two intra-articular administrations of platelet-rich plasma 14 days apart. The PBMTG received photobiomodulation with a therapeutic laser, with three sessions every other day in week one; two sessions in week two; a single session in week three; and one session/month on follow-up evaluation days. The PRP+PBMTG received the two combined therapies. The response to treatment was evaluated with weight-bearing distribution and the Canine Brief Pain Inventory, the Liverpool Osteoarthritis in Dogs, and the Canine Orthopedic Index. Evaluations were conducted before treatment and +8, +15, +30, +60, and +90 days after initial treatment. Normality was assessed with a Shapiro-Wilk test, and the groups' results in each evaluation moment were compared using a Mann-Whitney U test. Animals of both sexes (male n = 19, female n = 11) were included in the sample, with a mean age of 7.8 ± 2.5 years and a body weight of 26.5 ± 4.7 kg. Joints were classified as mild (n = 6, three in PRPG, two in PBMTG, and one in PRP+PBMTG), moderate (n = 18, six in PRPG, five in PBMTG, and seven in PRP+PBMTG), and severe (n = 6, one in PRPG, three in PBMTG, and two in PRP+PBMTG). No differences were found between groups at the initial evaluation. All treatments produced clinically significant improvements compared to the assessment on treatment day. The combination of PRP and photobiomodulation produced greater, longer-lasting improvements. PRP and photobiomodulation can improve objective outcomes and client-reported outcome measures in dogs with OA. Their combined use leads to greater, longer-lasting, clinically significant improvements.

Characterization of Leukocyte- and Platelet-Rich Plasma Derived from Female Collage Athletes: A Cross-Sectional Cohort Study Focusing on Growth Factor, Inflammatory Cytokines, and Anti-Inflammatory Cytokine Levels

Platelet-rich plasma (PRP) has been increasingly used in sports medicine owing to its various advantages. The purpose of our project was to standardize the parameters before performing large-scale clinical trials in the near future to precisely evaluate individual PRP quality. To examine the effects of regular exercise on PRP quality, this study focused on young female athletes, who have been relatively less studied. Blood samples were obtained from female college athletes (n = 35) and ordinary healthy adults (n = 30), which were considered as controls, and leukocyte-rich PRP (L-PRP) was prepared manually. Body composition indices were determined using a bathroom weight scale equipped with an impedance meter. Growth factors and cytokines were quantified using ELISA kits. Platelet-derived growth factor-BB (PDGF-BB) and Transforming-growth factors β1 (TGFβ1) levels (per platelet) in L-PRP were significantly lower in female athletes than in controls. In contrast, Interleukin-1β and Interleukin 1 receptor antagonist (IL-1RA) levels (per platelet and L-PRP) in L-PRP were significantly higher in athletes, and this difference was more prominent in IL-1RA. These findings suggest that L-PRP from athletes may facilitate the inflammatory phase of the healing process by regulating the pro-inflammatory and anti-inflammatory balance. These chemical compositions can be adopted as "must-check" parameters to characterize individual PRP preparations prior to clinical trials.

Lower extremity ultrasound-guided interventions: tendon, ligament, and plantar fascia

Lower extremity tendinopathy and soft tissue injury are common clinical problems that can cause significant disability. Ultrasound-guided minimally invasive treatments using orthobiologics and image-guided percutaneous treatments continue to gain relevance with an ever-growing body of literature. We review the indications, technique, risks, and benefits according to the literature of common ultrasound-guided interventions utilized in the lower extremities.

Is Low-Dose Dextrose Prolotherapy as Effective as High-Dose Dextrose Prolotherapy in the Treatment of Lateral Epicondylitis? A Double-Blind, Ultrasound Guided, Randomized Controlled Study

OBJECTIVES

To investigate the effects of prolotherapy (PrT) on pain, functionality, clinical improvement and to compare the 5% low and 15% high dose dextrose PrT in chronic lateral epicondylitis.

DESIGN

A double-blind, parallel groups, randomized controlled study.

SETTINGS

Outpatient Clinic.

PARTICIPANTS

Sixty patients (N=60), aged 44.30±10.31 years old, with chronic lateral epicondylitis were allocated randomly into 3 groups.

INTERVENTIONS

To Group 1 5% dextrose PrT, to Group 2 15% dextrose PrT, to Group 3 0.9% saline injections were done at 3 times (weeks 0, 3, 6), to the entheses of forearm extensors and annular ligament.

MAIN OUTCOME MEASURES

The primary outcomes were handgrip strength, visual analog scale-rest (VAS-R), visual analog scale-activity (VAS-A), pressure-pain threshold, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH). The secondary outcomes were clinical improvement (Disease Global Assessment Questionnaire), side effects, and complications. Primary outcomes were collected at baseline week 0, week 3, and 12. Secondary outcomes were collected at weeks 3 and 12.

RESULTS

In Group 2, VAS-A and VAS-R (at week 3), handgrip strength and pressure-pain threshold (at week 12) were significantly different than other groups (P<.05). In Groups 1 and 2, there was a difference in primary outcomes at week 12 than baseline (P<.05). In Group 3, there was no difference in VAS-R, VAS-A, and handgrip strength at weeks 3 and 12 than baseline (P>.05).

CONCLUSION

In chronic lateral epicondylitis, 5% and 15% dextrose PrT is more effective in pain, handgrip strength, functionality, and clinical improvement than %0.9 saline. There was no difference in functionality, clinical improvement, side effects, and complications between the PrT groups. 15% dextrose PrT was more effective in handgrip strength and pressure-pain threshold at week 12 and pain at week 3. We recommend 15% dextrose PrT based on this study.

Porcine Platelet Lysate Intra-articular Knee Joint Injections for the Treatment of Rabbit Cartilage Lesions and Osteoarthritis

Purpose

At present, autologous platelet-derived therapies such as platelet-rich plasma is widely used in the clinic, but allogeneic and xenogeneic therapies are currently in the research stage, mainly due to their biocompatibility in vivo. Platelet lysates depleted of antigens such as blood cells are a potential solution for allogeneic or xenogeneic applications. Platelet lysates can successfully promote the growth and differentiation of xenogeneic cells in vitro, but in vivo data are not yet available. This study aims to evaluate whether porcine platelet lysate can effectively avoid inflammatory reaction in rabbit knee joint, and then treat cartilage defect and arthritis.

Methods

We developed porcine platelet lysates containing undetectable antigens such as blood cells and complement. For xenogeneic application, platelet lysate was injected into rabbit knee joints to observe joint responses. To examine cartilage repair, osteochondral defects were created in rabbit knee joints. Rabbits were sacrificed three months after treatment with platelet lysate to observe cartilage regeneration and arthritis.

Results

The tissue sections in the rabbit knee joints showed no inflammatory reaction. Furthermore, the injection of platelet lysate was found to effectively inhibit the formation of cartilage arthritis in rabbit knee joints.

Conclusion

Our experimental results show that xenogeneic platelet lysate is a safe and effective method in the treatment of arthritis, which can be used as a research basis for future medical applications. The use of xenogeneic platelet lysate for regenerative therapy in vivo is feasible.

Effectiveness of lyophilized growth factors injection for subacromial impingement syndrome: a prospective randomized double-blind placebo-controlled study

BACKGROUND

Platelet-derived lyophilized growth factors (L-GFs) use a standardized number of allogenic pathogen-free platelets instead of autologous platelets used in PRP as a source of growth factors. This study aimed to evaluate the efficacy of L-GF injection versus placebo in subacromial impingement (SIS) treatment.

METHODS

The current randomized double-blind placebo-controlled study included sixty patients (40 females and 20 males, aged between 24 and 75 years) diagnosed with SIS (both clinically and sonographically). Patients were randomly assigned to two equal groups. Under ultrasound guidance, group 1 received subacromial saline injection, and group 2 received L-GF injection. Clinical examination, pain visual analogue scale (VAS), shoulder pain and disability index (SPADI) and shoulder ultrasound were performed before and at the 8th week after injection.

RESULTS

Follow-up assessment showed statistically significant improvement in the L-GF group regarding active flexion, active and passive internal rotation and extension, SPADI-disability scale, VAS and thickness of the supraspinatus tendon by US. Regression analysis showed that group 1 was approximately 30 times more likely than the L-GF group to experience painful arc at follow-up. Both groups showed statistically significant improvement in SPADI-pain scale and SPADI-total, flexion and abduction (still the mean value of abduction was significantly higher in the L-GF group).

CONCLUSIONS

L-GF injection resulted in clinically significant reductions in pain and functional disability outcomes in patients with SIS. An objective significant reduction in the thickness of the supraspinatus tendon, measured by ultrasound, in the L-GF group hopefully encourages proper healing and functioning in SIS.

TRIAL REGISTRATION

The identification number is NCT04330027, date of first registration (01/04/2020). Unique on 21/11/2019, Protocol ID: 0106178.

Prevalence, risk factor and outcome in middle-aged and elderly population affected by hemiplegic shoulder pain: An observational study

Background

Hemiplegic shoulder pain is the most common complication after stroke. It usually occurs during the critical period of stroke recovery and hinders the rehabilitation of upper extremity motor function. However, there are few studies on the risk factors, the development and prognosis of shoulder pain after stroke.

Objectives

This study aimed to observe the prevalence of post-stroke shoulder pain in the middle-aged and elderly population, find out the risk factors for post-stroke shoulder pain, and explore its effect on stroke outcome.

Methods

Eligible patients with hemiplegic shoulder pain in the rehabilitation unit were recruited and followed up at 2 and 4 months. The basic clinical information including age, gender, hypertension and atrial fibrillation history, stroke types, stroke location was recorded. Range of motion for shoulder, glenohumeral subluxation, muscle tension, activity of daily living of upper limb were measured. Data from blood test and shoulder ultrasonography were collected.

Results

480 stroke patients were screened within 1 year, and 239 patients were included in the statistical analysis. The prevalence of hemiplegic shoulder pain was 55.6% (133/239) at admission, 59.4% (142/239) after 2 months, and 55.1% (130/236) after 4 months. We found that shoulder pain was more likely to occur in women, patients with large-area stroke, increased tension of biceps brachii or triceps brachii, subluxation and limited passive range of motion of the shoulder. And the ability of daily living of patients with shoulder pain was significantly lower than that of patients without shoulder pain. Shoulder ultrasonography showed that the most common lesion in patients with shoulder pain was supraspinatus tendon thickening, and the thickness of supraspinatus tendon in the hemiplegic side of patients with shoulder pain was significantly higher than that of unaffected side. In addition, the hospitalization rate of patients with shoulder pain after 2 months and 4 months was significantly higher than that without shoulder pain.

Conclusions

Hemiplegic shoulder pain has a high prevalence and can last for several months. Multiple risk factors are involved. Moreover, hemiplegic shoulder pain affects the readmission rate of patients. Therefore, we should pay more attention to this problem in our clinical work. The application of various means to relieve shoulder pain will be conducive to the recovery of upper limb motor function and shorten the in-hospital rehabilitation time.

Efficacy and safety of platelet-rich plasma in the treatment of carpal tunnel syndrome: A network meta-analysis of different injection treatments

Purpose: Carpal tunnel syndrome (CTS) is a common form of median nerve compression in the wrist caused by focal peripheral neuropathy. Platelet-rich plasma (PRP) therapy could improve the healing ability by exposing the injured tissues to high concentrations of autologous growth factors. Our study aims to compare all injective treatments for CTS and assess the efficacy and priority of PRP therapy. Methods: We searched Medline, Embase, Web of Science, Cochrane databases, and Clinicaltrial.gov until 17 October 2022. We only included data from randomized controlled trials (RCTs) that evaluated PRP injection therapy or drug injection therapy. The included RCTs measured at least one of the following three outcomes with validated instruments: in the visual analog scale (VAS), symptom severity scale (SSS), and functional status scale (FSS). Results: Overall, 19 studies with 1,066 patients were included in this study. We used the SUCRA rankings to determine the merits of various therapies. In all, 5% dextrose injections were the best treatment strategy for the VAS (MD -1.22, 95% CI -2.66 to 0.23; SUCRA = 79.2%), followed by triamcinolone (high-dose) injections (MD -0.69, 95% CI -2.11 to 0.73; SUCRA = 62.7%) and PRP injections (MD -0.39, 95% CI -1.67 to 0.89; SUCRA = 60.0%). In the SSS, the most effective intervention was hydroxyprogesterone injections (MD -0.62, 95% CI -1.09 to -0.16; SUCRA = 91.0%). The SUCRA ranking of PRP was second only to steroids and estrogen (MD -0.39, 95% CI -0.60 to -0.18; SUCRA = 60.8%). In the FSS, the best regimen strategy was hydroxyprogesterone injections (MD 0.12, 95% CI -0.30 to 0.54; SUCRA = 99.5%), followed by triamcinolone (low-dose) injections (MD -0.02, 95% CI -0.54 to 0.49; SUCRA = 87.4%) and PRP injections (MD -0.26, 95% CI -0.43 to -0.09; SUCRA = 77.1%). Conclusion: PRP is an alternative choice for CTS treatment. PRP injection is second only to steroids and estrogen in the treatment efficacy of CTS, with a wide indication and safe outcome.

Multiple platelet-rich plasma injections are superior to single PRP injections or saline in osteoarthritis of the knee: the 2-year results of a randomized, double-blind, placebo-controlled clinical trial

INTRODUCTION

The primary purposes of this study were to prove the efficacy of PRP injection therapy on knee pain and functions by comparing patients with mild to moderate OA with a placebo control group, and also to understand the effectiveness of multiple doses compared to a single dose. It was hypothesized that PRP would lead to more favorable results than the placebo at 1, 3, 6, 12 and 24 months after treatment.

MATERIALS AND METHODS

237 patients diagnosed with OA were randomly separated into 4 groups, who were administered the following: single dose of PRP (n: 62), single dose of sodium saline (NS) (n: 59), three doses of PRP (n: 63), and three doses of NS (n: 53). Clinical evaluations were made pre-treatment and at 1, 3, 6, 12 and 24 months post-treatment, using the Knee Injury and Osteoarthritis Result Score (KOOS), Kujala Patellofemoral Score, knee joint range of motion (ROM), measurements of knee circumference (KC), and mechanical axis angle (MAA) and a Visual Analog Scale (VAS) for the evaluation of pain.

RESULTS

The better score values in the groups were recorded at 3 and 6 months. Patients treated with PRP maintained better scores at 3, 6 and 12 months compared to the NS groups (p < 0.05). Multiple doses of PRP were seen to be more effective than single-dose PRP at 6 and 12 months (p < 0.05). At the end of 24 months, there was no significant score difference across all the groups. The most positive change in scores was found in stage 2 OA, and the most positive change in ROM was in stage 3 OA patients. In the PRP groups, KC decreased more at 1 and 6 months (p < 0.05). Compared to other age groups, patients aged 51-65 years scored better at 6 months (p < 0.05). A negative correlation was determined with MAA scores (r = - 0.508, p < 0.001).

CONCLUSION

In comparison to the placebo (NS), leukocyte-rich PRP treatment was determined to be effective in the treatment of OA. Multiple doses of PRP increase the treatment efficacy and duration. Of all the patients treated with PRP, the best results were obtained by patients aged 51-65 years, with lower MAA, and by K/L stage 2 OA patients.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

REGISTRATION

NCT04454164 (ClinicalTrials.gov identifier).

Mesenchymal stem cells-derived microvesicles versus platelet-rich plasma in the treatment of monoiodoacetate-induced temporomandibular joint osteoarthritis in Albino rats

Temporomandibular joint osteoarthritis (TMJ-OA) is a serious disease, designated by severe joint pain and dysfunction. Limitations of current therapeutics have led to an increased interest in regenerative strategies. Recently, the non-surgical treatment of OA has seen increased use of biologic injectable therapies like mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). Although these biotherapies represent an admirable effort, more studies are necessary to determine their efficacy. Thus, the aim of this study was to assess the curative potential of a single intra-articular injection of bone marrow MSCs-derived microvesicles (BM-MSCs-MVs) versus a single intra-articular injection of PRP in monoiodoacetate (MIA)-induced TMJ-OA model in Albino rats. Forty-eight male rats were used. A single intra-articular unilateral MIA injection was utilized to induce TMJ-OA. One week post induction, rats were sorted into 3 groups (16 rats each): group (I): received no treatment, groups (II) & (III): received BM-MSCs-MVs and PRP respectively. Scarification was done at 2 and 4 weeks from onset of treatment. Histological changes of the condylar TMJ were examined with H&E staining. Expression of IL-1β, TNF-α, NF-κB, MMP-13, MMP-3, and collagen ΙΙ markers was detected using real-time PCR. Histologically, the osteoarthritic group exhibited degenerated condylar tissues which were aggravated at 4 weeks. Oppositely, a marked improvement in the condylar TMJ histology was noticed in both the BM-MSCs-MVs-and PRP-treated groups at both time intervals. Additionally, the treated groups showed a decrease in IL-1β, TNF-α, NF-κB, MMP-13 and MMP-3 and an increase in collagen ΙΙ genes expression in contrast to the untreated group. Moreover, this difference was significant in the BM-MSCs-MVs group as compared to the PRP-treated group. Our results concluded that BM-MSCs-MVs as well as PRP treatments were able to target the key pathological features in OA, mainly inflammation and matrix degradation, and helped in restoring condylar structure in TMJ-OA rat model. However, BM-MSCs-MVs treatment exhibited more efficient therapeutic potential as compared to PRP treatment.

Modified prolotherapy by 5% dextrose: Two years experiences of a traditional and complementary medicine practice center in Turkey

BACKGROUND

Prolotherapy (PrT) is an increasingly popular regenerative injection treatment for the management of musculoskeletal injuries. The diagnostic injection is a method for selecting suitable patients to apply PrT using subcutaneous 5% dextrose solution.

OBJECTIVE

The study aims to assess the PrT usage and modifications in the treatment of chronic low back pain and lumbar disc herniation and to define diagnostic injection procedure for PrT.

METHOD

Two thousand three hundred and eighty-two patients with low back pain or lumbar disc herniation were evaluated at the Traditional and Complementary Medicine Practice Center in Ankara, Turkey. Six hundred fifty-four patients were included in the study. Diagnostic injections were performed on all patients who were thought to be eligible candidates for PrT indications. A 4-or-6 week interval was allowed between treatment sessions.

RESULTS

Xix hundred and fifty-four patient treatments were completed. The Visual Analogue Scale (VAS) scores decreased to 5.1 ± 1.4 while 7.2 ± 1.1 before the diagnostic injection (p< 000.1). The VAS scores decreased from 7.2 ± 1.1 before the treatment to 0.9 ± 0.9 after 52 weeks of the treatment (p< 000.1). Thirty-four patients' treatments resulted in poor clinical results (5.2%), and 620 of the patients' pain improved (94.8%).

CONCLUSION

PrT can be regarded as a safe way of providing a meaningful improvement in pain and musculoskeletal function compared to the initial status. Diagnostic injection is an easy way to eliminate patients and may become a favorite treatment modality. 5% dextrose is a more simple and painless solution for PrT and also has a high success.

The Application of Platelet-Rich Plasma for Patients Following Total Joint Replacement: A Meta-Analysis of Randomized Controlled Trials and Systematic Review

Background

The clinical efficacy of platelet-rich plasma (PRP) in the treatment of total joint replacement (TJR) remains inconclusive. In this paper, systematic review and meta-analysis was adopted to assess the efficacy of using PRP for the treatment of TJR.

Methods

A comprehensive search of Medline, Embase, and Cochrane library databases for randomized controlled trial (RCT) articles recording data of PRP for TJR was conducted from inception to February 2022. Outcomes concerned were pain, range of motion (ROM), WOMAC score, length of hospital stay (LOS), hemoglobin (Hb) drop, total blood loss, wound healing rate, and wound infection. The methodological quality of the included RCTs was evaluated by using the Cochrane Risk of Bias Tool 2.0 (RoB 2.0). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was utilized to assess the level of evidence for the outcomes. Subgroup analysis was conducted according to the type of TJR.

Results

Ten RCTs were included in the meta-analysis. In the TKA subgroup, the available data demonstrated that there were significant differences in the outcomes of pain and Hb drop, while it was the opposite of ROM, WOMAC score, LOS, total blood loss, wound healing rate, and wound infection. In the THA subgroup, no significant differences could be seen between two groups in the outcomes of LOS and wound infection. However, the PRP group gained a higher wound healing rate in the THA subgroup.

Conclusion

The application of PRP did not reduce blood loss but improved the wound healing rate. However, more prospective and multicenter studies are warranted to confirm these results.

PRP Versus Standard of Care for Venous leg Ulcers: A Systematic Review and Meta-Analysis of Prospective Comparative Studies

Venous leg ulcers (VLUs) are chronic and recalcitrant lower limb wounds that affect millions of patients annually, severely reducing their quality of life, and causing a significant burden on the health care system. Recently, Platelet rich plasma (PRP) has been used to improve healing of VLUs. This systematic review aimed at evaluating the effectiveness of PRP versus the standard of care commonly used to treat VLUs. Ten prospective studies (8 randomized) met the inclusion criteria comprising 451 patients with 527 VLUs. Results were as follows: a) the weighted Odds Ratio (OR) of the mean healing rate was 2.84 (95% CI = 1.160 to 5.056, I2 = 41.4%, p = 0.0004), b) the mean healed ulcer areas were 79.2 ± 19% for the PRP group and 51.7 ± 36% for the control group (p = 0.007) in favor of the PRP group, and c) the weighted infection OR showed no significant difference between both groups. Additionally, negative correlations were found between healing rate and duration of VLUs and initial size of the ulcers. This meta-analysis demonstrated significant beneficial effects of PRP versus standard of care on healing rate, reduction in surface, and reduction in healing time of VLUs. Infection and other complications were similar to standard of care. Therefore, our analytical data would support the use of PRP as a safe and effective treatment for VLUs.

Allogeneic platelet-derived growth factors local injection in treatment of tennis elbow: a prospective randomized controlled study

PURPOSE

The purpose of this study aimed to evaluate the efficacy of local injection of allogeneic platelet-derived growth factors in treatment of patients with tennis elbow.

PATIENTS AND METHODS

This study included 120 tennis elbow patients randomly divided into two groups. The patients were locally injected with allogeneic growth factors (treatment group) or with normal saline (control group). The outcomes were assessed using Patient-Related Tennis Elbow Evaluation (PRTEE) and quick Disabilities of the Arm, Shoulder and Hand (qDASH) scales. The clinical outcomes were accordingly classified as excellent, good and poor. The patient's satisfaction and adverse effects were also recorded.

RESULTS

There was no statistically significant difference between the two groups regarding the age, gender, dominant arm or the pre-injection scores. At three month follow-up, the reductions in the mean PRTEE and qDASH scores were 88.7% and 70.6% in the treatment group versus 21.8% and 14.9% in the control group, respectively. At the last follow-up, the outcomes in the treatment group were excellent in 85% of patients and good in 15%, versus 8% and 32% in the control group. Overall, 95% were satisfied in the treatment group compared to 25% in control group. Forty patients in the treatment group experienced mild transient post-injection pain.

CONCLUSION

This study strongly suggests that local injection of allogeneic platelet-derived growth factors could be a promising safe treatment option for tennis elbow with significant pain relief, functional improvement and patient's satisfaction. Yet, additional larger studies are needed to assess the durability of these outcomes.

Orthobiologics: Diagnosis and Treatment of Common Tendinopathies

Orthobiologics, including platelet-rich plasma, prolotherapy, and mesenchymal stem cells, are seeing increasing use in the treatment of osteoarthritis (OA), muscle injury, and tendinopathy. This article reviews the biology and applications of orthobiologics in tendons, muscles, and joints, and focuses on platelet-rich plasma (PRP). Clinical evidence-based literature related to the use of PRP in the treatment of rotator cuff injury, lateral epicondylosis, Achilles tendinopathy, plantar fasciitis, knee OA, and acute muscle injury are discussed.

Efficacy of rehabilitative techniques in reducing hemiplegic shoulder pain in stroke: Systematic review and meta-analysis

BACKGROUND

Hemiplegic shoulder pain (HSP) is a disabling complication affecting stroke survivors. In this context, rehabilitation might play a key role in its clinical management. Recent systematic reviews of the impact of rehabilitative approaches on pain reduction in patients with HSP are lacking.

OBJECTIVE

This systematic review of randomized controlled trials (RCTs) with meta-analysis aimed to investigate the efficacy of rehabilitative techniques in reducing HSP in stroke survivors.

METHODS

PubMed, Scopus, and Web of Science were searched from inception to March 8, 2021 to identify RCTs of stroke survivors with HSP undergoing specific rehabilitative techniques combined with conventional therapy to reduce pain intensity. A network meta-analysis and meta-analysis of the Bayesian network of random effects were performed. The risk of bias of studies was assessed with Version 2 of the Cochrane Risk of Bias tool for randomized trials.

RESULTS

Of 1139 articles identified, 12 were included in the final synthesis. We analyzed data for 723 stroke survivors, reporting a significant overall decrease in pain intensity after a rehabilitative approach by the Bayesian meta-analysis (standardized mean difference 2.78, 95% confidence interval 0.89;-4.59; p = 0.003). We report a significant reduction in HSP with botulinum toxin type A injection (p = 0.001), suprascapular nerve pulsed radiofrequency (p = 0.030), suprascapular nerve block (p = 0.020), and trigger-point dry needling (p = 0.005) as compared with conventional rehabilitation. Concerning the effect size, we identified a Bayesian factor₁₀ of 97.2, with very strong evidence of superiority of rehabilitative techniques.

CONCLUSIONS

The present systematic review and meta-analysis showed that adding other rehabilitative techniques to conventional rehabilitation was significantly more effective than conventional rehabilitation alone in the complex management of patients affected by HSP.

Clinical outcome and risk factor predictive for failure of autologous PRP injections for low-to-moderate knee osteoarthritis

PURPOSE

To report the 5-year clinical efficacy of PRP intra articular injections in knee osteoarthritis (OA) and to investigate the risk factors predictive for treatment failure and poor clinical outcome.

METHODS

We retrospectively evaluated 118 patients treated for low to moderate knee OA demonstrated by X-Ray and magnetic resonance imaging (MRI) with autologous PRP injection from 2014 to 2018 with a mean 51.1 ± 14.8 (range 29 to 89) months follow-up. All the patients were evaluated with Lysholm and WOMAC score. The role of Kellgren Lawrence (KL) grade, patello-femoral (PF) degeneration, age, body mass index (BMI), relevant comorbilities, smoking status, gender, previous surgery or conservative measures were analyzed with univariate and multivariate analysis.

RESULTS

There was a significant improvement of all outcome measures at final follow-up and high satisfaction rate (79.7%). The overall failure rate was of 15.3% after a mean of 57.7 ± 15.1 (range 33 to 85) months. The BMI and the KL grade were identified as significant independent risk factor related to failure of autologous PRP injection. Patients under 60 reported significantly higher Tegner activity scale (p = 0.032) at final follow-up. Patients with KL grade 3 and patients with PF MRI-KL grade 3 had significantly lower Lysholm scores (p = 0.026 and p = 0.042 respectively) at final assessment. Younger patients with lower BMI and lower grade of radiographic OA had significantly longer therapeutic benefit (p < 0.05).

CONCLUSION

Intra articular PRP injections led to a significant clinical improvement in middle-aged adults with a low to moderate knee OA. BMI and high KL grade have been identified as significant risk factors predictive for failure at mid-term follow-up.

The use of biologics to improve patient-reported outcomes in hip preservation

Despite lack of clear understanding, the use of biologic treatment methods has increased in the United States. Therapeutic methods, including platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) and hyaluronic acid (HA) among other biologics, are commonly associated with relief of pain in a number of different orthopedic conditions. Within the past two decades, hip preservationists have investigated the roles of these biologic treatments in both non-operative and surgical management of common hip conditions. The purpose is to review the published literature surrounding the application and efficacy of biologics, most notably PRP, BMAC and HA, in the clinical management of hip conditions. The hip conditions examined in this review include hip osteoarthritis, femoroacetabular impingement syndrome and associated labral tear pathology, avascular necrosis of the femoral head and gluteal/hamstring tendinopathy. While our review of the literature suggests that there is support for the implementation of biologics to relieve pain and improve function for hip conditions. Through further research efforts, it is important to stay updated with the clinical efficacy of biologics in hip preservation.

Case Report: Rehabilitation After Platelet-Rich Growth Factors' Intra-Articular Injections for Knee Osteoarthritis: Two Case Reports of a Home-Based Protocol

Knee osteoarthritis (KOA) is a chronic progressive disease that can cause pain, functional impairment, and ultimately disability. A novel and promising therapeutic approach to KOA is the so-called regenerative medicine, a set of procedures designed to harness tissue regenerative capacity and optimize functional recovery. Increasing evidence points out that platelet-rich plasma (PRP) intra-articular injections can decrease pain and improve functional abilities in KOA patients. In the present case reports, we analyze two patients who were treated with PRP injections coupled with a posttreatment home-based rehabilitation program. The two patients were selected to represent two different populations: patient 1 was an 85-year-old with severe impairment of functional abilities, while patient 2 was a younger (59 years old) and more active patient. The protocol consisted in a series of exercise to be performed at home, during the five days following PRP injection for two consecutive weeks (10 days in total). The exercises were designed to reduce the inflammation after the injection, enhance the proprioceptive control of the treated lower limb, and strengthen hip and knee flexors and extensors, mainly by isometric work. Results were evaluated at two time points: before and 2 months after the first PRP injection. The outcomes considered were as follows: visual analog scale for pain, EuroQol 5 dimensions questionnaire, Tegner Activity Scale for functioning, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Both patients did not report any side effects from the treatment. Improvement in patient 1 was drastic at the two months follow-up as far as pain and functional abilities are concerned. Patient 2’s improvement was less evident, probably due to the higher starting point in both pain and functionality. Overall, the developed program seemed safe and was tolerated by the patients analyzed in the study, who performed it with good compliance.

Nonoperative and Operative Soft-Tissue and Cartilage Regeneration and Orthopaedic Biologics of the Knee: An Orthoregeneration Network (ON) Foundation Review

Orthoregeneration is defined as a solution for orthopedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include: drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the knee, including symptomatic osteoarthritis and chondral injuries, as well as injuries to tendon, meniscus, and ligament, including the anterior cruciate ligament. Promising and established treatment modalities include hyaluronic acid (HA) in liquid or scaffold form; platelet-rich plasma (PRP); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs), hematopoietic stem cells, endothelial progenitor cells, and growth factors; connective tissue progenitor cells (CTPs) including adipose-derived mesenchymal stem cells (AD-MSCs) and tendon-derived stem cells (TDSCs); matrix cell-based therapy including autologous chondrocytes or allograft; vitamin D; and fibrin clot. Future investigations should standardize solution preparations, because inconsistent results reported may be due to heterogeneity of HA, PRP, BMAC, or MSC preparations and regimens, which may inhibit meaningful comparison between studies to determine the true efficacy and safety for each treatment.

The immature platelet fraction affects the efficacy of platelet rich plasma therapy for knee osteoarthritis

Introduction

Platelet-rich plasma (PRP) therapy is used to treat pathological conditions such as degenerative inflammatory diseases including osteoarthritis (OA) by enhancing tissue repair and promoting anti-inflammatory effects. Although PRP therapy for patients with knee OA improved pain and functional scores, the association of clinical outcomes and quality of PRP including cell composition and concentration is unclear.

Methods

Therefore, this study analyzed blood cell counts, including the immature platelet fraction (IPF), in peripheral blood and PRP of 144 patients with knee OA who underwent PRP therapy. The mean leukocyte and platelet concentrations in whole blood and PRP were analyzed using an XN-1000 automated hematology analyzer. Visual analogue scale (VAS) scores and knee injury and osteoarthritis outcome scores (KOOS) before and 1 month after a single PRP injection were also determined.

Results

Higher platelet and lower leukocyte concentration rates were observed in PRP compared with whole blood. The platelet concentration in whole blood was negatively correlated with VAS improvement. The percentage of IPF (IPF%) in whole blood was positively correlated with VAS improvement and KOOS (pain) improvement, whereas the IPF% in PRP tended to correlate with VAS improvement. Furthermore, multivariate logistic regression demonstrated the high IPF% in whole blood was significantly associated with VAS improvement. The low percentage of neutrophil (neutrophil%) in PRP was significantly associated with the VAS improvement and KOOS (ADL) improvement.

Conclusions

Therefore, PRP efficacy for OA might depend on the patient's biological status.

•

High percentage of IPF (IPF%) in whole blood was significantly associated with VAS improvement.

•

Low neutrophil% in PRP was significantly associated with VAS improvement and KOOS (ADL) improvement.

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The PRP efficacy for knee OA might depend on the patient's biological status.

Phase I/II Clinical Trial of Autologous Activated Platelet-Rich Plasma (aaPRP) in the Treatment of Severe Coronavirus Disease 2019 (COVID-19) Patients

Background

The outbreak of Coronavirus Disease 2019 (COVID-19) has been increasing rapidly. This disease causes an increase in proinflammatory cytokine production that leads to cytokine storm or cytokine release syndrome (CRS). Autologous activated platelet-rich plasma (aaPRP) contains various types of growth factors and anti-inflammatory cytokines that may have the potential to suppress CRS. This study of phase I/II trial was aimed to evaluate the safety and efficacy of aaPRP to treat severe COVID-19 patients.

Methods

A total of 10 severe COVID-19 patients from Koja Regional Public Hospital (Koja RPH) were admitted to the intensive care unit (ICU). All patients received aaPRP administration three times. Primary outcomes involving the duration of hospitalization, oxygen needs, time of recovery, and mortality were observed. Secondary outcomes involving C-reactive protein (CRP), neutrophil, lymphocyte, and lymphocyte-to-CRP (LCR) and neutrophil-lymphocyte ratio (NLR) were analyzed.

Results

All patients were transferred to the ICU with a median duration of 9 days. All patients received oxygen at enrollment and nine of ten patients recovered from the ICU and transferred to the ward room. There was one patient who passed away in the ICU due to heart failure. The results of secondary outcomes showed that CRP value and lymphocytes counts were significantly decreased while neutrophils, LCR, and NLR were slightly increased after aaPRP administration.

Conclusions

Our results of the phase I/II trial demonstrated that the use of aaPRP in severe COVID-19 patients was safe and not associated with serious adverse events, which showed that aaPRP was a promising adjunctive therapy for severe COVID-19 patients.

Platelet heterogeneity enhances blood clot volumetric contraction: An example of asynchrono-mechanical amplification

Physiological processes such as blood clotting and wound healing as well as pathologies such as fibroses and musculoskeletal contractures, all involve biological materials composed of a contracting cellular population within a fibrous matrix, yet how the microscale interactions among the cells and the matrix lead to the resultant emergent behavior at the macroscale tissue level remains poorly understood. Platelets, the anucleate cell fragments that do not divide nor synthesize extracellular matrix, represent an ideal model to study such systems. During blood clot contraction, microscopic platelets actively pull fibers to shrink the macroscale clot to less than 10% of its initial volume. We discovered that platelets utilize a new emergent behavior, asynchrono-mechanical amplification, to enhanced volumetric material contraction and to magnify contractile forces. This behavior is triggered by the heterogeneity in the timing of a population of actuators. This result indicates that cell heterogeneity, often attributed to stochastic cell-to-cell variability, can carry an essential biophysical function, thereby highlighting the importance of considering 4 dimensions (space + time) in cell-matrix biomaterials. This concept of amplification via heterogeneity can be harnessed to increase mechanical efficiency in diverse systems including implantable biomaterials, swarm robotics, and active polymer composites.

Is Antiplatelet Therapy Contraindicated After Platelet-Rich Plasma Treatment? A Narrative Review

Background

Antiplatelet therapies are often withheld before and after platelet-rich plasma product (PRPP) administration due to theoretical concerns that therapies that inhibit the function of platelets would inhibit the effects of PRPP.

Purpose/Hypothesis

The purpose of this study was to evaluate the effect that antiplatelet therapies have on the ability of PRPP to stimulate wound healing and tissue regeneration. Our hypothesis was that antiplatelet therapies would have highly heterogeneous effects on the biological activity of PRPP.

Study Design

Narrative review.

Methods

The Medline database was searched via PubMed to identify all studies related to PRPP and antiplatelet therapies, yielding 1417 publications. After the search was confined to articles published after 1995, there were 901 articles remaining. All abstracts were then screened to identify animal or human clinical studies that focused on growth factor or inflammatory cytokine production or treatment outcomes. We limited our analysis to studies reporting on orthopaedic pathologies and in vitro studies of antiplatelet therapies. Ultimately, 12 articles fit the search criteria.

Results

The majority of studies reported on the use of nonsteroidal anti-inflammatory drugs as antiplatelet therapy. The majority of studies were in vitro analyses of growth factors, inflammatory cytokines, or cell viability, whereas 1 study examined clinical outcomes in an animal model. None of the studies investigated clinical outcomes in humans. All of the studies showed no effect or mixed effects of antiplatelet therapies on PRPP efficacy. One study showed PRPP recovery to baseline function after a 1-week washout period.

Conclusion

The literature did not provide support for the common clinical practice of withholding antiplatelet therapies in patients being treated with PRPP.

Platelet-rich plasma therapy in dogs with bilateral hip osteoarthritis

Background

Osteoarthritis (OA) is the most commonly diagnosed joint disease in companion animals, and hip OA is commonly diagnosed in the canine population. The use of platelet-rich plasma has gained increasing interest for the treatment of musculoskeletal conditions in companion animals. To evaluate the effect of the intra-articular administration of platelet-rich plasma in police working dogs with bilateral hip OA compared to a control group, twenty dogs were assigned to a control group (CG, n = 10) or treatment group (PG, n = 10), using the statistical analysis software. PG received two intra-articular administrations of platelet-rich plasma, 14 days apart, while CG received an intra-articular administration of saline, in the same moments. Response to treatment was determined with the Canine Brief Pain Inventory, Liverpool Osteoarthritis in Dogs, Canine Orthopedic Index, and Hudson Visual Analogue Scale, before treatment, + 8, + 15, + 30, + 60, + 90, + 120, 150, and + 180 days after initial treatment. Kaplan-Meier estimators were conducted and compared with the log-rank test. Cox proportional hazard regression analysis was performed to determine treatment survival, p < 0.05.

Results

The sample comprised 20 animals of both sexes (male n = 12, female n = 8), with a mean age of 8.4 ± 2.4 years and a bodyweight of 31.5 ± 5.7 kg. Joints were classified as moderate (13) and severe (7) according to the Orthopedic Foundation for Animals grading scheme. No differences were found between groups at the initial evaluation. Better results with the majority of scores were observed in the PG, in some cases lasting up to the last evaluation moment. Kaplan-Meier estimators showed that PG produced longer periods with better results in all scores compared to CG. Treatment was the covariate influencing all scores in the Cox regression analysis. OFA hip score also influenced two dimensions of the Canine Orthopedic Index.

Conclusion

The intra-articular administration of platelet-rich plasma can improve pain and functional scores of police working dogs with bilateral hip OA, compared with a control group. Its effects lasted for significantly longer periods, and treatment was the main covariate affecting the improvements observed.

Platelet-rich plasma for tendinopathy and osteoarthritis: a narrative review

Background

Musculoskeletal disorders include a wide range of degenerative and inflammatory problems, which can affect any part of the muscular and skeletal system. Platelet-rich plasma (PRP) has been a breakthrough in musculoskeletal medicine, especially with its effects to speed up soft tissue, cartilage, and bone healing. It is now thought that stem cells are able to reverse the degenerative process and promote rapid healing. Platelet-rich plasma (PRP) has received special attention in treating tendinopathy and osteoarthritis. This review aims to do a comprehensive review of the scientific evidence for the efficiency of PRP application in tendinopathy and osteoarthritis.

Main body of the abstract

In osteoarthritis treatment, platelet-rich plasma is thought to influence the whole joint environment by increasing chondrocyte proliferation. The injection of autologous PRP into the joint space and surrounding soft tissues delivers a concentrated dose of these growth factors, which accelerate the healing process and reduce pain.

Short conclusion

Many studies report some benefits in regard to pain and functionality, especially in tendinopathy, but further investigations are needed to incorporate PRP into clinical practice and be a common form of therapy for tendinopathy and osteoarthritis. Caution should be applied with any treatment we use in clinical practice, especially with PRP and other forms of injections.

Platelet-rich Plasma and Cell Therapy: The New Horizon in Hair Loss Treatment

Current medicinal therapies for treating hair loss have shortcomes due to variability and ineffectiveness, noncompliance, and adverse effects. The prevalence of hair loss and its associated negative psychological impact have driven research into regenerative medicine approaches, such as platelet-rich plasma (PRP) and cell-based therapies, in an attempt to find alternative, safe, effective, and reproducible treatments. Current research shows promising results from these therapies; however, more robust trials are needed to confirm the reported efficacies of PRP and cell-based therapies. Moreover, standardization of treatment preparation as well as dose and regimen are needed.

Role of platelet-rich plasma in the treatment of osteoarthritis: a meta-analysis

OBJECTIVE

The clinical efficacy of platelet-rich plasma (PRP) in the treatment of osteoarthritis remains controversial. In this paper, we evaluated the clinical efficacy of PRP in the treatment of osteoarthritis using meta-analysis, providing evidence for the selection of clinical treatment options.

METHODS

We performed a computer-based search of PubMed, Embase, and the Cochrane Library databases to retrieve articles using the search terms "platelet-rich plasma", "osteoarthrosis", and "knee joint". Quality evaluation and data extraction were performed. The combined effect was assessed using RevMan 5.3 software.

RESULTS

Five randomized controlled trials, involving 320 patients, were included in this study. No significant differences were observed in the International Knee Documentation Committee score, visual analog scale (VAS) score, or the absolute value of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score between the experimental and control groups. The absolute value of the VAS score and change in the WOMAC score were significantly decreased and patient satisfaction was increased in the experimental group, as compared with the control group.

CONCLUSION

The findings of this meta-analysis suggest that intra-articular injection of PRP is an effective treatment for osteoarthritis that can reduce post-operative pain, improve locomotor function, and increase patient satisfaction.

Using intra-articular allogenic lyophilized growth factors in primary knee osteoarthritis: a randomized pilot study

Objective: Investigating the safety in addition to clinical and structural efficacy of allogenic lyophilized growth factors (L-GFs) in patients with symptomatic primary knee osteoarthritis. Design: A prospective, open-label pilot study. A total of 31-patients randomized into non-intervention and intervention groups. Materials & methods: The intervention group received two intra-articular doses at baseline and after 2-months. Post-injection complications were documented, and the efficacy was assessed by Western Ontario and McMaster Universities Osteoarthritis Index scores and ultrasonography. Results: One dropout from the intervention group. The percentage of improvement of mean Western Ontario and McMaster Universities Osteoarthritis Index-scores and ultrasonography-detected effusion were statistically significant in the intervention group compared with the non-intervention. A brief, mild, post-injection pain was reported by all intervention group. Conclusion: This study provides the safety of intra-articular injection of allogenic L-GFs in knee osteoarthritis. The conclusion of efficacy was limited by small sample size and lack of control injection. Clinical trial registration: NCT04331327 (ClinicalTrials.gov, retrospectively registered).

Management of Osteoarthritis Using 1 Intra-articular Platelet Concentrate Administration in a Canine Osteoarthritis Model

BACKGROUND

Osteoarthritis (OA) represents a significant burden to societies, as it affects quality of life and performance and implies a large cost in terms of health care. Autologous platelets are a regenerative treatment modality for OA that are thought to be a potential stimulation of the natural healing cascade.

PURPOSE

To describe the effect of the platelet concentrate V-PET in the management of OA in a naturally occurring canine model, using several outcome assessment modalities.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 40 joints of active working police dogs with hip OA were randomly assigned to a control group (CG) and a platelet concentrate group (PCG; treatment) and evaluated. At treatment day (T0) and 8, 15, 30, 90, and 180 days after treatment, weight distribution, joint range of motion at flexion and extension, thigh girth, digital thermography, radiographic signs, 4 clinical metrology instruments, and synovial fluid interleukin 1 and C-reactive protein levels were recorded. Results were compared using repeated-measures analysis of variance with a Huynh-Feldt correction, paired-samples t test, or Wilcoxon signed rank test, with P < .05.

RESULTS

Dogs were 6.5 ± 2.4 years old (mean ± SD) and had a body weight of 26.7 ± 5.2 kg. At T0, 32 (80%) joints were graded as having mild OA, 6 (15%) as moderate, and 2 (5%) as severe. No differences were found between groups at T0. Between the PCG and CG, the symmetry index showed significant improvements in the PCG from 8 days (P = .01) to 180 days (P = .01). Joint flexion also improved in the PCG up to 90 days (P < .05) and extension improved up to 180 days (P < .01). Several clinical metrology instrument scores also improved up to 90 to 180 days after treatment. In the CG, radiographic signs progressed, while the PCG showed some improved signs. In both groups, increasing body weight and age corresponded with worse clinical and laboratory findings.

CONCLUSION

A single injection of platelet concentrate had a positive effect, lasting up to 6 months, on several clinical, imaging, and laboratory signs in a naturally occurring canine OA model.

CLINICAL RELEVANCE

We characterized the effects of this platelet concentrate in dogs, considered the gold standard of the study of OA, with a group of working animals with similar high demands as athletes.

Ultrasound-guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: A randomized controlled trial

BACKGROUND

Tendinosis is a chronic degenerative condition. Current research suggests both percutaneous needle tenotomy (PNT) and leukocyte-rich platelet-rich plasma (LR-PRP) may be effective treatments for chronic tendinosis, but no studies have assessed the effectiveness of PNT alone versus PNT with intratendinous LR-PRP for multiple tendon types in a single study.

OBJECTIVE

To assess the efficacy of PNT versus PNT + LR-PRP to treat chronic tendinosis.

STUDY DESIGN

Double-blind, randomized, controlled comparative treatment study.

SETTING

Primary academic institution.

PARTICIPANTS

A convenience sample of 40 participants who had chronic tendinosis (rotator cuff, wrist extensor, wrist flexor, hip abductor, proximal hamstring, patellar, or Achilles) confirmed via ultrasound, failed conservative treatment, and did not have tendon tears, known coagulopathy, or systemic illnesses.

INTERVENTIONS

Participants were randomly assigned to PNT (n = 19) or PNT + LR-PRP (n = 21). Participants and outcomes assessors were blinded to treatment assignments. PNT was performed with 20-30 passes of a 22-gauge needle under ultrasound guidance, with 1% lidocaine given outside the tendon. LR-PRP was processed from whole blood (30-60 mL) and injected into the affected tendon using the same PNT technique.

MAIN OUTCOME MEASURES

Primary outcome was current numerical rating scale pain at 6 weeks. Secondary outcomes were average pain, function, general well-being, and sleep quality at 6, 52, and 104 weeks.

RESULTS

Baseline characteristics were similar between groups. Overall, there were no significant differences between groups over time for any of the outcomes (P > .05). Between-group analyses showed significantly lower current and average pain after PNT compared to PNT + LR-PRP at 6 weeks (estimated-mean [SE]: 3.1[0.4] vs. 4.6[0.6], P = .04; 3.4[0.4] vs. 4.9[0.5], P = .03) only. Adverse event rates were low (PNT-3.9%; PNT + LR-PRP-5.0%) and related primarily to postprocedural pain and inflammation.

CONCLUSIONS

Although pain scores were lower after PNT compared to PNT + LR-PRP at 6 weeks, there were no between-group differences in outcomes at 52 or 104 weeks.

The Effect of Intradiscal Platelet-Rich Plasma Injection for Management of Discogenic Lower Back Pain: A Meta-Analysis

Objective

Although several researches of animal and human subjects have yielded promising results regarding intradiscal injection of platelet-rich plasma (PRP) for the management of intervertebral disc (IVD) pathologies, small sample sizes and unstandardized graft preparation procedures hampered these research efforts. Therefore, we conducted a meta-analysis to evaluate the effectiveness of intradiscal PRP injection for the treatment of discogenic lower back pain.

Methods

The PubMed, SCOPUS, Embase, and Cochrane Library databases were systematically searched for relevant studies published from January 01, 1980 to December 14, 2020. The keywords used for the search were (platelet-rich plasma) AND (intradiscal OR back pain OR lumbar spine OR discogenic). Filters were used to select studies with human participants; all study designs were included.

Results

After the systematic review, three articles, including one randomized control trial and two prospective observational studies, were included in the final analysis. Analysis of changes in visual analogue scale (VAS) scores showed that VAS scores were significantly reduced two and six months after intradiscal PRP injection (two months: standardized mean difference [SMD] = −0.837, 95% CI = −1.158 to −0.516, P < 0.001; six months: SMD = −1.430, 95% CI = −2.209 to −0.652, P < 0.001), but not after one month (SMD = −0.661, 95% CI = −1.346 to 0.023, P = 0.058). Regarding changes in Owestry Disability Index (ODI), ODI scores were significantly reduced after six months (SMD = −0.964, 95% CI = −1.885 to −0.043, P = 0.040).

Conclusion

Intradiscal PRP injections are effective in relieving pain and improving disabilities caused by discogenic lower back pain. However, the pain-reducing effect significantly manifests two or six months after the injections, but not after one month.

Intraarticular triamcinolone hexacetonide, stanozolol, Hylan G-F 20 and platelet concentrate in a naturally occurring canine osteoarthritis model

Osteoarthritis (OA) is a disease transversal to all mammals, a source of chronic pain and disability, a huge burden to societies, with a significant toll in healthcare cost, while reducing productivity and quality of life. The dog is considered a useful model for the translational study of the disease, closely matching human OA, with the advantage of a faster disease progression while maintaining the same life stages. In a prospective, longitudinal, double-blinded, negative controlled study, one hundred (N = 100) hip joints were selected and randomly assigned to five groups: control group (CG, n = 20, receiving a saline injection), triamcinolone hexacetonide group (THG, n = 20), platelet concentrate group (PCG, n = 20), stanozolol group (SG, n = 20) and hylan G-F 20 group (HG). Evaluations were conducted on days 0 (T0, treatment day), 8, 15, 30, 60, 90, 120, 150 and 180 days post-treatment, consisting of weight distribution analysis and data from four Clinical Metrology Instruments (CMI). Kaplan-Meier estimators were generated and compared with the Breslow test. Cox proportional hazard regression analysis was used to investigate the influence of variables of interest on treatment survival. All results were analyzed with IBM SPSS Statistics version 20 and a significance level of p < 0.05 was set. Sample included joints of 100 pelvic limbs (of patients with a mean age of 6.5 ± 2.4 years and body weight of 26.7 ± 5.2 kg. Joints were graded as mild (n = 70), moderate (n = 20) and severe (n = 10) OA. No differences were found between groups at T0. Kaplan-Meier analysis showed that all treatments produced longer periods with better results in the various evaluations compared to CG. Patients in HG and PCG took longer to return to baseline values and scores. A higher impact on pain interference was observed in THG, with a 95% improvement over CG. PCG and HG experienced 57-81% improvements in functional evaluation and impairments due to OA, and may be a better options for these cases. This study documented the efficacy of several approaches to relieve OA clinical signs. These approaches varied in intensity and duration. HG and PCG where the groups were more significant improvements were observed throughout the follow-up periods, with lower variation in results.

Platelet-Rich Plasma Injection for the Treatment of Hamstring Injuries: A Systematic Review and Meta-analysis With Best-Worst Case Analysis

BACKGROUND

Hamstring injuries are common and account for considerable time lost to play in athletes. Platelet-rich plasma has potential as a means to accelerate healing of these injuries.

PURPOSE

(1) To present the evidence of platelet-rich plasma injection in the treatment of hamstring injuries, (2) evaluate the "best-case scenario" in dichotomous outcomes, and (3) evaluate the "worst-case scenario" in dichotomous outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Two authors systematically reviewed the PubMed, Embase, and Cochrane Library databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with any discrepancies resolved by mutual consensus. The level of evidence was assessed per the criteria of the Oxford Centre for Evidence-Based Medicine and the quality of evidence by the Coleman Methodology Score. Meta-analysis by fixed effects models was used if heterogeneity was low (I² < 25%) and random effects models if heterogeneity was moderate to high (I²≥ 25%). P values <.05 were considered statistically significant.

RESULTS

A total of 10 studies were included with 207 hamstring injuries in the platelet-rich plasma group and 149 in the control group. Random-effects model for mean time to return to play that compared platelet-rich plasma + physical therapy to physical therapy alone non-significantly favored platelet-rich plasma + physical therapy (mean difference, -5.67 days). The fixed effects model for reinjury rates, which also compared platelet-rich plasma + physical therapy with physical therapy alone nonsignificantly favored platelet-rich plasma + physical therapy (risk ratio, 0.88). The best-case scenario fixed effects model for reinjury rates nonsignificantly favored platelet-rich plasma + physical therapy (risk ratio, 0.82). The worst-case scenario fixed effects model for reinjury rates nonsignificantly favored physical therapy alone (risk ratio, 1.13). The mean ± SD complication rate for either postinjection discomfort, pain, or sciatic nerve irritation was 5.2% ± 2.9% (range, 2.7% to 9.1%).

CONCLUSION

There has been statistically nonsignificant evidence to suggest that PRP injection ± PT reduced mean time to RTP or reinjury rates compared to no treatment or PT alone for hamstring injuries in a short-term follow-up. The complication profiles were favorable. Further studies of high quality and large cohorts are needed to better support or disprove the consensus of the systematic review and meta-analysis.

Intra-articular Injections With Either Triamcinolone Hexacetonide, Stanozolol, Hylan G-F 20, or a Platelet Concentrate Improve Clinical Signs in Police Working Dogs With Bilateral Hip Osteoarthritis

Objectives: To compare the effect of intra-articular treatment with triamcinolone hexacetonide (TH), stanozolol, hyaluronan, and a platelet concentrate in police working dogs with bilateral hip osteoarthritis (OA). Study Design: Prospective, longitudinal, double-blinded, negative controlled study. Sample Population: Fifty police working dogs with naturally occurring hip OA. Methods: Animals were randomly assigned to a control group (CG, n = 10), TH group (THG, n = 10), platelet concentrate group (PCG, n = 10), stanozolol group (SG, n = 10), and Hylan G-F 20 group (HG). On days 0 (T0), 8, 15, 30, 90, and 180 days post-treatment, weight-bearing distribution was evaluated. In those days, and on days 60, 120, and 150, four clinical metrology instruments were completed. Kaplan-Meier estimators were conducted and compared with the log-rank test. Cox proportional hazard regression analysis was performed to determine treatment survival. Significance was set at p < 0.05. Results: Patients had a mean age of 6.5 ± 2.4 years and body weight of 26.7 ± 5.2 kg. At T0, hips were classified as mild (n = 35), moderate (n = 10), and severe (n = 5), according to the Orthopedic Foundation for Animals grading scheme. No differences were found between groups at that moment considering age, body weight, OFA hip score, and all assessments performed. All treatments improved clinical signs in various OA dimensions in some groups, with a broad effect interval. PCG showed a lower range of variation while maintaining a positive result for more extended periods (p < 0.01 for symmetry index and 0.01 < p < 0.04 in the majority of scores). Breed, age, sex, and OFA grade did not significantly influence response to treatment. Conclusions and Clinical Relevance: This is the first prospective, negative controlled, double-blinded study to compare the effect of a single administration of these IA treatments in dogs with hip OA. HG and PCG recorded more significant improvements throughout the 180-day follow-up. In particular, PCG also registered a lower variation in results, seemingly the best therapeutic option. Nevertheless, improvements were still observed in THG and SG, and these treatment options can be considered, mainly when the first two treatments are not available.

Efficacy of platelet-rich plasma injections in patients with adhesive capsulitis of the shoulder

PURPOSE

The goal of this study is to investigate whether platelet-rich plasma (PRP) injections are effective in the management of adhesive capsulitis of the shoulder (AC). A triple-blind, randomized controlled trial was designed and conducted in a medical school hospital.

METHODS

32 adult patients with adhesive capsulitis (21 female, 11 male with a mean age of 57, ranging from 23 to 70) were included in this study. Patients had to have shoulder pain and restrictions in movements (at least 25% when compared to the other side, and at least in two directions) for three months minimum and nine months maximum. Patients were randomized to two groups, and one group took PRP injections for three times every two weeks, while the other group took saline injections in same frequency and volume. A standardized exercise program was also applied to all patients. Patients were evaluated with Shoulder Pain and Disability Index (SPADI), Visual Analogue Scales for pain and disability, ranges of movements, and use of analgesics in before, after, and third month after the initiation of the therapy.

RESULTS

Baseline comparisons between groups showed no differences. SPADI and ranges of motion in all directions showed significant improvements with therapy, and the group which took PRP injections showed better improvements when compared to the control group (p < 0.05). Visual Analogue Scale was found to be better for the PRP group after therapy and third month, and not for the control group (0.4 ± 1.06 and 0.17 ± 0.72 vs. 2.5 ± 2.6 and 2 ± 2.2, respectively, p < 0.05). Use of analgesics was not found to be significant for both groups (p > 0.05).

CONCLUSION

PRP injections were found to be effective in both pain and disability, and showed improvements in a restricted shoulder due to adhesive capsulitis. These findings might point out PRP as a therapeutic option in the management of adhesive capsulitis.

Platelet-rich plasma for laryngotracheal reconstruction: an experimental study

OBJECTIVES/HYPOTHESIS

This study was designed to evaluate the graft healing effect of topical application of platelet-rich plasma (PRP) for laryngotracheal reconstruction (LTR) in a rabbit model.

STUDY DESIGN

It is a prospective randomized control animal study.

MATERIALS AND METHODS

Sixteen healthy New Zealand White rabbits were assigned to two groups of eight animals each. The control group underwent LTR with anterior auricular cartilage graft. The PRP group underwent the same surgical procedure plus PRP application over the anastomosis and surgical field. Two animals in the PRP group and two animals in control group died due to severe respiratory distress on postoperative days 10, 12, 15, and 18. Six rabbits (n = 3 for control group and n = 3 for PRP group) were sacrificed at 4 weeks, and six rabbits (n = 3 for control group and n = 3 for PRP group) were sacrificed at 8 weeks. Laryngotracheal regions were evaluated histopathologically.

RESULTS

Macroscopically, the average anteroposterior and lateral diameter of the reconstructed region and the degree of lumen patency on postoperative 4th week and 8th week were not statistically different among two groups. There was no significant difference between the groups in terms of any of the microscopic findings when the analysis was made separately. However, analysis of the total number of rabbits has shown that new cartilage formation and angiogenesis were more pronounced in PRP group than control group.

CONCLUSIONS

Application of PRP contributed to better healing in airway surgery by promoting a release of growth factors that stimulate new cartilage formation and angiogenesis.

Efficacy of platelet-rich plasma in the treatment of hemiplegic shoulder pain

OBJECTIVE

The aim of this study was to examine the effects of platelet-rich plasma (PRP) on pain and functional outcomes in patients with hemiplegic shoulder pain. We compared the effects of PRP against saline solution by designing a double blind, randomized, prospective study.

DESIGN

Forty-four patients with hemiplegia were included in this study. All patients received a total of 3 injections, 1 week apart. The first group received PRP injections while the second group received placebo injections. After 3 months of follow-up, 40 patients completed the trial. Primary outcome measure was movement-induced pain score (VAS), and secondary outcome measures were spontaneous pain score, shoulder passive range of motion (ROM), functional independence measure score, and the amount of paracetamol used. All subjects were evaluated at baseline, 1 week, 1 month, and 3 months after the completion of the last injection.

RESULTS

Both groups showed an improvement in spontaneous and movement-related pain scores and shoulder passive ROM values on 1st and 3rd month visits (p < 0.05). No significance difference was detected between groups (p > 0.05). Similarly, FIM scores improved significantly in both groups (p < 0.05) but no difference was found between groups. Paracetamol use did not differ significantly between groups.

CONCLUSION

The PRP injections were found not to be superior to placebo. Improvements in both groups can be attributed to the use of rehabilitation techniques and exercises in all patients. There is still need for further research to show whether PRP is a treatment option in the course of hemiplegic shoulder pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03931824.

Platelet-Rich Plasma: The Journey so Far !

Platelet-rich plasma (PRP) is an autologous blood product, obtained after blood centrifugation. PRP is rich in growth factors which promote tissue-healing, alter angiogenesis, and possess versatile immunomodulatory effects, in the relative absence of any significant demonstrable adverse effects. Consequently, PRP has found application in multiple specialities in recent years, including dermatology. A literature search was performed on PubMed, Medline database, and Google Scholar, using keywords like platelet-rich plasma (PRP), platelet-concentrated plasma, platelet-rich growth factors, autologous platelet concentrate. Relevant studies were selected, and data was analyzed following extraction. Studies show that PRP has not only been used as an adjunctive modality but has been employed as a stand-alone therapy as well. Multiple authors have reported PRP to be efficacious in disparate dermatological conditions, like alopecia, skin rejuvenation, healing of refractory cutaneous ulcers, and even acne scar management. The strongest evidence so far has been demonstrated in androgenetic alopecia and facial skin rejuvenation. However, routine use in dermatological conditions is hampered by the relative paucity of high-quality evidence and large randomized studies. Furthermore, PRP composition and preparation methods are not yet standardized and even the treatment regimens proposed too vary widely. The present review provides a bird's eye view of the evidence available so far regarding the use of PRP in dermatology. The review focusses more on recent prospective studies, including randomized trials and tries to summarize the evidence in a brief, but comprehensive manner.

Orthobiologics in Elbow Injuries

Orthobiologics are exciting tools providing promising results for difficult orthopedic conditions. In the elbow there is high-level evidence for their use in lateral epicondylopathy and encouraging evidence for other elbow pathologies. This article provides an in-depth review of the current literature for the use of orthobiologics in elbow injuries.

The impact of platelet-rich plasma on postoperative outcomes after spinal fusion: a systematic review and meta-analysis

OBJECTIVE

Platelet-rich plasma (PRP) is a biological agent obtained by centrifuging a sample of blood and retrieving a high concentration of platelets and plasma components. The concentrate is then stimulated for platelet secretion of various growth factors and cytokines. Although it is not widely used in clinical practice, its role in augmenting bony union among patients undergoing spinal fusion has been assessed in several clinical studies. The objective of this study was to perform a systematic review and meta-analysis of the existing literature to determine the efficacy of PRP use in spinal fusion procedures.

METHODS

A comprehensive literature search was conducted using PubMed, Scopus, and EMBASE for studies from all available dates. From eligible studies, data regarding the fusion rate and method of assessing fusion, estimated blood loss (EBL), and baseline and final visual analog scale (VAS) scores were collected as the primary outcomes of interest. Patients were grouped by those undergoing spinal fusion with PRP and bone graft (PRP group) and those only with bone graft (graft-only group).

RESULTS

The literature search resulted in 207 articles. Forty-five full-text articles were screened, of which 11 studies were included, resulting in a meta-analysis including 741 patients. Patients without PRP were more likely to have a successful fusion at the last follow-up compared with those with PRP in their bone grafts (OR 0.53, 95% CI 0.34-0.84; p = 0.006). There was no statistically significant difference with regard to change in VAS scores (OR 0.00, 95% CI -2.84 to 2.84; p > 0.99) or change in EBL (OR 3.67, 95% CI -67.13-74.48; p = 0.92) between the groups.

CONCLUSIONS

This study found that the additional use of PRP was not associated with any significant improvement in patient-reported outcomes and was actually found to be associated with lower fusion rates compared with standard grafting techniques. Thus, PRP may have a limited role in augmenting spinal fusion.