Platelet-Rich Plasma in Orthopaedic Surgery and Sports Medicine: Pearls, Pitfalls, and New Trends in Research

Clinical benefit of high tibial osteotomy combined with the intervention of platelet-rich plasma for severe knee osteoarthritis

PURPOSE

The objective of present study was to investigate the therapeutic effects of high tibial osteotomy (HTO) combined with platelet-rich plasma (PRP) for severe knee osteoarthritis (KOA).

METHODS

This was a double-blinded, randomized, placebo-controlled trial. The participants were randomly divided by computerderived random charts into 3 groups: 24 participants in group A (24 knees) received a treatment option of HTO combined with PRP, 25 participants in group B (25 knees) received a treatment program of HTO combined with hyaluronic acid, and 25 participants in group C (25 knees) received a treatment method of HTO combined with normal saline (NS) (physiological control/placebo). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and visual analog scale (VAS) were measured preoperatively and at the final follow-up. Status of articular cartilage was assessed according to the International Cartilage Repair Society grade and the presence of newly formed cartilaginous tissue by arthroscopy. MRI was completed of knee joint to measure the cartilaginous thickness.

RESULTS

Compared to Group B and C, the final follow-up results of knee function in Group A were significantly different (P < 0.001), such as the total WOMAC score 18.54 (SD 4.17), the VAS score 1.72 (SD 0.53). Cartilage regeneration of femur and tibia in Group A was observed in all patients. The cartilaginous thickness in Group A were significantly different (P < 0.001), such as the anterior patella femoral region 3.52 (SD 0.47), the anterior meniscal region 1.16 (SD 0.24), the posterior meniscal region 1.24 (SD 0.26) and the posterior condyle region 2.25 (SD 0.31).

CONCLUSIONS

The addition of combined PRP to HTO may be a more reasonable choice to relieve knee pain and decelerate the progression of the medial KOA.

Effectiveness of platelet-rich plasma in the treatment of moderate knee osteoarthritis: a randomized prospective study

[Purpose] To assess the effects of different numbers of platelet-rich plasma (PRP) applications on pain and physical function in grade 3 knee osteoarthritis (OA). [Subjects and Methods] A total of 102 patients with grade 3 knee OA were randomly divided into three groups: Group 1 received a single injection of PRP, Group 2 received two injections of PRP two weeks apart, Group 3 received three injections of PRP at 2-weeks intervals. All patients were evaluated with a visual analog scale (VAS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and the Timed-Up and Go test (TUG) before the treatment and at 1, 3 and 6 months after the treatment. [Results] Ninety-eight patients (15 males, 83 females) completed the study. The mean ages of the patients were 53.5±6.6, 54.9±5.3, and 55.1±5.6 years in Group 1, Group 2, and Group 3, respectively. Statistically significant improvements were noted in all of the evaluated measures in all of the groups. The mean differences of Group 1-Group 2 and Group 1-Group 3 WOMAC total, WOMAC pain, WOMAC stiffness, and WOMAC function scores were statistically significant. [Conclusion] PRP is an effective treatment for functional status and pain in moderate knee osteoarthritis and a minimum of two injections is appropriate.

Platelet-rich plasma in orthopedic therapy: a comparative systematic review of clinical and experimental data in equine and human musculoskeletal lesions

BACKGROUND

This systematic review aimed to present and critically appraise the available information on the efficacy of platelet rich plasma (PRP) in equine and human orthopedic therapeutics and to verify the influence of study design and methodology on the assumption of PRP's efficacy. We searched Medline, PubMed, Embase, Bireme and Google Scholar without restrictions until July 2013. Randomized trials, human cohort clinical studies or case series with a control group on the use of PRP in tendons, ligaments or articular lesions were included. Equine clinical studies on the same topics were included independently of their design. Experimental studies relevant to the clarification of PRP's effects and mechanisms of action in tissues of interest, conducted in any animal species, were selected.

RESULTS

This review included 123 studies. PRP's beneficial effects were observed in 46.7% of the clinical studies, while the absence of positive effects was observed in 43.3%. Among experimental studies, 73% yielded positive results, and 7.9% yielded negative results. The most frequent flaws in the clinical trials' designs were the lack of a true placebo group, poor product characterization, insufficient blinding, small sampling, short follow-up periods, and adoption of poor outcome measures. The methods employed for PRP preparation and administration and the selected outcome measures varied greatly. Poor study design was a common feature of equine clinical trials. From studies in which PRP had beneficial effects, 67.8% had an overall high risk of bias. From the studies in which PRP failed to exhibit beneficial effects, 67.8% had an overall low risk of bias.

CONCLUSIONS

Most experimental studies revealed positive effects of PRP. Although the majority of equine clinical studies yielded positive results, the human clinical trials' results failed to corroborate these findings. In both species, beneficial results were more frequently observed in studies with a high risk of bias. The use of PRP in musculoskeletal lesions, although safe and promising, has still not shown strong evidence in clinical scenarios.

The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis

PURPOSE

The purpose of this systematic review was to synthesize the available Level I and Level II literature on platelet-rich plasma (PRP) as a therapeutic intervention in the management of symptomatic knee osteoarthritis (OA).

METHODS

A systematic review of Medline, Embase, Cochrane Central Register of Controlled Trials, PubMed, and www.clinicaltrials.gov was performed to identify all randomized controlled trials and prospective cohort studies that evaluated the clinical efficacy of PRP versus a control injection for knee OA. A random-effects model was used to evaluate the therapeutic effect of PRP at 24 weeks by use of validated outcome measures (Western Ontario and McMaster Universities Arthritis Index, visual analog scale for pain, International Knee Documentation Committee Subjective Knee Evaluation Form, and overall patient satisfaction).

RESULTS

Six Level I and II studies satisfied our inclusion criteria (4 randomized controlled trials and 2 prospective nonrandomized studies). A total of 577 patients were included, with 264 patients (45.8%) in the treatment group (PRP) and 313 patients (54.2%) in the control group (hyaluronic acid [HA] or normal saline solution [NS]). The mean age of patients receiving PRP was 56.1 years (51.5% male patients) compared with 57.1 years (49.5% male patients) for the group receiving HA or NS. Pooled results using the Western Ontario and McMaster Universities Arthritis Index scale (4 studies) showed that PRP was significantly better than HA or NS injections (mean difference, -18.0 [95% confidence interval, -28.8 to -8.3]; P < .001). Similarly, the International Knee Documentation Committee scores (3 studies) favored PRP as a treatment modality (mean difference, 7.9 [95% confidence interval, 3.7 to 12.1]; P < .001). There was no difference in the pooled results for visual analog scale score or overall patient satisfaction. Adverse events occurred more frequently in patients treated with PRP than in those treated with HA/placebo (8.4% v 3.8%, P = .002).

CONCLUSIONS

As compared with HA or NS injection, multiple sequential intra-articular PRP injections may have beneficial effects in the treatment of adult patients with mild to moderate knee OA at approximately 6 months. There appears to be an increased incidence of nonspecific adverse events among patients treated with PRP.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Conservative treatment of asymmetric ankle osteoarthritis

This review article summarizes the currently available (poor) evidence of conservative treatment of asymmetric ankle osteoarthritis in the literature and adds the authors' experience with the particular technique. The use of dietary supplementation, viscosupplementation, platelet-rich plasma, nonsteroidal anti-inflammotory drugs, corticosteroid injections, physical therapy, shoe modifications and orthoses, and patient's education in asymmetric ankle osteoarthritis is outlined. There definitively is a place for conservative treatment with reasonable success in patients whose ankles do not qualify anymore for joint-preserving surgery and in patients with medical or orthopedic contraindications for realignment surgery, total ankle replacement, and ankle arthrodesis.