Platelet-rich plasma versus hyaluronic acid injections for knee osteoarthritis: a propensity-score analysis

Most Publications Regarding Platelet-Rich Plasma Use in the Knee Are From Asia, Investigate Injection for Osteoarthritis, and Show Outcome Improvement: A Scoping Review

PURPOSE

To evaluate and synthesize the available literature related to platelet-rich plasma (PRP) treatment of knee pathologies and to provide recommendations to inform future research in the field.

METHODS

PubMed, CINAHL, and Scopus databases were queried on October 6, 2023. All identified citations were collated and uploaded into Covidence for screening and data extraction. Studies were included if they were human studies published in English with adult cohorts that received PRP as a procedural injection or surgical augmentation for knee pathologies with patient-reported outcome measures (PROMs) and level of evidence Levels I-IV.

RESULTS

Our search yielded 2,615 studies, of which 155 studies from 2006 to 2023 met the inclusion criteria. Median follow-up was 9 months (±11.2 months). Most studies (75.5%) characterized the leukocyte content of PRP, although most studies (86%) did not use a comprehensive classification scheme. In addition, most studies were from Asia (50%) and Europe (32%) and were from a single center (96%). In terms of treatment, 74% of studies examined PRP as a procedural injection, whereas 26% examined PRP as an augmentation. Most studies (68%) examined treatment of knee osteoarthritis. Many studies (83%) documented significant improvements in PROMs, including 93% of Level III/IV evidence studies and 72% of Level I/II evidence studies, although most studies (70%) failed to include minimal clinically important difference values. The visual analog scale was the most-used PROM (58% of studies), whereas the Short Form Health Survey 36-item was the least-used PROM (5% of studies).

CONCLUSIONS

Most published investigations of knee PRP are performed in Asia, investigate procedural injection for osteoarthritis, and show significant outcome improvements. In addition, this review highlights the need for better classification of PRP formulations.

LEVEL OF EVIDENCE

Level IV, scoping review of Level I-IV studies.

Long-term effectiveness of intra-articular injectables in patients with knee osteoarthritis: a systematic review and Bayesian network meta-analysis

BACKGROUND

Intra-articular injectables are proposed as a solution for pain relief and functional improvement in knee osteoarthritis (OA), however most studies involving intra-articular knee injectables are focused on short-term relief, leaving the recommendations regarding long-term management unclear. This network meta-analysis aimed to evaluate the mid- to long-term effectiveness of intra-articular knee injection of platelet-rich plasma (PRP), hyaluronic acid (HA), corticosteroids (CS), and their combinations for management of knee OA.

METHODS

Relevant studies were searched through PubMed, EMBASE, Scopus, and Cochrane Register of Trials databases from inception to 20th October, 2024 for randomized controlled trials (RCTs) of knee OA patients who had taken intra-articular injectable treatment with a follow-up duration of at least one year. The study included 37 RCTs involving 5089 patients. The outcomes assessed were pain relief and functional improvement of knee joint. The random effects Bayesian model was carried out for network meta-analysis. The surface under the cumulative ranking (SUCRA) curve demonstrated the rank probability of each injectable therapy for different outcomes.

RESULTS

Analysis revealed that, in terms of both knee pain relief and improvement of functional outcomes, the combined intra-articular injection of PRP and HA was ranked ahead of the isolated administration of PRP, followed by combination of HA with CS, HA alone, placebo, and CS at the end of one year.

CONCLUSION

These findings emphasize the sustained efficacy of PRP, particularly when combined with HA, in providing superior long-term pain relief and functional improvement in knee OA compared to other intra-articular injectables, highlighting its potential as a preferred treatment modality.

Intra-articular injections of hyaluronic acid versus plasma rich in growth factors (PRGF) for knee osteoarthritis: a meta-analysis of randomised controlled trials : A meta-analysis

INTRODUCTION

The present meta-analysis compared intra-articular injections of hyaluronic acid (HA) versus plasma rich in growth factors (PRGF) in patients with knee osteoarthritis (OA). The outcome of interest was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

METHODS

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses: the 2020 PRISMA statement. All the head-to-head randomised controlled trials (RCT) comparing intra-articular HA injections versus PRGF were accessed and included in the present study. Only studies that clearly stated that injections were performed in patients with knee OA, irrespective of the severity of OA, were considered. Data concerning the WOMAC index were retrieved at baseline and last follow-up. The endpoint of interest was to investigate whether intra-articular HA injections are associated with WOMAC score improvement compared to PRGF injections at 4-6 months follow-up.

RESULTS

Data from 432 patients were collected and 76.3% (330 of 432) of the patients were women. The mean age of the patients was 58.2 ± 1.5 years and the mean body mass index (BMI) was 28.0 ± 0.5 kg/m2. At baseline, comparability in mean age, BMI, male:female ratio, WOMAC and related subscales were documented. The PRGF group evidenced lower values of the function subscale of the WOMAC index (P = 0.03). No difference was found in the overall WOMAC index (P = 0.05) and its stiffness (P = 0.4) and pain (P = 0.07) subscales.

CONCLUSION

The current level I evidence suggests that the use of PRGF might be associated with more favorable clinical outcomes than using HA.

Efficacy and safety of platelet-rich plasma for acute nonarteritic anterior ischemic optic neuropathy: a prospective cohort study

Background

As the most common acute optic neuropathy in older patients, nonarteritic anterior ischemic optic neuropathy (NAION) presents with varying degrees of visual acuity loss and visual field defect. However, there is no generally accepted treatment for NAION.

Objectives

To evaluate the efficacy and safety of platelet-rich plasma (PRP) for patients with acute NAION within 2 months.

Design

A prospective, nonrandomized controlled trial.

Methods

Twenty-five eyes of 25 patients were enrolled. Of them, 13 received anisodine hydrobromide and butylphthalide-sodium chloride injection continuously for 10 days as basic treatment in the control group, and 12 received two tenon capsule injections of PRP on a 10 days interval as an additional treatment in the PRP group. We compared the best-corrected visual acuity (BCVA) and capillary perfusion density (CPD) of radial peripapillary capillaries and the moth-eaten eara of the peripapillary superficial capillary plexus and deep capillary plexus at 1 day (D1) before the first PRP treatment and 7 days (D7), 14 days (D14), and 30 days (D30) after the first PRP injection. Ocular and systemic adverse effects were assessed.

Results

In the PRP group, a better BCVA occurred at D30 (adjusted p = 0.005, compared with D1, recovered from 0.67 ± 0.59 to 0.43 ± 0.59), and a significant improvement in CPD was observed at D30 (adjusted p < 0.001, p = 0.027, p = 0.027, compared with D1, D7, D14, in sequence, the value was 35.97 ± 4.65, 38.73 ± 4.61, 39.05 ± 5.26, 42.71 ± 4.72, respectively). CPD at D7 in the PRP group was better than that in the control group (p = 0.043). However, neither BCVA nor the moth-eaten area index were significantly different (all p > 0.5) between the two groups. The main adverse effect was local discomfort resolved within 1 week, and no other systemic adverse events occurred.

Conclusion

Tenon capsule injection of PRP was a safe treatment for AION and could improve capillary perfusion of the optic nerve head and might be helpful in increasing short-term vision in patients with acute NAION.

The effects of platelet-rich plasma injections in different stages of knee osteoarthritis

PURPOSE

Platelet-rich plasma (PRP) injections are challenging the current treatment options for knee osteoarthritis (KOA). Targeting the treatment to optimal stage of the symptomatic KOA may be crucial in the success and failure of treatment. The aim of this study is to compare the outcomes of PRP injections at different stages of KOA in order to determine the optimal stage of the KOA for PRP injection treatments.

METHODS

A total of 89 consecutive patients with symptomatic KOA Kellgren-Lawrence grade 1 to 3 (Group A grade 1, group B grade 2 and group C grade 3) were given three intra-articular injections of PRP with 2 weeks interval between injections. Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Range of Motion were measured before injection, at 15 days, 6 months, 12 months and, at last follow-up. Intergroup outcomes were compared.

RESULTS

The comparison of groups A and C showed that WOMAC scores were significantly higher in group C at 15 days [p = 0.047] and at last follow-up [p = 0.008] than in group A, as well as VAS scores at 6 months [p = 0.031] and at last follow-up [p = 0.008]. The overall WOMAC and VAS scores showed decrease in all the groups in minimum follow-up of 14 months. The other comparisons did not show significant differences in outcomes.

CONCLUSION

All the groups showed decrease in WOMAC and VAS, but patients with mild KOA benefit significantly more from the treatments than patients with more severe KOA.

Intra-articular injection of platelet-rich plasma in patients with hemophilia and painful knee joint cartilage degeneration

INTRODUCTION

Knee arthropathy causes pain to people with hemophilia (PWH). One of the current controversies is whether injections of intra-articular platelet-rich plasma (PRP) are effective in relieving the knee pain of PWH.

AREAS COVERED

A narrative literature review was conducted on the efficacy of PRP injections in the knees of PWH.

EXPERT OPINION

Intra-articular PRP knee injections are widely used in patients with knee osteoarthritis to relieve pain and delay total knee arthroplasty. Although numerous publications have supported the use of PRP in knee osteoarthritis, there is still major controversy regarding its true usefulness, given that a number of studies with a high degree of evidence have failed to show the efficacy of PRP. With respect to painful hemophilic arthropathy, the use of PRP injections is even more controversial, as there are only four publications on the subject supporting the use of PRP in hemophilia, all of them with a low degree of evidence. A publication with grade 1 evidence recommended against the use of PRP in hemophilic arthropathy because its efficacy has not been demonstrated. My opinion is that intra-articular PRP injections should not be used in hemophilia until there is more evidence of its benefits.

Effects of medications on incidence and risk of knee and hip joint replacement in patients with osteoarthritis: a systematic review and meta-analysis

Background

This systematic review and meta-analysis aimed to investigate the incidence and risk of knee and hip replacement in patients with osteoarthritis (OA) treated with different medications.

Methods

OVID MEDLINE, OVID EMBASE, Cochrane and Web of Science electronic databases were searched from inception to May 4th, 2022. Clinical trials, including randomized controlled trials, cohort studies and case–control studies, were selected. The meta-analysis effect size was estimated using either incidence with 95% confidence intervals (CIs) or odds ratio (OR)/relative risk (RR) with 95% CIs. The risk of bias and heterogeneity among studies were assessed and analyzed.

Results

Forty studies were included, involving 6,041,254 participants. The incidence of joint replacement in patients with OA varied according to the study design and treatments. The incidence of knee arthroplasty varied from 0 to 70.88%, while the incidence of hip arthroplasty varied from 11.71 to 96.43%. Compared to non-users, bisphosphonate users had a reduced risk of knee replacement (RR = 0.71, 95% CI: 0.66–0.77; adjusted hazard ratio [aHR] = 0.76, 95% CI: 0.70–0.83). Compared to intra-articular corticosteroid users, hyaluronic acid (HA) users had a higher risk of knee arthroplasty (RR = 1.76, 95% CI: 1.38–2.25). No publication bias was observed.

Conclusions

Bisphosphonate treatment is associated with a reduced risk of knee replacement. More studies are needed to validate our results due to the limited number of eligible studies and high heterogeneity among studies.

Is intraarticular enjections effective on pain management in patients with late stage primer gonarthrosis during COVID-19 pandemic? A single centre experience

Background: Primary gonarthrosis is a progressive disease that increases with age and leads to limitations in activities of daily living. Until surgery is performed, nonsteroidal anti-inflammatory drugs, intraarticular injections, and physical therapy methods are used. Purpose: This study aims to compare the clinical outcomes of intra- articular corticosteroid (CCS) and hyaluro nic acid (HA) injections for pain relief in primary gonartrhosis in COVID -19 pandemic period. Study Design: Retrospective Cohort Study. Methods: In this study, 88 patients who underwent intra-articular CCS and HA injection between August 2020 and March 2021 due to Kellgren-Lawrence stage 2 and higher gonarthrosis were investigated. Patients were divided into two groups. Group I represents the patients who received HA injections, and group II represents the patients who received CCS injection. Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS) scores were used for the preoperative and postoperative functional evaluations of the patients. Results: Group I included 40 patients and group II included 48 patients. The mean age was 59.4 ± 7.3 years, and the average follow-up period was 12 ± 2,6 months. The pre-intervention WOMAC scores were 13,5 in Group I and 13.6 in Group II, KSS scores were 26,5 in Group I and 25,2 in Group II. While there was a significant change in the control at month 1 in both groups, no difference was found between the groups. At the 6th month control, the improvement in group 1 continued at a significant level compared to the pre-injection period, while group 2 returned to the pre-injection level. (p

Comparative Study of the Efficacy of Hyaluronic Acid, Dry Needling and Combined Treatment in Patellar Osteoarthritis-Single-Blind Randomized Clinical Trial

Background: Osteoarthritis of the knee is one of the most common ailments worldwide, and pain management of this condition is critical. Methods: A multicentre randomized controlled trial RCT with three months of follow-up, conducted in parallel groups: hyaluronic acid (HA), dry needling (DN) and ultrasound (US) and isometrics of quadriceps. 60 participants took part in the RCT who were diagnosed with osteoarthritis (Grade 3) of the knee by MRI and active adults (age: 23.41 ± 1.68 years; height: 1.79 ± 0.08 m; body mass: 78.33 ± 9.03 kg; body mass index (BMI): 24.14 ± 1.45 kg/m²). After the assigned intervention, VAS, WOMAC, IPAQ and the Star Excursion Balance test were measured at baseline. At 24 h, 15 days, 30 days, 90 days and 180 days follow-up, all variables were measured again. Results: Comparing statistically significant differences between groups, VAS scores were significant at post-test measurement (HA vs. US + isometric and DN vs. US + isometric) at 24 h (HA vs. DN), at 15 days (HA vs. US + isometric and DN vs. US + isometric) and at 1 month (US + isometric vs. HA and US + isometric vs. DN). Conclusions: There is an improvement in pain intensity in knee osteoarthritis in the short term in patients undergoing DN and conventional US + isometric treatment, but in the long term the HA group shows an improvement in pain intensity. There is also a significant difference in the improvement of knee function at different phases of the study in the various intervention groups. The combination of DN and HA in clinical practice is the best option for the treatment of osteoarthritis.

Engineering of Viscosupplement Biomaterials for Treatment of Osteoarthritis: A Comprehensive Review

Osteoarthritis (OA) is a progressive degenerative disease that causes severe pain and functional limitation, especially during locomotion. It is the most common arthritis type that damages the surface of articular cartilage until the underlying bone. In the past decade, the scientific community has made a considerable effort to improve or discover therapeutical products used as a form of conservative treatment capable of restoring the damaged articular tissue, avoiding, as far as possible, the use of surgical practices. The most common and direct nonoperative application available for OA treatment is the viscosupplementation (VS) procedure that demonstrates a safe, effective method and is less painful for the patients. The most recent works dealing with the design, development, and validation of viscosupplement products in preclinical and clinical trials for OA treatment are overviewed herein. In general, despite the development of new products, hyaluronic acid continues to be among the most reported intra‐articular viscosupplement products used in clinical trials, typically used as an isolated product or conjugated with other biologicals or drugs, such as platelet‐rich plasma and corticosteroids (CS). However, this issue is still demanding innovation. Approaches comprising new biomaterials as VS products, with intrinsic bioactivity, economical, and environmental friendliness, are required.

Time to Total Knee Arthroplasty after Intra-Articular Hyaluronic Acid or Platelet-Rich Plasma Injections: A Systematic Literature Review and Meta-Analysis

Intra-articular (IA) hyaluronic acid (HA) and platelet-rich plasma (PRP) injections are increasingly being prescribed for knee osteoarthritis (KOA). However, failure of the medical treatment may result in total knee arthroplasty (TKA). We wondered if IA HA or PRP injections (intervention) may delay the time to TKA (outcome) among KOA patients (population), compared to KOA patients not receiving these injections (comparator). For this systematic literature review (SLR) and meta-analysis, we selected observational studies with at least one group of patients receiving IA HA or PRP and with TKA data available. The main outcome was time from the diagnosis of KOA to TKA. We included 25 articles in the SLR (2,824,401 patients) and four in the meta-analysis. The mean strengthening the reporting of observational studies in epidemiology (STROBE) score was 63%. For patients receiving versus not receiving HA injections, the delay between a declared diagnosis of KOA to TKA was increased by 9.8 months (95% CI (8.2-11.4)). As compared with standard of care, the effect size of HA injections for this outcome was 0.57 (95% CI (0.36-0.76)). Only one study described a median time from PRP injections to TKA of 4.1 years (range 0.3-14.7). IA HA injections were associated with increased time to TKA. Causality cannot be concluded because of missing confounder factors as comorbidities. Data were insufficient to conclude any effect of PRP injections on TKA delay.

Intra-Articular Injection of Platelet-Rich Plasma Is More Effective than Hyaluronic Acid or Steroid Injection in the Treatment of Mild to Moderate Knee Osteoarthritis: A Prospective, Randomized, Triple-Parallel Clinical Trial

Purpose: To prospectively compare the efficacy and safety of intra-articular injections of platelet-rich plasma (PRP) with hyaluronic acid (HA) and glucocorticosteroid (CS) control groups for knee osteoarthritis (KOA) in a randomized, triple-parallel, single-center clinical trial. Methods: A total of 75 patients were randomly assigned to one of three groups receiving a single injection of either leukocyte-poor platelet-rich plasma (25 knees), hyaluronic acid (25 knees), or glucocorticosteroid (25 knees). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was collected at baseline and 6, 12, and 26 weeks after treatment. Results: After 6 weeks of PRP administration, a decrease in the mean WOMAC value was observed in all three study groups. Three months after administration, the greatest decrease in the mean WOMAC value was obtained in the PRP group. The results in the HA and CS groups were similar (p = 0.681). In the one-way analysis of variance and post hoc analysis using the HSD Tukey test, a significantly greater improvement was shown by comparing the PRP and CS groups (p = 0.001), and the PRP and HA groups (p = 0.010). After intra-articular injection of CS, the reduction in pain was greatest 6 weeks after administration, and the mean value was the lowest among all groups. During subsequent visits, the value of the pain subscale increased, and after 6 months, it was the highest among the studied groups. Using the Wilcoxon paired test, no PRP effect was found to reduce stiffness at the 6-month follow-up (p = 0.908). Functional improvement was achieved in all groups, i.e., a decrease in the value of this subscale 6 months after administration. The largest decrease was seen in the group that received PRP (p < 0.001) and then in the HA group. The smallest decrease among the investigated methods was shown in the CS group. Conclusions: Intra-articular injections of PRP can provide clinically significant functional improvement for at least 6 months in patients with mild to moderate KOA which is superior to HA or CS injections.

Subchondral versus intra-articular orthobiologic injections for the treatment of knee osteoarthritis: a review

Recent perspectives suggest that osteoarthritis (OA) is a disease involving not only the articular cartilage but also the osteochondral unit, including the synovium, supportive cartilage and subchondral bone. Current conservative treatments for OA are symptomatic and do not prevent progression or reverse the disease process. Compelling data show that intra-articular orthobiologic injections, such as platelet-rich plasma and mesenchymal stromal cells, are effective in providing relief of OA symptoms. However, recent data suggest that injections of orthobiologics into the subchondral bone may be superior to intra-articular injections for the management of OA. This review highlights the rationale and current evidence for intra-articular and subchondral bone injections of orthobiologics for the treatment of OA.

Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis: a Bayesian network meta-analysis

INTRODUCTION

Regarding the efficacy of intra-articular injections of platelet-rich plasma, hyaluronic acid and corticosteroids, current evidence is controversial. The superiority of one technique over another is questioned and debates are ongoing. The purpose of the present study was to compare and investigate the efficacy of these intra-articular infiltrations in patients with knee osteoarthritis (OA). A Bayesian network meta-analysis of randomized clinical trials (RCTs) was conducted comparing patient outcomes at 3, 6 and 12-months of follow-up.

MATERIALS AND METHODS

This Bayesian network meta-analysis was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health care interventions. All the RCTs comparing the outcomes of two or more intra-articular infiltrations of interest for knee OA were considered for inclusion. The outcomes of interest were the WOMAC and VAS scores. The network meta-analyses were performed using the STATA routine for Bayesian hierarchical random-effects models.

RESULTS

Data from 30 RCTs (3463 patients) were collected. At 3-months follow-up, PRP showed the best WOMAC scores, followed by the Placebo, CCS and HA. At 6-months follow-up, PRP showed the best WOMAC scores, followed by HA, CCS and Placebo. At 12-months follow-up, PRP showed the best WOMAC scores, followed by the Placebo, HA and CCS. At 3-months follow-up, the PRP showed the best VAS scores, followed by CCS, HA and Placebo. At 6-months follow-up, PRP showed the best VAS scores, followed by CCS, Placebo and HA. At 12-months follow-up, the PRP showed the best VAS scores, followed by CCS, Placebo and HA.

CONCLUSION

Intra-articular injections of PRP demonstrated the best overall outcome compared to steroids, hyaluronic acid and placebo for patients with knee osteoarthrosis at 3, 6 and 12-months follow-up. Among CCS, hyaluronic acid and placebo, no discrepancies were detected.

LEVEL OF EVIDENCE

I, Bayesian network meta-analysis of RCTs.

Mechanistic Insight on the Interaction between OPN and Integrin ανβ3 in Osteoarthritis

Osteoarthritis (OA) is a joint disease characterized by cartilage degeneration. Osteopontin (OPN) is involved in the initiation, repair, and maintenance of metabolic homeostasis in normal articular cartilage. This study investigated the role of OPN and its interaction with the integrin ανβ3 receptor in the expression of hyaluronic acid (HA) in OA chondrocytes. Overexpression of OPN significantly increased the expression of integrin ανβ3 and hyaluronic acid synthases (HAS) and synthesis of HA. Depleting OPN in OA chondrocytes showed the opposite trend for integrin alpha;νβ3, HAS, and HA. Nonspecifically and specifically blocking integrin receptor using GRGDSP and integrin ανβ3 antibody downregulated HAS and HA; both were inhibited to similar extents. The expression of HAS and HA was predominantly regulated by the interaction between OPN and integrin ανβ3. Taken together, we have delineated the importance of the OPN/integrin ανβ3/HAS/HA axis in OA and identified OPN as a promising candidate for molecular therapy for use in patients with OA.