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Scientific literature review: PRP (Platelet Rich Plasma) for the treatment of Osteoarthritis

Platelet rich plasma (PRP) has been used for the treatment of symptomatic arthritis for many years. While most of the available research focusses on the knee, there are also some trials investigating the effect of PRP on osteoarthritis (OA) of the hip and the thumb. To us at the Orthobiologics Clinic it looks as if PRP works equally well regardless of the joint affected. However, we felt that it is difficult to compare different PRP treatments with each other as there is a wide variety in the way they are prepared, their Leucocyte count, activation status and concentration levels. We were pleased to see several randomised trials comparing PRP with corticosteroid injections and Hyaluronic Acid (HA). Work has also been done to compare single injections of PRP with multiple injections. The benefits of combining PRP with HA have also been explored. At the Orthobiologics Clinic we have carefully analysed the literature and concluded that PRP is safe and effective in the treatment of osteoarthritis (OA). We would also recommend the use of two to three injections of PRP and to possibly combine PRP with HA to maximise the benefits.

Platelet-Rich Plasma Treatment in Symptomatic Patients With Knee Osteoarthritis: Preliminary Results in a Group of Active Patients

Alberto Gobbi, Georgios Karnatzikos, Vivek Mahajan, Somanna Malchira (2012)

This is one of the earlier trials looking into the effect of PRP in the treatment of osteoarthritis (OA) of the knee. The authors followed up 50 patients for 12 months, all patients had 2 injections of PRP. 25 of these patients had previously undergone surgery in the form of either cartilage shaving or microfracture. All function and pain scores improved significantly at 6 and 12 months regardless of whether patients had undergone previous surgery. The authors concluded that PRP treatment showed positive effects in patients with knee OA. Operated and non-operated patients showed significant improvement by means of diminishing pain and improved symptoms and quality of life.

At the Orthobiologics Clinic we felt that this publication from the early days of PRP nicely demonstrates the potential benefits of using PRP in the treatment of osteoarthritis. However, we agree with the authors that the multitude of different PRP preparations make a comparison difficult. We also agree with the authors that only randomised controlled trials can truly define the benefits and durability of treatment of OA with platelet rich plasma.

Efficacy of Intra-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review

Carlos J. Meheux, Patrick C. McCulloch, David M. Lintner, Kevin E. Varner, Joshua D. Harris (2016)

The authors identified prospective randomised trials comparing PRP (platelet-rich plasma) with Hyaluronic Acid (HA) or placebo injections for the treatment of knee osteoarthritis (OA) with a minimal follow-up of 6 months. 6 suitable publications were identified. The analysis showed that all but one publication showed significant benefits from the use of PRP. Both PRP and HA were more effective than placebo treatment. PRP showed better outcomes than HA. The authors concluded that Clinical outcomes and WOMAC scores are significantly better after PRP versus HA at 3 to 12 months post injection.

At the Orthobiologics Clinic we were interested to see that PRP not only performed better than placebo, but also showed superior outcomes compared to Hyaluronic Acid at 3, 6 and 12 months.

Comparison of Efficiency Between Corticosteroid and Platelet Rich Plasma Injection Therapies in Patients With Knee Osteoarthritis

Ece USLU GUVENDI, Ayhan ASKIN, Guven GUVENDI, Hikmet KOCYIGIT (2017)

In this trial 50 patients with moderate knee osteoarthritis (OA) were randomised into 3 groups: corticosteroid injection, single PRP injection or 3 PRP injections. Patients were followed up after 2 and 6 months. The authors found that injections with corticosteroids only provided short-term symptom relief, while PRP injection treatment resulted in a sustained symptom improvement at 6 months. Both PRP groups fared equally well. The authors concluded that PRP is a safe treatment option and efficient in OA symptom control up to six months after application. The treatment response obtained with corticosteroid injection has a shorter duration than PRP treatment.

At the Orthobiologics clinic we were delighted to see a randomised trial demonstrating the benefits of treatment with PRP. However, we would have much liked to see a longer follow-up of at least 1 year.

Treatment of knee osteoarthritis: platelet-derived growth factors vs. hyaluronic acid. A randomized controlled trial

Claudio Lisi, Cesare Perotti, Luigia Scudeller, Luigi Sammarchi, Francesca Dametti, Valeria Musella, Giuseppe Di Natali (2018)

In this trial patients with osteoarthritis (OA) of the knee were randomly allocated to treatment with either PRP (platelet-rich plasma) or Hyaluronic Acid (HA). The length of follow-up was one year. There were 28 patients (29 knees) in the PRP group and 22 patients (25 knees) in the HA group and all patients had either 3 injections with PRP or 3 injections with HA. Patients and outcome assessors were blinded to the treatment used. Patients had MRI scans prior to treatment and after 6 months. The authors found that 48% of patients in the PRP group showed at least 1 grade of improvement on the MRI scan after 6 months, but only 8% in the HA group. Patients in the PRP group also showed consistently better outcomes in their symptom scores. There were no complications in either group. The authors concluded that Activated platelet-rich plasma reduces articular damage as evident at MRI, as soon as six months after treatment; it reduces pain and improves patient's function and overall quality of life.

The Orthobiologics Clinic team was pleased to see this well-designed randomised trial with blinding of patients and outcome assessors. The trial not only demonstrated the safety of treatment with PRP, but also superior outcomes compared to treatment with HA. We were intrigued to see the improvements in the MRI scans in the patients who underwent treatment with PRP.

Single- and double-dose of platelet-rich plasma versus hyaluronic acid for treatment of knee osteoarthritis: A randomized controlled trial

Mehdi Tavassoli, Nasser Janmohammadi, Akram Hosseini, Soraya Khafri, Seyed Mokhtar Esmaeilnejad-Ganji (2019)

The authors of this recent publications randomly allocated patients with osteoarthritis of the knee into 3 groups: single PRP injection, 2 PRP injections and 3 injections with Hyaluronic Acid (HA). Patients were then followed up for 3 months. 86% of patients in the single PRP group experienced an improvement in symptoms of at least 30%. The corresponding figures were 100% in the double PRP group and 0% in the HA group. The overall outcomes were better in patients who received PRP compared to those who were treated with HA. 2 injections with PRP worked better than a single injection. The authors concluded that PRP is a safe and efficient therapeutic option for the treatment of knee osteoarthritis. PRP was demonstrated to be significantly more effective than hyaluronic acid. They also found that the efficacy of PRP increases after multiple injections.

At the Orthobiologics Clinic we were pleased to see yet another prospective randomised trial demonstrating the benefits of PRP in the treatment of osteoarthritis. We were however slightly disappointed with the short follow-up of only 3 months.

Randomized controlled trial comparing hyaluronic acid, platelet-rich plasma and the combination of both in the treatment of mild and moderate osteoarthritis of the knee

Lana JFSD, Weglein A, Sampson S, Vicente EF, Huber SC, Souza CV, Ambach MA, Vincent H, Urban-Paffaro A, Onodera CMK, Annichino-Bizzacchi JM, Santana MHA, Belangero WD (2016)

The authors treated 105 patients with mild to moderate osteoarthritis (OA) of the knee. Patients were randomly allocated to 3 treatment groups: Platelet Rich Plasma (PRP), Hyaluronic Acid (HA) or PRP + HA. All patients received 3 injections of the allocated substance and were then followed up for 1 year. The trial demonstrated greater improvements in pain and physical activity scores in those patients who had PRP compared to HA after 1 year. The PRP + HA group showed better improvements in pain and functional limitations then the HA patients after 1 year. PRP + HA showed increased physical function after 1 and 3 months compared to PRP. The authors concluded that the findings of the study support the use of autologous PRP as an effective treatment of mild to moderate knee osteoarthritis. It also demonstrates that the combination of HA and PRP resulted in better outcomes than HA alone up to 1 year and PRP alone up to 3 months. Furthermore, the results suggest that combination of PRP and HA could potentially provide better functional outcomes in the first 30 days after treatment with both PRP and HA alone.

At the Orthobiologics Clinic we noted with interest the better outcomes in the PRP + HA group - a trend seen in other trials.

Clinical therapy of hyaluronic acid combined with plateletrich plasma for the treatment of knee osteoarthritis

WENXING YU, PENG XU, GUILING HUANG and LIN LIU (2017)

This trial involved 360 patients with osteoarthritis of the knee. Patients were randomly allocated into four groups: Platelet Rich Plasma (PRP), Hyaluronic Acid (HA), PRP + HA and placebo. Patients were followed up for 1 year. The authors found that PRP was more effective at reducing pain than HA. PRP + HA resulted in more pain and a better healing response as seen on tissue samples under the microscope compared to PRP or HA. The authors concluded that these results suggested that a treatment combining PRP and HA may be a potential option for patients with knee osteoarthritis in the future.

At the Orthobiologics Clinic we were left a bit perplexed by this trial. Whilst we liked the study set-up (large number of patients, random allocation into 4 groups, blinding of patients and assessors to treatment), we did not quite understand the confusing description of the number of injections received not only at the start of the trial, but also during the trial (maintenance injections). We were also somewhat bewildered to see that different doses of PRP and HA were used and that some patients received such high doses of substances that they developed side effects (something not seen in any other published trials where the dose of HA/PRP was much lower). We could not help thinking that is it appears that ethical committees in other parts of this world apply different ethical standards when approving trials. Considering these flaws, it is difficult to draw any meaningful conclusions from this trial.

Intra-articular injections of platelet-rich plasma, hyaluronic acid or corticosteroids for knee osteoarthritis. A prospective randomized controlled study

Y. Huang, X. Liu, X. Xu, J. Liu (2019)

120 patients with osteoarthritis of the knee participated in this trial. They were randomly allocated into 3 treatment groups: PRP injection, HA injection or corticosteroid injection. All patients were followed for 1 year. Similar improvements were found in all groups after 3 months. Patients injected with PRP showed significantly better outcomes after 6, 9 and 12 months. The authors concluded that intra-articular PRP injections into the knee for symptomatic early stages of knee OA are a valid treatment option. The clinical efficacy of PRP was comparable to that of HA and corticosteroid injections after 3 months and the long-term efficacy of PRP was superior to HA and corticosteroids.

At the Orthobiologics Clinic we liked this well-designed trial demonstrating the positive outcomes that can be achieved with PRP injections in the treatment of osteoarthritis of the knee. We would be interested in seeing a similar trial with a 2-year follow-up.

Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial)

Seyed Ahmad Raeissadat, Seyed Mansoor Rayegani, Hossein Hassanabadi, Mohammad Fathi, Elham Ghorbani, Marzieh Babaee and Kamran Azma (2015)

The authors included 160 patients with OA of the knee. All patients were randomly allocated to treatment with either PRP (2 injections) or HA (3 injections) with a follow-up of 1 year. The authors found that pain scores after 1 year improved in both groups, but more so in patients who underwent PRP injection treatment. The authors concluded that this study suggests that PRP injection is more effective than HA injection in reducing symptoms and improving quality of life. They also concluded that PRP injection treatment is a therapeutic option in select patients with knee OA who have not responded to conventional treatment.The Orthobiologics Clinic team thought that this was yet another publication demonstrating the superior outcomes following PRP injection treatment over HA injections.

Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial

Gokay Gormeli, Cemile Ayse Gormeli, Baybars Ataoglu, Cemil Colak, Okan Aslanturk, Kadir Ertem (2015)

The authors randomly divided 162 patients into four groups: 3 PRP injections, 1 PRP injection, 1 HA injection, 1 placebo (saline) injection. Patients were followed up for 6 months. The authors found that all treatment groups showed better results than the placebo group. Patients who had 3 PRP injections showed better knee scores than all other patients. The better improvements seen in the 3 PRP injection group was only significant in patients with mild arthritis. After 6 months there was no difference between 1 PRP and 1 HA injection. The authors concluded that the clinical results of this study suggest PRP and HA treatment for all stages of knee OA. For patients with early OA, multiple (3) PRP injections are useful in achieving better clinical results. For patients with advanced OA, multiple injections do not significantly improve the results of patients in any group.

At the Orthobiologics Clinic we would have liked to see a longer follow-up period than 6 months. At the same time, we were intrigued to see better results in patients with mild arthritis who received three PRP injections compared with only one PRP injection.

Platelet-Rich Plasma Versus Hyaluronic Acid Injections for Knee Osteoarthritis: A Propensity-Score Analysis

J. A. Annaniemi, J. Pere, S. Giordano (2019)

The authors of this trial reviewed the case notes of patients with osteoarthritis (OA) of the knee who had previously undergone injection treatment with either PRP or HA. The authors set themselves the goal of not only looking at the clinical outcomes, but also to see whether any group of patients was more likely to eventually end up with total knee replacement surgery. The mean follow-up was 16 months. The authors found that patients in the HA group were more likely to require knee replacement surgery (36%) than those who had PRP treatment (5.3%). HA patients had poorer outcomes for range of movement and various pain and knee scores. The authors concluded that intra-articular injections of platelet-rich plasma associated with better outcomes than hyaluronic acid in knee osteoarthritis. Platelet-rich plasma might prolong the time to arthroplasty and provide a valid therapeutic option in selected patients with knee osteoarthritis not responding to conventional treatments. Further larger studies are needed to validate this promising treatment modality.

At the Orthobiologics Clinic we analysed the results of this publication with great interest. While there are plenty of publications analysing and demonstrating the potential benefits of injection treatment with PRP, this is the first scientific paper suggesting that PRP injection treatment increases the time until patients may eventually have to undergo knee replacement surgery. The Orthobiologics Clinic team felt that this supports the notion, that PRP injection treatment plays a role in bridging the gap between other non-operative treatments for osteoarthritis and treatment with joint replacement surgery.

Ultrasound-Guided Injection of Platelet-Rich Plasma and Hyaluronic Acid, Separately and in Combination, for Hip Osteoarthritis A Randomized Controlled Study

Dante Dallari, Cesare Stagni, Nicola Rani, Giacomo Sabbioni, Patrizia Pelotti, Paola Torricelli, Matilde Tschon, and Gianluca Giavaresi (2016)

111 patients with osteoarthritis of the hip were randomly allocated to three treatment groups: 3 injections with PRP, 3 injections with HA or 3 injections with PRP+HA. Patients were followed up for 12 months. The authors found that patients in the PRP-only group showed better results in terms of pain and hip function scores than patients in the HA and the PRP+HA groups. Pain scores in the HA group were improved at the 2-month stage but were worse than the baseline after 6 and 12 months. Patients in the PRP+HA group had better outcomes than patients treated with HA but did not respond quite as well as patients in the PRP-only group. The authors concluded that results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip OA without relevant side effects. The benefit was significantly more stable up to 12 months as compared with the other tested treatments. The addition of PRP+HA did not lead to a significant improvement in pain symptoms.

At the Orthobiologics Clinic we were pleased to see a publication investigating the outcomes of PRP injection treatment for OA of the hip. We were also pleased to see that PRP seems to work just as well in the hip as it does in the knee. We noticed with interest that the combination of PRP with HA did not work as well in the hip as has been demonstrated in the knee. Clearly more research is needed to investigate the role of PRP+HA combination treatment in the hip.

Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial

Michael-Alexander Malahias, Leonidas Roumeliotis, Vasileios S. Nikolaou, Efstathios Chronopoulos, Ioannis Sourlas, and Georgios C. Babis (2018)

The authors randomly allocated 33 patients with osteoarthritis (OA) of the base of thumb carpometacarpal joint (CMC-J) into 2 groups either receiving 2 injections with PRP or 2 corticosteroid injections. All injections were carried out using Ultrasound guidance. Patients were followed up for 1 year. The authors found that patients in the PRP group had significantly better pain scores, function scores and satisfaction scores after 1 year compared to patients who received corticosteroid injections. The authors concluded that corticosteroids offer short-term relief of symptoms, but PRP might achieve a lasting effect of up to 12 months in the treatment of early to moderate symptomatic TMJ arthritis. One could hear a big sigh of relief at the Orthobiologics Clinic when we finally found a publication looking into the effectiveness of PRP in the treatment of base of thumb OA. We were delighted to see that PRP seems to work just as well in the thumb as in the knee. We would like to see more clinical trials investigating the use of PRP in the upper limb.

  • British Trauma Society
  • British Orthopaedic Trainees Association
  • Spire Healthcare
  • Manchester Orthopaedic Group