Efficacy and safety profile of a compound composed of platelet-rich plasma and hyaluronic acid in the treatment for knee osteoarthritis (preliminary results)

Efficacy of intra-articular injection of combined platelet-rich-plasma (PRP) and hyaluronic acid (HA) in knee degenerative joint disease: a prospective, randomized, double-blind clinical trial

PURPOSE

Intra-articular injections of hyaluronic acid (HA) and platelet-rich plasma (PRP) represent promising options in the conservative treatment of early stages of knee osteoarthritis (OA). Although the combined use of these two compounds seems to have a synergistic effect in pre-clinical studies, few clinical trials compared the association of PRP and HA with PRP and HA alone. The aim of study is to evaluate the efficacy of combined intra-articular injections of PRP and HA in the treatment of mild to moderate knee OA, compared to PRP and HA alone.

METHODS

One hundred and seventy-four patients were prospectively enrolled and randomized to undergo three intra-articular injections of either HA or PRP or the combination of PRP and HA with a two-week interval period. Patients were evaluated before treatment and after 3, 6, and 12 months using Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee subjective score, Visual Analogue Scale and TEGNER Activity Scores.

RESULTS

All the treatments proved to be effective in reducing pain and improving joint function. The analysis of covariance did not show statistically significant differences among the three groups for any of the investigated outcome parameters after 6 and 12 months (WOMAC: p = 0.45 and p = 0.64, respectively). No significant differences were found in terms of adverse events (p = 0.49) and painkiller use (p = 0.28 and p = 0.56, respectively) among the three groups.

CONCLUSION

This multicenter, prospective, randomized, double-blind controlled trial revealed that intra-articular injections of PRP + HA, PRP, or HA represent a safe and viable treatment with comparable efficacy in terms of pain relief and functional outcomes in mild to moderate knee OA.

Efficacy and Safety of Hyaluronic Acid and Platelet-Rich Plasma Combination Therapy Versus Platelet-Rich Plasma Alone in Treating Knee Osteoarthritis: A Systematic Review

Knee osteoarthritis (KOA) is a chronic degenerative disease of the joint characterized by biochemical and biomechanical alterations of articular cartilage, degradation of the joint edge, and subchondral bone hyperplasia. Nowadays, intra-articular hyaluronic acid (HA) or platelet-rich plasma (PRP) has become a popular treatment modality for treating KOA. Each treatment can be used independently or in combination. However, the efficacy and safety of combination treatment are still inconclusive, and there is a lack of high-quality level 1 studies that support using combination therapy over PRP alone. Consequently, we conducted a systematic review to examine the effectiveness and safety of combining HA and PRP therapy versus using PRP therapy alone in KOA patients. Based on the most up-to-date evidence, the dual approach of PRP and HA therapy yields outcomes similar to PRP therapy alone in the short term, up to 12 months. Nonetheless, when considering longer-term results, particularly in the 24-month follow-up, dual therapy holds the potential to produce superior outcomes compared to PRP alone therapy. Additionally, in terms of safety, dual therapy has been associated with slightly fewer adverse events.

Autologous microfragmented adipose tissue and leukocyte-poor platelet-rich plasma combined with hyaluronic acid show comparable clinical outcomes for symptomatic early knee osteoarthritis over a two-year follow-up period: a prospective randomized clinical trial

PURPOSE

The purpose of this prospective randomized clinical trial is to compare the clinical outcomes of three injections of leucocyte-poor platelet-rich plasma (LP-PRP) and hyaluronic acid (HA) to a single dose of autologous microfragmented adipose tissue (AMAT) in patients with mild osteoarthritis at a two-year follow-up.

METHODS

Eighty symptomatic knees in fifty patients (mean age: 62.38 ± 11.88 years) with Kellgren-Lawrence grade 0 to 2 osteoarthritis were non blinded, randomly allocated into two equal groups. Group 1 consisted of 40 knees that received autologous LP-PRP + HA; Group 2 consisted of 40 knees treated with a single dose of AMAT injection. The outcomes were measured by Tegner, Marx, Visual Analogue Scale (VAS) for pain, International Knee Documentation Committee, and Knee Injury and Osteoarthritis Outcome Score (KOOS) at 6 (T1), 12 (T2), and 24 (T3) months. Adverse events were recorded at each follow-up timepoint. To assess score differences among subjects of the same gender and age, a subgroup analysis was performed.

RESULTS

Both groups had significant clinical and functional improvement at 6, 12, and 24 months (p < 0.05). Comparing the two groups, the AMAT groups showed significantly higher pre-operative Marx score (3.35 ± 4.91 vs. 1.78 ± 3.91) and VAS score (5.03 ± 2.02 vs. 3.85 ± 1.68) (p < 0.05), higher VAS (3.89 ± 2.51 vs. 2.64 ± 2.00) at T2 and KOOS-ADL (79.60 ± 20.20 vs. 65.68 ± 23.62), and lower KOOS-Sports (50.30 ± 30.15 vs. 68.35 ± 30.39) at T3 (p < 0.05). No patient from either group had experienced major adverse effects. In the LP-PRP group 12 (30%) patients presented swelling, redness, and mild pain for one day after injection and two patients had synovitis for two days and required paracetamol and local ice. In AMAT group 5 (12.5%) patients had ecchymosis and bruising at the fat aspiration site for three days.

CONCLUSION

AMAT did not show significant superior clinical improvement compared with three LP-PRP combined with HA injections in terms of functional improvement at different follow-up points. Both procedures were safe with no major complications reporting good results at mid-term follow-up, improving knee function, pain, and quality of live regardless of age and gender.

LEVEL OF EVIDENCE

Level I-Prospective Randomized Clinical Trial.

Efficacy and safety of platelet-rich plasma combined with hyaluronic acid versus platelet-rich plasma alone for knee osteoarthritis: a systematic review and meta-analysis

Purpose

To systematically evaluate the curative efficacy and safety of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) in the treatment of knee osteoarthritis (KOA), comparing with platelet-rich plasma alone.

Methods

Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI) and Embase were searched for randomized controlled trials (RCTs) and cohort studies regarding the efficacy and safety of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) in the treatment of knee osteoarthritis (KOA) comparing with platelet-rich plasma alone before January 15, 2022. The methodological quality of the ultimately included studies was assessed comprehensively, and meta-analysis was implemented using RevMan 5.3 software.

Results

Thirteen articles (9 RCTs, 4 cohort studies), including 1118 patients, were covered. There was no significant difference between the PRP + HA therapy and PRP-alone therapy in VAS scores at 3 months, 6 months and 12 months, WOMAC total scores at 3 months and KOOS at 1 month and 6 months. Compared with PRP-alone therapy, PRP + HA therapy was associated with significantly better improvement in VAS scores at 1 month, WOMAC total scores at 6 months, KOOS at 3 months, IKDC scores at 6 months and Lequesne index scores at 3 and 6 months. However, the smallest treatment effect of VAS scores, WOMAC total scores, KOOS and IKDC scores did not exceed the minimum clinically important difference (MCID). However, PRP + HA therapy got a greater reduction in the rate of adverse events, compared with PRP-alone therapy.

Conclusion

The results of this meta-analysis indicated that PRP + HA therapy was not found to be superior to PRP-alone therapy in pain relief and function improvement for patients with KOA. However, combined PRP with HA injections was generally safer than PRP injections alone, by assessing the incidence of adverse events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03398-6.

Comparing efficacy of a single intraarticular injection of platelet-rich plasma (PRP) combined with different hyaluronans for knee osteoarthritis: a randomized-controlled clinical trial

BACKGROUND

Intraarticular plasma-rich platelet (PRP) and hyaluronic acid (HA) have each been shown to be effective for treating knee osteoarthritis (OA). Evidence supporting the combination therapy is controversial. This study aimed to investigate the efficacy of a single intraarticular PRP injection combined with different HAs in patients with knee OA.

METHODS

In this prospective randomized-controlled trial, 99 patients with Kellgren-Lawrence grade 2 knee OA with average knee pain ≥ 30 mm on a 0-100 mm pain visual analog scale (VAS) were randomized into two groups. The PRP + Artz group received a single intraarticular HA (Artz, 2.5 ml, 10 mg/ml) followed by 3 ml PRP (n = 50). The PRP + HYAJOINT Plus group received a single intraarticular cross-linked HA (HYAJOINT Plus, 3 ml, 20 mg/ml) followed by 3 ml PRP (n = 49). All patients were evaluated before and at 1, 3 and 6 months after injections. The primary outcome was the VAS pain reduction from baseline at 6 months. Secondary outcome measures included Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequesne index, single leg stance (SLS) test and patient satisfaction.

RESULTS

Ninety-five patients were analyzed by intention-to-treat analysis. Both groups improved significantly in VAS pain, WOMAC, Lequesne index and SLS at 1, 3 and 6 months post intervention (p < 0.05). Between-group comparisons showed no significant differences at most follow-up time points, except better improvements in Lequesne index at 1 month (p = 0.003) and WOMAC-stiffness score at 6 months (p = 0.020) in the PRP + Artz group, and superiority in SLS at 1, 3 and 6 months in the PRP+ HYAJOINT Plus group (p < 0.001, p = 0.003 and p = 0.004). Additional Johnson-Neyman analyses showed that among the patients with baseline WOMAC-pain score > 8.5, WOMAC-function score > 21.7 and WOMAC-total score > 32.0, respectively, those treated with PRP + HYAJOINT Plus injections had better effects in WOMAC-pain, WOMAC-function and WOMAC-total scores than those treated with PRP + Artz at 3 months postinjection (p < 0.05). Both groups reported high satisfaction. No serious adverse events occurred during the study.

CONCLUSIONS

A single PRP injection combined with Artz or HYAJOINT Plus is effective and safe for 6 months in patients with knee OA. Both injection regimens are potential treatment options for knee OA. Further studies are needed to confirm these results.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT04931719), retrospectively. Date of registration 18/6/2021.

NAME OF TRIAL REGISTRY

Comparing efficacy of single PRP combined with different hyaluronans for knee osteoarthritis.

LEVEL OF EVIDENCE

Therapeutic Level 1.

Swiss Medical Devices for Autologous Regenerative Medicine: From Innovation to Clinical Validation

Regenerative medicine, based on the use of autologous tissues and embryonic, stem or differentiated cells, is gaining growing interest. However, their preparation, in a manner compliant with good practices and health regulations, is a technical challenge. The aim of this manuscript is to present the design of reliable CE marked medical devices for the preparation of standardized platelet-rich plasma (PRP) and other autologous biologics intended for therapeutic uses. There are numerous PRP isolation processes. Depending on the methodology used, PRP composition varies greatly in terms of platelet concentration, platelet quality, and level of contamination with red and white blood cells. This variability in PRP composition might affect the clinical outcomes. The devices presented here are based on a specific technology, patented all over the world, that allows the precise separation of blood components as a function of their density using thixotropic separator gels in closed systems. This allows the preparation, in an automated manner, of leukocyte poor PRP with a standardized composition. Production of different forms of PRP is a clinical asset to suit various therapeutic needs. Therefore, we are offering solutions to prepare PRP either in liquid or gel form, and PRP combined with hyaluronic acid. These biologics have been successfully used in many different therapeutic domains, resulting in more than 150 published clinical studies. We also developed the CuteCell technology platform for cell culture expansion for further autologous cell therapies. This technology enables the safe and rapid in vitro expansion of cells intended for therapeutic use in good manufacturing practices (GMP) and autologous conditions, using blood-derived products as culture media supplementation. We summarize in this article our 20 years’ experience of research and development for the design of PRP devices and, more recently, for PRP combined with hyaluronic acid.

Efficacy of Oxygen-Ozone Therapy and Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis: A Meta-analysis and Systematic Review

Context

This systematic review and meta-analysis evaluated the effect of the intra-articular injection of platelet-rich plasma (PRP) and oxygen-ozone therapy and provided an evidence-based methodology to treat KOA.

Method

Databases, including Cochrane Library, PubMed, and EMBASE, were searched. The retrieval period was before 2021. Two reviewers performed the process of screening and data extraction. Mean differences were calculated [95% confidence interval (CI)] with an inverse-variance method and fixed effect model. Meta-analysis was performed using the latest version of STATA version 16.

Results

A total of 12 studies out of 769 articles were evaluated. The mean difference of visual analog scale score between ozone and control groups in the first month after injection was -0.02 (MD, -0.02; 95% CI: -0.32, 0.28; P < 0.05). Mean differences of WOMAC pain, stiffness, and physical function score between baseline and after PRP were -3.53 (MD: -3.53; 95% CI: -4.04, -3.02; P = 0.00), -0.60 (MD: -0.60; 95% CI: -4.0 - 0.864, -0.34; P = 0.00), and -5.96 (MD: -5.96; 95% CI: -7.83, -4.09; P = 0.00).

Conclusions

Our results showed that to treat knee osteoarthritis, using PRP for a longer period of 6 - 12 months after the intervention shows better clinical results, while oxygen-ozone therapy has short-term results.

Efficacy of a Novel Intra-Articular Administration of Platelet-Rich Plasma One-Week Prior to Hyaluronic Acid versus Platelet-Rich Plasma Alone in Knee Osteoarthritis: A Prospective, Randomized, Double-Blind, Controlled Trial

Recent studies have suggested that the combined injection of platelet-rich plasma (PRP) and hyaluronic acid (HA) may have additive benefits for knee osteoarthritis over PRP alone, but there is insufficient evidence to support this combined injection. Moreover, the simultaneous injection of PRP and HA may offset the combined effect. Hence, the aim of this prospective, randomized, double-blind study was to assess their combined efficacy with a novel injection protocol. Forty-six study subjects with unilateral knee osteoarthritis were randomized to receive either a single-dose injection of HA (intervention group) or normal saline (control group) 1 week after a single-dose injection of leukocyte-poor PRP. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and static balance and the risk of falls measured by Biodex Balance System were, respectively, the primary and secondary outcome measures. Evaluations were performed at baseline, 1 month, 3 months, 6 months, and 12 months post-injection. The intervention group exhibited significant declines in WOMAC pain, stiffness, and total scores, as well as static balance, compared to the control group (p < 0.05). These randomized double-blind control trials, with novel protocol of intra-articular injection of PRP 1-week prior to HA, provide greater symptom relief and improve static balance compared to PRP alone in patients with knee osteoarthritis.

Treating Knee Osteoarthritis With Platelet-Rich Plasma and Hyaluronic Acid Combination Therapy: A Systematic Review

BACKGROUND

Platelet-rich plasma (PRP) and hyaluronic acid (HA) are injectable treatments for knee osteoarthritis. The focus of previous studies has compared their efficacy against each other as monotherapy. However, a new trend of combining these 2 injections has emerged in an attempt to have a synergistic effect.

PURPOSE

To systematically review the clinical literature examining the combined use of PRP + HA.

DESIGN

Systematic review.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Embase. The following search terms were used: knee osteoarthritis AND platelet rich plasma AND hyaluronic acid. The review was performed by 2 independent reviewers who applied the inclusion/exclusion criteria and independently extracted data, including methodologic scoring, PRP preparation technique, HA composition, and patient-reported outcomes (PROs).

RESULTS

A total of 431 articles were screened, 12 reviewed in full, and 8 included in the final analysis: 2 case series, 3 comparative, and 3 randomized studies. Average follow-up was 9 months. The modified Coleman Methodology Score was 38.13 ± 13.1 (mean ± SD). Combination therapy resulted in improved PROs in all studies. Of the comparative and randomized studies, 2 demonstrated that combination therapy was superior to HA alone. However, when PRP alone was used as the control arm (4 studies), combination therapy was not superior to PRP alone.

CONCLUSION

Combination therapy with PRP + HA improves PROs and is superior to HA alone but is not superior to PRP alone.

Platelet-Rich Plasma and Stem Cell Injections in the Treatment of Arthritis of the Knee

Platelet-rich plasma (PRP) and stem cell (SC) injections have become increasingly common in the treatment of knee arthritis. This systematic review was performed to answer the following questions: (1) What effects does intraarticular PRP injection have in the setting of knee arthritis? (2) What effects does intra-articular SC injection have in the setting of knee arthritis? (3) What adverse events have been reported in the literature from PRP injections for knee arthritis? (4) What adverse events have been reported in the literature from SC injections for knee arthritis? [Orthopedics. 2021;44(6):376-383.].

Comparing the efficacy of dual Platelet-Rich Plasma (PRP) and Hyaluronic Acid (HA) therapy with PRP-alone therapy in the treatment of knee osteoarthritis: a systematic review and meta-analysis

Purpose

This study aims to compare the efficacy of a dual therapy of Platelet-Rich Plasma (PRP) and Hyaluronic Acid (HA) compared with PRP-alone therapy in the treatment of knee osteoarthritis (KOA).

Methods

PubMed, Embase, CINAHL, SCOPUS, Cochrane Library, grey literature and bibliographic references were searched from inception to January 2021. Only randomized controlled trials (RCTs) and retrospective cohort studies comparing the effect of PRP and HA versus PRP-alone therapy for KOA were included. Literature retrieval and data extraction were conducted by three independent reviewers. Pooled analysis of Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), International Knee Documentation Committee (IKDC) scores and adverse events were conducted.

Results

Ten studies (7 RCTs, 3 cohort studies) involving 983 patients were covered. Dual PRP and HA therapy resulted in significant reduction in VAS compared to PRP-alone therapy at 4–6 weeks (P < 0.00001) and 12 months (P < 0.00001). Dual therapy resulted in better WOMAC score improvement at 3 (P = 0.02), 6 (P = 0.05) and 12 months (P < 0.0001) compared to PRP-alone therapy. The IKDC score for dual therapy was also higher at 6 months compared to PRP-alone therapy (P = 0.007). Regarding adverse events, dual therapy was generally safer than PRP-alone therapy (P = 0.02).

Conclusion

While there is a paucity of large high-quality Level I studies, current best evidence suggests that dual therapy with PRP and HA for KOA may be effective at providing pain relief and improvement in function up to 1 year following administration.

Level of evidence

II.

Efficacy of different platelet-rich plasma injections in the treatment of mild-moderate knee osteoarthritis: A systematic review and meta-analysis

AIMS

This study aimed to compare the efficacy of different numbered sets of injections of platelet-rich plasma (PRP) in the treatment of mild-moderate knee osteoarthritis (OA).

METHODS

A comprehensive search in three databases of Cochrane Library, Embase, and PubMed was conducted to find relevant articles that investigated the efficacy of PRP injection therapies in the treatment of mild-moderate knee OA through August 2020. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores were the primary outcomes and visual analogue scale (VAS) was the secondary outcome. The pooled improvements amongst different injection therapies were compared.

RESULTS

No significant differences in the improvement of WOMAC pain were observed amongst 1-, 2-, and 3-injection therapies at 3- (P = .26) and 6-month (P = .13) follow-ups. For a 12-month follow-up, the difference amongst different therapies reached borderline significance (P = .05) in which 3-injection therapy had a significantly better improvement than 2-injection therapy (P = .02) and reached borderline significance compared with 1-injection (P = .07). However, no significant differences in the improvement of VAS scores were observed amongst three injection therapies for all the follow-up visits (P > .05). For WOMAC function score, 3-injection therapy performed significantly better than 1-injection (P < .00001) or 2-injection therapy (P < .0001) only at 12-month follow-up visit.

CONCLUSIONS

Our results demonstrated that 3-injection therapy of PRP in the treatment of mild-moderate knee OA had the best efficacy in pain relief and function improvement compared with 1- and 2-injection therapies.

A Prospective Study Comparing Leukocyte-Poor Platelet-Rich Plasma Combined with Hyaluronic Acid and Autologous Microfragmented Adipose Tissue in Patients with Early Knee Osteoarthritis

The objective of this study was to compare the clinical efficacy of repeated doses of leucocyte-poor platelet-rich plasma (LP-PRP) plus hyaluronic acid (HA) to a single dose of autologous microfragmented adipose tissue (AMAT) injections in patients with early osteoarthritis (OA) symptoms. Eighty knees in 50 patients (mean age: 61.3 years) were randomly allocated into two equal groups in a nonblinded design and prospectively followed for 12 months. Group 1 received three intra-articular injections (1 month apart) using autologous LP-PRP+HA. Group 2 received a single dose of AMAT injection. Outcomes were measured by PROMs Tegner, Marx, visual analog scale, and Knee Injury and Osteoarthritis Outcome Score (KOOS) at 6 and 12 months. Both groups had significant clinical and functional improvement at 6 and 12 months. The differences between groups were statistically significant in Tegner score and KOOS symptoms (both P < 0.05) at 6 months in group 2. The test with statistically significant differences (P < 0.05) at 12 months was Tegner (P < 0.001), with group 2 having a higher median than group 1. LP-PRP+HA and AMAT lead to clinical and functional improvement at 6 and 12 months. AMAT showed better clinical results in Tegner and KOOS symptoms at 6 months and Tegner at 12 months. Understanding which therapy offers the most benefits with the least risk can significantly improve the quality of life for millions of people affected by OA. Long-term randomized controlled studies are needed to verify differences in efficacy.

Intra-Articular Platelet-Rich Plasma Combined With Hyaluronic Acid Injection for Knee Osteoarthritis Is Superior to Platelet-Rich Plasma or Hyaluronic Acid Alone in Inhibiting Inflammation and Improving Pain and Function

PURPOSE

To evaluate the effectiveness and explore the therapeutic mechanisms of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) as a treatment for knee osteoarthritis (KOA).

METHODS

In total, 122 knees were randomly divided into HA (34 knees), PRP (40 knees), and PRP+HA (48 knees) groups. Platelet densities in whole blood and PRP were examined using Wright-Giemsa staining. Visual analogue scale, Lequesne, Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm scores, and postoperative complications were evaluated. High-frequency color Doppler imaging was used to observe the synovium and cartilage. Enzyme-linked immunosorbent assays were used to quantify interleukin-1β, tumor necrosis factor-α, matrix metalloproteinase-3, and tissue inhibitor of metalloproteinase-1 levels in synovial fluid.

RESULTS

The platelet density in PRP was 5.13-times that in whole blood (P = .002). At 24 months, pain and function scores in the PRP+HA group were better than those in the HA-alone and PRP-alone groups (P_pain = .000; P_function = .000). At 6 and 12 months, synovial hyperplasia in the PRP and PRP+HA groups was improved (P < .05). After 6 and 12 months, the synovial peak systolic velocity, synovial end-diastolic velocity, systolic/diastolic ratio, and resistance index were improved in the PRP+HA group (P < .05). Complications were greatest in the PRP group (P = .008). After 6 and 12 months, interleukin-1β, tumor necrosis factor-α, matrix metalloproteinase-3, and tissue inhibitor of metalloproteinase-1 in the PRP and PRP+HA groups decreased (P < .05), with more apparent inhibition in the PRP+HA group (P < .05).

CONCLUSIONS

PRP combined with HA is more effective than PRP or HA alone at inhibiting synovial inflammation and can effectively improve pain and function and reduce adverse reactions. Its mechanism involves changes in the synovium and cytokine content.

LEVEL OF EVIDENCE

Level II, Prospective cohort study.

Comparing efficacy of intraarticular single crosslinked Hyaluronan (HYAJOINT Plus) and platelet-rich plasma (PRP) versus PRP alone for treating knee osteoarthritis

Intraarticular hyaluronan or platelet-rich plasma (PRP) is widely used in the treatment of knee osteoarthritis (OA). The efficacy of combined hyaluronan with PRP remained inconclusive. This study aimed to investigate the efficacy of combined a single crosslinked hyaluronan (HYAJOINT Plus) and a single PRP versus a single PRP in patients with knee OA. In a prospective randomized-controlled trial, 85 patients with knee OA (Kellgren-Lawrence 2) were randomized to receive a single intraarticular injection of HYAJOINT Plus (3 ml, 20 mg/ml) followed by 3 ml PRP (the combined-injection group, N = 43) or a single injection of 3 ml PRP (the one-injection group, N = 42). The primary outcome was the change from baseline in the visual analog scale (VAS) pain (0–00 mm) at 6 months. Secondary outcomes included The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, Likert Scale), Lequesne index, single leg stance test (SLS), use of rescue analgesics and patient satisfaction at 1, 3 and 6 months. Seventy-eight patients were available for the intention-to-treat analysis at 6 months. Both groups improved significantly in VAS pain, WOMAC, Lequesne index and SLS at each follow-up visit (p < 0.001). Patients receiving a single PRP experienced significantly greater improvements in VAS pain than patients receiving combined injections at 1-month follow-up (adjusted mean difference: − 5.6; p = 0.017). There were no significant between-group differences in several of the second outcomes at each follow-up visit, except the WOMAC-pain and WOMAC-stiffness scores favoring the one-injection group at 1 month (p = 0.025 and p = 0.011). However, at 6-month follow-up, the combined-injection group achieved significantly better VAS pain reduction (p = 0.020). No serious adverse events occurred following injections. In conclusion, either combined injections of HYAJOINT Plus and PRP or a single PRP alone was safe and effective for 6 months in patients with Kellgren-Lawrence 2 knee OA. Combined injections of HYAJOINT Plus and PRP achieved better VAS pain reduction than a single PRP at 6 months. The results indicating a long term benefit effect of a combination of HYAJOINT Plus and PRP in a particular subset of patients with moderate knee OA need to be replicated in larger trials.

ClinicalTrials.gov number NCT04315103.

The perspectives of intra-articular therapy in the management of osteoarthritis

Management of Osteoarthritis (OA) still is a challenge for clinicians. Taking into account a multidisciplinary approach including pharmacological and non-pharmacological treatments, intra-articular (IA) injection could be considered as an effective local therapy. Areas covered This review provides a new perspective of IA treatment going beyond current available IA agents. We describe novel biological targets for developing new IA agents and innovative modalities of delivery systems. Additional topics include predictors of response for a better choice of IA agents for each patient, diagnostic and prognostic role of biomarkers, accuracy of IA injection, and cost-effectiveness of IA injection. Expert opinion IA treatments seem to be very promising for the management of OA. Identifying clinical and biochemical predictive factors could drive clinician to the appropriate therapeutic approach. To date, there is a gap regarding the benefit of IA treatments in the 'real practice' once they have been adopted. However, considering these promising effects of IA approach, several open questions remain not clarified.

The use of cellular matrix in symptomatic knee osteoarthritis

Knee osteoarthritis is a degenerative "wear and tear" disorder affecting mainly population over 50 years old. It can also present in younger people, especially after an injury or as a part of other diseases. While many therapeutic options exist for knee osteoarthritis, none of them has the potential to cure this condition. Cellular Matrix represents a combination of natural non-crosslinked hyaluronic acid (HA), thixotropic cell separation gel, and sodium citrate anticoagulant solution. A combination of Cellular Matrix with autologous platelet-rich plasma (A-PRP) is a novel therapeutic approach to the management of knee osteoarthritis. It is assumed that the active components HA and PRP have a synergistic effect contributing to a better therapeutic outcome in patients with knee osteoarthritis. Physiotherapy could provide an additional benefit. This is a retrospective pilot study assessing the potential benefit of Cellular Matrix and A-PRP combined with physiotherapy in the management of chronic knee osteoarthritis. Twenty-five patients were enrolled in the study and injected with three doses of Cellular Matrix combined with A-PRP with a time span of 2 weeks between each injection. All patients received standardized physiotherapy. The results showed that 68% of patients achieved more than 50% improvement in pain, stiffness, and function of the knee joints. There were no adverse reactions. This retrospective pilot study confirmed the positive effect of PRP and HA combination in the management of mild and moderate knee osteoarthritis. These preliminary results need to be verified in randomized control trials.

Effects and safety of the combination of platelet-rich plasma (PRP) and hyaluronic acid (HA) in the treatment of knee osteoarthritis: a systematic review and meta-analysis

Background

Studies have shown that the combined application of hyaluronic acid (HA) and platelet-rich plasma (PRP) can repair degenerated cartilage and delay the progression of knee osteoarthritis (KOA). The purpose of this study was to explore the efficacy and safety of the intra-articular injection of PRP combined with HA compared with the intra-articular injection of PRP or HA alone in the treatment of KOA.

Methods

The PubMed, Cochrane Library, EMBASE and China National Knowledge Infrastructure (CNKI) databases were searched from inception to December 2019. Randomized controlled trials and cohort studies of PRP combined with HA for KOA were included. Two orthopaedic surgeons conducted the literature retrieval and extracted the data. Outcome indicators included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the Lequesne Index, the visual analogue scale (VAS) for pain, and adverse events (AEs). Review Manager 5.3 was used to calculate the relative risk (RR) or standardized mean difference (SMD) of the pooled data. STATA 14.0 was used for quantitative publication bias evaluation.

Results

Seven studies (5 randomized controlled trials, 2 cohort studies) with a total of 941 patients were included. In the VAS comparison after 6 months of follow-up, PRP combined with HA was more likely to reduce knee pain than PRP alone (SMD: − 0.31; 95% confidence interval (CI): − 0.55 to − 0.06; P = 0.01 < 0.05). PRP combined with HA for KOA achieved better improvements in the WOMAC Function Score (SMD: -0.32; 95% CI: − 0.54 to − 0.10; P < 0.05) and WOMAC Total Score (SMD: -0.42; 95% CI: − 0.67 to − 0.17; P < 0.05) at the 12-month follow-up than did the application of PRP alone. In a comparison of Lequesne Index scores at the 6-month follow-up, PRP combined with HA improved knee pain scores more than PRP alone (SMD: -0.42; 95% CI: − 0.67 to − 0.17; P < 0.05). In terms of AEs, PRP combined with HA was not significantly different from PRP or HA alone (P > 0.05).

Conclusions

Compared with intra-articular injection of PRP alone, that of PRP combined with HA can improve the WOMAC Function Scores, WOMAC Total Score, 6-month follow-up VAS ratings, and Lequesne Index scores. However, in terms of the incidence of AEs, PRP combined with HA is not significantly different from PRP or HA alone.

Use of intraarticular injections of platelet-rich plasma in the treatment of knee osteoarthritis: A review article

Osteoarthritis is one of the most common degenerative conditions affecting knee joint. As our understanding in the disease pathogenesis is evolving, so do the treatment modalities. One of the postulated mechanisms suggests the production of inflammatory cytokines secondary to repeated micro trauma than in turn lead to cartilage damage overtime. Cartilage being avascular structure has limited potential for repair. Based on this, recent studies have been focusing on stimulating cartilage-healing process by growth factors. This is where platelet-rich plasma comes in to light. Literature is showing promising results of platelet-rich plasma in treating knee osteoarthritis. In this review we have discussed the preparation, composition, classification, uses of platelet-rich plasma as well as evidence for its efficacy and complications.

Sodium Hyaluronate and Platelet-Rich Plasma for Partial-Thickness Rotator Cuff Tears

Purpose

The treatment of partial-thickness rotator cuff tears (PTRCT) remains controversial. Few studies have focused on the conservative and new measurements of small to medium PTRCT. The use of sodium hyaluronate (SH) or platelet-rich plasma (PRP) as a method for rotator cuff repair requires further investigation. The aim of this study was to evaluate the combined use of SH and PRP in the treatment of small to medium PTRCT.

Study Design

A double-blinded randomized trial was used in this study.

Methods

Individuals with PTRCT detected by clinical examination and magnetic resonance imaging (MRI) were included in this study. The patients were randomly assigned to receive subacromial injections of normal saline, SH, PRP, or SH + PRP once a week for 4 wk. The primary outcome measure was the Constant score, and the secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) and the visual analog scale scores. All of the clinical outcomes were assessed at pretreatment and 1, 3, 6, and 12 months posttreatment. MRI was used to evaluate the evolution of the cuff defect after 1 yr.

Results

The PRP group and the SH + PRP group showed a significantly higher Constant score and ASES score after the treatments. There were significant differences between the SH + PRP group and the SH or PRP group at 12 months in the Constant, visual analog scale, and ASES scores. MRI results showed that the tear size significantly decreased in both the PRP and the SH + PRP groups, especially in the SH + PRP group.

Conclusion

Our study provided evidence of the efficacy of PRP injection in the healing of small to medium PTRCT. Moreover, the combined injection of SH and PRP yielded a better clinical outcome than SH or PRP alone.

Xenotransplantation of human dental pulp stem cells in platelet-rich plasma for the treatment of full-thickness articular cartilage defects in a rabbit model

Stem cells in platelet-rich plasma (PRP) scaffolds may be a promising treatment for cartilage repair. Human dental pulp stem cell (hDPSC) subpopulations have been identified to have substantial angiogenic, neurogenic and regenerative potential when compared with other stem cell sources. The present study evaluated the potential of hDPSCs in a PRP scaffold to regenerate full-thickness cartilage defects in rabbits. Full-thickness articular cartilage defects were created in the patellar groove of the femur of 30 rabbits allocated into three experimental groups: Those with an untreated critical defect (CTL), those treated with PRP (PRP) and those treated with stem cells in a PRP scaffold (PRP+SC). The patellar grooves of the femurs from the experimental groups were evaluated macroscopically and histologically at 6 and 12 weeks post-surgery. The synovial membranes were also collected and evaluated for histopathological analysis. The synovial lining cell layer was enlarged in the CTL group compared with the PRP group at 6 weeks (P=0.037) but not with the PRP+SC group. All groups exhibited low-grade synovitis at 6 weeks and no synovitis at 12 weeks. Notably, macroscopic grades for the area of articular cartilage repair for the PRP+SC group were significantly improved compared with those in the CTL (P=0.001) and PRP (P=0.049) groups at 12 weeks. Furthermore, histological scores (modified O'Driscoll scoring system) of the patellar groove articular cartilage in the PRP+SC and PRP groups, in which the articular cartilage was primarily hyaline-like, were significantly higher compared with those in the CTL group at 12 weeks (P=0.002 and P=0.007, respectively). The present results support the therapeutic use of hDPSCs for the treatment of full-thickness articular cartilage defects.

Biologic Therapies for the Treatment of Knee Osteoarthritis

BACKGROUND

The use of biologic therapies for the management of knee osteoarthritis has increased, despite insufficient evidence of efficacy. Our aim was to complete a systematic review and analysis of reports utilizing the highest level-of-evidence evaluating: (1) platelet-rich plasma injections (PRPs); (2) bone marrow-derived mesenchymal stem cells (BMSCs); (3) adipose-derived mesenchymal stem cells (ADSCs); and (4) amnion-derived mesenchymal stem cells (AMSCs).

METHODS

PubMed, Embase, and Cochrane Library databases were queried for studies evaluating PRP injections, BMSCs, ADSCs, and AMSCs in patients with knee osteoarthritis. Of 1009 studies identified within the last 5 years, 123 met inclusion criteria. A comprehensive analysis of all levels-of-evidence was performed, as well as separate analysis on level-of-evidence I studies. Level-of-evidence was determined by the American Academy of Orthopedic Surgeons classification system.

RESULTS

Although the majority of PRP reports demonstrated improvements in pain and/or function, others revealed no substantial improvements. Similar findings were noted for BMSCs, ADSCs, and AMSCs. Assessments of BMSC studies yielded majority with positive clinical results, although short-lived. Studies on ADSCs revealed improved clinical outcomes, but equivocal radiographic outcomes. Studies evaluating AMSCs demonstrated improvements in pain and function, and decreased radiographic evidence of osteoarthritis.

CONCLUSION

Despite some promising early results for PRP, BMSC, ADSC, and AMSC therapies, the majority of level-of-evidence I studies have multiple problems: small sample sizes, potentially inappropriate control cohorts, short-term follow-up, and so on. Despite the limitations, there still appears to be evidence justifying their use for knee osteoarthritis management. More high-level, larger human studies utilizing standardized protocols are needed.

Active viscosupplements for osteoarthritis treatment

OBJECTIVE

Osteoarthritis is a chronic, painful and disabling disease which prevalence is increasing in developing countries. Patients with osteoarthritis present a reduced synovial fluid viscoelasticity due to a reduction in concentration and molecular weight of hyaluronic acid. Currently, the main treatment used to restore the compromised rheological properties of synovial fluid is the viscosupplementation by hyaluronic acid injections that can be combined with oral anti-inflammatory drugs for pain relief. Combination of viscosupplements with chemical agents or drugs is emerging as a new strategy to provide a double action of synovial fluid viscoelasticity recovery and the therapeutic effect of the bioactive principle.

METHODS

In this review, we present the latest research on the combination of viscosupplements with active molecules. We conducted a literature review of articles published in different web search engines and categorized according to the active molecule introduced into the viscosupplement.

RESULTS

Generally, the introduction of anti-inflammatory molecules have shown to improve pain relief although some cytotoxicity has been demonstrated especially for non-steroidal anti-inflammatory drugs. Other molecules such as antioxidant or disease modifying osteoarthritis drugs have been reported to improve viscosupplementation action. Drug delivery systems combined with hyaluronic acid could enhance the activity of the encapsulated molecules and provide better control over the drug release. Finally, biological approaches such as the use of stem cells or platelet-rich plasma seem to be the most promising strategies for cartilage recovery.

CONCLUSIONS

Combination therapy of viscosupplements with therapeutic agents, drug delivery systems or regenerative therapies can improve viscosupplementation outcome in terms of pain relief and joint functionality. However, further research is needed in order to reach more conclusive results.

Choice of intra-articular injection in treatment of knee osteoarthritis: platelet-rich plasma, hyaluronic acid or ozone options

PURPOSE

This study was performed to compare the efficacy of treatment in three groups of patients with knee osteoarthritis (OA) given an intra-articular injection of platelet-rich plasma (PRP), hyaluronic acid (HA) or ozone gas.

METHODS

A total of 102 patients with mild-moderate and moderate knee OA who presented at the polyclinic with at least a 1-year history of knee pain and VAS score ≥4 were randomly separated into three groups. Group 1 (PRP group) received intra-articular injection of PRP × 2 doses, Group 2 (HA group) received a single dose of HA, and Group 3 (Ozone group) received ozone × four doses. Weight-bearing anteroposterior-lateral and Merchant's radiographs of both knees were evaluated. WOMAC and VAS scores were applied to all patients on first presentation and at 1, 3, 6 and 12 months.

RESULTS

At the end of the 1st month after injection, significant improvements were seen in all groups. In the 3rd month, the improvements in WOMAC and VAS scores were similar in Groups 1 and 2, while those in Group 3 were lower (p < 0.001). At the 6th month, while the clinical efficacies of PRP and HA were similar and continued, the clinical effect of ozone had disappeared (p < 0.001). At the end of the 12th month, PRP was determined to be both statistically and clinically superior to HA (p < 0.001).

CONCLUSION

In the treatment of mild-moderate knee OA, PRP was more successful than HA and ozone injections, as the application alone was sufficient to provide at least 12 months of pain-free daily living activities.

LEVEL OF EVIDENCE

Therapeutic study, Level I.