Platelet-Rich Plasma for the Management of Hip and Knee Osteoarthritis

Does the Combination of Platelet-rich Plasma and Supervised Exercise Yield Better Pain Relief and Enhanced Function in Knee Osteoarthritis? A Randomized Controlled Trial

BACKGROUND

Knee osteoarthritis is a leading cause of disability with substantial healthcare costs, and efficient nonsurgical treatment methods are still needed. Platelet-rich plasma (PRP) injections and exercise therapy are used frequently in clinical practice. Whether PRP or PRP combined with exercise is more effective than exercise alone is unclear.

QUESTIONS/PURPOSES

(1) Which treatment relieves knee osteoarthritis pain better: PRP alone, exercise, or PRP combined with exercise? (2) Does PRP alone, exercise, or PRP combined with exercise yield better results in terms of the WOMAC score, performance on the 40-m fast-paced walk test and stair climbing test, and the SF-12 health-related quality of life score?

METHODS

In this randomized, controlled, three-arm clinical trial, we recruited patients with mild-to-moderate (Kellgren-Lawrence Grade II or III) knee osteoarthritis with a minimum of 3 points on the 11-point numeric rating scale for pain. During the study period, 157 patients with a diagnosis of knee osteoarthritis were screened and 84 eligible volunteers were enrolled in the study. Patients were randomly allocated (1:1:1) into either the exercise group (28), PRP group (28), or PRP + exercise group (28). Follow-up proportions were similar between the groups (exercise: 89% [25], PRP: 86% [24], PRP + exercise: 89% [25]; p = 0.79). All patients were analyzed in an intention-to-treat manner. There were no between-group differences in age, gender, arthritis severity, and baseline clinical scores (pain, WOMAC, functional performance tests, and health-related quality of life). The exercise group underwent a 6-week structured program consisting of 12 supervised individual sessions focused on strengthening and functional exercises. Meanwhile, the PRP group received three weekly injections of fresh, leukocyte-poor PRP. The PRP + exercise group received a combined treatment with both interventions. The primary outcome was knee pain over 24 weeks, measured on an 11-point numeric rating scale for pain (ranging from 0 to 10, where 0 represents no pain and 10 represents the worst pain, with a minimum clinically important difference [MCID] of 2). The secondary outcome measures included the WOMAC index (ranging from 0 to 100, with lower scores indicating a lower level of disability and an MCID of 12), the durations of the 40-meter fast-paced walk test and stair climbing test, and the SF-12 health-related quality of life score. For the a priori sample size calculation, we used the numeric rating scale score for pain at 24 weeks as the primary outcome variable. The MCID for the numeric rating scale was deemed to be 2 points, with an estimated standard deviation of 2.4. Based on sample size calculations, a sample of 24 patients per group would provide 80% power to detect an effect of this size between the groups at the significance level of p = 0.05.

RESULTS

We found no clinically important differences in improvements in pain-defined as ≥ 2 points of 10-at 24 weeks when comparing exercise alone to PRP alone to PRP + exercise (1.9 ± 0.7 versus 3.8 ± 1.8 versus 1.4 ± 0.6; mean difference between PRP + exercise group and exercise group -0.5 [95% confidence interval -1.2 to 0.4]; p = 0.69). Likewise, we found no differences in WOMAC scores at 24 weeks of follow-up when comparing exercise alone to PRP alone to PRP + exercise (10 ± 9 versus 26 ± 20 versus 7 ± 6; mean difference between PRP + exercise group and exercise group -3 [95% CI -12 to -5]; p = 0.97). There were no differences in any of the other secondary outcome metrics among the PRP + exercise and exercise groups.

CONCLUSION

PRP did not improve pain at 24 weeks of follow-up in patients with mild-to-moderate knee osteoarthritis compared with exercise alone. Moreover, exercise alone was clinically superior to PRP alone, considering function and the physical component of health-related quality of life. Despite the additional costs and endeavors related to PRP products, the combination of PRP and exercise did not differ from exercise alone. The results of this randomized controlled trial do not support the use of PRP injections in the treatment of patients diagnosed with mild-to-moderate knee osteoarthritis. Consequently, exercise alone is the recommended treatment for reducing pain and enhancing function throughout this timeframe.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Effect of platelet-rich plasma injections versus placebo on pain and quality of life in patients with hip osteoarthritis: A double-blind, randomized clinical trial

Objectives

This study aims to compare the efficacy of intra-articular platelet-rich plasma (PRP) injections over a saline placebo in terms of reduction of pain and impact on quality of life among patients with hip osteoarthritis.

Patients and methods

A total of 60 patients (29 males, 31 females, mean age: 57.9±7.3 years; range, 47 to 69 years) with known hip osteoarthritis of Kellgren-Lawrance (KL) Grades 2/3 were randomized into placebo (n=30) and PRP groups (n=30) between June 2014 and June 2015. Both groups received intra-articular injections into the hip joint under ultrasound guidance for three consecutive weeks. The patients were followed for six months, and pain reduction was assessed using the Visual Analog Scale (VAS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire, and Short Form Health Survey-36 (SF-36).

Results

Intra-articular PRP treatment showed no advantage over a saline placebo in terms of VAS scores during activity. Both groups showed a significant improvement in VAS activity scores at one and six months. The placebo group showed improvements in VAS resting scores, whereas the PRP group did not. Both groups showed no improvement in WOMAC-total scores. Both groups showed no significant improvement across most SF-36 domains with the exception of improved physical role functioning at one month and general health at one and six months in the placebo group.

Conclusion

Intra-articular injections of PRP show no significant difference compared to a saline placebo over a period of six months on pain, function, and quality of life scores in patients with hip osteoarthritis.

Risk of Periprosthetic Joint Infection after Intra-Articular Injection: Any Difference among Shoulder, Knee and Hip?

Osteoarthritis is a degenerative joint disease caused by the wear and tear of joint cartilage. The definitive and resolving treatment is prosthetic replacement of the articular surface, the demand of which is on the rise for patients with mild to moderate severity. However, a conservative strategy may be considered that aims to reduce and contain pain symptoms by postponing surgical treatment in the case of worsening that can no longer be otherwise controlled. Intra-articular infiltrations, like other therapeutic strategies, are not without complications, and among these the most feared is joint infection, especially in anticipation of future prosthetic replacement. Is important to avoid periprosthetic joint infections because they represent one of the third most common reasons for revision surgery. Using cases found in the literature, the aim of this article is to determine if there is a real correlation between the type of injections, the number of doses injected and the time between infiltrations and the surgical procedure.

Platelet-Rich Plasma Injections in Chronic Lateral Ankle Instability: A Case Series

The platelet-rich plasma (PRP) approach may be an effective treatment for joint and cartilage pathologies. However, the rationale for its effectiveness on joint instability is limited. This study aimed to assess the safety and effectiveness of PRP injections in patients with chronic lateral ankle instability (CLAI). This retrospective study was performed at a single-center outpatient clinic between January 2015 and February 2023 and included pre-intervention assessment and short-term follow-up. Patients were excluded if they had received previous surgical treatment or had constitutional hyperlaxity, systemic diseases, or grade II or III osteoarthritis. The clinical and functional evaluation consisted of the Karlsson score, the Cumberland Ankle Instability Tool (CAIT), Good's grading system, the patient's subjective satisfaction level, and the time required to return to exercise. The entire PRP therapy regime consisted of three PRP administrations at 7-day intervals and follow-up appointments. PRP was administered both intraarticularly and into talofibular ligaments. A total of 47 consecutive patients with CLAI were included, 11 were female (23.4%), with a mean age at intervention of 31.19 ± 9.74 years. A statistically significant improvement was found in the CAIT and Karlsson scores at 3 months (27.74 ± 1.68 and 96.45 ± 4.28, respectively) relative to the pre-intervention status (10.26 ± 4.33 and 42.26 ± 14.9, respectively, p < 0.000). The mean follow-up of patients with CLAI was 17.94 ± 3.25 weeks. This study represents successful short-term functional and clinical outcomes in patients with CLAI after PRP treatment, with no adverse effects. It demonstrates the feasibility of a randomized controlled trial to further assess this therapy.

Phytochemicals against Osteoarthritis by Inhibiting Apoptosis

Osteoarthritis (OA) is a chronic joint disease that causes pathological changes in articular cartilage, synovial membrane, or subchondral bone. Conventional treatments for OA include surgical and non-surgical methods. Surgical treatment is suitable for patients in the terminal stage of OA. It is often the last choice because of the associated risks and high cost. Medication of OA mainly includes non-steroidal anti-inflammatory drugs, analgesics, hyaluronic acid, and cortico-steroid anti-inflammatory drugs. However, these drugs often have severe side effects and cannot meet the needs of patients. Therefore, safe and clinically appropriate long-term treatments for OA are urgently needed. Apoptosis is programmed cell death, which is a kind of physiologic cell suicide determined by heredity and conserved by evolution. Inhibition of apoptosis-related pathways has been found to prevent and treat a variety of diseases. Excessive apoptosis can destroy cartilage homeostasis and aggravate the pathological process of OA. Therefore, inhibition of apoptosis-related factors or signaling pathways has become an effective means to treat OA. Phytochemicals are active ingredients from plants, and it has been found that phytochemicals can play an important role in the prevention and treatment of OA by inhibiting apoptosis. We summarize preclinical and clinical studies of phytochemicals for the treatment of OA by inhibiting apoptosis. The results show that phytochemicals can treat OA by targeting apoptosis-related pathways. On the basis of improving some phytochemicals with low bioavailability, poor water solubility, and high toxicity by nanotechnology-based drug delivery systems, and at the same time undergoing strict clinical and pharmacological tests, phytochemicals can be used as a potential therapeutic drug for OA and may be applied in clinical settings.

Emerging Roles of Macrophage Polarization in Osteoarthritis: Mechanisms and Therapeutic Strategies

Osteoarthritis (OA) is the most common chronic degenerative joint disease in middle-aged and elderly people, characterized by joint pain and dysfunction. Macrophages are key players in OA pathology, and their activation state has been studied extensively. Various studies have suggested that macrophages might respond to stimuli in their microenvironment by changing their phenotypes to pro-inflammatory or anti-inflammatory phenotypes, which is called macrophage polarization. Macrophages accumulate and become polarized (M1 or M2) in many tissues, such as synovium, adipose tissue, bone marrow, and bone mesenchymal tissues in joints, while resident macrophages as well as other stromal cells, including fibroblasts, chondrocytes, and osteoblasts, form the joint and function as an integrated unit. In this study, we focus exclusively on synovial macrophages, adipose tissue macrophages, and osteoclasts, to investigate their roles in the development of OA. We review recent key findings related to macrophage polarization and OA, including pathogenesis, molecular pathways, and therapeutics. We summarize several signaling pathways in macrophage reprogramming related to OA, including NF-κB, MAPK, TGF-β, JAK/STAT, PI3K/Akt/mTOR, and NLRP3. Of note, despite the increasing availability of treatments for osteoarthritis, like intra-articular injections, surgery, and cellular therapy, the demand for more effective clinical therapies has remained steady. Therefore, we also describe the current prospective therapeutic methods that deem macrophage polarization to be a therapeutic target, including physical stimulus, chemical compounds, and biological molecules, to enhance cartilage repair and alleviate the progression of OA.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND

Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type.

METHODS

Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities.

RESULTS

Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial).

CONCLUSIONS

Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of Placebo Response to Local (Intra-Articular) Therapy In Osteoarthritis: An Individual Participant Data Meta-Analysis

OBJECTIVE

We undertook this study to evaluate potential predictors of placebo response with intra-articular (IA) injections for knee/hip osteoarthritis (OA) using individual participant data (IPD) from existing trials.

METHODS

Randomized placebo-controlled trials evaluating IA glucocorticoid or hyaluronic acid published to September 2018 were selected. IPD for disease characteristics and outcome measures were acquired. Potential predictors of placebo response included participant characteristics, pain severity, intervention, and trial design. Placebo response was defined as at least a 20% reduction in baseline pain. Logistic regression models and odds ratios were computed as effect measures to evaluate patient and pain mechanisms and then pooled using a random effects model. Generalized mixed-effect models were applied to intervention and trial characteristics.

RESULTS

Of 56 eligible trials, 6 shared data, and these were combined with the existing 4 OA Trial Bank studies, yielding 10 studies with IPD of 621 placebo participants for analysis. In the total placebo population, at short-term follow-up, the use of local anesthetic and ultrasound guidance were associated with reduced odds of placebo response. At midterm follow-up, mid- to long-term trial duration was associated with increased odds of placebo response, and worse baseline function scores were associated with reduced odds of a placebo response.

CONCLUSION

The administration of local anesthetics or ultrasound guidance may reduce IA placebo response at short-term follow-up. At midterm follow-up, participants with worse baseline function scores may be less likely to respond to IA placebo, and mid- to long-term trial duration may enhance the placebo response. Further studies are required to corroborate these potential predictors of IA placebo response.

Ten years of injectable platelet-rich fibrin

The use of platelet-rich fibrin (PRF) has seen widespread advantages over platelet-rich plasma (PRP) in many fields of medicine. However, until 2014, PRF remained clinically available only in its solid clotted form. Modifications to centrifugation protocols and tube technology have led to the development of a liquid injectable version of PRF (i-PRF). This narrative review takes a look back at the technological developments made throughout the past decade and further elaborates on their future clinical applications. Topics covered include improvements in isolation techniques and protocols, ways to further concentrate i-PRF, and the clinical impact and relevance of cooling i-PRF. Next, various uses of i-PRF are discussed, including its use in regenerative periodontology, implantology, endodontics, temporomandibular joint injections, and orthodontic tooth movement. Furthermore, various indications in medicine are also covered, including its use in sports injuries and osteoarthritis of various joints, treatment of diabetic ulcers/wound care, and facial esthetics and hair regrowth. Finally, future applications are discussed, mainly its use as a drug delivery vehicle for small biomolecules, such as growth factors, antibiotics, exosomes, and other medications that may benefit from the controlled and gradual release of biomolecules over time.

Comparison of Conventional Dose Versus Superdose Platelet-Rich Plasma for Knee Osteoarthritis: A Prospective, Triple-Blind, Randomized Clinical Trial

Background

Confusion persists regarding the ideal dosage of platelet-rich plasma (PRP) injection for knee osteoarthritis (OA).

Purpose/Hypothesis

The purpose of the study was to compare the efficacy of 2 different single-injection PRP dosages in patients with early knee OA-a conventional 4 mL dose and a superdose of 8 mL. It was hypothesized that 8 mL of PRP would be superior to 4 mL of PRP in this patient population.

Study Design

Randomized clinical trial; Level of evidence, 1.

Methods

Patients with early knee OA (Kellgren-Lawrence grades 1 and 2) who met the inclusion criteria were randomly divided into 2 groups: Group A (n = 50 knees) received a 4-mL PRP injection, and group B (n = 49 knees) received an 8-mL PRP injection, both prepared using the same procedure. Patients were evaluated at the baseline, 6 weeks, 3 months, and 6 months using the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the WOMAC-Pain subscale, the visual analog scale for pain, the Knee injury and Osteoarthritis Outcome Score, and patient satisfaction, and results were compared between the groups.

Results

The baseline characteristics of the 2 groups were comparable (group A: mean age, 51.96 ± 6.93 years; group B: mean age, 49.12 ± 9.8 3 years). Leucocyte-depleted PRP with 3.5 times concentration (final product platelet concentration, 706.74 × 103-μL) was injected. The mean absolute platelet count injected was 2.82 ± 0.0012 billion in group A and 5.65 ± 0.0022 billion in group B. All patient-reported outcome scores improved significantly in both groups from the baseline to the final follow-up (P < .001), with overall trends and results significantly better in group B than in group A (P < .001). Patient satisfaction at the 6-month follow-up was also better in group B (96%) compared with group A (68%). Short (2 to 7 days) self-limiting complications, such as pain and stiffness, occurred more often in group B (P < .001).

Conclusion

Patients with early knee OA had significantly better improvement in pain and function when treated with an 8-mL injection of PRP compared with a 4-mL injection of PRP. The larger dose of PRP had approximately twice the number of platelets.

Registration

CTRI/2020/02/023403 (Clinical Trials Registry-India identifier).

Association of body composition and physical activity with pain and function in knee osteoarthritis patients: a cross-sectional study

OBJECTIVE

The objective of this study is to delineate disparities between patients with knee osteoarthritis (KOA) based on obesity status, investigate the interplay among body composition, physical activity and knee pain/function in patients with KOA and conduct subgroup analyses focusing on those with KOA and obesity.

DESIGN

Cross-sectional study.

SETTING

Residents of eight communities in Shijiazhuang, Hebei Province, China, were surveyed from March 2021 to November 2021.

PARTICIPANTS

178 patients with symptomatic KOA aged 40 years or older were included.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was knee pain, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index-pain (WOMAC-P) scale. Secondary outcome measures included function, evaluated through the WOMAC-function (WOMAC-F) scale and the Five-Time-Sit-to-Stand Test (FTSST). Data analysis involved t-tests, Wilcoxon rank-sum tests, χ2 tests, linear and logistical regression analysis.

RESULTS

Participants (n=178) were 41-80 years of age (median: 65, P25-P75: 58-70), and 82% were female. Obese patients (n=103) had worse knee pain and self-reported function (p<0.05). In general patients with KOA, body fat mass was positively associated with bilateral knee pain (β=1.21 (95% CI 0.03 to 0.15)), WOMAC-P scores (β=0.25 (95% CI 0.23 to 1.22)), WOMAC-F scores (β=0.28 (95% CI 0.35 to 1.29)) and FTSST (β=0.19 (95% CI 0.03 to 0.42)), moderate-intensity to low-intensity physical activity was negatively associated with bilateral knee pain (β=-0.80 (95% CI -0.10 to -0.01)) and Skeletal Muscle Index (SMI) was negatively associated with WOMAC-F scores (β=-0.16 (95% CI -0.66 to -0.03)). In patients with KOA and obesity, SMI was negatively associated with FTSST (β=-0.30 (95% CI -3.94 to -0.00)).

CONCLUSION

Patients with KOA and obesity had worse knee pain and self-reported function compared with non-obese patients. Greater fat mass, lower muscle mass and lower moderate-intensity to low-intensity physical activity were associated with increased knee pain and poor self-reported function. More skeletal muscle mass was associated with the improvement of objective function.

The silencing of NREP aggravates OA cartilage damage through the TGF-β1/Smad2/3 pathway in chondrocytes

Background

Osteoarthritis (OA) is a common chronic degenerative joint disease. Due to the limited understanding of its complex pathological mechanism, there is currently no effective treatment that can alleviate or even reverse cartilage damage associated with OA. With improvement in public databases, researchers have successfully identified the key factors involved in the occurrence and development of OA through bioinformatics analysis. The aim of this study was to screen for the differentially expressed genes (DEGs) between the normal and OA cartilage through bioinformatics, and validate the function of the TGF-β1/Smad2/3 pathway-related neuron regeneration related protein (NREP) in the articular cartilage.

Methods

The DEGs between the cartilage tissues of OA patients and healthy controls were screened by bioinformatics, and functionally annotated by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. The expression levels of the DEG in human and murine OA cartilage was verified by reverse transcription-quantitative PCR (RT-qPCR), Western blotting and immunohistochemistry (IHC). RT-qPCR, Western-blotting, Cell Counting Kit-8(CCK8) and EdU assays were used to evaluate the effects of knocking down NREP in normal chondrocytes, and the molecular mechanisms were investigated by RT-qPCR, Western blotting and IHC.

Results

In this study, we identified NREP as a DEG in OA through bioinformatics analysis, and found that NREP was downregulated in the damaged articular cartilage of OA patients and mouse model with surgically-induced OA. In addition, knockdown of NREP in normal chondrocytes reduced their proliferative capacity, which is the pathological basis of OA. At the molecular level, knock-down of NREP inactivated the TGF-β1/Smad2/3 pathway, resulting in the downregulation of the anabolic markers Col2a1 and Sox9, and an increase in the expression of the catabolic markers MMP3 and MMP13.

Conclusion

NREP plays a key role in the progression of OA by regulating the TGF-β1/Smad2/3 pathway in chondrocytes, and warrants further study as a potential therapeutic target.

Transplantation of Gelatin Microspheres Loaded with Wharton's Jelly Derived Mesenchymal Stem Cells Facilitates Cartilage Repair in Mice

BACKGROUND

Knee osteoarthritis (KOA) is a prevalent chronic joint disease caused by various factors. Mesenchymal stem cells (MSCs) therapy is an increasingly promising therapeutic option for osteoarthritis. However, the chronic inflammation of knee joint can severely impede the therapeutic effects of transplanted cells. Gelatin microspheres (GMs) are degradable biomaterial that have various porosities for cell adhesion and cell-cell interaction. Excellent elasticity and deformability of GMs make it an excellent injectable vehicle for cell delivery.

METHODS

We created Wharton's jelly derived mesenchymal stem cells (WJMSCs)-GMs complexes and assessed the effects of GMs on cell activity, proliferation and chondrogenesis. Then, WJMSCs loaded in GMs were transplanted in the joint of osteoarthritis mice. After four weeks, joint tissue was collected for histological analysis. Overexpressing-luciferase WJMSCs were performed to explore cell retention in mice.

RESULTS

In vitro experiments demonstrated that WJMSCs loaded with GMs maintained cell viability and proliferative potential. Moreover, GMs enhanced the chondrogenesis differentiation of WJMSCs while alleviated cell hypertrophy. In KOA mice model, transplantation of WJMSCs-GMs complexes promoted cartilage regeneration and cartilage matrix formation, contributing to the treatment of KOA. Compared with other groups, in WJMSCs+GMs group, there were fewer cartilage defects and with a more integrated tibia structure. Tracking results of stable-overexpressing luciferase WJMSCs demonstrated that GMs significantly extended the retention time of WJMSCs in knee joint cavity.

CONCLUSION

Our results indicated that GMs facilitate WJMSCs mediated knee osteoarthritis healing in mice by promoting cartilage regeneration and prolonging cell retention. It might potentially provide an optimal strategy for the biomaterial-stem cell based therapy for knee osteoarthritis.

Management of chondral and osteochondral lesions of the hip : A comprehensive review

Chondral and osteochondral lesions encompass several acute or chronic defects of the articular cartilage and/or subchondral bone. These lesions can result from several different diseases and injuries, including osteochondritis dissecans, osteochondral defects, osteochondral fractures, subchondral bone osteonecrosis, and insufficiency fractures. As the cartilage has a low capacity for regeneration and self-repair, these lesions can progress to osteoarthritis. This study provides a comprehensive overview of the subject matter that it covers. PubMed, Scopus and Google Scholar were accessed using the following keywords: "chondral lesions/defects of the femoral head", "chondral/cartilage lesions/defects of the acetabulum", "chondral/cartilage lesions/defects of the hip", "osteochondral lesions of the femoral head", "osteochondral lesions of the acetabulum", "osteochondral lesions of the hip", "osteochondritis dissecans," "early osteoarthritis of the hip," and "early stage avascular necrosis". Hip osteochondral injuries can cause significant damage to the articular surface and diminish the quality of life. It can be difficult to treat such injuries, especially in patients who are young and active. Several methods are used to treat chondral and osteochondral injuries of the hip, such as mesenchymal stem cells and cell-based treatment, surgical repair, and microfractures. Realignment of bony anatomy may also be necessary for optimal outcomes. Despite several treatments being successful, there is a lack of head-to-head comparisons and large sample size studies in the current literature. Additional research will be required to provide appropriate clinical recommendations for treating chondral/osteochondral injuries of the hip joint.

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.

Interventional Techniques for the Management of Knee Osteoarthritis: A Literature Review

Osteoarthritis of the knee is a prevalent condition that causes pain, discomfort, and disability that can severely impact the quality of life. This literature review aims to review the various interventional pain management techniques available to treat knee osteoarthritis. It analyzes the efficacy of various interventions such as intra-articular corticosteroids, prolotherapy, viscosupplementation, platelet-rich plasma, and genicular nerve blocks with radiofrequency ablation or cryoneurolysis. We searched databases for studies published in the past 20 years. A total of 37 articles were included. The literature supports the idea that a comprehensive treatment plan consisting of the various aforementioned techniques can provide relief for patients while delaying or avoiding joint replacement surgery.

Comparing Intra-articular Platelet-Rich Plasma With Hyaluronic Acid for the Treatment of Hip Osteoarthritis: A Systematic Review and Meta-Analysis

Hip osteoarthritis (HOA), a prevalent condition among those aged 55 years and above, is a significant cause of joint pain and functional impairment and it contributes to the overall burden of chronic pain experienced by the elderly population. While platelet-rich plasma (PRP) and hyaluronic acid (HA) injections have emerged as innovative therapeutic approaches for managing osteoarthritis, their effectiveness in HOA remains a subject of contention. Therefore, the objective of this review was to assess the efficacy of PRP versus HA in terms of pain relief and functional outcomes for the management of HOA. We searched PubMed, Cochrane Library, and Google Scholar databases from 2013 to 2023 to identify pertinent randomized controlled trials (RCTs). A total of seven trials (478 participants) were included. The selected studies underwent quality assessment using the updated Cochrane risk of bias tool. The pain and functional outcomes were examined using measures of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scale, visual analog scale (VAS), and Harris hip score (HHS). In the meta-analysis, standard mean differences (SMDs) along with 95% confidence intervals (CIs) to estimate overall effect magnitudes for continuous outcomes were extracted. Statistical significance was determined using p-values below 0.05. At six months, the PRP group experienced a significantly lower standard mean WOMAC pain score (SMD = -0.38, CI = -0.64 - 0.13; p = 0.03). No significant differences in WOMAC pain scores were noted at one to two months (SMD = 0.09, CI = -0.24, 0.43; p = 0.59), and at 12 months (SMD = -0.85, CI = -1.81, 0.12; p = 0.09). Similarly, for VAS, patients on PRP showed a slight improvement in their VAS scores at six months (SMD = -0.50, CI = -0.89, -0.12; p < 0.01). However, no significant differences in VAS between the PRP groups and the HA groups were observed at one to two months (SMD = -0.22, CI = -0.49, 0.04; p = 0.10) and at 12 months (SMD = -0.22, CI: -0.63, 0.19; p = 0.29). In terms of hip dysfunction, there was no statistically significant standard mean difference in HHS between the PRP and HA groups at six months (SMD = 0.02, CI = -0.40, 0.44; p = 0.93), and at 12 months (SMD = -0.31, CI = -0.32, 0.22; p = 0.73). This review and meta-analysis provide insights into emerging treatments for HOA, especially considering that PRP shows potential benefits and safety for patients with HOA during mid-term follow-up in a 12-month period. Nevertheless, it is necessary to conduct research that includes high-quality designs and larger sample sizes to validate the comparative efficacy of these treatments.

The efficacy of the leg swing and quadriceps strengthening exercises versus platelet-rich plasma and hyaluronic acid combination therapy for knee osteoarthritis: A retrospective comparative study

The aim of this was to investigate the efficacy of physical exercise (leg swing and quadriceps strengthening exercises) versus platelet-rich plasma (PRP) and hyaluronic acid (HA) combination therapy. From January 2020 to August 2021, 106 patients with Kellgren-Lawrence Grade I-III knee osteoarthritis were divided into leg swing and quadriceps strengthening exercises (Group A) and intra-articular combination injections of PRP and HA (Group B) according to the treatment strategies. Patients in Group A received regular leg swing and quadriceps strengthening exercises for 3 months. Patients in Group B received 2 intra-articular combination injections of PRP (2 mL) and HA (2 mL) every 2 weeks. The primary outcome measures were the Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities (WOMAC) score. Secondary outcomes included single leg stance test and functional activity by 2-minute walk test and time up and go test. All outcomes were evaluated at baseline and again 1, 3, 6, and 12 months. The VAS and WOMAC scores were similar in both groups at 1 and 3 months after treatment (P > .05); however, Group A patients had significantly superior VAS and WOMAC scores than Group B patients at 6 and 12 months after treatment. For the single leg stance test, 2-minute walk test, and time up and go test, Group A patients were significantly superior to Group B throughout follow-up (P < .001). The leg swing and quadriceps strengthening exercises resulted in a significantly better clinical outcomes than the combined PRP and HA therapy, with a sustained lower pain score and improved quality of life, balance ability, and functional activity within 12 months.

Current evidence on mesenchymal stem cells for hip osteoarthritis: a narrative review

There are limited data on the use of mesenchymal stem cell injections for hip osteoarthritis. The goal of this study was to evaluate the literature by analyzing outcomes and comparing methodologies. Online search of PubMed, SportsDiscus and Case Reports Keywords was completed using the keywords 'stem cells' and 'hip' and 'osteoarthritis'. Six studies met the inclusion and exclusion criteria. Five out the six studies had statistically significant improvement in patient reported outcomes after mesenchymal stem cell injections. Only two studies provided information on radiological changes and findings were positive. None of the studies reported major complications. Small series of non-randomized controlled trials completed to date in the use of mesenchymal stem cells for the treatment of hip osteoarthritis reported the procedures to be safe and provide a positive clinical response. Randomized controlled trials must be performed to further confirm mesenchymal stem cells as a treatment option for hip osteoarthritis.

Inflammatory ultrasound features as prognostic factors of pain and functional outcomes following intra-articular platelet-rich plasma in knee osteoarthritis

AIM

To explore inflammatory ultrasound predictors of improvements in pain and function over 2, 6, and 12 months following administration of intra-articular platelet-rich plasma (PRP) in knee osteoarthritis (OA).

METHOD

Patients with painful mild-moderate radiographic knee OA from a subset of the RESTORE RCT underwent ultrasound assessment according to the standardized OMERACT scanning protocol to detect inflammatory features such as synovitis, synovial hypertrophy, and effusion with power Doppler. The study knee was treated with 3 once-weekly PRP injections obtained after centrifugation at 1500 g for 5 min. Numerical Rating Score (NRS), Intermittent and Constant Osteoarthritis Pain (ICOAP) questionnaire, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) function sub-score were used to measure pain and functional severity. Separate linear regression models were performed to determine whether baseline ultrasound-detected features of inflammation predicted the improvement in pain and function following PRP injection in both unadjusted and adjusted models for confounders.

RESULTS

Forty-four participants were included, with 25 (56.8%) being female. In an unadjusted model, higher OMERACT scores for inflammatory features such as global synovitis and/or effusion were significantly associated with greater improvement in all outcomes measured at 2 months but not at 6 and 12 months for pain measures. Only global synovitis showed significant association with functional improvement at 2 and 12 months. Similar findings were observed in the adjusted model.

CONCLUSION

Ultrasound indices of knee inflammation predicted short-term improvements in pain severity and both short- and longer-term improvements in function following intra-articular PRP injection.

Myths and truths on biophysics-based approach in rehabilitation of musculoskeletal disorders

Musculoskeletal disorders (MSD) are a crucial issue in current literature due to their impact on physical function, social, and economic costs. Rehabilitation plays a pivotal role in the therapeutic management of these disabling conditions with growing evidence underlining positive effects in improving functional outcomes. However, to date, several questions are still open about the mechanisms underpinning functional improvements while recent research is now focusing on a deeper understanding of the biophysical processes underpinning the macroscopical effects of these treatments. Thus, this narrative review aims at providing a comprehensive overview about the state of the art of biophysical dimensions of currently available treatments for MSD. PubMed, Scopus, CENTRAL, PEDro, and Web of Science were searched between March 2022 and October 2022 for in vitro and in vivo studies, clinical trials, systematic reviews, and meta-analysis addressing the issue of biophysics-based approach in rehabilitation of MSD. Our findings showed that a biophysical approach might be integrated into regenerative rehabilitation, aiming at enhancing regenerative processes by mechanical and biophysical stimuli. In addition, a biophysical-based approach has been proposed to improve knowledge about several instrumental physical therapies, including shock wave therapies, low-level laser therapy, ultrasound, short-wave diathermy, electrical stimulation, pulsed electromagnetic field, and vibration therapy. In accordance, emerging research is now focusing on the biophysical properties of several medical procedures to improve pain management in patients with MSD. Taken together, our results showed promising results of the integration of a biophysical-based approach in rehabilitation, albeit several limitations currently limit its implementation in routine clinical setting. Unfortunately, the state of the art is still inconclusive, and the low quality of clinical studies based on the biophysical approach did not provide clear treatment protocols. Further studies are needed to promote a precise rehabilitation approach targeting biological modification and enhancing the functional improvement of patients with MSDs.

Platelet-Rich Plasma for Knee Osteoarthritis: What Does the Evidence Say?

The utilization of platelet-rich-plasma as a therapeutic intervention for knee osteoarthritis has gained immense attention since 2008. The increase in the number of scientific publications dedicated to this area can be attributed to the majority of favorable results reported in clinical trials and basic science studies. However, despite the growing evidence, the use of platelet-rich plasma in clinical practice still poses controversial aspects. The potential mechanisms of action described for platelet-rich-plasma so far indicate that it could serve as a disease-modifying drug, acting to counteract important aspects of knee osteoarthritis pathophysiology (cartilage breakdown, inflammation, and bone remodeling). Nevertheless, its efficacy in slowing down the progression of knee osteoarthritis remains unproven. While inconsistencies have been noted, the majority of controlled clinical trials and meta-analyses advocate for the utilization of platelet-rich-plasma in treating knee osteoarthritis, as it has demonstrated greater efficacy than hyaluronic acid and placebo, with a follow-up of at least 1 year. Despite advancements made in certain areas, significant diversity persists regarding the formulations used, therapeutic regimen, extended follow-up periods, patient selection, and assessment of clinically relevant outcomes. Consequently, the leading clinical practice guidelines do not recommend its use. In light of the emerging evidence, this narrative review aims to provide an objective evaluation of the recent available scientific literature (last 5 years) focused on randomized clinical trials and meta-analyses to present a current overview of the topic.

Efficacy of the combination therapy of platelet-rich plasma and hyaluronic acid on improving knee pain and dysfunction in patients with moderate-to-severe KOA: a protocol for a randomised controlled trial

INTRODUCTION

54% of patients with moderate-to-severe knee osteoarthritis (KOA) still reported persistent pain and functional loss after conservative treatment according to guidelines. As an emerging treatment, platelet-rich plasma (PRP) has been proven to significantly relieve pain and improve activity function in patients with mild-to-moderate KOA, either used alone or in combination with hyaluronic acid (HA). However, it is still unclear of its efficacy in moderate-to-severe KOA. This study aims to evaluate the clinical efficacy of PRP and the combination therapy of PRP and HA in patients with moderate-to-severe KOA and to explore the potential synergistic effect of PRP and HA.

METHODS AND ANALYSIS

This triple-blind randomised controlled trial will involve a total of 162 participants with moderate-to-severe KOA from two study centres. Participants will be allocated randomly into three groups: the HA group, the PRP group and the combination (PRP+HA) group and, respectively, receive HA (2.5 mL)+saline (3 mL)/PRP (3 mL)+saline (2.5 mL)/PRP (3 mL)+HA (2.5 mL) intra-articular injection each week for 4 consecutive weeks. All of the injections will be performed under the guidance of ultrasound. The primary outcome is the change of Western Ontario and McMaster Universities Osteoarthritis Index from baseline to 6 months, and secondary outcomes include the change of ultrasound images (suprapatellar bursa effusion and synovitis), Timed Up and Go test and 12-Item Short-Form Health Survey. All outcomes will be evaluated at baseline and 1-month, 3-month and 6-month follow-ups. Data will be analysed on intention-to-treat principles and a per-protocol basis.

ETHICS AND DISSEMINATION

This protocol was approved by the Medical Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University (reference number (2021)-02-231-02). The study results will be submitted to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2100050974.

The role of WNT and IL-1 signaling in osteoarthritis: therapeutic implications for platelet-rich plasma therapy

Different from inflammatory arthritis, where biologicals and targeted synthetic molecules have revolutionized the disease course, no drug has demonstrated a disease modifying activity in osteoarthritis, which remains one of the most common causes of disability and chronic pain worldwide. The pharmacological therapy of osteoarthritis is mainly directed towards symptom and pain relief, and joint replacement is still the only curative strategy. Elucidating the disease pathophysiology is essential to understand which mechanisms can be targeted by innovative therapies. It has extensively been demonstrated that aberrant WNT and IL-1 signaling pathways are responsible for cartilage degeneration, impaired chondrocyte metabolism and differentiation, increased extracellular matrix degradation, and altered subchondral bone homeostasis. Platelet-rich plasma is an autologous blood derivative containing a concentration of platelets that is much higher than the whole blood counterpart and has shown promising results in the treatment of early knee osteoarthritis. Among the proposed mechanisms, the modulation of WNT and IL-1 pathways is of paramount importance and is herein reviewed in light of the proposed regenerative approaches.

Pulsed Radiofrequency and Platelet Rich Plasma in Degenerative Joint Arthritis: Two Case Reports and Literature Analyses

(1) Background: Osteoarthritis (OA) is a debilitating joint disease. The are several therapies available for OA. According to current knowledge, the combination of Platelet-Rich Plasma (PRP) and Pulsed Radiofrequency (PRF) can be applied in the treatment of pain of nociceptive origin due to peripheral tissue damage. (2) Methods: We performed a narrative review identifying the articles by searching electronic databases. A retrospective analysis of patients with OA treated with PRF and PRP in "Vito Fazzi" Hospital (Lecce, Italy) was performed. (3) Results: A total of four publications on the use of PRP and PRF in degenerative joint arthritis were included in our review. In our experience, two patients with OA were treated with PRP and PRF after unsuccessful conservative treatment. Patient pain score, daily activity ability, active range of activity, and muscle strength improved after treatment. Patients reported a higher level of satisfaction. No major adverse events were reported. (4) Conclusions: The goal of the combined application of the two treatments is to make full use of the analgesic effect of PRF and the repairing effect of PRP. At present, the therapeutic potential of PRP and PRF in OA remains unmet.

A model-based quantitative analysis of efficacy and associated factors of platelet rich plasma treatment for osteoarthritis

OBJECTIVE

While platelet rich plasma (PRP) has been extensively studied in treating osteoarthritis (OA), there has been an ongoing debate regarding the efficacy of PRP and the optimal subpopulation for PRP treatment remains unknown. The authors hereby aim to establish a pharmacodynamic model-based meta-analysis to quantitatively evaluate PRP efficacy, comparing with hyaluronic acid (HA) and identify relevant factors that significantly affect the efficacy of PRP treatment for OA.

METHODS

The authors searched for PubMed and the Cochrane Library Central Register of Controlled Trials of PRP randomized controlled trials (RCTs) for the treatment of symptomatic or radiographic OA from the inception dates to 15 July 2022. Participants' clinical and demographic characteristics and efficacy data, defined as Western Ontario and McMaster Universities Osteoarthritis Index and visual analog scale pain scores at each time point were extracted.

RESULTS

A total of 45 RCTs (3829 participants) involving 1805 participants injected with PRP were included in the analysis. PRP reached a peak efficacy at ~ 2-3 months after injection in patients with OA. Both conventional meta-analysis and pharmacodynamic maximal effect models showed that PRP was significantly more effective than HA for joint pain and function impairment (additional decrease of 1.1, 0.5, 4.3, and 1.1 scores compared to HA treatment at 12 months for Western Ontario and McMaster Universities Osteoarthritis Index pain, stiffness, function, and visual analog scale pain scores, respectively). Higher baseline symptom scores, older age (≥60 years), higher BMI (≥30), lower Kellgren-Lawrence grade (≤2) and shorter OA duration (<6 months) were significantly associated with greater efficacy of PRP treatment.

CONCLUSION

These findings sugges t that PRP is a more effective treatment for OA than the more well-known HA treatment. The authors also determined the time when the PRP injection reaches peak efficacy and optimized the targeting subpopulation of OA. Further high-quality RCTs are required to confirm the optimal population of PRP in the treatment of OA.

Regenerative methods in osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis that can affect all joint structures. The primary goals of osteoarthritis treatment are to alleviate pain, reduce functional limitations, and improve quality of life. Despite its high prevalence, treatment options for osteoarthritis are limited, with most therapeutic approaches focusing on symptom management. Tissue engineering and regenerative strategies based on biomaterials, cells, and other bioactive molecules have emerged as viable options for osteoarthritis cartilage repair. Platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) are the most commonly used regenerative therapies today to protect, restore, or increase the function of damaged tissues. Despite promising results, there is conflicting evidence regarding the efficacy of regenerative therapies, and their efficacy remains unknown. The data suggest that more research and standardization are required for the use of these therapies in osteoarthritis. This article provides an overview of the application of MSCs and PRP applications.

Comparing the Efficacy of Intra-articular Platelet-Rich Plasma and Corticosteroid Injections in the Management of Frozen Shoulder: A Randomized Controlled Trial

Introduction Periarthritis of the shoulder, or frozen shoulder (FS), is a common, painful, and disabling condition with varied treatment strategies. Intra-articular (IA) corticosteroid (CS) injections are a popular treatment option, but their efficacy is often temporary. Platelet-rich plasma (PRP) has emerged as an alternative therapy for adhesive capsulitis, but the literature on its effectiveness is limited. This study aimed to compare the efficacy of IA PRP and CS injections in managing FS. Methods In this prospective, randomized study, 68 patients who met the inclusion criteria were enrolled and randomized using a computer-generated table into two groups: Group 1 (IA PRP) received 4 ml PRP, and Group 2 (IA CS) received 2 ml (80 mg) of methylprednisolone acetate mixed with 2 ml normal saline (for a total of 4 ml) as a CS injection in the IA area of the shoulder. Outcome measures included pain; shoulder range of motion (ROM); the condensed version of the disabling conditions of the arm, shoulder, and hand (QuickDASH) score; and the shoulder pain and disability index (SPADI) score. Participants were monitored via follow-up for 24 weeks, with pain and function assessed at each evaluation using the visual analog scale (VAS) score, the SPADI score, and the QuickDASH score. Results The IA PRP injections demonstrated better long-term outcomes than the IA CS injections, significantly improving pain, shoulder ROM, and daily activity performance. After 24 weeks, the mean VAS score in the PRP and methylprednisolone acetate groups was 1.00 (1.0 to 1.0) and 2.00 (2.0 to 2.0), respectively (P≤0.001). The mean QuickDASH score was 41.83 ± 6.33 in the PRP group and 48.76 ± 5.08 in the methylprednisolone acetate group (P≤0.001). The mean SPADI score was 53.32 ± 7.49 in the PRP group and 59.24 ± 5.80 in the methylprednisolone acetate group (P≤0.001), indicating a significant improvement in the PRP group's pain and disability scores after 24 weeks. The rate of complications was similar between the two groups. Conclusions Our findings suggest that IA PRP injections provide better long-term results than IA CS injections for managing FS. Platelet-rich plasma can be used as a treatment modality for better outcomes, particularly when the patient is contraindicated or refuses CS treatment. Further research is needed to evaluate the efficacy of these treatment modalities at different stages of FS and explore the potential benefits of ultrasound-guided injections.

Patients With Knee Osteoarthritis Who Receive Platelet-Rich Plasma or Bone-Marrow Aspirate Concentrate Injections Have Better Outcomes Than Patients Who Receive Hyaluronic Acid: Systematic Review and Meta-analysis

PURPOSE

To systematically review the literature in order to compare the efficacy and safety of platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and hyaluronic acid (HA) injections for the treatment of knee osteoarthritis (OA).

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I studies that compared the clinical efficacy of at least 2 of the following 3 injection therapies: PRP, BMAC, and HA for knee OA. The search phrase used was knee AND osteoarthritis AND randomized AND ("platelet rich plasma" OR "bone marrow aspirate" OR "hyaluronic acid"). Patients were primarily assessed based on patient-reported outcome scores (PROs) including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) score.

RESULTS

Twenty-seven studies (all Level I) met inclusion criteria, including 1,042 patients undergoing intra-articular injection(s) with PRP (mean age 57.7 years, mean follow-up 13.5 months), 226 patients with BMAC (mean age 57.0 years, mean follow-up 17.5 months), and 1,128 patients with HA (mean age 59.0 years, mean follow-up 14.4 months). Non-network meta-analyses demonstrated significantly better post-injection WOMAC (p < 0.001), VAS (p < 0.01), and Subjective IKDC scores (p < 0.001) in PRP patients when compared to HA patients. Similarly, network meta-analyses demonstrated significantly better post-injection WOMAC (p < 0.001), VAS (p = 0.03), and Subjective IKDC (p < 0.001) scores in BMAC patients when compared to HA patients. There were no significant differences in post-injection outcome scores when comparing PRP to BMAC.

CONCLUSION

Patients undergoing treatment for knee OA with PRP or BMAC can be expected to experience improved clinical outcomes when compared to HA patients.

LEVEL OF EVIDENCE

I, Meta-Analysis of Level I studies.

Composition of Platelet-Rich Plasma Prepared From Knee Osteoarthritic Patients: Platelets, Leukocytes, and Subtypes of Leukocyte

INTRODUCTION

Platelet-rich plasma (PRP) has gained increasing popularity in the orthopedic field. There has been still no consensus on PRP preparation technique, thus providing a variety of final PRP products. Different preparation techniques lead to different compositions of PRP, which include platelet concentration, the number of leukocytes, and their subtypes. Here, we studied those compositions of PRP compared to whole blood samples.

METHODS

There were 335 participants who met the inclusion and exclusion criteria. Each participant underwent a blood drawing process to prepare PRP for their knee osteoarthritis treatment. We categorized baseline platelet concentration in whole blood samples into three groups: less than 2 x 10⁵/µL (Group 1), between 2 x 10⁵/µL and 2.99 x 10⁵/µL (Group 2), and greater than 2.99 x 10⁵/µL (Group 3). The primary outcome was reported as the platelet concentration in PRP and the ratio of platelet concentration in PRP compared to baseline whole blood samples. The secondary outcome was reported as the ratios of leukocyte, lymphocyte, and neutrophil in PRP compared to the baseline whole blood samples.

RESULTS

The average platelet concentration in PRP was 1.26 x 10⁶/µL (6.3 times higher compared to baseline whole blood samples). The mean platelet concentration of PRP in Group 1, Group 2, and Group 3 was 1.08 x 10⁶/µL, 1.38 x 10⁶/µL, and 1.71 x 10⁶/µL, respectively (p-value = 0.0001). The platelet concentration ratio of PRP condition to the baseline whole blood was 6.9, 5.8, and 4.2 in Group 1, Group 2, and Group 3, respectively (p-value = 0.0018). The average ratio of leukocytes in PRP to whole blood was 1.5. The average ratio of lymphocytes and neutrophils in PRP to whole blood was 2.0 and 0.5, respectively.  Conclusion: Different baseline platelet concentrations in whole blood samples provided significantly different platelet concentrations in PRP. The baseline platelet concentration in whole blood also provided an inverse relation to the fold change of the platelet concentration in PRP. Subtypes of leukocytes changed from neutrophil-predominated in the baseline whole blood samples to lymphocyte-predominated in PRP.

MSCs-laden silk Fibroin/GelMA hydrogels with incorporation of platelet-rich plasma for chondrogenic construct

Repair of osteochondral defects and regeneration of cartilage is a major challenge. In this work, the mesenchymal stem cells (MSCs)-laden hydrogel was designed using silk fibroin (SF) and gelatin methacrylate (GelMA), to encapsulate platelet-rich plasma (PRP). Initially, GelMA was synthesized, and SF was prepared using silkworm cocoon, then MSCs-laden SF/GelMA (SG) hydrogel was fabricated. The physicochemical properties of the hydrogels were evaluated using Fourier-transform infrared spectroscopy, scanning electron microscope, and rheometry. After hydrogel preparation, the viability of MSCs in the hydrogels was investigated via CCK-8 analysis and fluorescent images. The MSCs-laden SG hydrogel containing PRP was subsequently injected into the cartilage defect area in Sprague Dawley rats. Hematoxylin and eosin (H&E), Masson staining, and Mankin scores evaluation confirmed the new cartilage formation in 8 weeks. The results presented in the study, therefore, showed that the prepared MSCs-laden SG hydrogel loaded with PRP has the potential for cartilage reconstruction, which is crucial to the treatment of knee osteoarthritis.

Multiple Injections of Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Current Evidence in Randomized Controlled Trials

In recent years, various clinical trials have focused on treating knee osteoarthritis (KOA) with multiple injections of platelet-rich plasma (PRP). However, compared with the multiple hyaluronic acid (m-HA) injections, the clinical efficacy of multiple PRP (m-PRP) injections for KOA still remains controversial among these studies. Therefore, we aimed to compare the clinical effectiveness of m-PRP injections with m-HA injections in the treatment of KOA in this systematic review. Relevant clinical trials were searched via bibliographic databases, including Medline, PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials, to compare the m-PRP and m-HA injections in the treatment of KOA. Finally, fourteen randomized controlled trials, including 1512 patients, showed the postoperative VAS, WOMAC, IKDC, or EQ-VAS scores and were enrolled in this systematic review. Compared with the group of intra-articular m-HA injections, the group of intra-articular m-PRP injections was lower in the VAS scores at 3-month (WMD = −0.25; 95%CI, −0.40 to −0.10, p = 0.0009) and 12-month (WMD = −0.64; 95%CI, −0.79 to −0.49, p < 0.00001) follow-ups. In addition, the group of intra-articular m-PRP injections was also lower in the WOMAC scores at 1-month (WMD = −1.23; 95%CI, −2.17 to −0.29, p = 0.01), 3-month (WMD = −5.34; 95%CI, −10.41 to −0.27, p = 0.04), 6-month (WMD = −11.02; 95%CI, −18.09 to −3.95, p = 0.002), and 12-month (WMD = −7.69; 95%CI, −12.86 to −2.52, p = 0.004) follow-ups. Furthermore, compared with the group of intra-articular m-HA injections, the group of intra-articular m-PRP injections was higher in the IKDC scores at 3-month (WMD = 7.45; 95%CI, 2.50 to 12.40, p = 0.003) and 6-month (WMD = 5.06; 95%CI, 1.94 to 8.18, p = 0.001) follow-ups. However, the long-term adverse side of m-PRP injections for KOA still needs more large-scale trials and long-term follow-ups.

Research trends of platelet-rich plasma therapy on knee osteoarthritis from 2011 to 2021: A review

BACKGROUND

Platelet-rich plasma (PRP) has been widely used to alleviate osteoarthritis of the knee, and research results are abundant. However, there are no bibliometric reports in publications in this field. Therefore, the current status of PRP for the treatment of osteoarthritis of the knee from 2011 to 2021 was analyzed using Citespace 6.1.R2 software.

METHODS

Publications regarding PRP treating Knee Osteoarthritis between 2011 and 2021 were extracted from the Web of Science database. CiteSpace was used to analyze the number of publications, countries, institutions, journals, authors, cited references, and keywords by using standard bibliometric indicators.

RESULTS

A total of 988 publications were searched from 2011 to 2021. In the last decade, the number of publications has increased in the field. Brian J. Cole was the author with the most output, with 31 relevant articles, and Giuseppe Filardo ranked first in cited authors. Am J Sport Med was the most cited journal. In this field, the most prolific country is the United States and the most prolific institution is Rush University. An article published by Sandeep Patel ranked first in cited references with 118 citations. "Randomized controlled trial" was the most bursting keyword and other more popular keywords about PRP for knee osteoarthritis: "hyaluronic acid," "double-blind," and "mesenchymal stem cell."

CONCLUSION

This bibliometric study provides a decade of current clinical research on PRP for the treatment of osteoarthritis of the knee, which can help researchers understand the hot spots in the field and provide a new direction for their research.

Platelet-rich plasma attenuates the severity of joint capsule fibrosis following post-traumatic joint contracture in rats

Background: Post-traumatic joint contracture (PTJC) mainly manifests as excessive inflammation leading to joint capsule fibrosis. Transforming growth factor (TGF)-β1, a key regulator of inflammation and fibrosis, can promote fibroblast activation, proliferation, migration, and differentiation into myofibroblasts. Platelet-rich plasma (PRP) is considered to have strong potential for improving tissue healing and regeneration, the ability to treat joint capsule fibrosis remains largely unknown. Methods: In this study, we aimed to determine the antifibrotic potential of PRP in vivo or in vitro and its possible molecular mechanisms. The TGF-β1-induced primary joint capsule fibroblast model and rat PTJC model were used to observe several fibrotic markers (TGF-β1, α-SMA, COL-Ⅰ, MMP-9) and signaling transduction pathway (Smad2/3) using histological staining, qRT-PCR and western blot. Results: Fibroblasts transformed to myofibroblasts after TGF-β1 stimulation with an increase of TGF-β1, α-SMA, COL-Ⅰ, MMP-9 and the activation of Smad2/3 in vitro. However, TGF-β1-induced upregulation or activation of these fibrotic markers or signaling could be effectively suppressed by the introduction of PRP. Fibrotic markers' similar changes were observed in the rat PTJC model and PRP effectively reduced inflammatory cell infiltration and collagen fiber deposition in the posterior joint capsule. Interestingly, HE staining showed that articular cartilage was degraded after rat PTJC, and PRP injection also have the potential to protect articular cartilage. Conclusion: PRP can attenuate pathological changes of joint capsule fibrosis during PTJC, which may be implemented by inhibiting TGF-β1/Smad2/3 signaling and downstream fibrotic marker expression in joint capsule fibroblasts.

Assessment of the effectiveness and satisfaction of platelet-rich plasma compared with hyaluronic acid in knee osteoarthritis at minimum 7-year follow-up: A post hoc analysis of a randomized controlled trial

Background: Knee osteoarthritis (KOA) can be effectively treated conservatively using platelet-rich plasma (PRP) injections into the affected joints. While the short-term therapeutic clinical benefits were well documented, the mid-term results remain undetermined. To clarify its efficacy, the mid-term clinical outcomes of intra-articular injections of either PRP or hyaluronic acid (HA) in KOA were compared. Methods: One hundred patients who complied with the inclusion criteria were randomized to undergo once a week 3 weeks, intra-articular injections of either PRP or HA. Patients were evaluated before the injection, at 3, 6, and a mean of 78.9 months of follow-up. Eighty-five patients reached the final evaluation. Data on survival, re-intervention, pain, function, imaging, and satisfaction were collected and analyzed. Results: With surgery for any reason as the endpoint, the cumulative survival rate of the PRP group was 90%, while that of the HA group was 74%. There was a significant difference between the two groups in the total re-intervention rate (56.7% vs 16.2%, p < 0.05). The comparative analyses showed significant intergroup differences in the visual analog scale (VAS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) (p < 0.01, p < 0.05, respectively) at the final follow-up. And base on the regression analyses, the type of treatment, age, and Kellgren-Lawrence (K-L) grade served as statistically an independent determinants of VAS (p < 0.001, p = 0.034, p < 0.001, respectively). Likewise, those variables independently determined WOMAC in our study. However, no difference was observed in the imaging evaluation, containing the K-L grade and Cartilage Lesion Score, between the two groups (p > 0.05). Besides, the satisfaction treated by the PRP was 78.6%, with a superiority compared with HA (55.8%, p < 0.05), and no complications were noted in the whole treatment process among patients who participated. Conclusion: PRP was more effective than HA in survival and re-intervention rates, VAS, and WOMAC, although there were no significant differences in the imaging evaluation between the two groups. Furthermore, patients treated with PRP were associated with higher satisfaction compared with HA.

Combination of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) in the treatment of knee osteoarthritis: a meta-analysis of randomised controlled trials

OBJECTIVES

The purpose of this meta-analysis was to investigate the efficacy and safety of mesenchymal stem cells (MSCs) combined with platelet-rich plasma (PRP) in the treatment of knee osteoarthritis (KOA).

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Patients with KOA.

INTERVENTIONS

Use of MSCs+PRP.

PRIMARY AND SECONDARY OUTCOMES

Visual Analogue Scale (VAS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and adverse reactions.

DATA SOURCES

PubMed, Cochrane Library, Embase and China National Knowledge Infrastructure were searched from inception to 15 July 2021.

MEASURES

The OR or weighted mean difference (WMD) of relevant outcome indicators was calculated. Study quality was evaluated using the risk-of-bias assessment tool version 2.0. Heterogeneity among studies was evaluated by calculating I². If I²＜50%, a fixed-effect model was applied; conversely, if I² ≥50%, a random-effect model was applied.

RESULTS

Six controlled clinical trials with 493 cases were included. The meta-analysis results showed that in terms of the VAS score 3 months after treatment, MSCs+PRP had no significant effect on the reduction of the VAS score in patients with KOA compared with the control (p=0.09), hyaluronic acid (HA) (p=0.15) or PRP alone (p=0.07). MSCs+PRP was more effective in reducing the VAS score at 6 and 12 months after treatment than the control (WMD=-0.55, 95% CI -0.87 to -0.22, p<0.001), HA (WMD=-1.20, 95% CI -2.28 to -0.13, p=0.03) or PRP alone (WMD=-0.54, 95% CI -0.89 to -0.18, p=0.003). Regarding the decrease in the total WOMAC score at 3 and 6 months after treatment, MSCs+PRP showed better clinical efficacy than the control or HA alone (p<0.01). Compared with the control, MSCs+PRP exhibited no significant difference in reducing the total WOMAC score 12 months after treatment (p=0.39). There was no significant difference between MSCs+PRP and the control in terms of improvement of the KOOS 12 months after treatment (p=0.16). Compared with MSCs alone, MSCs+PRP exhibited no significant difference in the incidence of adverse reactions (p=0.22) 12 months after treatment.

CONCLUSIONS

Treatment with MSCs+PRP showed good clinical efficacy in improving pain and joint function in patients with KOA. Compared with MSCs alone, there was no significant difference in the incidence of adverse reactions with MSCs+PRP.

PROSPERO REGISTRATION NUMBER

CRD 42021275830.

Medium-Term Effect of Treatment with Intra-Articular Injection of Sodium Hyaluronate, Betamethasone and Platelet-Rich Plasma in Patients with Temporomandibular Arthralgia: A Retrospective Cohort Study

Temporomandibular joint disorders are associated with pain and reduced jaw mobility. The aim of this study was to compare the long-term effect on pain of intra-articular TMJ injections of betamethasone, sodium hyaluronate and platelet-rich plasma. The sample was made up of 114 patients, who were randomly distributed into three groups at least three years ago and who achieved a total remission of pain after treatment. We found that the median number of months without pain was, according to each group, as follows: platelet-rich plasma: 33; sodium hyaluronate: 28; betamethasone: 19. Both platelet-rich plasma and sodium hyaluronate lead to significant pain-free time after treatment; when we compare bethametasone with the two other substances, it proved to be very ineffective.

Medicinal plants and their secondary metabolites in alleviating knee osteoarthritis: A systematic review

BACKGROUND

With the increasing ages of the general population, the incidence of knee osteoarthritis (KOA) is also rising, and KOA has become a major health problem worldwide. Recently, medicinal plants and their secondary metabolites have gained interest due to their activity in treating KOA. In this paper, a comprehensive systematic review of the literature was performed concerning the effects of medicinal plant extracts and natural compounds against KOA in recent years. The related molecular pathways of natural compounds against KOA were summarized, and the possible crosstalk among components in chondrocytes was discussed to propose possible solutions for the current situation of treating KOA.

PURPOSE

This review focused on the molecular mechanisms by which medicinal plants and their secondary metabolites act against KOA.

METHODS

Literature searches were performed in the PUBMED, Embase, Science Direct, and Web of Science databases for a 10-year period from 2011 to 2022 with the search terms "medicinal plants," "bioactive compounds," "natural products," "phytochemical," "knee osteoarthritis," "knee joint osteoarthritis," "knee osteoarthritis," "osteoarthritis of the knee," and "osteoarthritis of knee joint."

RESULTS

According to the results, substantial plant extracts and secondary metabolites show a positive effect in fighting KOA. Plant extracts and their secondary metabolites can affect the diagnostic and prognostic biomarkers of KOA. Natural products inhibit the expression of MMP1, MMP3, MMP19, syndecan IV, ADAMTS-4, ADAMTS-5, iNOS, COX-2, collagenases, IL-6, IL-1β, and TNF-α in vitro and in vivo and . Cytokines also upregulate the expression of collagen II and aggrecan. The main signaling pathways affected by the extracts and isolated compounds include AMPK, SIRT, NLRP3, MAPKs, PI3K/AKT, mTOR, NF-κB, WNT/β-catenin, JAK/STAT3, and NRF2, as well as the cell death modes apoptosis, autophagy, pyroptosis, and ferroptosis.

CONCLUSION

The role of secondary metabolites in different signaling pathways supplies a better understanding of their potential to develop further curative options for KOA.

Umbilical Cord PRP vs. Autologous PRP for the Treatment of Hip Osteoarthritis

Umbilical cord platelet-rich plasma (C-PRP) has more growth factors and anti-inflammatory molecules compared with autologous PRP (A-PRP) derived from peripheral blood. The aim of this study was to compare intra-articular C-PRP or A-PRP injections in terms of safety and clinical efficacy for the treatment of patients with hip osteoarthritis (OA). This study investigated the results of 100 patients with hip OA treated with three weekly ultrasound-guided injections of either C-PRP or A-PRP. Clinical evaluations were performed before the treatment and after two, six, and twelve months with the HHS, WOMAC, and VAS scores. No major adverse events were recorded. Overall, the improvement was limited with both treatments. Significant improvements in VAS (p = 0.031) and HHS (p = 0.011) were documented at two months for C-PRP. Patients with a low OA grade (Tonnis 1-2) showed a significantly higher HHS improvement with C-PRP than A-PRP at twelve months (p = 0.049). C-PRP injections are safe but offered only a short-term clinical improvement. The comparative analysis did not demonstrate benefits compared with A-PRP in the overall population, but the results are influenced by OA severity, with C-PRP showing more benefits when advanced OA cases were excluded. Further studies are needed to confirm the most suitable indications and potential of this biological injective approach.

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.

Umbilical Cord-Derived Stem Cells for the Treatment of Knee Osteoarthritis: A Systematic Review

Background:

The use of mesenchymal stem cells (MSCs) for the treatment of knee osteoarthritis (OA) has gained recent interest in the orthopaedics community.

Purpose:

To review the literature to evaluate the efficacy of umbilical cord–derived MSCs in the treatment of OA of the knee joint.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We searched the PubMed, Cochrane Library, and Embase databases to identify studies with evidence levels from 1 to 4 that evaluated the clinical efficacy of human umbilical cord–derived MSC (hUC-MSC) injections for knee OA. The search phrase used was “umbilical cord knee osteoarthritis.” In the studies reviewed, patients were assessed based on the macroscopic International Cartilage Regeneration & Joint Preservation Society (ICRS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and the subjective International Knee Documentation Committee (IKDC) score.

Results:

A total of 7 studies met inclusion criteria, including 385 patients undergoing injection of hUC-MSCs (mean age, 59.7 years). The mean follow-up was 23.4 months. Weighted averages of the WOMAC, macroscopic ICRS, subjective IKDC, and VAS scores all showed improvement from before to after treatment. No severe adverse reactions were recorded.

Conclusion:

Patients undergoing treatment of knee OA with hUC-MSCs might be expected to experience improvements in clinical outcomes. Additional high-quality randomized studies are needed to better determine the efficacy of hUC-MSC for the treatment of knee OA.

Cell therapies for chondral defects of the talus: a systematic review

Background

This systematic review investigated the efficacy and safety of surgical procedures augmented with cell therapies for chondral defects of the talus.

Methods

The present systematic review was conducted according to the 2020 PRISMA guidelines. PubMed, Google scholar, Embase, and Scopus databases were accessed in March 2022. All the clinical trials investigating surgical procedures for talar chondral defects augmented with cell therapies were accessed. The outcomes of interest were to investigate whether surgical procedures augmented with cell therapies promoted improvement in patients reported outcomes measures (PROMs) with a tolerable rate of complications.

Results

Data from 477 procedures were retrieved. At a mean follow-up of 34.8 ± 9.7 months, the Visual Analogic Scale (VAS) improved of 4.4/10 (P = 0.002) and the American Orthopaedic Foot and Ankle Score (AOFAS) of 31.1/100 (P = 0.0001) points. No improvement was found in Tegner score (P = 0.4). Few articles reported data on complications. At last follow-up, the rate of reoperation and failure were 0.06% and 0.03%, respectively. No graft delamination or hypertrophy was observed.

Conclusion

The current evidence suggests that cell therapies may be effective and safe to enhance surgical procedures for chondral defects of the talus. These results should be considered within the limitations of the present study. The current literature should be enriched with randomized controlled clinical trials with larger population size and longer follow-up.

Platelet-Rich Plasma Versus Hyaluronic Acid for Hip Osteoarthritis Yields Similarly Beneficial Short-Term Clinical Outcomes: A Systematic Review and Meta-analysis of Level I and II Randomized Controlled Trials

PURPOSE

To systematically review the literature to compare the efficacy of platelet-rich plasma (PRP) and hyaluronic acid (HA) injections for the treatment of hip osteoarthritis (OA).

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that compared the clinical efficacy of PRP and HA injections for hip OA. The search phrase used was hip, osteoarthritis, platelet-rich plasma, hyaluronic acid, randomized. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Visual Analog Scale (VAS) for pain, and the Harris Hip Score (HHS). Subanalyses were performed for any outcome score in which ≥3 studies reported results.

RESULTS

Six studies (5 level I, 1 level II) met inclusion criteria, including 211 patients undergoing intra-articular injection with PRP (mean age 60.0 years, mean follow-up 12.2 months) and 197 patients with HA (mean age 62.3 years, mean follow-up 11.9 months). No significant differences were found in the weighted improvement of any outcome score (WOMAC, VAS, or HHS) from preinjection to postinjection between groups. When excluding a study with the highest risk of bias to eliminate heterogeneity, pooled subanalysis demonstrated no significant differences in WOMAC subscores between PRP and HA groups. Similarly, in a pooled subanalysis that isolated patients treated with leukocyte-poor PRP, no significant differences in WOMAC subscores were found between PRP and HA groups.

CONCLUSION

Patients undergoing treatment for hip OA with either PRP or HA injections can expect to experience similarly beneficial short-term clinical outcomes.

LEVEL OF EVIDENCE

II, systematic review of level I and II studies.

The non-operative management of primary osteoarthritis

Osteoarthritis is a syndrome characterised by joint pain, resulting in functional limitation and a decreased quality of life. This chronic condition is one of the major public health problems facing society today and is likely to become more prevalent. The expected increase is because of the primary causative factors, advancing age and obesity, becoming increasingly prevalent in society. The diagnosis of osteoarthritis can be made clinically when activity related joint pain is present, alongside morning joint stiffness that lasts for less than 30 minutes. However, a radiological diagnosis can also be made.

This article examines the current management strategies, as outlined by the National Institute for Health and Care Excellence guidelines for osteoarthritis. Although numerous surgical options are available, this article focuses on the non-operative strategies currently used. The emphasis in this article is on general principles of treatment rather than treatment options for specific joints.

Effects of Different Nonsteroidal Anti-Inflammatory Drugs Combined with Platelet-Rich Plasma on Inflammatory Factor Levels in Patients with Osteoarthritis

Objective. To investigate the effects of different nonsteroidal anti-inflammatory drugs combined with platelet-rich plasma on inflammatory factor levels in patients with osteoarthritis. Methods. The clinic data of 120 patients with osteoarthritis who were treated in our hospital (June 2019-June 2021) were retrospectively reviewed. All the patients were given platelet-rich plasma. According to the different nonsteroidal anti-inflammatory drugs the patients received, they were equalized into diclofenac sodium group, celecoxib group, and iguratimod group, with 40 cases in each group. After treatment, the patients’ clinical efficacy was compared and analyzed. Results. After treatment, the pain degrees of the patients in the three groups were gradually reduced. After 4 weeks and 8 weeks of treatment, the statistical differences in the scores of Visual Analogue Scale (VAS) were found among the three groups. Specifically, compared with the other two groups, the iguratimod group had remarkably lower VAS scores ( $P<0.05$ ) and the celecoxib group had signally lower VAS scores compared with the diclofenac sodium group ( $P<0.05$ ). After treatment, the inflammatory factor levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) in the diclofenac sodium group were observably higher compared with the celecoxib group ( $P<0.05$ ), and the inflammatory factor levels in the celecoxib group were remarkably higher compared with the iguratimod group ( $P<0.05$ ). Before treatment, no notable difference in the Lysholm scores was found among the three groups, and the patients’ knee joint function was gradually improved after treatment. To be specific, after 4 and 8 weeks of treatment, the iguratimod group had observably higher Lysholm scores compared with the other two groups ( $P<0.05$ ), and the celecoxib group had signally higher Lysholm scores compared with the diclofenac sodium group ( $P<0.05$ ). The iguratimod group got markedly lower Western Ontario and McMaster Universities (WOMAC) score compared with the celecoxib group ( $P<0.05$ ); Compared with the diclofenac sodium group, the celecoxib group got remarkably lower WOMAC score ( $P<0.05$ ). During treatment, few patients suffered from mild gastrointestinal discomfort and hepatic dysfunction in the three groups, and no other severe adverse reactions were found. No statistical difference in the total incidence of adverse reactions among the three groups was observed ( $P>0.05$ ). Conclusion. The combination of nonsteroidal anti-inflammatory drugs with platelet-rich plasma can further reduce the inflammatory reactions of the patients with osteoarthritis and improve their knee joint function. Significantly, the iguratimod, with high safety, has observably better effects on inhibiting inflammatory factors and improving knee joint function compared with diclofenac sodium and celecoxib.