Platelet-Rich Plasma Combined With Hyaluronic Acid Improves Pain and Function Compared With Hyaluronic Acid Alone in Knee Osteoarthritis: A Systematic Review and Meta-analysis

Updates in the Treatment of Knee Osteoarthritis

Knee osteoarthritis (OA) is an inflammatory and degenerative condition resulting in articular cartilage destruction and functional loss. Its prevalence has grown considerably due to increased life expectancy and obesity, and its diagnosis relies on evaluation, medical examination, and confirmation by supplementary radiographic images. Knee OA is multifactorial and influenced by several local, systemic, and external aspects. In addition, its progress and therapeutic responses highly depend on the characteristics of each subject. The initial recommendation is drug treatment and alternative therapies to improve quality of life. However, if these treatments are unsuccessful, one must consider surgical treatment. Surgical options include arthroscopies, osteotomies, and partial and total arthroplasties, while non-surgical treatments include medications and alternative therapies such as infiltrations, acupuncture, and physical exercise. It is worth highlighting that biomarkers can be a significant strategy for early disease detection, assessment of disease activity, prediction of prognosis, and monitoring a better response to therapy. Nevertheless, this topic must be the focus of further research to confirm its findings.

Osteoarthritis: Insights into Diagnosis, Pathophysiology, Therapeutic Avenues, and the Potential of Natural Extracts

Osteoarthritis (OA) stands as a prevalent and progressively debilitating clinical condition globally, impacting joint structures and leading to their gradual deterioration through inflammatory mechanisms. While both non-modifiable and modifiable factors contribute to its onset, numerous aspects of OA pathophysiology remain elusive despite considerable research strides. Presently, diagnosis heavily relies on clinician expertise and meticulous differential diagnosis to exclude other joint-affecting conditions. Therapeutic approaches for OA predominantly focus on patient education for self-management alongside tailored exercise regimens, often complemented by various pharmacological interventions primarily targeting pain alleviation. However, pharmacological treatments typically exhibit short-term efficacy and local and/or systemic side effects, with prosthetic surgery being the ultimate resolution in severe cases. Thus, exploring the potential integration or substitution of conventional drug therapies with natural compounds and extracts emerges as a promising frontier in enhancing OA management. These alternatives offer improved safety profiles and possess the potential to target specific dysregulated pathways implicated in OA pathogenesis, thereby presenting a holistic approach to address the condition's complexities.

Hyaluronate acid plus platelet-rich plasma is superior to steroids for pain relief less than 6 months using injection therapy of partial rotator cuff tears: A systematic review and network meta-analysis

PURPOSE

We conducted our network meta-analysis to compare the efficacy of the steroid injections to other injectable therapies in partial-thickness rotator cuff tears (PTRCTs).

METHODS

A systematic literature search was performed until October 25, 2021 in three databases (CENTRAL, Embase, MEDLINE). Eligible studies compared the efficacy of steroid, hyaluronic acid (HA), platelet-rich plasma (PRP), the combination of HA and PRP (HA+PRP), and adipose-derived regenerative cells (ADRC) in RC tears. The primary outcomes were the Visual Analogue Scale (VAS), Constant Murley Score (CMS), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. Using paired and network meta-analysis, we calculated pooled mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

We included a total of seven articles in the quantitative synthesis. In shorter periods, the HA+PRP combination was superior to the other substances we investigated (HA+PRP: VAS (0-4 weeks): MD: -0.99 [CI = -1.62, -0.36]; CMS (0-3 months): 20.56 [CI = 16.18, 24.94]. This combination was followed by the use of HA or PRP alone, depending on the duration of follow-up and the outcome being studied. In our study, short-term results suggest that saline is superior to steroids for partial tears, but this trend is reversed at six-month follow-up.

CONCLUSION

Our results suggest the combination of HA and PRP to be a more effective therapeutic option for partial RC ruptures for short terms, but there is no significant difference after 6 months.

LEVEL OF EVIDENCE

II, Included of Level of Evidence studies I-II.

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.

Arthroscopy and Musculoskeletal Biologics

Orthopaedic biologics holds great promise. Absent peer-reviewed clinical musculoskeletal research, orthobiologics indications and treatment recommendations will remain opaque. In a Call for Papers, Arthroscopy; Arthroscopy Techniques; and Arthroscopy, Sports Medicine, and Rehabilitation editors invite authors to submit clinical musculoskeletal biologics original scientific research, and technical notes with video. Each year, the top articles will be awarded inclusion in an annual Biologics Special Issue. Future investigators and current readers could follow the science while being mindful of the regulatory environment.

Orthopaedic Musculoskeletal Biologics Research Impacts Patient Care: The First Annual Arthroscopy Orthobiologics Virtual Special Issue

Orthobiologics can modify symptoms and improve healing in a variety of musculoskeletal conditions as a part of office-based care or as an adjunct to surgery. Orthobiologics harness the benefits of naturally derived blood components, autologous tissue, and growth factors to reduce inflammation and optimize the host-healing environment. The Arthroscopy family of journals seeks to positively influence evidence-based clinical decision-making by publishing peer-reviewed biologics research. This special issue contains recent influential articles strategically chosen to positively impact patient care.

Comparison of Various Modalities in the Treatment of Early Knee Osteoarthritis: An Unsolved Controversy

Introduction Osteoarthritis (OA) of the knee is a common degenerative disease, relatively more prevalent among middle-aged people. It is one of the major reasons for walking-related disability. Recently, early knee OA has been seen as an imperative concern in many younger patients who struggle with the disabling effect of pain and management is extremely speckled. Degenerative changes such as loss of cartilage, subchondral bone changes, synovial inflammation, and meniscal degeneration are seen in OA. Symptoms are relieved by therapeutic strategies such as lifestyle behaviour changes, exercise, and oral and injectable medications. Intra-articular delivery of drugs acts as a direct effect on the target tissue, which grossly reduces side effects and is commonly preferred nowadays. The current study is a comparative assessment of the functional outcomes associated with various treatment modalities in osteoarthritis of the knee, i.e., arthroscopic debridement, arthroscopic debridement with microfracture, platelet-rich plasma (PRP) injection, and hyaluronic acid. Methods A retrospective observational hospital-based study was conducted among 139 cases of osteoarthritis. Patients aged between 40-60 years with diagnosed Kellgren- Lawrence grade 1 and 2 OA knee, who underwent arthroscopic debridement, arthroscopic debridement with microfracture, PRP injection, or hyaluronic acid in our institute were included. Results The mean age was 52.83 + 6.8 years. The mean BMI was 27.45 + 1.6 kg/m². At the time of diagnosis of OA, the mean visual analogue scale for pain (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were 7.26 +0.7 and 55.30 + 2.21 respectively. Out of the total, 88 (63.3%) were females and 51 (36.7%) were males. Right-sided OA knee was seen in the majority of study participants. Of the total, 93 (66.9%) patients had grade 2 and only 46 (33.1%) had grade 1 OA. A statistically significant difference was found between the mean VAS and WOMAC score at the time of diagnosis, three weeks, three months, as well as at six months of therapy. In the hyaluronic acid treatment, no significant difference was found in mean VAS and WOMAC scores. Conclusion Various treatments are available for early-diagnosed OA. According to the findings of this study, overall improvement was seen in VAS and WOMAC scores at the follow-up after six months of specific treatment. In a period over six months, arthroscopic debridement with micro-fracture was more effective and safe when compared with other modalities of treatment for early OA knee. Also, injection of PRP was superior to other methods for VAS pain reduction, and WOMAC-pain and WOMAC-stiffness scores improved at one month.

Is the Combination of Platelet-Rich Plasma and Hyaluronic Acid the Best Injective Treatment for Grade II-III Knee Osteoarthritis? A Prospective Study

Background

Knee osteoarthritis is a common disease with increasing incidence and prevalence in western countries. It can cause severe pain and functional limitations, thereby representing a threat for patients' quality of life and a burden for national health systems. Intra-articular injections with hyaluronic acid (HA) and platelet-rich plasma (PRP) have been used for decades in order to reduce the symptoms caused by osteoarthritis. In recent years, a combination of HA and PRP has been introduced in clinical practice with the aim to minimize the clinical presentation of osteoarthritis and potentially delay articular degeneration.

Materials and Methods

Sixty cases with grade II-III knee osteoarthritis according to the Kellgren-Lawrence classification were included in a prospective study, focused on the evaluation of clinical and functional outcomes after intra-articular knee injections. Cases were randomly divided into three groups. Twenty cases (Group A) were injected with HA, 20 (Group B) had PRP, and the remaining 20 (Group C) received a combination of HA and PRP. Basal WOMAC score and VAS score were recorded before the treatment and repeated within 3 and 6 months after the treatment.

Results

At 6-month follow-up, Group C (PRP + HA) was the one with the lowest WOMAC and VAS mean values. It was also the only group that reported a reduction in the two values both in the first three months and in the following three months. No major complication was recorded.

Conclusion

The combination of platelet-rich plasma and hyaluronic acid can be effective in the treatment of grade II-III knee osteoarthritis in a short-to-mid-term scenario. It represents an innovative and valuable alternative to the administration of its two components alone.

Platelet-Rich Plasma Gel Matrix (PRP-GM): Description of a New Technique

Several musculoskeletal conditions are triggered by inflammatory processes that occur along with imbalances between anabolic and catabolic events. Platelet-rich plasma (PRP) is an autologous product derived from peripheral blood with inherent immunomodulatory and anabolic properties. The clinical efficacy of PRP has been evaluated in several musculoskeletal conditions, including osteoarthritis, tendinopathy, and osteonecrosis. When used in combination with hyaluronic acid (HA), a common treatment alternative, the regenerative properties of PRP are significantly enhanced and may provide additional benefits in terms of clinical outcomes. Recently, a new PRP-derived product has been reported in the literature and is being referred to as "plasma gel". Plasma gels are obtained by polymerizing plasmatic proteins, which form solid thermal aggregates cross-linked with fibrin networks. Plasma gels are considered to be a rich source of growth factors and provide chemotactic, migratory, and proliferative properties. Additionally, clot formation and the associated fibrinolytic reactions play an additional role in tissue repair. There are only a few scientific articles focusing on plasma gels. Historically, they have been utilized in the fields of aesthetics and dentistry. Given that the combination of three products (PRP, HA, and plasma gel) could enhance tissue repair and wound healing, in this technical note, we propose a novel regenerative approach, named "PRP-HA cellular gel matrix" (PRP-GM), in which leukocyte-rich PRP (LR-PRP) is mixed with a plasma gel (obtained by heating the plasma up) and HA in one syringe using a three-way stopcock. The final product contains a fibrin-albumin network entangled with HA's polymers, in which the cells and biomolecules derived from PRP are attached and released gradually as fibrinolytic reactions and hyaluronic acid degradation occur. The presence of leukocytes, especially monocytes and macrophages, promotes tissue regeneration, as type 2 macrophages (M2) possess an anti-inflammatory feature. In addition, HA promotes the viscosuplementation of the joint and induces an anti-inflammatory response, resulting in pain relief. This unique combination of biological molecules may contribute to the optimization of regenerative protocols suitable for the treatment of degenerative musculoskeletal diseases.

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.

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.

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.

Injectable Natural Polymer Hydrogels for Treatment of Knee Osteoarthritis

Osteoarthritis (OA) is a serious chronic and degenerative disease that increasingly occurs in the aged population. Its current clinical treatments are limited to symptom relief and cannot regenerate cartilage. Although a better understanding of OA pathophysiology has been facilitating the development of novel therapeutic regimen, delivery of therapeutics to target sites with minimal invasiveness, high retention, and minimal side effects remains a challenge. Biocompatible hydrogels have been recognized to be highly promising for controlled delivery and release of therapeutics and biologics for tissue repair. In this review, the current approaches and the challenges in OA treatment, and unique properties of injectable natural polymer hydrogels as delivery system to overcome the challenges are presented. The common methods for fabrication of injectable polysaccharide-based hydrogels and the effects of their composition and properties on the OA treatment are detailed. The strategies of the use of hydrogels for loading and release cargos are also covered. Finally, recent efforts on the development of injectable polysaccharide-based hydrogels for OA treatment are highlighted, and their current limitations are discussed.

Overview of First-Line and Second-Line Pharmacotherapies for Osteoarthritis with Special Focus on Intra-Articular Treatment

Osteoarthritis (OA) can be defined as the result of pathological processes of various etiologies leading to damage to the articular structures. Although the mechanism of degenerative changes has become better understood due to the plethora of biochemical and genetic studies, the drug that could stop the degenerative cascade is still unknown. All available forms of OA therapy are based on symptomatic treatment. According to actual guidelines, comprehensive treatment of OA should always include a combination of various therapeutic options aimed at common goals, which are pain relief in the first place, and then the improvement of function. Local treatment has become more common practice, which takes place between rehabilitation and pharmacological treatment in the hierarchy of procedures. Only in the case of no improvement and the presence of advanced lesions visible in imaging tests, should surgery be considered. Currently, an increasing number of studies are being published suggesting that intra-articular injections may be as effective or even more effective than non-steroidal anti-inflammatory drugs (NSAIDs) and result in fewer systemic adverse events. The most commonly used preparations are hyaluronic acid (HA), glucocorticosteroids (GS), and also platelet-rich plasma (PRP) in recent years. This review aims to present the mechanism of action and clinical effectiveness of different pharmacological options in relieving pain and improving functions in OA as well as the emerging approach in intra-articular treatment with PRP.

Emerging and New Treatment Options for Knee Osteoarthritis

Osteoarthritis (OA) is the most prevalent type of arthritis worldwide, resulting in pain and often chronic disability and a significant burden on healthcare systems globally. Non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, intra-articular corticosteroid injections are of little value in the long term, and opioids may have ominous consequences. Radiotherapy of knee OA has no added value. Physical therapy, exercises, weight loss, and lifestyle modifications may give pain relief, improve physical functioning and quality of life. However, no single treatment has regenerating potential for damaged articular cartilage. Due to a better understanding of osteoarthritis, innovative new treatment options have been developed. In this narrative review, we focus on emerging OA knee treatments, relieving symptoms, and regenerating damaged articular cartilage that includes intra-articular human serum albumin, conventional disease-modifying anti-rheumatic drugs (DMARDs), lipid-lowering agents (statin), nerve growth factors antagonists, bone morphogenetic protein, fibroblast growth factors, Platelet-Rich Plasma (PRP), Mesenchymal Stem Cells (MSC), exosomes, interleukin-1 blockers, gene-based therapy, and bisphosphonate.

Injections in the osteoarthritic knee: a review of current treatment options

Knee osteoarthritis is a degenerative condition characterized by progressive cartilage degradation, subchondral damage, and bone remodelling. Among the approaches implemented to achieve symptomatic and functional improvements, injection treatments have gained increasing attention due to the possibility of intra-articular delivery with reduced side effects compared to systemic therapies.

In addition to well-established treatment options such as hyaluronic acid (HA), cortico-steroids (CS) and oxygen-ozone therapy, many other promising products have been employed in the last decades such as polydeoxyribonucleotide (PDRN) and biologic agents such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs). Moreover, ultrasound-guided intra-meniscal injection and X-ray-guided subchondral injection techniques have been introduced into clinical practice.

Even when not supported by high evidence consensus, intra-articular CS and HA injections have gained precise indications for symptomatic relief and clinical improvement in OA. Biological products are strongly supported by in vitro evidence but there is still a lack of robust clinical evidence. PRP and MSCs seem to relieve OA symptoms through a regulation of the joint homeostasis, even if their capability to restore articular cartilage is still to be proved in vivo.

Due to increasing interest in the subchondral bone pathology, subchondral injections have been developed with promising results in delaying joint replacement. Nevertheless, due to their recent development and the heterogeneity of the injected products (biologic agents or calcium phosphate), this approach still lacks strong enough evidence to be fully endorsed.

Combined biological treatments, nano-molecular approaches, monoclonal antibodies and ‘personalized’ target therapies are currently under development or under investigation with the aim of expanding our armamentarium against knee OA.

Cite this article: EFORT Open Rev 2021;6:501-509. DOI: 10.1302/2058-5241.6.210026

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.

Editorial Commentary: Injections for Knee Osteoarthritis: Doc, You Gotta Help Me!

Injections for the pain caused by knee osteoarthritis have been the focus of significant research for the last few decades. Systematic reviews and meta-analyses suggest that platelet-rich plasma (PRP) can provide up to 12 months of pain relief in these patients, superior to both cortisone and hyaluronic acid. There is also some evidence for a synergistic effect when combining both PRP and hyaluronic acid. Bone marrow aspirate concentrate (BMAC) has significantly greater levels of interleukin-1ra than PRP, as well as a small concentration of mesenchymal stromal cells. However, BMAC is yet unproven in its efficacy, and obtaining BMAC is not as simple as taking blood. Research into the use of expanded autologous and allogenic mesenchymal stem cells continues and shows future promise. For today, PRP remains the gold standard for the treatment of pain associated with knee osteoarthritis.

Comprehensive Review of Knee Osteoarthritis Pharmacological Treatment and the Latest Professional Societies' Guidelines

Osteoarthritis is the most common musculoskeletal progressive disease, with the knee as the most commonly affected joint in the human body. While several new medications are still under research, many symptomatic therapy options, such as analgesics (opioid and non-opioid), nonsteroid anti-inflammatory drugs, symptomatic slow-acting drugs in osteoarthritis, and preparations for topical administration, are being used, with a diverse clinical response and inconsistent conclusions across various professional societies guidelines. The concept of pharmacogenomic-guided therapy, which lies on principles of the right medication for the right patient in the right dose at the right time, can significantly increase the patient’s response to symptom relief therapy in knee osteoarthritis. Corticosteroid intra-articular injections and hyaluronic acid injections provoke numerous discussions and disagreements among different guidelines, even though they are currently used in daily clinical practice. Biological options, such as platelet-rich plasma and mesenchymal stem cell injections, have shown good results in the treatment of osteoarthritis symptoms, greatly increasing the patient’s quality of life, especially when combined with other therapeutic options. Non-inclusion of the latter therapies in the guidelines, and their inconsistent stance on numerous therapy options, requires larger and well-designed studies to examine the true effects of these therapies and update the existing guidelines.