The effectiveness of leucocyte-poor platelet-rich plasma injections on symptomatic early osteoarthritis of the knee: the PEAK randomized controlled trial

The effect of intra-articular autologous protein solution on knee osteoarthritis symptoms

Aims

Knee osteoarthritis (OA) is characterized by a chronic inflammatory process involving multiple cytokine pathways, leading to articular cartilage degeneration. Intra-articular therapies using pharmaceutical or autologous anti-inflammatory factors offer potential non-surgical treatment options. Autologous protein solution (APS) is one such product that uses the patient's blood to produce a concentrate of cells and anti-inflammatory cytokines. This study evaluated the effect of a specific APS intra-articular injection (nSTRIDE) on patient-reported outcome measures compared to saline in moderate knee OA.

Methods

A parallel, double-blinded, placebo-controlled randomized controlled trial was conducted, where patients with unilateral moderate knee OA (Kellgren-Lawrence grade 2 or 3) received either nSTRIDE or saline (placebo) injection to their symptomatic knee. The primary outcome was the difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months post-intervention. Secondary outcomes included WOMAC component scores, Knee injury and Osteoarthritis Outcome Score (KOOS), and visual analogue scale (VAS) scores at all follow-up timepoints (three, six, and 12 months).

Results

A total of 40 patients were analyzed (21 nSTRIDE; 19 saline) in the study. No significant difference was found between nSTRIDE and saline groups for WOMAC total score at 12 months (mean difference -10.4 (95% CI -24.4 to 3.6; p = 0.141). There were no significant differences in WOMAC or KOOS scores across all timepoints. VAS scores favoured the saline group for both rest and worst pain scales at 12 months post-injection (mean difference (worst) 12 months 21.5 (95% CI 6.2 to 36.8; p = 0.008); mean difference (rest) 12 months 17.8 (95% CI 2.2 to 33.4; p = 0.026)). There were no adverse events recorded in either study group.

Conclusion

Our study demonstrates no significant differences between nSTRIDE and saline groups in KOOS and WOMAC scores over time. Notably, APS injection resulted in significantly worse pain symptoms at 12 months compared to saline injection.

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.

Pharmacotherapy for osteoarthritis-related pain: current and emerging therapies

INTRODUCTION

Osteoarthritis (OA) related pain has affected millions of people worldwide. However, the current pharmacological options for managing OA-related pain have not achieved a satisfactory effect.

AREAS COVERED

This narrative review provides an overview of the current and emerging drugs for OA-related pain. It covers the drugs' mechanism of action, safety, efficacy, and limitations. The National Library of Medicine (PubMed) database was primarily searched from 2000 to 2024.

EXPERT OPINION

Current treatment options are limited and suboptimal for OA pain management. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are the recognized and first-line treatment in the management of OA-related pain, and other drugs are inconsistent recommendations by guidelines. Emerging treatment options are promising for OA-related pain, including nerve growth factor (NGF) inhibitors, ion channel inhibitors, and calcitonin gene-related peptide (CGRP) antagonists. Besides, drugs repurposing from antidepressants and antiepileptic analgesics are shedding light on the management of OA-related pain. The management of OA-related pain is challenging as pain is heterogeneous and subjective. A more comprehensive strategy combined with non-pharmacological therapy needs to be considered, and tailored management options to individualized patients.

Randomized Controlled Trials on Platelet-Rich Plasma for Knee Osteoarthritis Poorly Adhere to the Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) Guidelines: A Systematic Review

BACKGROUND

Platelet-rich plasma (PRP) treatment for knee osteoarthritis has grown exponentially over the past decade; however, its scientific evaluation is highly variable. The American Academy of Orthopaedic Surgeons addressed the need for the standardization of orthobiologics studies by publishing the Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) guidelines in May 2017. In total, the MIBO guidelines are divided into 12 categories, encompassing 23 checklist items.

HYPOTHESIS/PURPOSE

The purpose of this study was to analyze how well randomized controlled trials (RCTs) on PRP interventions for knee osteoarthritis adhered to the MIBO guidelines. We hypothesized that most articles would report <80% of the MIBO criteria.

STUDY DESIGN

Systematic review; Level of evidence, 1.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to perform a systematic review in the PubMed/MEDLINE and Web of Science databases. Inclusion criteria included English-language RCTs that assessed PRP interventions for knee osteoarthritis and reported beginning patient enrollment in June 2017 or later. The original 23 MIBO checklist items were separated and modified into a 44-point checklist. Adherence was determined by calculating the total percentage of checklist items that each article adequately and clearly reported from the 44-point checklist.

RESULTS

A total of 25 RCTs (2356 patients) were included in this study. The weighted mean age was 57.7 ± 4.4 years, with 42.9% being male. On average, only 53.1% ± 10.4% (range, 31.8%-77.3%) of the 44-point MIBO checklist items were reported per article. No articles had adherence rates ≥80%, 5 (20.0%) had rates between 60% and 79.9%, and 20 (80.0%) had rates ≤59.9%. Categories fluctuated in adherence, with "Intervention" having the greatest adherence (100.0%) and "Activation" having the lowest (14.0%). Additionally, 4 (33.3%) categories had adherence rates ≥80%, 0 had rates from 60% to 79.9%, and 8 (66.7%) had rates ≤59.9%.

CONCLUSION

The overall mean adherence to MIBO guidelines by RCTs on PRP interventions for knee osteoarthritis was 53.1%. To increase the reproducibility, improve transparency, and assess the treatment efficacy of future PRP studies, reporting of MIBO guidelines should be improved.

Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

PURPOSE

To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months.

METHODS

A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function.

RESULTS

Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively.

CONCLUSIONS

At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I to II studies.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, scoping Review of level I-IV studies.

A Greater Platelet Dose May Yield Better Clinical Outcomes for Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Systematic Review

PURPOSE

To determine whether the platelet dose administered during a platelet-rich plasma (PRP) injection for knee osteoarthritis (OA) affects clinical outcomes.

METHODS

A systematic review was performed by searching PubMed, Cochrane Library, and Embase for randomized controlled trials with at least 1 study arm using PRP for knee OA. Only studies that provided a platelet count, concentration, or dose with a minimum of 6-month outcome scores were included. Studies in which the PRP group had statistically significant positive outcomes were separated from those without statistical significance. The average platelet doses for studies with positive outcomes in the PRP group were compared with those without positive outcomes.

RESULTS

After exclusion criteria were applied, 29 studies were analyzed. Of the 29, there were 31 arms that used PRP as a treatment method, of which 28 had statistically significant positive outcomes at 6 months compared with the control group. The mean platelet dose in the 28 with a positive outcome was 5,500 ± 474 × 106, whereas the 3 that had no positive difference had a mean platelet dose of 2,302 ± 437 × 106 (P < .01). There were 18 studies with 12-month outcomes, with 16 of 18 having positive outcomes. The positive studies had an average platelet dose of 5,464 ± 511, whereas the studies that had no statistical difference had an average platelet dose of 2,253 ± 753 × 106 (P < .05).

CONCLUSIONS

Improved clinical outcomes from PRP injections for knee OA may be related to a greater platelet dose.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Effectiveness of Yijinjing exercise in the treatment of early-stage knee osteoarthritis: a randomized controlled trial protocol

INTRODUCTION

Knee osteoarthritis (KOA) is still a challenging degenerative joint disease with high morbidity and disease burden. Early-stage KOA, the focus of this study, could present a Window of Opportunity to arrest the disease process and reduce the disease burden. Yijinjing exercise is an important part of physical and psychological therapies in Traditional Chinese Exercise and may be an effective treatment. However, there is no clinical efficacy assessment of Yijinjing exercise for patients with early-stage KOA. Therefore, we designed a randomised controlled trial to evaluate the effectiveness of Yijinjing exercise on patients with early-stage KOA.

METHODS AND ANALYSIS

This is a parallel-design, two-arm, analyst assessor-blinded, randomised controlled trial. In total, 60 patients with early-stage KOA will be recruited and randomly assigned to the Yijinjing exercise group (n=30) and health education group (n=30) at a ratio of 1:1, receiving 12 weeks of Yijinjing exercise or health education accordingly. The primary outcome will be measured with the Western Ontario and McMaster Universities Osteoarthritis Index, and the secondary outcomes will include the Visual Analogue Scale, Short-Form 36 Item Health Survey Questionnaire, Beck Depression Inventory, Perceived Stress Scale, Berg Balance Scale, and Gait Analysis for a comprehensive assessment. Outcome measures are collected at baseline, at 12 week ending intervention and at the 12 week, 24 week and 48 week ending follow-up. The primay time point will be 12 weeks postintervention. Adverse events will be recorded for safety assessment.

ETHICS AND DISSEMINATION

This study has been approved by the ethical application of the Shanghai Municipal Hospital of Traditional Chinese Medicine Ethics Committee (2021SHL-KY-78).

TRIAL REGISTRATION NUMBER

ChiCTR2200065178.

Distal femur fractures: basic science and international perspectives

Distal femur fractures are challenging injuries to manage, and complication rates remain high. This article summarizes the international and basic science perspectives regarding distal femoral fractures that were presented at the 2022 Orthopaedic Trauma Association Annual Meeting. We review a number of critical concepts that can be considered to optimize the treatment of these difficult fractures. These include biomechanical considerations for distal femur fixation constructs, emerging treatments to prevent post-traumatic arthritis, both systemic and local biologic treatments to optimize nonunion management, the relative advantages and disadvantages of plate versus nail versus dual-implant constructs, and finally important factors which determine outcomes. A robust understanding of these principles can significantly improve success rates and minimize complications in the treatment of these challenging injuries.

Osteoarthritis year in review 2023: Epidemiology & therapy

OBJECTIVE

To highlight some important findings from osteoarthritis (OA) epidemiology and therapy research undertaken over the past year.

METHODS

Search of MEDLINE and EMBASE databases between April 1, 2022 to March 3, 2023 using "exp *Osteoarthritis/" as the preliminary search term. The search was limited to articles published in English and including human subjects. Final inclusions were based on perceived importance and results that may inform improved identification of risk factors or OA treatments, as well as OA subgroups of potential relevance to risk factors or treatment approaches.

RESULTS

3182 studies were screened, leaving 208 eligible for inclusion. This narrative review of thirty-three selected studies was arranged into: a) OA predictors - population-based studies, b) Specific predictors of OA and OA outcome; c) Intra-articular injections, and d) OA phenotypes. There was some suggestion of sex differences in predictors of incidence or outcomes. Body mass index changes appear largely to affect knee OA outcomes. Evidence points to a lack of benefit of viscosupplementation in knee OA; findings were variable for other injectables. Studies of OA phenotypes reveal potentially relevant clinical and pathophysiological differences.

CONCLUSIONS

Identifying risk factors for the incidence/progression of OA represents an ongoing and important area of OA research. Sex may play a role in this understanding and bears consideration and further study. For knee injectables other than viscosupplementation, additional high-quality trials appear warranted. Continued investigation and application of phenotyping across the OA disease, illness and care spectrum may be key to developing disease-modifying agents and their appropriate selection for individuals.

Platelet-Rich Plasma Therapy: An Effective Approach for Managing Knee Osteoarthritis

Platelet-rich plasma (PRP) is a promising non-invasive therapeutic intervention for knee osteoarthritis (KOA) that has generated significant interest due to anecdotal accounts of its efficacy, resulting in reduced recovery time in various orthopedic interventions. This systematic review examines the effectiveness of PRP in managing KOA. Specifically, it seeks to determine the extent to which PRP can treat KOA patients effectively, alleviate KOA symptoms, and improve patient outcomes. Additionally, the review aims to identify the optimal concentration and composition of PRP required to achieve therapeutic results in KOA. Furthermore, the review investigates whether PRP can modify the synovial environment structurally and immunologically to improve outcomes in KOA patients. We conducted a comprehensive literature search on PubMed, Orthogate, Clinicaltrials.gov, and Embase of clinical trials investigating PRP treatment in KOA patients in the last five years. The results indicated that PRP is effective in treating KOA patients. Evidence shows that PRP therapy can alleviate pain, enhance joint function, increase range of motion, and improve mobility in KOA patients. PRP was effective in treating KOA when the mean platelet concentration of PRP treatment was 4.83 to 5.91 times higher than the baseline whole blood platelet concentration. However, studies investigating PRP with a mean platelet concentration of 3.48 to 4.04 times higher than baseline failed to demonstrate statistically significant improvements. PRP therapy slowed down KOA progression, which validates its effectiveness in impeding further structural damage and arresting the degenerative impact of the disease. Nonetheless, further investigation is necessary to examine how PRP therapy can modify the progression of the disease. Furthermore, future research should identify the most effective platelet concentration levels that provide optimal symptom relief. There is a need for further research to identify the specific PRP configuration that is most pertinent in a clinical setting, as there is a lack of standardization in PRP manufacturing protocols, including the variety of experimental setups and dosing schedules utilized in different studies.

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.

Surgical Versus Non-Surgical Treatments for the Knee: Which Is More Effective?

Osteoarthritis is a degenerative joint disease that is extremely prevalent in society. It affects more than 25% of Americans above the age of 18 years. According to July 2020 publication by the Centers for Disease Control (CDC), osteoarthritis affects approximately 325 million Americans. One of the organs that is most affected by osteoarthritis is the knee. Over the years, we have developed non-surgical treatments, such as physical therapy (PT) and injections, and surgical treatments, such as total knee arthroplasty (TKA) and arthroscopic lavage, for knee osteoarthritis (KOA). If a patient fails with non-surgical options, which are tried first to avoid the risks of surgery, the patient may be considered for knee surgery. This article will investigate the different non-surgical options and TKA as treatment options for KOA based on current literature. The goal of this paper is to be a comprehensive resource for physicians and patients with KOA to make an informed decision. A systematic literature search was conducted using PubMed. The search terms were based on the type of treatments for KOA. To find articles that compared TKA to non-surgical treatments, the terms included "osteoarthritis", "total knee", and "non-surgical treatments," in combination. For other non-surgical treatments such as PT, weight reduction, and injections, a combination of the treatment, "osteoarthritis", and "knee" were included in the search. For the tier 1 process, any randomized controlled trials were included. Any case reports, observational studies, and cross-sectional studies were eliminated from the search. For the tier 2 review process, any articles that did not have relevance to the topic were eliminated after reading the abstracts of the articles. After review of the literature, the data seem to suggest that TKA with 12 weeks of non-surgical treatment improved pain and functionality of the knee more than just 12 weeks of non-surgical treatment when followed up at 12 and 24 months. However, non-surgical treatment before TKA delays the need for surgery. Supervised PT, either in a group or individual format, has been shown to delay TKA in 95% patients in the group that received PT at the end of one year. In addition, weight reduction has been shown as an effective strategy to improve pain and functionality in KOA patients, which decreases the urgency for surgery. Furthermore, platelet-rich plasma (PRP) injections have been shown to have long-term symptomatic relief for KOA compared to hyaluronic acid (HA) and corticosteroid injections. However, HA and corticosteroid injections are beneficial in treating KOA more than receiving no treatment. Physicians often have difficulty deciding whether to pursue conservative or surgical treatment for patients with KOA. The non-surgical treatments explored in this review - PT, injections, and weight reduction - can provide symptomatic relief and, in some cases, delay the need for surgical intervention. However, based on some randomized clinical trials mentioned in the article, patients receiving TKA have more relief, better quality of life, and improved functionality compared to non-surgical therapy. However, a critical review of this important field of debate shows that there are limited randomized controlled studies comparing the effectiveness of TKA and non-surgical treatments for KOA. We believe that this controversial topic needs further clinical investigation.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Comparison of the clinical effectiveness of activated and non-activated platelet-rich plasma in the treatment of knee osteoarthritis: a systematic review and meta-analysis

INTRODUCTION/OBJECTIVES

Platelet-rich plasma (PRP) has shown to be clinically effective in the treatment of knee osteoarthritis (OA). Notwithstanding, some inconsistences remain due to methodological differences in PRP preparation such as the use (or not) of activation strategies. We aimed to evaluate whether the use of non-activated PRP would be as effective as activated PRP in patients with knee OA.

METHOD

All randomized, placebo-controlled trials were identified through a search in MEDLINE, EMBASE, Scopus, and Web of Science up to June 2022. Pre- and post-injection pain and function scores were collected. The meta-analysis was conducted with a random-effects model and generic inverse variance method. Effect sizes were estimated using standardized mean differences (SMD).

RESULTS

Fourteen clinical trials involving 1292 subjects were included for meta-analysis. Exogenous activation of PRP revealed a significant pain relief (SMD, - 1.05 [95% CI - 1.58 to - 0.52]; p = 0.0001) and a significant functional improvement (SMD, - 1.21 [95% CI - 1.75 to - 0.67]; p < 0.0001) unlike studies describing the use of a non-activated PRP. The sensitivity analysis indicated that the effect size for both outcomes was not influenced by a single study.

CONCLUSIONS

The results of this systematic review suggest that the use of an exogenously activated PRP is more effective in improving both pain and functional scores in patients with knee OA. Key Points • Results from meta-analysis suggest that exogenously activated PRP is clinically more effective than non-activated PRP. • The use of an activated PRP was more frequently reported by the included studies. • The most frequent method for activation was the use of calcium chloride (CaCl₂).

Standardization and validation of a conventional high yield platelet-rich plasma preparation protocol

BACKGROUND

Of late, numerous randomised controlled trials report platelet-rich plasma (PRP) to be ineffective with preparation protocols of low platelet yield despite using expensive commercial PRP kits.

OBJECTIVE

This study aims to identify and standardize a preparation protocol for PRP with maximum platelets yield and concentration to obtain favourable results without the use of commercial preparation kits.

MATERIALS & METHODS

Blood samples were collected from 40 healthy volunteers who signed informed consent for participation in the study. The double spin protocol of PRP preparation was analyzed for variables such as centrifugal acceleration, time, and volume of blood processed and final product utilized. The final PRP prepared was investigated for platelet recovery, concentration, integrity, and viability. Each protocol investigated with technical and biological duplicates to avoid reporting and sampling bias.

RESULTS

We noted maximum platelet recovery (86-99%) with a consistent 6.4 ± 0.8 times the baseline concentration of platelets with first centrifugation at 100g for 15 min followed by second centrifugation at 1600g for 20 min. We did not note a loss of integrity or viability of the platelets in the final product from the above-said protocol. We also validated the protocol among all the study participants demonstrating consistency.

CONCLUSION

The preparation of PRP by the double-spin protocol using 10 ml of blood at 100 g followed by 1600 g for 15 and 20 min respectively in a 15 ml tube and using the lower 1/3rd of the final product demonstrated consistent high platelet recovery (86-99%) and concentration (6x) without disturbing the platelet integrity or viability.

Does Bone Marrow Edema Influence the Clinical Results of Intra-Articular Platelet-Rich Plasma Injections for Knee Osteoarthritis?

Platelet-rich plasma (PRP) is increasingly used for the intra-articular treatment of knee osteoarthritis (OA). However, clinical studies on PRP injections reported controversial results. Bone marrow edema (BME) can cause symptoms by affecting the subchondral bone and it is not targeted by intra-articular treatments. The aim of this study was to investigate if the presence of BME can influence the outcome of intra-articular PRP injections in knee OA patients. A total of 201 patients were included in the study, 80 with and 121 without BME at the baseline MRI. BME area and site were evaluated, and BME was graded using the Whole-Organ Magnetic Resonance Imaging Score (WORMS). Patients were assessed with International Knee Documentation Committee (IKDC) score Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, the EuroQol-Visual Analogue Scale (EQ-VAS), and the Tegner score at baseline, 2, 6, and 12 months. Overall, the presence of BME did not influence the clinical results of intra-articular PRP injections in these patients treated for knee OA. Patients with BME presented a similar failure rate and clinical improvement after PRP treatment compared to patients without BME. The area and site of BME did not affect clinical outcomes. However, patients with a higher BME grade had a higher failure rate.