The Cost-Effectiveness of Platelet-Rich Plasma Injections for Knee Osteoarthritis: A Markov Decision Analysis

Economic Studies for Lower-Extremity Joint Arthroplasty: An Example-Based Review

As health care costs in the United States continue to rise, understanding the various economic studies and what constitutes them will become increasingly important for orthopaedic surgeons. In this review, we discuss the three major types of economics studies and provide examples of each. Cost-effective analyses are the gold standard for economic analyses and allow for the direct comparison of monetary costs and patient-centered outcomes. Cost-benefit analyses are similar to cost-effective analyses but compare both costs and benefits in monetary terms. Cost minimization analyses are the most common type of economic analysis, and they simply compare costs between two experimental groups.

Mechanisms and applications of the regenerative capacity of platelets-based therapy in knee osteoarthritis

Osteoarthritis (OA) is the most prevalent joint disease in the elderly population and its substantial morbidity and disability impose a heavy economic burden on patients and society. Knee osteoarthritis (KOA) is the most common subtype of OA, which is characterized by damage to progressive articular cartilage, synovitis, and subchondral bone sclerosis. Most current treatments for OA are palliative, primarily aim at symptom management, and do not prevent the progression of the disease or restore degraded cartilage. The activation of α-granules in platelets releases various growth factors that are involved in multiple stages of tissue repair, suggesting potential for disease modification. In recent years, platelet-based therapies, such as platelet-rich plasma, platelet-rich fibrin, and platelet lysates, have emerged as promising regenerative treatments for KOA, but their related effects and mechanisms are still unclear. Therefore, this review aims to summarize the biological characteristics and functions of platelets, classify the products of platelet-based therapy and related preparation methods. Moreover, we summarize the basic research of platelet-based regeneration strategies for KOA and discuss the cellular effects and molecular mechanisms. Further, we describe the general clinical application of platelet-based therapy in the treatment of KOA and the results of the meta-analysis of randomized controlled trials.

Pain Management Strategies in Osteoarthritis

Pain is the major symptom of osteoarthritis (OA) and is an important factor in strategies to manage this disease. However, the current standard of care does not provide satisfactory pain relief for many patients. The pathophysiology of OA is complex, and its presentation as a clinical syndrome is associated with the pathologies of multiple joint tissues. Treatment options are generally classified as pharmacologic, nonpharmacologic, surgical, and complementary and/or alternative, typically used in combination to achieve optimal results. The goals of treatment are the alleviation of symptoms and improvement in functional status. Several studies are exploring various directions for OA pain management, including tissue regeneration techniques, personalized medicine, and targeted drug therapies. The aim of the present narrative review is to extensively describe all the treatments available in the current practice, further describing the most important innovative therapies. Advancements in understanding the molecular and genetic aspects of osteoarthritis may lead to more effective and tailored treatment approaches in the future.

There Is Wide Variation in Platelet-rich Plasma Injection Pricing: A United States Nationwide Study of Top Orthopaedic Hospitals

BACKGROUND

Demand for platelet-rich plasma (PRP) injections for osteoarthritis has dramatically increased in recent years despite conflicting evidence regarding its efficacy and highly variable pricing in the top orthopaedic centers in the United States, because PRP is typically not covered by insurance. A previous study investigating the mean price of PRP injections obtained information only from centers advertising online the availability of PRP injections. Thus, there is a need for further clarification of the overall availability and variability in cost of PRP injections in the orthopaedic community as well as an analysis of relevant regional demographic and hospital characteristics that could be associated with PRP pricing.

QUESTIONS/PURPOSES

Our study purposes were to (1) report the availability and price variation of knee PRP injections at top-ranked United States orthopaedic centers, (2) characterize the availability of pricing information for a PRP injection over the telephone, (3) determine whether hospital characteristics (Orthopaedic Score [ U . S. News & World Report measure of hospital orthopaedic department performance], size, teaching status, and rural-urban status) were associated with PRP injection availability and pricing, and (4) characterize the price variation, if it exists, of PRP injections in three metropolitan areas and individual institutions.

METHODS

In this prospective study, a scripted telephone call to publicly listed clinic telephone numbers was used to determine the availability and price estimate (amount to be paid by the patient) of a PRP injection for knee osteoarthritis from the top 25 hospitals from each United States Census region selected from the U.S. News & World Report ranking of best hospitals for orthopaedics. Univariable analyses examined factors associated with PRP injection availability and willingness to disclose pricing, differences across regions, and the association between hospital characteristics (Orthopaedic Score, size, teaching status, and rural-urban status) and pricing. The Orthopaedic Score is a score assigned to each hospital by U . S. News & World Report as a measure of hospital performance based partly on patient outcomes, with higher scores indicating better outcomes.

RESULTS

Overall, 87% (87 of 100) of respondents stated they offered PRP injections. Pricing ranged from USD 350 to USD 2815 (median USD 800) per injection, with the highest prices in the Northeast. The largest price range was in the Midwest, where more than two-thirds of PRP injections given at hospitals that disclosed pricing cost USD 500 to USD 1000. Of the hospitals that offered PRP injections, 68% (59 of 87) were willing to disclose price information over the telephone. PRP injection pricing was inversely correlated with hospital Orthopaedic Score (-3% price change [95% CI -5% to -1%]; p = 0.01) and not associated with any of the other hospital characteristics that were studied, such as patient population median income and total hospital expenses. An intracity analysis revealed wide variations in PRP pricing in all metropolitan areas that were analyzed, ranging from a minimum of USD 300 within 10 miles of metropolitan area B to a maximum of USD 1269 within 20 miles of metropolitan area C.

CONCLUSION

We found that although PRP injections are widely available, pricing continues to be a substantial financial burden on patients, with large price variability among institutions. We also found that if patients are willing to shop around in a metropolitan area, there is potential to save a meaningful amount of money.

CLINICAL RELEVANCE

As public interest in biologics in orthopaedic surgery increases, knowledge of its pricing should be clarified to consumers. The debated efficacy of PRP injections, combined with our findings that it is an expensive out-of-pocket procedure, suggests that PRP has limited cost-effectiveness, with variable, discrete pricing. As such, the price of PRP injections should be clearly disclosed to patients so they can make informed healthcare decisions.

Long term improvement of knee osteoarthritis after injection of single high/very high volume of very pure PRP: A retrospective analysis of patients optimally managed in dedicated centers

Introduction

PRP is gaining increasing interest for pain relief and improvement of joint function in patients with knee osteoarthritis (KOA) but practices and results remain heterogeneous limiting its adoption as standard of care. Current international recommendations are to collect real-life evidence of efficacy with a systematic monitoring of PRP quality and patients' outcomes. We aimed to analyze the response of patients presenting KOA and treated with standardized PRP injection in routine care. We also investigated the potential contributing factors including patient's phenotype and PRP characteristics.

Methods

Patients with symptomatic KOA and that failed first-line therapy received a single injection of a qualified PRP prepared using medical devices allowing to recover a high/very high volume of very pure PRP. Visual analogue scale (VAS) and Western Ontario and McMaster Osteoarthritis Index (WOMAC) score were recorded at baseline and during 18 months follow-up.

Results

431 patients had available follow-up data at 3 months, 291 at 6 months, 137 at 12 months and 44 at 18 months. PRP induced a significant decrease of WOMAC score at all follow up endpoints (29.2 ± 19.2 at 3 months, p < 0.001 and 25.9 ± 19.7 at 12 months, p < 0.01, compared to 39.7 ± 18.9 at baseline). Similar results were observed for pain VAS (38.9 ± 23.3 at 3 months, p < 0.001 and 35.3 ± 24.1 at 12 months, p < 0.05, compared to 56.0 ± 20.7 at baseline). Changes at 12 months were correlated to baseline scores and to the level of improvement at 3 months. The proportion of OMERACT OARSI responders reached 56.2 % for the total cohort and 60.4 % for severe patients at 6 months. Treatment failure occurred for 8.4 % of patients. Age, BMI or Kellgren-Lawrence grade did not impact on efficacy.

Conclusion

This real-life study evidences the clinical benefit of a standardized high or very high-volume injection of very pure PRP in patients with KOA, including those with a severe grade. It opens perspectives in the positioning of such strategy to delay arthroplasty and provide insights on factors able to anticipate long term efficacy.

Experts Achieve Consensus on a Majority of Statements Regarding Platelet-Rich Plasma Treatments for Treatment of Musculoskeletal Pathology

PURPOSE

To establish consensus statements on platelet-rich plasma (PRP) for the treatment of musculoskeletal pathologies.

METHODS

A consensus process on the treatment of PRP using a modified Delphi technique was conducted. Thirty-five orthopaedic surgeons and sports medicine physicians participated in these consensus statements on PRP. The participants were composed of representatives of the Biologic Association, representing 9 international orthopaedic and musculoskeletal professional societies invited due to their active interest in the study of orthobiologics. Consensus was defined as achieving 80% to 89% agreement, strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement.

RESULTS

There was consensus on 62% of statements about PRP.

CONCLUSIONS

(1) PRP should be classified based on platelet count, leukocyte count, red blood count, activation method, and pure-plasma versus fibrin matrix; (2) PRP characteristics for reporting in research studies are platelet count, leukocyte count, neutrophil count, red blood cell count, total volume, the volume of injection, delivery method, and the number of injections; (3) the prognostic factors for those undergoing PRP injections are age, body mass index, severity/grade of pathology, chronicity of pathology, prior injections and response, primary diagnosis (primary vs postsurgery vs post-trauma vs psoriatic), comorbidities, and smoking; (4) regarding age and body mass index, there is no minimum or maximum, but clinical judgment should be used at extremes of either; (5) the ideal dose of PRP is undetermined; and (6) the minimal volume required is unclear and may depend on the pathology.

LEVEL OF EVIDENCE

Level V, expert opinion.

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.

Office-Based Intraosseous Infiltrations of PRGF as an Effective Treatment for Knee Osteoarthritis: A Retrospective Observational Clinical Study

The aim of this study was to explore and assess office-based ultrasound-guided intraosseous and intra-articular infiltrations of plasma rich in growth factors (PRGF) in patients with moderate and severe knee osteoarthritis (KOA). Seventy-nine patients (30 women and 49 men) with grade 3-4 KOA according to the Kellgren-Lawrence classification participated in the study. All patients were treated with a minimally invasive technique using local anesthesia WALANT (wide-awake local anesthesia no tourniquet) in the ambulatory setting. A PRGF intra-articular infiltration and two intraosseous infiltrations in the tibial plateau and femoral condyle were performed weekly for a total of three sessions. The evaluation of the results was carried out using knee injury and osteoarthritis outcome score (KOOS) at baseline and post-treatment. After a follow-up period of 11 months (median) [interquartile range, 7-14], all the KOOS domains showed statistically significant improvement (p < 0.001). Moreover, 88% of the patients showed a pain reduction of at least 10 points (minimally clinically important improvement) from pre- to post-treatment. Our retrospective study using the in-office procedure of ultrasound-guided combination of intra-articular and intraosseous infiltrations of PRGF is a safe and efficacious approach for the treatment of grade 3-4 knee osteoarthritis.

Mathematical Analysis of the Effectiveness of Screening for Intracranial Aneurysms in First-Degree Relatives of Persons with Subarachnoid Hemorrhage

OBJECTIVE

Population screening for aneurysms in patients with risk factors and preventive surgical treatment are beneficial according to numerous studies. One of the most significant risk factors is heredity, namely, the presence of first-degree relatives (FDR) with aneurysmal subarachnoid hemorrhage (aSAH). Nevertheless, there are still no generally accepted approaches or evidence bases regarding the benefits of the aneurysm screening strategy.

METHODS

Mathematical modeling of the dynamics of aneurysm development in the population was carried out using an algorithm implementing a discrete Markov's chain. To implement the model, all probabilities of events and distributions are taken from available literature sources. Three-dimensional time of flight noncontrast magnetic resonance angiography was chosen as a screening method. Patients underwent preventive surgical treatment if an aneurysm was detected.

RESULTS

Screening and preventive treatment in the general population reduces the prevalence of aneurysms by 1.74% (3.44% in the FDR group) and the prevalence of aSAH by 14.36% (37.48% in the FDR group). Mortality due to aSAH was reduced by 14.44%. The number of disabilities also decreases. The occurrence of deep disability was reduced by 20.2% in the FDR group. Economic analysis of the part of the population consisting of FDRs showed annual savings of ies also decr CONCLUSIONS: The mathematical model demonstrated that screening and preventive treatment of cerebral aneurysms can reduce aSAH-associated morbidity and mortality. In the FDR group, there was decrease in the prevalence of aSAH and decrease in associated mortality. Screening for cerebral aneurysms is cost-effective.

The Role of Platelet-Rich Plasma Therapy in Joint Arthroplasty A Mini-Review

Orthobiologics are playing an increasingly large role in the clinical setting across multiple fields of surgery. Particularly, in the field of orthopedic surgery, the employment of platelet-rich plasma (PRP) therapy in total joint arthroscopy (TJA) has become popular for its prompted benefits of controlling pain, blood loss, and increased wound healing. PRP was originally used for thrombolytic conditions, however, the aforementioned potential benefits have led to its increased use across various fields of medicine including dermatology, neurosurgery, orthopedics, and sports medicine. Currently, there is a persisting gap in the literature surrounding the mechanism of action of PRP, as well as its true role in increasing positive patient outcomes in the context of TJA. Thus, this review aims to briefly highlight the physiological mechanisms underlining PRP therapy, evaluate recent preclinical and clinical data about its effects on TJA patient outcomes, and to describe its concomitant use in novel orthopedic-applications.

Substantial Variability in Platelet-Rich Plasma Composition Is Based on Patient Age and Baseline Platelet Count

Purpose

To evaluate the effect of age, sex, body mass index (BMI), and baseline blood count on the final composition of platelet rich-plasma (PRP) and to evaluate the variability of PRP applied in the same patient at 2 different times.

Methods

Potential subjects treated with PRP between January 2019 and December 2021 were identified in an institutional registry. Patient demographics and baseline blood count were prospectively recorded in a consecutive series of patients treated with PRP for a musculoskeletal condition in our Institution. The influence of sex, BMI, age, and baseline blood count on final platelet concentrations in PRP was evaluated. Finally, intrapersonal variability was evaluated.

Results

A total of 403 PRP injections from 357 patients were analyzed from an institutional prospective registry of PRP between January 2019 and December 2021. A directly proportional variation in PRP platelet count of 3.8× was observed for each unit increase in baseline blood platelet count. For every decade increase, we observed an approximate decrease of 32,666 platelets. When the first dose of PRP platelet counts was compared with the second dose of PRP platelet counts between the same patients, significant differences were found. A mean of 890,018 platelets in the first PRP and a mean of 1,244,467 in the second PRP with a mean difference of 354,448 was found (P = .008). We did not find differences in the final concentration of platelets regarding sex, BMI, or PRP protocol.

Conclusions

Overall the final composition of PRP (platelet count) was significantly influenced by patient's age and baseline platelet count. In contrast, BMI, sex and the rest of the components of the baseline blood count did not have a significant influence on final PRP. Furthermore, in patients who received 2 doses of PRP, the final concentration of platelets varied significantly between the 2 preparations.

Level of Evidence

Level IV, prognostic case series.

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.

Orthobiologics: Current Status in 2023 and Future Outlook

Orthobiologic agents, including platelet-rich plasma, connective tissue progenitor cells derived from bone marrow, adipose, and other tissues, and purified cytokines and small peptides, have tremendous potential to target deficiencies in soft-tissue healing. The principal limitation currently is the variability in the composition and biologic activity of orthobiologic formulations, making it difficult to choose the optimal treatment for a specific tissue or pathology. Current data suggest that orthobiologics are "symptom-modifying," but there is little evidence that they can lead to true tissue regeneration ("structure-modifying"). A critically important need at this time is to identify sentinel markers of potency and biologic activity for different orthobiologic formulations so that we can match the treatment to the desired biologic effect for a specific tissue or pathology. Improved understanding of the underlying cellular and molecular mechanisms of tissue degeneration and repair will allow a precision medicine approach where we can choose the optimal orthobiologic treatment of specific orthopaedic problems. It is important for the clinician to be aware of the evolving regulatory status of orthobiologic treatments. Emerging therapies such as the use of exosomes and gene therapy approaches hold great promise as improved methods to both treat symptoms and affect tissue regeneration.

Optimising the current model of care for knee osteoarthritis with the implementation of guideline recommended non-surgical treatments: a model-based health economic evaluation

AIMS OF THE STUDY

Structured exercise, education, weight management and painkiller prescription are guideline recommended non-surgical treatments for patients suffering from knee osteoarthritis. Despite its endorsement, uptake of guideline recommended non-surgical treatments remains low. It is unknown whether the implementation of these treatments into the current model of care for knee osteoarthritis would be cost-effective from a Swiss statutory healthcare perspective. We therefore aimed to (1) assess the incremental cost-effectiveness ratio of an optimised model of care incorporating guideline recommended non-surgical treatments in adults with knee osteoarthritis and (2) the effect of total knee replacement (TKR) delay with guideline recommended non-surgical treatments on the cost-effectiveness of the overall model of care.

METHODS

A Markov model from the Swiss statutory healthcare perspective was used to compare an optimised model of care incorporating guideline recommended non-surgical treatments versus the current model of care without standardised guideline recommended non-surgical treatments. Costs were derived from two Swiss health insurers, a national database, and a reimbursement catalogue. Utility values and transition probabilities were extracted from clinical trials and national population data. The main outcome was the incremental cost-effectiveness ratio for three scenarios: "base case" (current model of care vs optimised model of care with no delay of total knee replacement), "two-year delay" (current model of care vs optimised model of care + two-year delay of total knee replacement) and "five-year delay" (current model of care vs optimised model of care + five-year delay of total knee replacement). Costs and utilities were discounted at 3% per year and a time horizon of 70 years was chosen. Probabilistic sensitivity analyses were conducted.

RESULTS

The "base case" scenario led to 0.155 additional quality-adjusted life years (QALYs) per person at an additional cost per person of CHF 341 (ICER = CHF 2,203 / QALY gained). The "two-year delay" scenario led to 0.134 additional QALYs and CHF -14 cost per person. The "five-year delay" scenario led to 0.118 additional QALYs and CHF -501 cost per person. Delay of total knee replacement by two and five years led to an 18% and 36% reduction of revision surgeries, respectively, and had a cost-saving effect.

CONCLUSION

According to this Markov model, the optimisation of the current model of care by implementing guideline recommended non-surgical treatments would likely be cost-effective from a statutory healthcare perspective. If implementing guideline recommended non-surgical treatments delays total knee replacement by two or five years, the amount of revision surgeries may be reduced.

How Does Platelet-Rich Plasma Compare Clinically to Other Therapies in the Treatment of Knee Osteoarthritis? A Systematic Review and Meta-analysis

BACKGROUND

There has been an increase in interest in the use of biological therapies in orthopaedic conditions such as knee osteoarthritis. Platelet-rich plasma (PRP) is one of these therapies, but it still lacks consistent results.

PURPOSE

To evaluate the effects (benefits and harms) of PRP intra-articular injection compared with other nonsurgical methods for the treatment of knee osteoarthritis.

STUDY DESIGN

Systematic review and meta-analysis of randomized and quasi-randomized controlled trials; Level of evidence, 2.

METHODS

Three electronic databases were searched to identify relevant studies published before January 2021. The primary outcomes were pain, function, and failure of treatment. Risks of bias of all trials were assessed using a Cochrane risk of bias tool. The Grading of Recommendations Assessment, Development and Evaluation System was used to assess the quality of evidence of included studies.

RESULTS

A total of 40 studies with 3035 participants were included. Analysis of this review focused on comparing PRP with hyaluronic acid, corticosteroid, and saline, as we believe they are the most relevant comparisons with the most studies available. At 6-month follow-up, PRP was as effective as and in some studies more effective than other therapies regarding pain, function, and stiffness. However, current evidence is of low or very low quality and is based on trials with high risk of bias and great heterogeneity among them. No significant difference among treatments was found concerning major adverse events and treatment failure.

CONCLUSION

Although studies suggest that PRP may be more effective than or at least as effective as other modalities of nonsurgical treatment for knee osteoarthritis in terms of pain, function, and adverse events, serious limitations and methodological flaws are considerable in the current literature. Therefore, the authors are not able to make recommendations for clinical practice regarding PRP for knee osteoarthritis.

Platelet-rich plasma use for hip and knee osteoarthritis in the United States

BACKGROUND

Hip and knee osteoarthritis (OA) are rising in prevalence and increasingly affecting younger patients. There is a rising demand for therapeutics to address its growing disease burden. Platelet-rich plasma (PRP) therapy has been used to treat various musculoskeletal conditions, but its role in OA treatment is not well understood. Even still, there is significant interest in this biologic for treatment of OA. The purpose of this study was to determine the PRP utilization trends in the United States for hip and knee OA.

METHODS

This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had received PRP injections for hip and knee OA from 2010 to 2018. Injection incidence was evaluated on an annual basis and by patient demographics, geographic distribution, and medical specialty under which the treatment was administered.

RESULTS

A total of 3,884 PRP injections were administered over the study period, 15% for hip OA and 85% for knee OA. PRP injections per 100,000 patient cases increased by an average year-over-year percentage of 53% and 12% for hip and knee OA, respectively. The highest injection incidences were observed in patients younger than 44 years of age. 58% of both hip and knee PRP injections were administered in general orthopaedic practices.

CONCLUSION

These findings show that PRP is increasingly being used as a treatment modality for hip and knee OA. There is a need for further research on its long term outcomes.

The Application of Platelet-Rich Plasma for Patients Following Total Joint Replacement: A Meta-Analysis of Randomized Controlled Trials and Systematic Review

Background

The clinical efficacy of platelet-rich plasma (PRP) in the treatment of total joint replacement (TJR) remains inconclusive. In this paper, systematic review and meta-analysis was adopted to assess the efficacy of using PRP for the treatment of TJR.

Methods

A comprehensive search of Medline, Embase, and Cochrane library databases for randomized controlled trial (RCT) articles recording data of PRP for TJR was conducted from inception to February 2022. Outcomes concerned were pain, range of motion (ROM), WOMAC score, length of hospital stay (LOS), hemoglobin (Hb) drop, total blood loss, wound healing rate, and wound infection. The methodological quality of the included RCTs was evaluated by using the Cochrane Risk of Bias Tool 2.0 (RoB 2.0). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was utilized to assess the level of evidence for the outcomes. Subgroup analysis was conducted according to the type of TJR.

Results

Ten RCTs were included in the meta-analysis. In the TKA subgroup, the available data demonstrated that there were significant differences in the outcomes of pain and Hb drop, while it was the opposite of ROM, WOMAC score, LOS, total blood loss, wound healing rate, and wound infection. In the THA subgroup, no significant differences could be seen between two groups in the outcomes of LOS and wound infection. However, the PRP group gained a higher wound healing rate in the THA subgroup.

Conclusion

The application of PRP did not reduce blood loss but improved the wound healing rate. However, more prospective and multicenter studies are warranted to confirm these results.

Real-world evidence to assess the effectiveness of platelet-rich plasma in the treatment of knee degenerative pathology: a prospective observational study

Objective:

The present work aims to analyse the effectiveness of platelet-rich plasma (PRP) in degenerative knee pathology based on real-world data and to evaluate possible factors influencing the response to treatment.

Methods:

In total, 531 cases were analysed collecting data on gender, age, body mass index, pathology location, severity, number of cycles and route of administration. Clinical outcome was evaluated at 6 and 15 months after treatment, using the Knee injury and Osteoarthritis Outcome Score (KOOS) and obtaining percentages of Minimal Clinically Important Improvement (MCII). Blood and PRP samples were randomly tested as a quality control measure to ensure the correct properties. Comparative statistical tests and multivariate regression were performed for the analysis of the variables.

Results:

The PRP applied had a platelet concentration factor of 1.67, with no leukocytes or erythrocytes. The percentage of patients with MCII at 6 and 15 months after PRP application was 59.32% and 70.62%, respectively. Patients with MCII were younger (p = 0.0246) and with lower body mass index (p = 0.0450). The treatment had a better response in mild/moderate cases than in severe cases (p = 0.0002). Intraosseous PRP application in severe cases improved the effect of intraarticular PRP (p = 0.0358). The application of a second cycle of PRP only improved the response in patients without MCII at 6 months (p = 0.0029), especially in mild/moderate cases (p = 0.0357).

Conclusion:

The applications of PRP in degenerative knee pathologies is an effective treatment, but this effectiveness nonetheless depends on several variables. Real-world data can complement that from clinical trials to provide valuable information.

The Cost-Effectiveness of Robotic-Assisted Versus Manual Total Knee Arthroplasty: A Markov Model-Based Evaluation

INTRODUCTION

The purpose of this study was to investigate the cost-effectiveness of robotic-assisted total knee arthroplasty (TKA) versus conventional manual TKA in patients with knee osteoarthritis.

METHODS

A Markov model simulated the lifetime outcomes of TKA of patients at average age 60 years. Costs of robotic-assisted TKA included a preoperative CT scan and the costs for acquisition and use of robotic equipment (average $706,250). We used three institutional case volumes to generate average per-case robotic costs: low volume (10 cases, $71,025 per case), mid volume (100 cases, $7,463 per case), and high volume (200 cases, $3,931 per case). Systematic reviews were used to determine early (≤1 year) and late (> 1 year) revision rates after robotic-assisted TKA (0.3 and 0.6%, respectively) and conventional TKA (0.78% and 1.5%, respectively). Outcomes were total costs and health outcomes measured in quality-adjusted life-years (QALYs). Costs and QALYs were organized into incremental cost-effectiveness ratios (ICERs). A procedure was considered cost-effective if its ICER fell below willingness-to-pay (WTP) thresholds of $50,000 and $100,000/QALY. Sensitivity analyses evaluated the effect of data uncertainty.

RESULTS

Robotic-assisted TKA produced 13.55 QALYs versus 13.29 QALYs for conventional TKA. Total costs per case for robotic-assisted TKA were $92,823 (low volume), $29,261 (mid volume), and $25,730 (high volume) compared with $25,113 for conventional. The ICERs for robotic-assisted TKAs were $256,055/QALY (low volume), $15,685/QALY (mid volume), and $2,331/QALY (high volume). ICERs for mid- and high-volume institutions were below WTP. Average number needed to treat was >42 and >24 robotic-assisted TKAs for cost-effectiveness at the $50,000 and $100,000/QALY WTP. Robotic-assisted TKAs remained cost-effective when annual revision rates <1.6% and quality of life values were >0.85.

CONCLUSION

With lower annualized revision rates and higher postoperative quality of life, robotic-assisted TKAs potentially offer improved health outcomes, especially when annual institutional case volume >24 cases per year. Continued prospective investigation will be crucial to demonstrate the value of this new technology.

Minoxidil, Platelet-Rich Plasma (PRP), or Combined Minoxidil and PRP for Androgenetic Alopecia in Men: A Cost-Effectiveness Markov Decision Analysis of Prospective Studies

Background

Androgenetic alopecia (AGA) is the most common cause of hair loss in men. In this study, we evaluated the cost-effectiveness of minoxidil monotherapy, minoxidil and platelet-rich plasma (PRP) combined therapy, and PRP monotherapy for the long-term treatment of early-onset AGA Hamilton-Norwood stages I-V in men.

Methodology

Markov modeling was performed to analyze the base-case parameters from 18 level I/II studies. The model base-case assumes a healthy 25-year-old man presenting to a dermatologist or plastic surgeon’s office as a new patient for the evaluation and treatment of AGA Hamilton-Norwood stages I-V (non-severe AGA in men). Simulations began at an age of 25 years and ran over 35 years. Analyses were conducted from healthcare and societal perspectives. Outcomes included incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay (WTP) thresholds were set at $50,000 and $100,000. Deterministic and probabilistic sensitivity analyses were performed to evaluate uncertainty over 10,000 simulations.

Results

From a healthcare perspective, compared to minoxidil monotherapy, the ICER for minoxidil+PRP was $52,036/quality-adjusted-life-year (QALY) and the ICER for PRP monotherapy was $439,303/QALY. The NMB of minoxidil monotherapy was $914,887, minoxidil+PRP was $914,350, and PRP monotherapy was $904,572 at a WTP threshold of $50,000. When the WTP threshold was increased to $100,000, the NMB of minoxidil+PRP was $1,843,908, minoxidil monotherapy was $1,831,237, and PRP monotherapy was $1,822,246. Societal trends were similar.

Conclusions

Minoxidil 5% topical twice-daily monotherapy provided cost-effective treatment for men with AGA Hamilton-Norwood stages I-V at a WTP threshold of $50,000, whereas combining minoxidil 5% with PRP provided cost-effective treatment at a WTP threshold of $100,000.

Level of evidence: Level II.

Recent Advances in Pharmacological Intervention of Osteoarthritis: A Biological Aspect

Osteoarthritis (OA) is a degenerative joint disease in the musculoskeletal system with a relatively high incidence and disability rate in the elderly. It is characterized by the degradation of articular cartilage, inflammation of the synovial membrane, and abnormal structure in the periarticular and subchondral bones. Although progress has been made in uncovering the molecular mechanism, the etiology of OA is still complicated and unclear. Nevertheless, there is no treatment method that can effectively prevent or reverse the deterioration of cartilage and bone structure. In recent years, in the field of pharmacology, research focus has shifted to disease prevention and early treatment rather than disease modification in OA. Biologic agents become more and more attractive as their direct or indirect intervention effects on the initiation or development of OA. In this review, we will discuss a wide spectrum of biologic agents ranging from DNA, noncoding RNA, exosome, platelet-rich plasma (PRP), to protein. We searched for key words such as OA, DNA, gene, RNA, exosome, PRP, protein, and so on. From the pharmacological aspect, stem cell therapy is a very special technique, which is not included in this review. The literatures ranging from January 2016 to August 2021 were included and summarized. In this review, we aim to help readers have a complete and precise understanding of the current pharmacological research progress in the intervention of OA from the biological aspect and provide an indication for the future translational studies.

Moving toward targeting the right phenotype with the right platelet-rich plasma (PRP) formulation for knee osteoarthritis

Intra-articular injections of platelet-rich plasma (PRP) and other novel blood-derived products developed specifically for osteoarthritis (OA) can provide pain relief and potential benefits in disease progression. Meta-analyses show the clinical superiority of PRP compared with other intra-articular injections, but results are modest and the effect sizes are small. PRP injections in knee OA are performed indiscriminately, but the clinical response varies enormously between patients because of an array of mixed OA phenotypes. Subgroup analyses are scarce; some studies stratify patients according to radiographic severity and found better results in early OA, without consensus for more advanced stages of the condition. Parallel identification of soluble and imaging biomarkers is essential to personalise and leverage PRP therapies. The inflammatory phenotype is most interesting from the PRP perspective because PRPs modulate inflammation by releasing a large pool of chemokines and cytokines, which interact with synovial fibroblasts and macrophages; in addition, they can modulate the innate immune response. No soluble biomarkers have been discovered that have implications for OA research and PRP interventions. Clinical examination of patients based on their inflammatory phenotype and imaging identification of pain sources and structural alterations could help discern who will respond to PRP. Synovial inflammation and bone marrow lesions are sources of pain, and intra-articular injections of PRP combined with subchondral bone injection can enhance clinical outcomes. Further refining ultrasound phenotypes may aid in personalising PRP therapies. Intra-articular delivery combined with injections in altered ligamentous structures, medial and coronal ligaments or premeniscal pes anserinus showed positive clinical outcomes. Although the evidence supporting these approaches are weak, they merit further consideration to refine PRP protocols and target the right OA phenotypes.

Screening for Intracranial Aneurysms in Individuals with a Positive First-Degree Family History: A Systematic Review

BACKGROUND

Subarachnoid hemorrhage secondary to rupture of an intracranial aneurysm (IA) is a devastating condition with high morbidity and mortality. Individuals with a positive family history of aneurysmal subarachnoid hemorrhage (aSAH) or IA can have an increased risk for aSAH or IA themselves. Screening is currently recommended in families with ≥2 affected first-degree relatives. We sought to assess the usefulness and cost-effectiveness of IA screening in individuals with a positive first-degree family history, relative to the number of family members affected.

METHODS

We performed a systematic literature search using PubMed and Google Scholar and identified additional studies by reviewing reference lists. Only original studies and review papers were considered. We excluded genetic diseases associated with IA and studies with unclear data concerning the number of first-versus second-degree relatives affected.

RESULTS

This review included 37 articles. Individuals with ≥2 affected first-degree relatives had a greater prevalence of IA (average 13.1% vs. 3% in the general population). Similarly, we found a greater prevalence of IA in individuals with ≥1 affected first-degree relative (average 4.8%, up to 19% in individuals with additional risk factors). The risk of aSAH also was increased in both categories. Recent studies stressed the importance of serial screening over time and suggested that such screening can be cost-effective in persons with only one first-degree relative with IA or aSAH.

CONCLUSIONS

While current guidelines do not recommend screening individuals with ≥1 first-degree relative affected, we found strong arguments in favor of this approach.

Current status of regenerative medicine in osteoarthritis

The high prevalence of osteoarthritis (OA), as well as the current lack of disease-modifying drugs for OA, has provided a rationale for regenerative medicine as a possible treatment modality for OA treatment. In this editorial, the current status of regenerative medicine in OA including stem cells, exosomes, and genes is summarized along with the author’s perspectives. Despite a tremendous interest, so far there is very little evidence proving the efficacy of this modality for clinical application. As symptomatic relief is not sufficient to justify the high cost associated with regenerative medicine, definitive structural improvement that would last for years or decades and obviate or delay the need for joint arthroplasty is essential for regenerative medicine to retain a place among OA treatment methods.

Cite this article: Bone Joint Res 2021;10(2):134–136.

Editorial Commentary: Platelet-Rich Plasma and Hyaluronic Acid Injection for Knee Osteoarthritis Are Both Cost Effective

Knee osteoarthritis is associated with an annual cost to society exceeding US$27 billion. Value-based treatment is an important consideration, and cost-benefit analyses are crucial to determine the benefits to both patients and society. The quality-adjusted life year (QALY) is a generic measure of burden including both quality and quantity. Recent studies have suggested that intra-articular injection of platelet-rich plasma (PRP) is effective treatment for knee osteoarthritis and comparable to hyaluronic acid (HA). Although the costs (dollars) per QALY were higher for PRP ($8,635) than for HA ($5,331), PRP was more cost effective at 1 year and was associated with an incremental cost-effectiveness ratio (ICER) of $12,628 QALY. Similarly, the utility value (proportion of QALY compared with perfect health) of PRP was higher by 0.11 QALY: 0.69 versus 0.58.

Multimodal approach to intraarticular drug delivery in knee osteoarthritis

The expectations from any future disease-modifying treatment for knee osteoarthritis (KOA) are extremely high as it has to impact the joint as a whole leading to favorable alterations of diverse tissues and functions. In this light, targeting the knee only from the inside may not be biologically justified for the management of a whole joint disease such as KOA. Our hypothesis to test is whether any injectable therapeutic intervention alone can lead to disease modification of KOA which is viewed in the complexity of the modern concept of osteoarthritis (OA) as a whole joint disease. Therefore, we aimed at analyzing the intraarticular route to the KOA patient in an attempt to unveil its "biological" constraints. A comprehensive search through databases was carried out using specific keywords to add objectivity to the main messages. The literature analysis has shown that "cutting-edge" intraarticular therapies may offer a key to non-invasive symptomatic relief. Changing the course of KOA, however, may necessitate a multimodal approach towards the knee joint including a combination of intraarticular injections with interventions on multiple levels. Importantly, our understanding of OA has evolved redefining the concept of the disease, being in interaction with the human body as a whole. Any future conservative disease-modifying treatment of KOA should aim at a multimodal, holistic approach towards the knee joint including but not limited only to intraarticular injections. A combination with other interventions should be further researched.