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

Efficacy and safety of platelet-rich plasma and hyaluronic acid combination therapy for knee osteoarthritis: a systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate whether a combination of platelet-rich plasma (PRP) and hyaluronic acid (HA) is more effective and safer than injection alone for treating KOA.

MATERIALS AND METHODS

MEDLINE (PubMed), the Cochrane Library, EMBASE, and Web of Science databases were systematically searched for articles published until January 2024, and gray literature and bibliographic references were searched. All published randomized controlled trials (RCTs) compared pain, functional outcomes, and adverse events (AEs) associated with PRP + HA therapy vs. PRP or HA treatments. Two independent researchers extracted the pertinent data and evaluated the methodological quality following the PRISMA guidelines. The primary outcomes were pain, functional outcomes, and AEs. A fixed-effects model was used for data analysis in cases with low heterogeneity (P > 0.10 and I2 < 50%). Otherwise, a random effects model was used.

RESULTS

Ten RCTs involving 943 patients were included in the analysis. The statistical findings did not differ between the treatment of PRP + HA and PRP alone, while a discernible enhancement in treatment efficacy was observed when compared to HA monotherapy: the visual analog scale scores at 1- (mean difference[MD], -1.00; 95% CI: -1.37 - -0.62; P < .001), 6- (MD, -1.87; 95% CI: -3.46 - -0.28; P = .02), 12-months (MD, -2.07; 95% CI: -3.77 - -0.38; P = .02), and the Western Ontario and McMaster Universities Arthritis Index total scores at 12-months (MD, -8.82; 95% CI: -14.48 - -3.16; P = .002). The incidence of adverse events was notably lower with PRP + HA than with HA alone (OR, 0.37; 95% CI: 0.19 - 0.69; P = .00) or PRP alone (OR, 0.51; 95% CI, 0.30 - 0.87; P = .01).

CONCLUSIONS

PRP + HA therapy resulted in more pronounced pain and functional improvement in symptomatic KOA patients than HA treatments, and combination therapy may have higher clinical safety than PRP or HA monotherapy.

Mesenchymal stem cells and platelet rich plasma therapy for knee osteoarthritis: an umbrella review of systematic reviews with meta-analysis

The effect of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) therapy on knee osteoarthritis (KOA) has been contradictory in previous meta-analyses. This umbrella review on published meta-analyses aimed to investigate the effect of MSCs and PRP on KOA. We systematically searched Scopus, PubMed, and Cochrane databases to include related meta-analyses. The outcome included studies reporting visual analog scale scores, the Western Ontario and McMaster Universities Osteoarthritis Index, Whole-Organ Magnetic Resonance Imaging Scores, International Knee Documentation Committee scores, and the Knee injury and Osteoarthritis Outcome Score. A total of 28 meta-analyses with 32 763 participants. MSCs and PRP therapies were significantly associated with an improvement in KOA scores. This umbrella meta-analysis supports the beneficial health effects of MSCs and PRP in KOA.

A Comprehensive Summary of the Meta-Analyses and Systematic Reviews on Platelet-Rich Plasma Therapies for Knee Osteoarthritis

INTRODUCTION

Osteoarthritis (OA), including that of the knee joint, represents a significant proportion of musculoskeletal injuries in the Canadian Armed Forces (CAF) due to the frequent, high-stress physical activity for which member participation is necessary. Platelet-rich plasma (PRP) is a conservative, autologous treatment that has the potential to relieve symptoms and improve functionality of military members to decrease the impact of the disease and ultimately strengthen the CAF.

MATERIALS AND METHODS

A search of systematic reviews and meta-analyses was conducted to determine the efficacy of PRP injections in treating knee OA. The Scopus database, PubMed database, and Omni academic search tools were scoped for relevant publications. English literature, published up to and including March 2023, that investigated only clinically randomized controlled trials (RCTs) was eligible for inclusion. The results of network meta-analyses were investigated and summarized independent of reviews and non-network meta-analyses.

RESULTS

A total of 225 unique systematic reviews and meta-analyses were initially identified, of which 39 publications, including 7 network meta-analyses, adhered to the defined inclusion and exclusion criteria. PRP was found to significantly alleviate symptoms of pain based on the visual analog scale and Western Ontario and McMaster Universities Arthritis Index pain scores within the 12-month follow-up. Function, activity, sport, quality of life, and stiffness were additionally determined to generally improve to a greater extent from PRP treatment compared to controls, while adverse effects were minor and temporary. PRP placed in the top 3 in 9 reported surface under the cumulative ranking curves, while individually reported rankings of leukocyte-poor and leukocyte-rich PRP both placed in the top 4. The clinical recommendations made were generally positive, with 17 publications acknowledging the benefits of PRP, 3 supporting possible efficacy, and an additional 8 recommending that it be an option for the conservative treatment of knee OA.

CONCLUSION

The results of this review support the efficacy of PRP for relieving symptoms of pain and improving function, stiffness, and quality of life for patients experiencing knee OA within 12 months. As a result, leukocyte-poor-PRP could be considered for members of the CAF with mild to moderate knee OA (Kellgren-Lawrence grades 1-3) to slow the progression of OA and extend the military careers of CAF members. There continues to be a need for future studies to investigate the longer-term effects of PRP to verify sustained benefits at follow-up points greater than 12 months, including findings of improvement in a delayed fashion at the 3- and 6-month timeframe compared to hyaluronic acid treatment.

Women show a positive response to platelet-rich plasma despite presenting more painful knee osteoarthritis than men

PURPOSE

The purpose of this study was to evaluate the impact of gender on the efficacy of platelet-rich plasma (PRP) in patients with knee osteoarthritis (KOA), comparing their short-term response between men and women.

METHODS

Four hundred-eighteen patients (529 knees) were included. Patients were treated with three injections of PRP on a weekly basis. Blood and PRP samples were randomly tested. Patients were asked to complete the knee injury and osteoarthritis outcome score (KOOS) and 12-item short form survey (SF-12), at baseline and 6 months. Success rates were calculated according to a reduction in the pain score of at least 9.3 points [minimal clinically important improvement (MCII)]. Comparative tests and multivariate regression were performed.

RESULTS

The PRP had a platelet concentration factor of 2.0X compared to blood levels, with no leucocytes or erythrocytes. KOOS scores showed an increase from baseline to 6 months (p < 0.0001). There was an increase in the physical component summary (PCS) (p < 0.0001) and mental component summary (MCS) (p < 0.01) of the SF-12. The number of knees of women with MCII was 156 out of 262 (59.6%), whereas the number of knees of men was 136 out of 267 (50.9%) (p = 0.0468). Women had worse baseline scores on pain (p = 0.009), PCS (p < 0.0001) and MCS (p < 0.0001).

CONCLUSION

Although the symptomatology generated by KOA was worse in women when compared to men, treatment with repeated injections of PRP was effective, ultimately achieving a higher improvement in women providing comparable final follow-up outcomes between men and women.

LEVEL OF EVIDENCE

Level IV.

Clinical Outcome of Multiple Platelet-Rich Plasma Injection and Correlation with PDGF-BB in the Treatment of Knee Osteoarthritis

(1) Background: Current treatments for knee osteoarthritis (KOA), such as intra-articular corticosteroids or hyaluronic acid (HA) injections, are controversial due to their ineffectiveness in preventing disease progression. Platelet-rich plasma (PRP) has become a promising and possible treatment for KOA. It is thought to enhance articular cartilage regeneration and reduce OA-related impairment. PRP contains growth factors such as PDGF-BB, which stimulates growth and inhibits joint damage. Based on numerous studies, after a certain amount of time, it was found that multiple PRP treatments reduced pain more than a single injection. This study evaluates the efficacy of multiple PRP (m-PRP) injections compared to multiple HA (m-HA) injections for KOA treatment, focusing on their correlation with PDGF-BB levels. (2) Methods: In this single-center, open-label, randomized, comparative clinical trial, 30 KOA patients received m-PRP and m-HA injections. VAS and WOMAC were used to evaluate clinical outcomes and PDGF-BB concentrations. (3) Results: The study analysis revealed a statistically significant reduction in pain indices. In both the m-PRP and m-HA groups after 12 weeks, m-PRP showed superior results. PDGF-BB concentrations also increased, with a strong negative correlation and statistical significance using Spearman's rho. (4) Conclusions: Multiple PRP injections are safe and associated with elevated PDGF-BB, reduced VAS and WOMAC scores, providing the potential for articular cartilage regeneration and inhibiting knee osteoarthritis progression.

Effects of Adding Extracorporeal Shockwave Therapy (ESWT) to Platelet-Rich Plasma (PRP) among Patients with Rotator Cuff Partial Tear: A Prospective Randomized Comparative Study

A rotator cuff tear is a prevalent ailment affecting the shoulder joint. The clinical efficacy of combined therapy remains uncertain for partial rotator cuff tears. In this study, we integrated extracorporeal shockwave therapy (ESWT) with platelet-rich plasma (PRP) injection, juxtaposed with PRP in isolation. Both cohorts exhibited significant improvements in visual analogue scale (VAS), Constant-Murley score (CMS), degrees of forward flexion, abduction, internal rotation, and external rotation, and the sum of range of motion (SROM) over the six-month assessment period. The application of ESWT in conjunction with PRP exhibited notable additional enhancements in both forward flexion (p = 0.033) and abduction (p = 0.015) after one month. Furthermore, a substantial augmentation in the range of shoulder motion (SROM) (p < 0.001) was observed after six months. We employed isobaric tag for relative and absolute quantitation (iTRAQ) to analyze the differential plasma protein expression in serum samples procured from the two groups after one month. The concentrations of S100A8 (p = 0.042) and S100A9 (p = 0.034), known to modulate local inflammation, were both lower in the ESWT + PRP cohort. These findings not only underscore the advantages of combined therapy but also illuminate the associated molecular changes.