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CI # 51540 Is intra-articular platelet-rich plasma (PRP) an effective treatment for osteoarthritis of the knee?: search

Search Summary

FPIN CIs, PURLS, HDAs 0 platelet-rich plasma and osteoarthritis

Cochrane Library

0 platelet rich plasm and knee osteoarthritis; no unique content found
PubMed

Systematic reviews & meta analyses

19 (platelet rich plasma[tw] OR platelet-rich plasma[mh] OR plasma rich in growth factor*[tw]) AND (injection* OR injections[mh]) AND (knee OR knees) AND (osteoarthritis OR arthritis) AND (Meta Analysis[pt] OR meta analy*[tw] OR metaanaly*[tw] OR systematic review*[tw] OR data synthesis[tw] OR data extraction[tw] OR Cochrane Database Syst Rev[ta]) AND english[la]
PubMed

RCTs; duplicates removed

28 (platelet rich plasma[tw] OR platelet-rich plasma[mh] OR plasma rich in growth factor*[tw]) AND (injection* OR injections[mh]) AND (knee OR knees) AND (osteoarthritis OR arthritis) AND (randomized controlled trial[pt] OR (random*[tw] NOT medline[sb])) NOT (Meta Analysis[pt] OR meta analy*[tw] OR metaanaly*[tw] OR systematic review*[tw] OR data synthesis[tw] OR data extraction[tw] OR Cochrane Database Syst Rev[ta]) AND english[la]
PubMed

Guidelines; duplicates removed

4 (platelet rich plasma[tw] OR platelet-rich plasma[mh]) AND (injection* OR injections[mh]) AND (knee OR knees) AND (osteoarthritis OR arthritis) AND (guideline*[tw] OR Guideline[pt] OR Practice Guideline[pt] OR Consensus Development Conference[pt] OR Consensus Development Conference, NIH[pt]) AND english[la]
National Guideline Clearinghouse   American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of osteoarthritis of the knee, 2nd edition. " The work group is unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee. "
UpToDate 1 UpToDate: Investigational approaches to the management of osteoarthritis -

Platelet-rich plasma — Platelet-rich plasma (PRP) is derived from autologous blood, with platelets being the main constituent. The mechanism of action is not well-understood, but it is thought to provide high concentrations of growth factors including tissue growth factor and platelet-derived growth factors, which can mediate the proliferation of mesenchymal stem cells and increase matrix synthesis and collagen formation [34]. PRP can reduce inflammation in an OA joint by enhancing the expression of NF-kappa-beta inhibitor, and thus reduce NF-kappa-beta signaling and dampen its downstream inflammatory cytokine activation [34]. It has shown the ability to switch off the inhibition of type II collagen and aggrecan gene expression in IL-1beta-activated NF-kappa-beta in chondrocytes [35]. Thus far, PRP has been predominantly been used to treat musculoskeletal conditions, particularly tendon-related pathologies.

A meta-analysis of 10 trials assessing the effect of PRP injections in patients with knee OA found a significant difference in pain scores in the PRP-treated groups [36]. However, the majority of the trials revealed a high likelihood of biases, and only one of the trials compared PRP injections with placebo.

No trials have examined the structural effects of PRP in OA joints. There is a lack of standardization of the preparations of PRP amongst the trials, with varying concentration of platelet, frozen versus fresh preparations, and the filtration of white cells. Additional standardized studies are required before the use of PRP in the treatment of OA can be validated.

DynaMed 1

DynaMed:  Osteoarthritis of the knee -

  • platelet-rich plasma (PRP) may improve symptoms of knee osteoarthritis compared to hyaluronic acid or placebo (level 2 [mid-level] evidence)
    • based on systematic review without reporting of individual study quality measures
    • systematic review of 6 studies (4 randomized trials and 2 prospective cohort studies) comparing PRP intra-articular injection to hyaluronic acid injection or saline (placebo) injection in 577 patients with symptomatic knee osteoarthritis
    • PRP injection associated with
      • reduced WOMAC score (mean difference -18, 95% CI -8.3 to -28.8) in analysis of 4 studies with 366 patients, results limited by significant heterogeneity
      • increased International Knee Documentation Committee score (mean difference 7.9, 95% CI 3.7-12.1) in analysis of 3 studies with 239 patients
    • no significant differences in pain assessed by visual analog scale score or in overall patient satisfaction in analyses of 2 studies with 196 patients, both results limited by significant heterogeneity
    • in pooled analysis with indirect comparisons, adverse events occurred in 8.4% with PRP vs. 3.8% with hyaluronic acid or saline (p = 0.002)
    • Reference - Arthroscopy 2013 Dec;29(12):2037
    • PRP may improve symptoms of knee arthritis compared to hyaluronic acid (level 2 [mid-level] evidence)
      • based on randomized trial without blinding and with allocation concealment not stated
      • 120 patients (mean age 66 years) with knee arthritis randomized to PRP (autologous conditioned plasma) 5.5 mL vs. hyaluronic acid 20 mg in 2 mL intra-articularly once weekly for 4 weeks and followed to 24 weeks
      • pain, articular stiffness, and functional limitation assessed by WOMAC scale (range 0-96) with higher scores indicating more severe symptoms (mean baseline score 76.9)
      • mean WOMAC score at 24 weeks 36.5 with PRP vs. 65.1 with hyaluronic acid (p < 0.001)
      • Reference - Am J Sports Med 2012 Dec;40(12):2822
    • single-injection PRP may improve symptoms of early knee osteoarthritis similar to 2 injections (level 2 [mid-level] evidence)
      • based on randomized trial with allocation concealment not stated
      • 78 patients with bilateral early knee osteoarthritis randomized to 1 of 3 intra-articular injections and followed for 6 months
        • PRP single injection
        • PRP 2 injections 3 weeks apart
        • placebo single injection
      • PRP single injection and PRP 2 injections 3 weeks apart associated with reduced pain, stiffness, and improved physical function (p < 0.001 for each vs. placebo)
      • no significant differences comparing PRP single injection vs. 2 injections
      • Reference - Am J Sports Med 2013 Feb;41(2):356
  • PRP appears similar for improvement of symptoms and function compared to hyaluronic acid (level 2 [mid-level] evidence)
    • based on randomized trial with wide confidence intervals
    • 192 patients with knee joint degeneration and pain for ≥ 4 months or swelling randomized to PRP vs. hyaluronic acid intra-articular injection once weekly for 3 weeks and followed for 12 months
    • mean age > 53 years in both groups
    • wide confidence intervals cannot exclude clinically relevant differences between groups
    • no significant difference in function or symptom scores at any time point but both groups improved from baseline
    • major adverse event or severe pain and swelling after hyaluronic acid injection in 2 patients; no major adverse events with PRP but significantly increased postinjection swelling and pain reported in PRP group
    • Reference - Am J Sports Med 2015 Jul;43(7):1575
  • PRP with high leukocyte concentration does not appear to improve function more than PRP with low leukocyte concentration or hyaluronic acid in patients with knee osteoarthritis (level 2 [mid-level] evidence)
    • based on systematic review with study-specific quality measures not reported for randomized trials
    • systematic review of 9 studies (6 randomized trials and 3 cohort studies) evaluating intra-articular injections in 1,055 patients with knee osteoarthritis
    • injections were
      • PRP with low leukocyte concentration (< concentration in whole blood)
      • PRP with high leukocyte concentration (> concentration in whole blood)
      • hyaluronic acid
      • placebo
    • no significant differences in WOMAC scores or adverse events comparing PRP with high leukocyte concentration to either PRP with low leukocyte concentration or hyaluronic acid in direct comparisons
    • in network meta-analysis including indirect comparisons, PRP with low leukocyte concentration rated as treatment with highest clinical efficacy after adjustment for baseline WOMAC scores
    • Reference - Am J Sports Med 2016 Mar;44(3):792

Author Information

Clinician Authors: Carrie Lynn Wilcox and Bob Marshall

Librarian:  Sarah Safranek

Search Due Date:  August 2016

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