Advertisement

Der Orthopäde

, Volume 48, Issue 3, pp 239–247 | Cite as

Intra-articular injections of platelet-rich plasma, hyaluronic acid or corticosteroids for knee osteoarthritis

A prospective randomized controlled study
  • Yong Huang
  • Xiaolu Liu
  • Xinliang Xu
  • Junbin LiuEmail author
Originalien

Abstract

Background

Knee osteoarthritis (KOA) is a degenerative joint disease leading to pain and disability for which no curative treatment exists. Intra-articular (IA) therapies are part of this multimodal approach and are approved by the Food and Drug Administration (FDA) and European Medicines Agency (EMA). Platelet-rich plasma (PRP), hyaluronic acid (HA), and corticosteroids (CS) have been increasingly used in recent years to treat KOA.

Purpose

To determine whether IA-PRP was superior to IA-HA or IA-CS administration routes in these patients.

Material and methods

In this trial the patients were randomized to IA-HA (2 ml/week, for 3 weeks), IA-CS (1 ml) or IA-PRP (3 times, 4 ml, every 3 weeks) groups. The outcome was assessed using the Western Ontario and McMaster Universities (WOMAC) score prior to the first injection and then at 3, 6, 9 and 12 months. Pain was evaluated by a visual analogue scale (VAS) prior to treatment and after 12 months.

Results

In this study 120 patients were randomized into 3 groups. There was a significant improvement in all scores (WOMAC, VAS) in each group compared to the pretreatment values (P< 0.05). The mean WOMAC scores for the IA-HA group from pretreatment to 3, 6, 9, and 12 months were 47.23 ± 5.37, 25.02 ± 4.98, 26.38 ± 5.20, 27.86 ± 4.34, and 30.64 ± 8.36, respectively. Similar improvements were noted in the IA-CS and IA-PRP groups. There were no significant differences in the WOMAC scores between the 3 groups 3 months after treatment (P > 0.05) but IA-PRP showed significantly lower scores 6, 9 and 12 months after treatment (P < 0.05).

Conclusion

Intra-articular PRP injections into the knee for symptomatic early stages of KOA are a valid treatment option. The clinical efficacy of IA-PRP is comparable to that of the IA-HA and IA-CS forms after 3 months and the long-term efficacy of IA PRP is superior to IA-HA and IA-CS.

Keywords

Degenerative joint disease Visual analog scale Multimodal treatment Assessment, outcomes Viscosupplementation 

Abbreviations

BMI

Body mass index

CS

Corticosteroids

DVT

Deep venous thrombosis

EQ-VAS

EuroQol-VAS

HA

Hyaluronic acid

HIV

Human immunodeficiency virus

IA

Intra-articular

IGF-1

Insulin-like growth factor 1

IKDC

International Knee Documentation Committee

KOA

Knee osteoarthritis

KOOS

Knee injury and osteoarthritis outcome score

MRI

Magnetic resonance imaging

PRP

Platelet-rich plasma

RCF

Relative centrifugal force

TGF-beta

Transforming growth factor beta

VAS

Visual analog scale

VEGF

Vascular endothelial growth factor

WOMAC

Western Ontario and McMasters Universities

Intraartikuläre Injektionen mit plättchenreichem Plasma, Hyaluronsäure oder Kortikosteroiden bei Kniearthrose

Eine prospektive, randomisierte, kontrollierte Studie

Zusammenfassung

Hintergrund

Kniearthrose ist eine degenerative Gelenkerkrankung, die mit Schmerzen und Einschränkungen einhergeht, für die es keine kurative Behandlung gibt. Intraartikuläre (IA) Therapien sind Teil dieses multimodalen Therapieansatzes und wurden von der Food and Drug Administration (FDA) und der Europäischen Arzneimittel-Agentur (EMA) zugelassen. Plättchenreiches Plasma (PRP), Hyaluronsäure (HA) und Kortikosteroide (CS) wurden in den letzten Jahren zunehmend zur Behandlung der Kniearthrose verwendet.

Zweck

Es sollte festgestellt werden, ob bei diesen Patienten IA-PRP einer Behandlung mit IA-HA oder IA-CS überlegen ist.

Material und Methoden

In dieser Studie wurden die Patienten in eine IA-HA-Gruppe (2 ml/Woche für 3 Wochen), eine IA-CS-Gruppe (1 ml) oder eine IA-PRP-Gruppe (3-mal 4 ml alle 3 Wochen) randomisiert. Die Ergebnisse wurden vor der ersten Injektion und dann nach 3, 6, 9 und 12 Monaten mittels des Western Ontario and McMaster Universities (WOMAC) Score ausgewertet. Die Schmerzen wurden vor der Behandlung und 12 Monate danach mittels der visuellen Analogskala (VAS) bewertet.

Ergebnisse

In dieser Studie wurden 120 Pateinten in 3 Gruppen randomisiert. In allen Scores (WOMAC, VAS) zeigte sich eine signifikante Verbesserung in jeder Gruppe im Vergleich zu den Werten vor der Behandlung (p< 0,05). Die mittleren WOMAC-Scores der IA-HA-Gruppe vom Zeitpunkt vor der Behandlung bis zu 3, 6, 9 und 12 Monaten betrugen 47,23 ± 5,37, 25,02 ± 4,98, 26,38 ± 5,20, 27,86 ± 4,34 bzw. 30,64 ± 8,36. Ähnliche Verbesserungen wurden in der IA-CS- und IA-PRP-Gruppe festgestellt. Es gab keine signifikanten Unterschiede in den WOMAC-Scores zwischen den 3 Gruppen 3 Monate nach der Behandlung (p > 0,05), aber IA-PRP zeigte signifikant niedrigere Scores 6, 9 und 12 Monate nach der Therapie (p < 0,05).

Schlussfolgerung

Intraartikuläre PRP-Injektionen ins Kniegelenk im symptomatischen Frühstadium einer Kniearthrose stellen eine valide Behandlungsoption dar. Die klinische Wirksamkeit von IA-PRP ist vergleichbar mit der Wirksamkeit der IA-HA- und IA-CS-Therapie nach 3 Monaten. Bezüglich der Langzeit-Wirksamkeit ist IA-PRP der Behandlung mit IA-HA und IA-CS überlegen.

Schlüsselwörter

Degenerative Erkrankung Visuelle Analogskala Multimodale Therapie Bewertung, Ergebnisse Viskosupplementation 

Notes

Acknowledgements

The authors would like to thank the research assistants from Jining No. 1 People’s Hospital of Shandong for their support and the patients enrolled in this study.

Compliance with ethical guidelines

Conflict of interest

Y. Huang, X. Liu, X. Xu and J. Liu declare that they have no competing interests.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the Ethics Committee of the Jining No. 1 People’s Hospital of Shandong. Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Curl WW, Krome J, Gordon ES, Rushing J (1997) Cartilage injuries: A review of 31,516 knee arthroscopies. Arthroscopy 13(4):456–460CrossRefGoogle Scholar
  2. 2.
    Litwic A, Edwards MH, Dennison EM et al (2013) Epidemiology and burden of osteoarthritis. Br Med Bull 105(1):185–199CrossRefGoogle Scholar
  3. 3.
    Tang X, Wang S, Zhan S et al (2016) The prevalence of symptomatic knee osteoarthritis in China: results from the China health and retirement longitudinal study. Arthritis Rheumatol 68(3):648–653CrossRefGoogle Scholar
  4. 4.
    Ling X, Michael CN (2003) High prevalence of knee, but not hip or hand osteoarthritis in Beijing elders: comparison with data of Caucasian in United States. Chung Hua I Hsueh Tsa Chih 83(14):1206–1209Google Scholar
  5. 5.
    Riddle DL, Jiranek WA, Hayes CW (2014) Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol 66(8):2134–2143CrossRefGoogle Scholar
  6. 6.
    Altman RD, Devji T, Bhandari M, Fierlinger A (2016) Clinical benefit of intra-articular saline as a comparator in clinical trials of knee osteoarthritis treatments: a systematic review and meta-analysis of randomized trials. Semin Arthritis Rheum 46(2):151–159CrossRefGoogle Scholar
  7. 7.
    He WW, Kuang MJ, Zhao J, Sun L (2017) Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: a meta-analysis. Int J Surg 39:95CrossRefGoogle Scholar
  8. 8.
    Nguyen C, Boutron I, Baron G (2017) Evolution of pain at 3 months by oral resveratrol in knee osteoarthritis (ARTHROL): protocol for a multicentre randomised double-blind placebo-controlled trial. BMJ Open 7(9):e17652CrossRefGoogle Scholar
  9. 9.
    Tammachote N, Kanitnate S, Yakumpor T, Panichkul P (2016) Intra-articular, single-shot hylan G‑F 20 hyaluronic acid injection compared with corticosteroid in knee osteoarthritis: a double-blind, randomized controlled trial. J Bone Joint Surg Am 98(11):885–892CrossRefGoogle Scholar
  10. 10.
    Bannuru RR, Schmid CH, Kent DM, Vaysbrot EE (2015) Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med 162(1):46–54CrossRefGoogle Scholar
  11. 11.
    Meheux CJ, McCulloch PC, Lintner DM, Varner KE, Harris JD (2016) Efficacy of intra-articular platelet-rich plasma injections in knee osteoarthritis: a systematic review. Arthroscopy 32(3):495–505CrossRefGoogle Scholar
  12. 12.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502CrossRefGoogle Scholar
  13. 13.
    Sturgill LP, Snyder-Mackler L, Manal TJ, Axe MJ (2009) Interrater reliability of a clinical scale to assess knee joint effusion. J Orthop Sports Phys Ther 39(12):845–849CrossRefGoogle Scholar
  14. 14.
    Dohan Ehrenfest DM, Rasmusson L, Albrektsson T (2009) Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol 27(3):158CrossRefGoogle Scholar
  15. 15.
    DeLong JM, Russell RP, Mazzocca AD (2012) Platelet-rich plasma: the PAW classification system. Arthroscopy 28(7):998–1009CrossRefGoogle Scholar
  16. 16.
    Marx RE (2004) Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg 62(4):489–496CrossRefGoogle Scholar
  17. 17.
    Lacci KM, Dardik A (2010) Platelet-rich plasma: support for its use in wound healing. Yale J Biol Med 83(1):1–9Google Scholar
  18. 18.
    Nikolidakis D, Jansen JA (2008) The biology of platelet-rich plasma and its application in oral surgery: literature review. Tissue Eng Part B Rev 14(3):249–258CrossRefGoogle Scholar
  19. 19.
    Osterman C, McCarthy MB, Cote MP et al (2015) Platelet-rich plasma increases anti-inflammatory markers in a human coculture model for osteoarthritis. Am J Sports Med 43(6):1474–1484CrossRefGoogle Scholar
  20. 20.
    Sakata R, McNary SM, Miyatake K et al (2015) Stimulation of the superficial zone protein and lubrication in the articular cartilage by human platelet-rich plasma. Am J Sports Med 43(6):1467–1473CrossRefGoogle Scholar
  21. 21.
    Zhou Q, Xu C, Cheng X et al (2016) Platelets promote cartilage repair and chondrocyte proliferation via ADP in a rodent model of osteoarthritis. Platelets 27(3):212–222CrossRefGoogle Scholar
  22. 22.
    Sakata R, Reddi AH (2016) Platelet-rich plasma modulates actions on articular cartilage lubrication and regeneration. Tissue Eng Part B Rev 22(5):408–419CrossRefGoogle Scholar
  23. 23.
    Sundman EA, Cole BJ, Karas V et al (2014) The anti-inflammatory and matrix restorative mechanisms of platelet-rich plasma in osteoarthritis. Am J Sports Med 42(1):35–41CrossRefGoogle Scholar
  24. 24.
    van Buul GM, Koevoet WL, Kops N et al (2011) Platelet-rich plasma releasate inhibits inflammatory processes in osteoarthritic chondrocytes. Am J Sports Med 39(11):2362–2370CrossRefGoogle Scholar
  25. 25.
    Cook JL, Smith PA, Bozynski CC et al (2016) Multiple injections of leukoreduced platelet rich plasma reduce pain and functional impairment in a canine model of ACL and meniscal deficiency. J Orthop Res 34(4):607–615CrossRefGoogle Scholar
  26. 26.
    Campbell KA, Saltzman BM, Mascarenhas R et al (2015) Does intra-articular platelet-rich plasma injection provide clinically superior outcomes compared with other therapies in the treatment of knee osteoarthritis? A systematic review of overlapping Meta-analyses. Arthroscopy 31(11):2213–2221CrossRefGoogle Scholar
  27. 27.
    Gobbi A, Lad D, Karnatzikos G (2015) The effects of repeated intra-articular PRP injections on clinical outcomes of early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 23(8):2170–2177CrossRefGoogle Scholar
  28. 28.
    Laudy AB, Bakker EW, Rekers M et al (2015) Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: a systematic review and meta-analysis. Br J Sports Med 49(10):657–672CrossRefGoogle Scholar
  29. 29.
    Montanez-Heredia E, Irızar S, Huertas PJ et al (2016) Intra-articular injections of platelet-rich plasma versus hyaluronic acid in the treatment of osteoarthritic knee pain: a randomized clinical trial in the context of the Spanish national health care system. Int J Mol Sci 17(7):E1064CrossRefGoogle Scholar
  30. 30.
    Smith PA (2016) Intra-articular autologous conditioned plasma injections provide safe and efficacious treatment for knee osteoarthritis: an FDA-sanctioned, randomized, double-blind, placebo-controlled clinical trial. Am J Sports Med 44(4):884–891CrossRefGoogle Scholar
  31. 31.
    Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A (2013) Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Am J Sports Med 41(2):356–364CrossRefGoogle Scholar
  32. 32.
    Hart R, Safi A, Komzák M, Jajtner P, Puskeiler M, Hartová P (2013) Platelet-rich plasma in patients with tibiofemoral cartilage degeneration. Arch Orthop Trauma Surg 133(9):1295–1301CrossRefGoogle Scholar
  33. 33.
    Torrero JI, Aroles F, Ferrer D (2012) Treatment of knee chondropathy with platelet rich plasma. Preliminary results at 6 months of follow-up with only one injection. J Biol Regul Homeost Agents 26(2 Suppl 1):71–78Google Scholar
  34. 34.
    Filardo G, Kon E, Pereira Ruiz MT et al (2012) Platelet-rich plasma intra-articular injections for cartilage degeneration and osteoarthritis: single- versus double-spinning approach. Knee Surg Sports Traumatol Arthrosc 20(10):2082–2091CrossRefGoogle Scholar
  35. 35.
    Kon E, Mandelbaum B, Buda R, Filardo G et al (2011) Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: from early degeneration to osteoarthritis. Arthroscopy 27(11):1490–1501CrossRefGoogle Scholar
  36. 36.
    Gormeli G, Gormeli CA, Ataoglu B et al (2017) Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc 25(03):958–965CrossRefGoogle Scholar
  37. 37.
    Paterson KL, Nicholls M, Bennell KL et al (2016) Intra-articular injection of photo-activated platelet rich plasma in patients with knee osteoarthritis: a double-blind, randomized controlled pilot study. BMC Musculoskelet Disord 17(1):1–9CrossRefGoogle Scholar
  38. 38.
    Forogh B, Mianehsaz E, Shoaee S et al (2015) Effect of single injection of Platelet-Rich Plasma in comparison with corticosteroid on knee osteoarthritis: a double-blind randomized clinical trial. J Sports Med Phys Fitness 56(7–8):901–908Google Scholar
  39. 39.
    Napolitano M, Matera S, Bossio M et al (2012) Autologous platelet gel for tissue regeneration in degenerative disorders of the knee. Blood Transfus 10(1):72–77Google Scholar
  40. 40.
    Filardo G, Kon E, Buda R et al (2011) Platelet-rich plasma intra-articular knee injections for the treatment of degenerative cartilage lesions and osteoarthritis. Knee Surg Sports Traumatol Arthrosc 19(4):528–535CrossRefGoogle Scholar
  41. 41.
    Kon E, Buda R, Filardo G et al (2010) Platelet-rich plasma: intra-articular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc 18(4):472–479CrossRefGoogle Scholar
  42. 42.
    Jang SJ, Kim JD, Cha SS (2013) Platelet-rich plasma (PRP) injections as an effective treatment for early osteoarthritis. Eur J Orthop Surg Traumatol 23(5):573–580CrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  • Yong Huang
    • 1
  • Xiaolu Liu
    • 1
  • Xinliang Xu
    • 2
  • Junbin Liu
    • 2
    Email author
  1. 1.School of Medicine and Life SciencesJinan UniversityJinanChina
  2. 2.Department of TraumatologyJining NO.1 People’s Hospital of ShandongJiningChina

Personalised recommendations