|Year : 2020 | Volume
| Issue : 1 | Page : 57-61
The effect of intra-articular PRP (platelet rich plasma) injection in knee osteoarthritis - A short term results
Ashutosh Kumar1, Ritesh Runu2, Santosh Kumar3, Nishant Kashyap4, Abhijeet Subhash4, Gaurav Khemka5, Raj Kumar6, Shailesh Kumar7
1 Assistant Professor, Dept. of Orthopaedics, DMCH, Darbhanga, India
2 Additional Professor, IGIMS, India
3 Professor and Head, IGIMS, India
4 Assistant Professor, IGIMS, India
5 Senior Resident, Dept. of Orthopaedics, IGIMS, India
6 Associate Professor, Dept. of PMR, IGIMS, India
7 Additional Professor, Dept. of Microbiology, IGIMS, India
|Date of Submission||13-Aug-2019|
|Date of Acceptance||16-Feb-2020|
|Date of Web Publication||16-Nov-2020|
Additional Professor, Orthopaedics, IGIMS, Patna
Source of Support: None, Conflict of Interest: None
Pain and functional limitations are important clinical features in knee osteoarthritis. Platelet-rich plasma from autologous blood is being used for symptomatic relief in early knee osteoarthritis. The aim of this study was to assess the efficacy of platelet rich plasma in patients of early knee osteoarthritis. All 50 patients received single intra-articular injection of Platelet Rich Plasma in both knees. Assessment was done by VAS pain scale and WOMAC function score pre injection and 1 week and 3 months post injection. Platelet Rich Plasma showed significant improvement in pain and function at 1 week and 3 months post injection. There was no loss of follow-up. Few patients reported pain for 2 days after the injection which resolved spontaneously. We conclude that Platelet-rich plasma therapy is simple, cheap, feasible and minimally invasive intervention for early knee osteoarthritis. It reduces the analgesic intake and improves the function of knee joint in short term.
Keywords: Knee Osteoarthritis (KOA), Platelet Rich Plasma (PRP), Visual Analogue Scale (VAS), West Ontario McMaster (WOMAC) score.
|How to cite this article:|
Kumar A, Runu R, Kumar S, Kashyap N, Subhash A, Khemka G, Kumar R, Kumar S. The effect of intra-articular PRP (platelet rich plasma) injection in knee osteoarthritis - A short term results. J Indira Gandhi Inst Med Sci 2020;6:57-61
|How to cite this URL:|
Kumar A, Runu R, Kumar S, Kashyap N, Subhash A, Khemka G, Kumar R, Kumar S. The effect of intra-articular PRP (platelet rich plasma) injection in knee osteoarthritis - A short term results. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2021 Feb 26];6:57-61. Available from: http://www.jigims.co.in/text.asp?2020/6/1/57/300742
| Introduction|| |
Knee osteoarthritis (KOA) is a degenerative disorder with proliferative changes in the bone and synovium. Early stage is associated with inflammatory changes in the synovium and minimal degeneration of articular cartilage. Due to pain patients avoid walking and knee exercises which lead to further degeneration of cartilage. Several modalities of treatment like steroids, hyaluronic acid and many other modalities of treatment have been tried with variable results. Previous study on platelet rich plasma (PRP) shows good results in KOA.
Osteoarthritis alters the normal joint metabolism favouring increased catabolism and decreased anabolism. Platelet alpha-granules contain and release numerous growth factors, including hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF) and transforming growth factor-b (TGF-b). PRP acts at various levels to alter the joint homeostasis. In cartilage it decreases catabolism, improves anabolism and promotes chondral remodelling. Higher amounts of prostaglandin (PG) and collagen II synthesis have been documented by Akeda et al and Pereira et al.
Increasing chondrocyte proliferation and production of matrix molecules have also been observed. The apoptotic pathway of osteoarthritic chondrocytes is influenced as insulin-like growth factor 1 (IGF-1) in PRP may down regulate the expression of programmed cell death- 5 (PDCD5). Lower levels of apoptosis were detected in vivo studies by Mifune et al.
To check the hypothesis we conducted the study to know the efficacy of PRP in KOA among our population.
| Materials and Methods|| |
This was a prospective trial on patients of KOA from April 2018 and August 2019 presenting to Orthopaedics OPD in our institute. Approval was obtained from our institutional ethics committee vide letter no. 281/IEC/2018/IGIMS and informed consent was taken by all patients. Total 65 patients with KOA were enrolled. Following inclusion and exclusion criteria 15 patients were excluded and total 50 patients with bilateral KOA were followed up for 3 months.
- Grade I, II, III osteoarthritis as per Ahlback’s radiological grading.
- Patients in age group of 35-70 years.
- Patients who understood the aim of study, treatment modality and gave a formal consent.
- Patients with knee pain for more than 6 months and not responding to analgesics and exercises.
- Osteoarthritis secondary to inflammatory joint disease.
- Patients with other diseases, affecting the knee joint like crystal arthropathy, symptomatic chondrocalcinosis, acute synovitis, excessive joint effusion (>100 ml), cystic diseases around the knee joint (e.g. popliteal cyst)
- Metabolic bone diseases.
- Late stages of osteoarthritis, grade 4.
- Intra-articular injections in knee given within three months.
- Relative contraindications pertaining to platelet concentrate use - history of thrombocytopenia, use of anticoagulant therapy, active infection, tumour, metastatic disease.
| Methods|| |
Preparation of platelet-rich plasma
30 ml of venous blood in acid citrate dextrose (ACD) tube was collected and centrifuged at ‘soft’ spin (1500 rpm) for 5 minutes. Supernatant plasma containing platelets was transferred to another sterile tube (without anticoagulant). This was centrifuged again at higher speed (3000rpm) for 10 minutes to obtain a platelet concentrate. The upper 2/3 rd with platelet poor plasma was discarded and remaining lower 1/3 rd with PRP was taken for injection, which was approximately 5-6 ml.
Figure: Process of preparing PRP. Dots indicate platelets. Platelet activation was done by addition of calcium gluconate in a 1:10 ratio (1 ml calcium gluconate per 10 ml of PRP). It was finally injected in knee joint.
| Results|| |
There were total 50 patients with 100 knees with average age 51 years (30-69). Average duration of symptoms was 2.6 years (6 months to 9 yrs).
Grade 1 KOA, improvement was seen in pain and function both. Among these minimal improvement noticed in 3 patients (case no. 19, 30 and 35). All three were females. These patients had generalised body ache more anxious pre and post injection.
Grade 2 KOA, pain improvement was significant in all patients except one (case no. 47). Similarly significant improvement was noticed in function post PRP. Grade 3 KOA, pain improved in 33% patients while functional improvement was seen in 50% patients.
| Discussion|| |
The present study confirms some of the findings emerging from the literature. In spite of the large number of reviews available, current evidence on intra-articular injections of PRP is based mainly on low quality studies. Sanchez et al. published a retrospective observational study on the effectiveness of intra-articular injections of a platelet concentrate in 60 patients, half treated with intra-articular injections of PRGF(Plasma Rich Growth Factor) and half with injections of Hyaluronic acid (HA). The results shows that autologous PRP injections showed more and longer efficacy as compared to HA injections in reducing pain and symptoms and recovering articular function. Similar findings were reported by Sampson et al. and Wang- Saegusa et al. in their subsequent case series. Napolitano et al. treated 27 patients, affected by either simple chondropathy or initial OA. Significant results were obtained after treatment without the occurrence of adverse events. Within last two years a case report and four case series have been published,,,, these studies confirmed the safety of the procedure and the encouraging clinical results obtained by previous authors.
Recently, Sanchez et al. investigated the efficacy of single-spinning leukocyte-free PRP versus HA in 153 patients followed up for six months. The percentage of responders which was found to be significantly higher in the PRP group was the only parameter in which a clear superiority of PRP emerged. Cerza et al. on the other hand, in their randomized trial, treated 120 patients with either autologous conditioned plasma (ACP) or HA. The ACP group showed significantly better performance than the HA group in all treatment categories, including patients affected by grade-III knee OA. Patel et al., were the first to test PRP versus saline in a randomized trial. Seventy-eight patients affected by Kellgren-Lawrence grade I-III OA were included and treated bilaterally with one injection of PRP, two injections of PRP (three weeks apart) or one injection of saline. A significant difference was observed between PRP and saline solution in terms of clinical outcome. Interestingly, no difference was reported between patients who received one or two PRP injections.
In our series, grade 1 and 2 knees responded well to PRP. The pain relief was significant in both these grades. The analgesic use reduced significantly. These patients participated in exercise programme after injection in better way than before PRP. The function score also improved in both these grades. This may be due to reduction in inflammatory markers in the synovial fluid and gradual recovery of cartilage.
In grade 3, 10 patients affected by severe OA were included because the patients refused surgical treatment. The PRP was used as a “biological modulator” with the aim of providing stimulus to normalize the articular environment. In these cases, PRP provided temporary relief. It documented that, this biological approach is not capable of providing substantial benefit in severe OA. These patients may require invasive approaches such as arthroscopic lavage, partial or total knee replacement. The pain relief in these patients was not significant but short term function improvement was noticed.
This study, despite its limitations (the small number of patients included with short duration of study and the lack of a control group), confirmed some of the most important findings of other trials and also showed that this particular PRP formulation, is effective in early/moderate knee degenerative pathology and may provide short-term clinical benefit.
| Conclusion|| |
PRP has a role in the short term pain relief and functional improvement in grade I and II KOA. But there is insignificant improvement in grade III KOA which needs other invasive procedures. This improvement may be due to antiinflammatory mechanisms and chondral remodeling. Platelet-rich plasma therapy is simple, cheap, feasible and minimally invasive intervention for early KOA. It reduces the analgesic intake and improves the function of knee joint in short term.
The informed consent for publishing for educational purposes was taken from patient.
| References|| |
Boswell SG, Cole BJ, Sundman EA. Platelet-rich plasma: a milieu of bioactìve factors. Arthroscopy. 2012; 28(3): 429-439.
Akeda K, An HS, Okuma M Platelet-rich plasma stìmulates porcine artìcular chondrocyte proliferatìon and matrix biosynthesis. 2006; 14(12), 1272-1280.
Pereira RC, Scaranari M, Benelli R. Dual effect of platelet lysate on human articular cartìlage: maintenance of chondrogenic potential and a transient proinflammatory actìvity followed by an inflammatìon resolutìon. 2013; Part A 19(11-12), 1476-1488.
Park SI, Lee HR, Kim S. Time sequentìal modulation in expression of growth factors from platelet-rich plasma (PRP) on the chondrocyte cultures. Mol Cell Biochem 2012; 361(1-2), 9-17.
Yang SY, Ahn ST, Rhie JW. Platelet supernatant promotes proliferatìon of auricular chondrocytes and formation of chondrocyte mass. Ann Plast Surg 2000; 44(4), 405-411.
Spreafico A, Chellini F, Frediani B. Biochemical investigatìon of the effects of human platelet releasates on human artìcular chondrocytes. J Cell Biochem 2002; 108(5), 1153-1165.
Gaissmaier C, Fritz J, Krackhardt T. Effect of human platelet supernatant on proliferatìon and matrix synthesis of human artìcular chondrocytes in monolayer and three-dimensional alginate cultures. Biomaterials 2005; 26(14), 1953-1960.
Sundman EA, Cole BJ, Karas V.The antì-inflammatory and matrix restoratìve mechanisms of platelet rich plasma in osteoarthritìs. Are J Sports Med 2014; 42(1), 35-41.
Anitua E, Sanchez M, Nurden AT. Platelet released growth factors enhance the secretìon of hyaluronic acid and induce hepatocyte growth factor productìon by synovial fibroblasts from arthritìc patìents. Rheumatology (Oxford) 2007;46(12), 1769-1772.
Yin Z, Yang X, Jiang Y. Platelet-rich plasma combined with agarose as a bioactìve scaffold to enhance cartìlage repair: an in vitro study. J Biomater Appl 2013; 28(7), 1039-1050.
Arnoczky SP, Delos D, Rodeo SA. What is platelet-rich plasma? Oper Tech Sports Med 2011; 19(3), 142-148.
Sampson S, Reed M, Silvers H, Meng M, Mandelbaum B. Injectìon of platelet-rich plasma in patìents with primary and secondary knee osteoarthritìs: a pilot study. Am J Phys Med Rehabil. 2010; 89:961969.
Wang-Saegusa A, Cugat R, Ares O, Seijas R, Cuscó X, Garcia-Balletbó M. Infiltratìon of plasma rich in growth factors for osteoarthritìs of the knee short-term effects on functìon and quality of life. Arch Orthop Trauma Surg. 2011; 131:311-317.
Napolitano M, Matera S, Bossio M, Crescibene A, Costabile E, Almolla J,et al. Autologous platelet gel for tìssue regeneration in degenerative disorders of the knee. Blood Transfus. 2012; 10:72-77.
Torrero JI, Aroles F, Ferrer D. Treatment of knee chondropathy with platelet rich plasma. Preliminary results at 6 months of follow-up with only one injectìon. J Biol Regul Homeost Agents. 2012; 26( 2 Suppl 1):71S-78S.
Jang SJ, Kim JD, Cha SS. Platelet-rich plasma (PRP) injectìons as an effectìve treatment for early osteoarthritìs. Eur J Orthop Surg Traumatol. 2012; 23:573-580.
Gobbi A, Karnatzikos G, Mahajan V, Malchira S. Platelet-rich plasma treatment in symptomatìc patìents with knee osteoarthritis: preliminary results in a group of actìve patìents. Sports Health. 2012; 4:162-172.
Freitag JB, Barnard A. To evaluate the effect of combining photo- activation therapy with platelet-rich plasma injections for the novel treatment of osteoarthritis. BMJ Case Rep. 2013; 2013 pii: bcr2012007463.
Halpern B, Chaudhury S, Rodeo SA, Hayter C, Bogner E, Potter HG, et al. Clinical and MRI outcomes after platelet-rich plasma treatment for knee osteoarthritis. Clin J Sport Med. 2013; 23:238-239.
Sánchez M, Fiz N, Azofra J, Usabiaga J, Aduriz Recalde E, Garcia Gutierrez A,et al. A randomized clinical trial evaluating plasma rich in growth factors (PRGF-Endoret) versus hyaluronic acid in the short- term treatment of symptomatic knee osteoarthritis. Arthroscopy. 2012; 28:1070-1078.
Cerza F, Carnì S, Carcangiu A, Di Vavo I, Schiavilla V, Pecora A, et al. Comparison between hyaluronic acid and platelet-rich plasma, intraarticular infiltration in the treatment of gonarthrosis. Am J Sports Med. 2012; 40:2822-2827.
Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Am J Sports Med. 2013; 41:356-364.
Torricelli P, Fini M, Filardo G, Tschon M, Pischedda M, Pacorini A, et al. Regenerative medicine for the treatment of musculoskeletal overuse injuries in competition horses. Int Orthop. 2011; 35:15691576.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]