Southworth TM, Naveen NB, Tauro TM, et al.The Journal of Knee Surgery, 2019

With average life expectancy and the rising prevalence of obesity, osteoarthritis (OA) is creating an increasingly large financial and physical burden on the U.S. population today. As the body ages and experiences trauma, articular cartilage surfaces in joints are gradually worn away, leading to OA. Traditionally, treatment options have included lifestyle modifications, pain management, and corticosteroid injections, with joint replacement reserved for those who have exhausted nonsurgical measures. More recently, hyaluronic acid, micronized dehydrated human amniotic/chorionic membrane tissue, and platelet-rich plasma (PRP) injections have started to gain traction. PRP has been shown to have both anti-inflammatory effects through growth factors such as transforming growth factor-beta and insulin-like growth factor 1, and stimulatory effects on mesenchymal stem cells and fibroblasts.

Multiple studies have indicated that PRP is superior to hyaluronic acid and corticosteroids in terms of improving patient-reported pain and functionality scores. Unfortunately, there are many variations in PRP preparation, and lack of standardization in factors, such as speed and duration of centrifugation, leads to wide ranges of platelet and leukocyte concentrations.

Cole BJ, Karas V, Hussey K, et al.American Journal of Sports Medicine, 2017.

The use of platelet-rich plasma (PRP) for the treatment of osteoarthritis (OA) has demonstrated mixed clinical outcomes in randomized controlled trials when compared with hyaluronic acid (HA), an accepted nonsurgical treatment for symptomatic OA. Biological analysis of PRP has demonstrated an anti-inflammatory effect on the intra-articular environment.

PURPOSE: To compare the clinical and biological effects of an intra-articular injection of PRP with those of an intra-articular injection of HA in patients with mild to moderate knee OA. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.

METHODS: A total of 111 patients with symptomatic unilateral knee OA received a series of either leukocyte-poor PRP or HA injections under ultrasound guidance. Clinical data were collected before treatment and at 4 time points across a 1-year period. Synovial fluid was also collected for analysis of proinflammatory and anti-inflammatory markers before treatment and at 12 and 24 weeks after treatment. Several measures were used to assess results: (1) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale; (2) International Knee Documentation Committee (IKDC) subjective knee evaluation, visual analog scale (VAS) for pain, and Lysholm knee score; and (3) difference in intra-articular biochemical marker concentrations.

RESULTS: here were 49 patients randomized to treatment with PRP and 50 randomized to treatment with HA. No difference was seen between the groups in the primary outcome measure (WOMAC pain score). In the secondary outcome measure, linear contrasts identified a significantly higher IKDC score in the PRP group compared with the HA group at 24 weeks (mean +/- standard error [SE], 65.5 +/- 3.6 vs 55.8 +/- 3.8, respectively; P = .013) and at final follow-up (52 weeks) (57.6 +/- 3.37 vs 46.6 +/- 3.76, respectively; P = .003). Linear contrasts also identified a statistically lower VAS score in the PRP group versus the HA group at 24 weeks (mean +/- SE, 34.6 +/- 3.24 vs 48.6 +/- 3.7, respectively; P = .0096) and 52 weeks (44 +/- 4.6 vs 57.3 +/- 3.8, respectively; P = .0039). An examination of fixed effects showed that patients with mild OA and a lower body mass index had a statistically significant improvement in outcomes. In the biochemical analysis, differences between groups approached significance for interleukin-1beta (mean +/- SE, 0.14 +/- 0.05 pg/mL [PRP] vs 0.34 +/- 0.16 pg/mL [HA]; P = .06) and tumor necrosis factor alpha (0.08 +/- 0.01 pg/mL [PRP] vs 0.2 +/- 0.18 pg/mL [HA]; P = .068) at 12-week follow-up.

CONCLUSION: We found no difference between HA and PRP at any time point in the primary outcome measure: the patient-reported WOMAC pain score. Significant improvements were seen in other patient-reported outcome measures, with results favoring PRP over HA. Preceding a significant difference in subjective outcomes favoring PRP, there was a trend toward a decrease in 2 proinflammatory cytokines, which suggest that the anti-inflammatory properties of PRP may contribute to an improvement of symptoms.