|Year : 2019 | Volume
| Issue : 3 | Page : 1108-1112
Evaluation of platelet-rich plasma injection in knee osteoarthritis patients
Samar J Suleiman1, Alaa A Labeeb1, Mahmoud A El-Sorogy2
1 Department of Rheumatology, Physical Medicine and Rehabilitation, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Rheumatology, Physical Medicine and Rehabilitation, Nabarouh Hospital, Dakahlia, Egypt
|Date of Submission||10-Apr-2018|
|Date of Acceptance||24-Jun-2018|
|Date of Web Publication||17-Oct-2019|
Mahmoud A El-Sorogy
Mansoura, Dakahlia 32717
Source of Support: None, Conflict of Interest: None
The aim of this study was to determine the effect of local injection of platelet-rich plasma (PRP) in patients with mild and moderate knee osteoarthritis (OA) and its effect on pain in comparison to corticosteroid injection.
OA is one of the most prevalent chronic musculoskeletal diseases worldwide. The use of PRP appeared in the last years for the management of symptoms of knee OA.
Patients and methods
This study included 50 patients with knee OA. Our patients were divided to two groups: a group of 25 patients who were injected intra-articularly with about 3–4 ml of PRP and another of 25 patients who were injected intra-articularly with triamcinolone acetate for one affected knee. We measure and assess all patients by Western Ontario and McMaster Universities Osteoarthritis Index and visual analog score – pain questionnaires before injection and after 1 and 3 months of injection.
There was a highly statistically significant difference between preinjection and postinjection after 1 month with more decrease in postinjection (P < 0.001) and highly statistically significant difference between preinjection and follow-up injection in Western Ontario and McMaster Universities Osteoarthritis Index score with more decrease in follow-up (P < 0.001). Also there was a highly significant decrease in visual analog score scale readings in postinjection (P < 0.001) and follow-up after 3 months of injection (P < 0.001).
Intra-articular injection PRP is an effective method for the treatment of knee OA. Also, PRP intra-articular injection is more effective than intra-articular injection of corticosteroid.
Keywords: knee osteoarthritis, platelet-rich plasma, triamcinolone acetate, visual analog score, Western Ontario and McMaster Universities Osteoarthritis Index
|How to cite this article:|
Suleiman SJ, Labeeb AA, El-Sorogy MA. Evaluation of platelet-rich plasma injection in knee osteoarthritis patients. Menoufia Med J 2019;32:1108-12
|How to cite this URL:|
Suleiman SJ, Labeeb AA, El-Sorogy MA. Evaluation of platelet-rich plasma injection in knee osteoarthritis patients. Menoufia Med J [serial online] 2019 [cited 2019 Nov 19];32:1108-12. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/1108/268809
| Introduction|| |
Knee osteoarthritis (OA) is a common degenerative disease characterized by chronic pain, joint stiffness, reduced function, cartilage degradation, loss of subchondral bone, and synovial inflammation . Recent studies have focused on modern therapeutical methods stimulating the cartilage healing process, including application of gene therapy, cytokine inhibitors, stem cells, and growth factors .
Platelet growth factors were found to stimulate the healing process and lead to partial modification of the damaged tissue .
| Patients and Methods|| |
Fifty patients with OA knee were diagnosed according to the American College of Rheumatology (ACR) criteria for the classification of OA of the knee . Our patients were recruited from the outpatient clinic of Rheumatology, Physical Medicine and Rehabilitation Department, Menoufia University Hospital during a period between 2016 and 2018. The study included both sexes. Forty-two (84%) patients were women and eight (16%) were men. Their age ranged from 40 to 70 years.
All patients were from the Menofia Governorate. Ethical written consent was obtained from all patients after a full explanation of the study.
Patients were diagnosed as OA knee as arthralgia since the past 3 months with radiologic evidence of mild to moderate OA knee according to the Kellgren–Lawrence scale  based on knee OA criteria of ACR. We excluded patients with local abscess, diabetes mellitus, malignancy, pregnancy, blood disorders, nonsteroidal, anti-inflammatory or systemic steroids within 1 week prior to randomization.
All patients will be subjected to demographic data recording, history taking, and clinical examination including general examination  and local examination of knee joints .
All patients have undergone complete blood count, erythrocyte sedimentation rate, rheumatoid factor, C-reactive protein, hepatitis C virus antibody, and serum uric acid. And also radiological examination such as plain radiography of the knee joint (anteroposterior view standing). On first visit, the assessment questionnaires were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)  and visual analog score (VAS) . VAS and WOMAC are subjective assessments.
Randomization was done in a double-blind way. The patients were divided into group I which included 25 patients who were injected intra-articularly with about 3–4 ml of platelet-rich plasma (PRP) and group II which included 25 patients who were injected intra-articularly with 2 ml triamcinolone acetonide for one affected knee.
Then, they ware re-evaluated again after 1 month of injection and after 3 months. PRP preparation was collecting taking 10 ml of venous blood sample from each patient into two tubes containing an anticoagulant (sterile sodium citrated tubes). The tubes will be centrifuged at 1800 rpm for 15 min separating plasma (top layer) from the packed red blood cells (bottom layer). The red blood cell layer is discarded and the second centrifuge at 3500 rpm for 10 min yields a more concentrated platelet layer after extraction of platelet-poor plasma .
The data collected were tabulated and analyzed by the statistical package for the social sciences, version 22.0, on IBM compatible computer (SPSS Inc., Chicago, Illinois, USA). Two types of statistics were done: descriptive statistics included percentage (%), range, mean, and SD and analytical statistics which included Student's t test, Mann–Whitney test, and Fisher's exact test. A value of P value more than 0.05 signifies no difference, significant difference if P value less than 0.05, and highly significant difference if P value less than 0.001.
| Results|| |
This study was carried out on 50 patients diagnosed with knee OA. They were divided into two groups, the first group included 25 patients [six (24%) males and 19 (76%) females] which received intra-articular injection of autologous PRP and the second group included 25 patients [two (8%) men and 23 (92%) women] which received intra-articular injection of triamcinolone acetonide. Both groups were injected only one time. Clinically, all the patients were evaluated before the treatment and at 1 and 3 months of injection with subjective VAS and WOMAC score. There was no significant difference in patients' age groups, BMI, and sex [Table 1].
There was no statistically significant difference in preinjection between the two groups in total WOMAC score [Table 2].
|Table 2: Comparison between the platelet-rich plasma group and the triamcinolone group according to Western Ontario and McMaster Universities Osteoarthritis Index score|
Click here to view
Postinjection after 1 month there was a statistically highly significant difference between the two groups in total WOMAC score with more decrease in PRP group (P < 0.01) [Table 2].
In the follow-up after 3 months, there was a highly significant difference between two groups in total WOMAC score with more decrease in the PRP group (P < 0.01) [Table 2].
In group I, there was a highly statistical significant difference between preinjection and postinjection after 1 month in total WOMAC score with more decrease in postinjection (P < 0.01) [Table 3].
|Table 3: Comparison between total Western Ontario and McMaster Universities Osteoarthritis Index score preinjection versus 1 month postinjection and follow-up 3 months in the platelet-rich plasma group|
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Also, there was a highly statistical significant difference between preinjection to follow-up after 3 months injection in total WOMAC score with more decrease in follow-up (P < 0.01) [Table 3].
In the PRP group, there was a highly significant difference between preinjection to postinjection and preinjection to follow-up after 3 months of injection by VAS scale readings in (P < 0.01) [Table 3].
By comparison both groups recorded a highly significant decrease in VAS scale readings postinjection and in follow-up with more decrease in the PRP group (P < 0.01) [Table 4].
|Table 4: Comparison of visual analog score scale preinjection to postinjection and preinjection to follow-up injection in both groups|
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No side effects or complications were observed during the period of study.
| Discussion|| |
The aim of this study was to determine the effect of local injection of PRP in patients with mild and moderate knee OA and its effect on pain in comparison to corticosteroid injection. The study was carried out on 50 patients suffering from mild to moderate primary OA of the knee joint, diagnosed clinically and by plain radiograph. Twenty-five patients were treated with PRP intra-articular knee injections and 25 patients were treated with triamcinolone intra-articular knee injections. The number of patients was according to the patients attending the outpatient clinic of Rheumatology, Physical Medicine and Rehabilitation Department, Menoufia University Hospital during the period from January 2016 to January 2017.
The study included 50 patients with knee OA diagnosed according to the ACR criteria for the classification of OA of the knee. Randomization was done in a double-blind way as the patients were divided into two groups: 25 patients were injected intra-articularly with about 3–4 ml of PRP and 25 patients were injected intra-articularly with 2 ml triamcinolone acetonide for the one affected knee.
All patients were prospectively evaluated at baseline and after 1 month and 3 months follow-up and a comparison of PRP intra-articular knee injections versus triamcinolone intra-articular knee injections was done.
The results of this study showed that the preinjection mean total WOMAC score was 59.76 ± 9.68, then changed after 1month postinjection to 20.12 ± 6.94 and in follow-up after 3 months to 22.60 ± 12.51 [Table 3]with noticeable improvement in pain, stiffness, and degree of difficulty of patients with knee OA. This is in agreement with Raeissadat et al. study  in which the mean total WOMAC before treatment was 39.12 ± 16. 25 and 21.05 ± 14.73 after treatment which (P = 0.001). Another study showed a marked improvement in the mean score of the WOMAC index, from 38.76T 16.50 to 14.35T 14.18 points at 3 months follow-up and to 18.85T 14.09 points at 6 months follow-up . Also, a meta-analysis found PRP injection to be more effective than hyaluronic acid (HA), as evaluated by WOMAC .
Also our results were in accordance with another study by Kavadar et al. , who noted a statistically significant improvement in all of the evaluated measures after PRP injection. The study done by Patel and colleagues found a statistically significant improvement in all WOMAC parameters within 2–3 weeks and lasting until the final follow-up at 6 months, with slight worsening at the 6-month follow-up. The mean WOMAC scores (pain, stiffness, physical function, and total score) at baseline were 49.86, and at final follow-up were 27.18, showing significant improvement . Gobbi et al.  stated that all patients showed significant improvement in all scores at 6 and 12 months (P < 0.01) and returned to previous activities and concluded that PRP treatment showed positive effects in patients with knee OA.
Our study shows a highly significant difference of pain scores as detected by the VAS between preinjection and postinjection after 1 month and between preinjection and follow-up after 3 months (P < 0.001) with improvement of pain. The VAS of pain mean value was 7.72 ± 1.02 at preinjection, then changed to 2.84 ± 1.34 postinjection after 1 month, and to 3.24 ± 1.64 at follow-up after 3 months [Table 4].
In agreement with our results, one study found the mean VAS of pain after a single injection of PRP to be 4.54 ± 0.613 and it changed to 2.16 ± 1.543 after 6 months . Another study found that the mean VAS was 5.9 ± 1.3 and became 3.9 ± 1.1 after 6 months . The Kilincoglu et al.  study found that the mean VAS of the PRP group was at pretreatment 7.2 ± 1.07, third month posttreatment it was 3.59 ± 0.76, and became 2.13 ± 0.67 after 6 months. Also Gobbi et al.  found that the mean VAS pretreatment was 4.1 ± 0.7 and became 2.2 ± 0.4 after 6 months.
Moreover, a recent study have evaluated the effect of intra-articular injection of PRP in knee OA and found that PRP was more successful than HA and ozone injections in providing at least 12 months of pain-free daily living activities . A meta-analysis showed that at 6 months postinjection, PRP is slightly superior to HA in relieving pain and improving the functional scores .
In contrast to our study and to many of the above-mentioned studies, a study by Filardo et al.  showed that PRP does not provide a superior clinical improvement with respect to HA, and therefore it should not be preferred to viscosupplementation as injective treatment of patients affected by knee cartilage degeneration and OA. This difference can be explained by different methods of preparation of RPR and also the storage method of PRP units as they were stored at −30°C, so PRP may lose some of its beneficial properties and the platelets may become degranulated.
In our study, we compared PRP intra-articular knee injections with triamcinolone intra-articular knee injections and we found a highly significant difference between the PRP group and the triamcinolone group postinjection after 1 month and there was a highly significant difference between the PRP group and the triamcinolone group in follow-up after 3 months by total WOMAC score with a decrease in the PRP group [Table 2].
Also, by VAS there was no significant difference in preinjection between both groups [Table 4].
After 1 month, there was highly significant difference in VAS in postinjection with more improvement in the PRP group than the triamcinolone group, where in group PRP the preinjection mean VAS was 7.72 ± 1.02, changed after 1 month in postinjection to 2.84 ± 1.34, and in the triamcinolone group the mean VAS was 7.84 ± 0.62 and changed after 1 month in postinjection to 5.12 ± 1.67 [Table 4].
And there was a highly significant difference in VAS in follow-up after 3 months of injection with improvement in the PRP group more than that of the triamcinolone group, where the VAS in the PRP group was 3.24 ± 1.64 but the VAS in the triamcinolone group increased again to 7.20 ± 1.32 [Table 4].
In accordance with our results, a study found that one shot of PRP injection decreased the joint pain more and in long term alleviated the symptoms and enhanced the activity of daily living and quality of life in short-term duration in comparison with corticosteroid. The mean pain severity in the group treated with corticosteroid before intervention was 79.1 ± 13.4. It changed to 63.2 ± 19.7 at 2 months and to 72.5 ± 16.2 at 6 months follow-up. In the PRP group, the mean pain severity was 80.4 ± 14.4 before intervention and turned into 45.1 ± 23.4 in the 2 months follow-up and 44.6 ± 15.6 in the sixth month follow-up .
One study found that intra-articular injection of corticosteroids caused masking of pain which allowed the patient to resume activity but possibly caused further destruction to the joint . Another study found a short period of benefits of 6 weeks or longer with intra-articular corticosteroid therapy compared with placebo . Also, the PRP treatment gave better results than HA in reducing pain and symptoms and aids in the recovery of articular function up to 6 months .
Also a recent Egyptian study concluded that intra-articular injection of autologous PRP is a safe, minimally invasive, low-cost procedure to deliver growth factors for cartilage healing and regeneration, and hence it is useful for the treatment of OA of the knee and helps to reduce pain and improve knee function and the quality of life .
| Conclusion|| |
From the previous discussion, we concluded that PRP intra-articular injection is an effective method for the treatment of knee OA. It is a safe and economic alternative method of treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thorstensson CA, Andersson ML, Jönsson H, Saxne T, Petersson IF. Natural course of knee osteoarthritis in middle-aged subjects with knee pain: 12-year follow-up using clinical and radiographic criteria. Ann Rheum Dis 2009; 68
Wang-Saegusa A, Cugat R, Ares O, Seijas R, Cuscó X, Garcia-Balletbó M. Infiltration of plasma rich in growth factors for osteoarthritis of the knee short-term effects on function and quality of life. Arch Orthop Trauma Surg 2011; 131
Smyth NA, Murawski CD, Fortier LA, Cole BJ, Kennedy JG. Platelet-rich plasma in the pathologic processes of cartilage: review of basic science evidence. Arthroscopy 2013; 29
Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al
. Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee. Arthritis Rheum 1986; 29
Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957; 16
Epstein O, Perkin GD, Cookson J, Watt IS, Rakhit R, Robins A, et al
. Clinical examination
ed.: Maryland Heights, Missouri, USA: Mosby Ltd; 2008. 20–50.
Maricara N, Callaghan MJ, Parkes MJ, Felson DT, O'Neill TW. Clinical assessment of effusion in knee osteoarthritis – a systematic review. Semin Arthritis Rheum 2016; 45
McConnell S, Kolopack P, Davis AM. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties. Arthritis Rheum 2001; 45
Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain 2003; 4
Co AY. Plantar fasciosis treatment with platelet-rich plasma. Podiatry Inst J 2012; 33
Raeissadat SA, Rayegani SM, Babaee M, Ghorbani E. The effect of platelet-rich plasma on pain, function, and quality of life of patients with knee osteoarthritis. Pain Res Treat 2013; 2013:165967.
Spaková T, Rosocha J, Lacko M, Harvanová D, Gharaibeh A. Treatment of knee joint osteoarthritis with autologous platelet-rich plasma in comparison with hyaluronic acid. Am J Phys Med Rehabil 2012; 91
Sadabad HN, Behzadifar M, Arasteh F, Behzadifar M, Dehgha HR. Efficacy of platelet-rich plasma versus hyaluronic acid for treatment of knee osteoarthritis: a systematic review and meta-analysis. Electron Physician 2016; 8
Kavadar G, Demircioglu DT, Celik MY, Emre TY. Effectiveness of platelet-rich plasma in the treatment of moderate knee osteoarthritis: a randomized prospective study J Phys Ther Sci 2015; 27
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
Gobbi A, Karnatzikos G, Mahajan V, Malchira S. Platelet-rich plasma treatment in symptomatic patients with knee osteoarthritis: preliminary results in a group of active patients. Sports Health 2012; 4
Hassan AS, El-Shafey AM, Ahmed HS, Hamed MS. Effectiveness of the intra-articular injection of platelet rich plasma in the treatment of patients with primary knee osteoarthritis. Egypt Rheumatol 2015; 37
Kilincoglu V, Yeter A, Servet E, Kangal M, Yildirim M. Short term results comparison of intraarticular platelet-rich plasma (PRP) and hyaluronic acid (ha) applications in early stage of knee osteoarthritis. Int J Clin Exp Med 2015; 8
Duymus TM, Mutlu S, Dernek B, Komur B, Aydogmus S, Kesiktas FN. Choice of intra-articular injection in treatment of knee osteoarthritis: platelet-rich plasma, hyaluronic acid or ozone options. Knee Surg Sports Traumatol Arthrosc 2017; 25
Dai WL, Zhou AG, Zhang H, Zhang J. Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials. Arthroscopy 2017; 33
Filardo G, Di Matteo B, Di Martino A, Merli ML, Cenacchi A, Fornasari P, et al
. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: a randomized controlled trial. Am J Sports Med 2015; 43
Forogh B, Mianehsaz E, Shoaee S, Ahadi T, Raissi GR, Sajadi S. 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 2016; 56
Ruddy S, Harris ED, Sledge CB, Sergent JS, Budd RC. Kelley's textbook of rheumatology
ed.: Philadelphia, USA: Saunders; 2001. 1419–1432.
McGarry JG, Daruwalla ZJ. The efficacy, accuracy and complications of corticosteroid injections of the knee joint. Knee Surg Sports Traumatol Arthrosc 2011; 19
Kon E, Mandelbaum B, Buda R, Filardo G, Delcogliano M, Timoncini A, et al
. Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology, from early degeneration to osteoarthritis. Arthroscopy 2011; 27
Montaser LM, Eid TA, Helwa MA, Mesregah MK. Application of platelet-rich plasma preparation rich in growth factors in knee osteoarthritis. Menoufia Med J 2017; 30
[Table 1], [Table 2], [Table 3], [Table 4]