Background
Prevalence and impact of knee osteoarthritis
Current treatment paradigm
Platelet-rich plasma as an emerging therapy
Aim
Methods
Search methods for identification of studies
Study inclusion and exclusion criteria
Types of outcome measures
Primary outcome
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Change in score using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores as well as the visual analog scales (VAS) at 6 months post-intervention.
Secondary outcomes
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Outcomes at 1, 3, 9- and 12-months post-intervention were assessed where available.
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Stratification of analyses by Kellgren Lawrence (KL) grade were performed where possible.
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Individual sub-scores as well as overall score from each scoring tool is assessed.
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Efficacy of single versus multiple injections of platelet-rich plasma.
Data collection and analysis
Selection of studies
Data extraction and management
Assessment of risk Bias and heterogeneity
Measures of treatment effect
Data synthesis
Results
Search results
Study characteristics
Study | Sample (n) | Dropouts | Study Design | Population | Intervention design | Follow-up period | Outcome Measurement |
---|---|---|---|---|---|---|---|
Huang et al. (2019) [26] | 265 recruited 120 participants (46% female) 40 received PRP, 40 received CS and 40 HA (HA patients not included) | 0 145 did not meet inclusion criteria | Prospective, randomised study | Kellgren/Lawrence grade 1–2 Aged 40–65 Chinese patients recruited from May 2016 | 1 injection per group, received once Anatomically guided injections 4 ml LP-PRP 1 ml corticosteroid | 12 months | WOMAC and VAS scores at 3, 6,9- and 12-months post intervention |
Khan et al. (2018) [29] | 150 patients recruited 101 participants (76.5% female) 52 received PRP, 51 received CS | 49 | Randomised control trial | Kellgren/Lawrence grade 2 and ACR osteoarthritis criteria Aged 40–63 Pakistani patients recruited between July ‘17-July ‘18 | 2 injections per group, given at 0 months and 2 months. Anatomically guided injections 5 ml PRP (LR/LP not specified) 1 mil (40 mg) triamcinolone | 6 months | WOMAC and VAS scores at 2 months, then every 2 weeks until 6 months |
Naderi et al. (2018) [30] | 72 recruited 67 participated (82% female) 33 received PRP, 34 received corticosteroids | 5 | Randomised control trial with Quad ruple block randomisation | Kellgren/Lawrence or ACR grade 2–3 osteoarthritis Aged 30–75 Iranian patients between April ‘16- June ‘17, recruited in a hospital | 3 injections performed once a month for 3 consecutive months in both groups Ultrasound guided injections 5 ml LR-PRP 40 mg triamcinolone | 6 months | VAS and KOOS scores before the onset of treatment, once a month after treatment and 6 months after treatment. |
Freire et al. (2018) [28] | 50 patients (25 PRP, 25 corticosteroids) (84% female) Double-blinded block randomisation | 0 | Randomised, controlled, longitudinal, double blind, comparative, descriptive study | Kellgren/Lawrence 2–4 Aged 30–90 Brazilian patients, recruited in a medical centre | 1 injection performed once in each group Anatomically guided injections 5 ml LP- PRP 2.5 ml triamcinolone | 6 months | KSS, WOMAC, Kellgren-Lawrence scores evaluated before treatment, at 1 months and 6 months post-intervention |
Camurcu et al. (2018) [31] | 132 patients recruited (83% female) 37 PRP, 40 PRP+ steroid, 38 steroid | 17 | Prospective longitudinal study | Kellgren-Lawrence grade 2–3 Aged 40–80 Turkish patients recruited in 2016 | 1 injection of PRP only, PRP + steroid, or steroid only Anatomically guided injection 3 ml LR-PRP 1 ml methylprednisolone | 12 months (for 115 patients) | VAS and WOMAC at 1,3, 6- and 12-months post-intervention |
Phul et al. (2018) [27] | 80 patients recruited 40 in each group: PRP or corticosteroid (67.5% female) | 0 | Randomised control trial | Kellgren/Lawrence grade 2–4 Aged 40–75 Pakistani patients recruited between Feb- August 2015 | 1 injection in both groups Anatomically guided injection for PRP; fluoroscopically guided corticosteroid injection 4–6 microml LR-PRP 40 ml triamcinolone | 3 months | VAS at baseline and 3 months post-intervention |
Uslu et al. (2017) [20] | 57 patients recruited 50 participants (92% female) 17 received CS, 19 single PRP, 14 triple PRP injection | 7 | Prospective, randomised, single-blind (physician blind) | Kellgren/Lawrence grade 3 Aged 50–75 Turkish patients between June ‘15- March ‘16, hospital setting | 3 groups receiving either 1 PRP injection, 3 PRP injections (given 1 week apart) or 1 steroid injection Anatomically guided injections LR-PRP, dose not specified Corticosteroid suspension equivalent to 5 mg betamethasone | 6 months | VAS, WOMAC and HAD scale (an assessment of anxiety and depression) with follow up at baseline, 2 and 6 months post-intervention |
Jubert et al. (2017) [22] | 65 patients included (72% female) 35 PRP, 30 corticosteroid | 0 | Prospective randomised, double-blind, parallel controlled study | Kellgren/Lawrence grade 3–4 Aged 40–80 Patients between Aug ‘13- July ‘14 | 1 injection per group given once Anatomically guided injections 4 ml LP-PRP 2 ml betamethasone | 6 months | VAS, KOOS and SF36 scores at 1, 3- and 6-months post-intervention |
Preparation and dosages of PRP and corticosteroids
Risk of Bias within studies
Sponsorship, publication Bias and heterogeneity of included studies
Outcomes by timeframe
Pain Score Reduction (WOMAC/VAS) | |||||
---|---|---|---|---|---|
Outcome | Number of studies | Pooled SMD (95 CI) | P | Heterogeneity | |
I2 (%) | P | ||||
1 month | 4 | −0.07 [−0.49, 0.35] | 0.74 | 65 | 0.03 |
3 month | 6 | −0.51 [− 0.90, − 0.12] | 0.01 | 72 | 0.003 |
6 month | 7 | −0.78 [− 1.34, − 0.23] | 0.005 | 88 | < 0.00001 |
9 months | 1 | − 1.63 [− 2.14, − 1.12] | < 0.00001 | n/a | n/a |
12 months | 2 | −1.12 [− 3.34, 1.09] | 0.32 | 97 | < 0.00001 |
LP-PRP | 3 | −0.61 [− 0.92, − 0.29] | 0.00002 | 16 | 0.31 |
LR-PRP | 5 | −0.98 [−1.79, − 0.17] | 0.02 | 92 | < 0.00001 |
Single PRP injection | 5 | −0.52 [−1.11, 0.07] | 0.08 | 87 | < 0.00001 |
Triple PRP Injection | 2a | −0.94 [−1.31, − 0.58] | < 0.00001 | 12 | 0.29 |
Outcome | Pooled mean difference (MD) | |||||
---|---|---|---|---|---|---|
No. Studies | WOMAC (/96) | P | No. Studies | VAS (/10) | P | |
3 months | 3 | −2.15 [−5.65, 1.35] | 0.23 | 4 | − 0.51 [− 1.02, 0.01] | 0.05 |
6 months | 4 | −9.51 [− 15.20, −3.83] | 0.05 | 4 | − 0.97 [− 1.94, 0.00] | 0.05 |
6 months: KL 1–2 | 1 | −3.86 [−6.01, − 1.71] | 0.0004 | 1 | −0.28 [− 0.97, 0.41] | 0.43 |
6 months: KL 2–3 | 2 | − 9.10 [− 15.73, − 2.46] | 0.007 | 2 | − 0.68 [− 2.01, 0.65] | 0.32 |
9 months* | 1 | −8.04 [− 10.19, − 5.89] | < 0.00001 | – | – | – |
12 months | 2 | − 8.10 [− 23.86, 7.65] | 0.31 | 2 | −0.07 [− 0.42, 0.28] | 0.69 |
LP-PRP | 2 | − 7.95 [− 18.14, 2.24] | 0.13 | 2 | −0.39 [− 1.01, 0.23] | 0.22 |
LR-PRP | 2 | − 11.26 [− 19.88, − 2.64] | 0.01 | 5 | − 0.98 [− 1.80, − 0.16] | 0.02 |
Triple PRP injection | 2 | −9.65 [− 21.35, 2.04] | 0.11 | 3 | −1.30 [− 2.33, − 0.26] | 0.01 |
Single PRP Injection | 2 | −9.10 [− 15.75, − 2.46] | 0.007 | 44 | − 0.26 [− 1.03, 0.52] | 0.52 |
KL grade: outcomes at six months
Subscore analysis
WOMAC subscores
WOMAC Subscale Score Reduction | ||||
---|---|---|---|---|
Outcome | Pooled mean difference (95 CI) | P | Heterogeneity | |
I2 (%) | P | |||
Pain | −2.66 [−4.73, −0.60] | 0.01 | 93 | < 0.00001 |
Stiffnessa | −1.95 [−2.30, − 1.59] | < 0.00001 | 0 | 0.78 |
Physical Function | −5.47 [− 13.80, 2.86] | 0.2 | 97 | 0.00001 |