Intra-articular injections of platelet-rich plasma in symptomatic knee osteoarthritis: a consensus statement from French-speaking experts

Abstract

Purpose There has been much debate regarding the use of intra-articular injections of platelet-rich plasma (PRP) as symptomatic treatment for knee osteoarthritis. The objective of this consensus was to develop guidelines for PRP injections in knee osteoarthritis according to the French National Authority for Health recommendations. Methods Fifteen physicians from different French-speaking countries (10 rheumatologists, 4 specialists in rehabilitation and sports medicine and 1 radiologist) were selected for their expertise in the areas of PRP and osteoarthritis. A comprehensive literature review was conducted on Medline including all published therapeutic trials, open studies, meta-analysis and systematic reviews focusing on the effects of PRP in knee OA, as well as fundamental studies concerning the characteristics of the various types of PRP and their mechanisms, indexed before April 2019. Using the method recommended by the French National Authority for Health inspired by the Delphi consensus process, 25 recommendations were finally retained and evaluated. The recommendations were classified as appropriate or not appropriate, with strong or relative agreement, or uncertain if a consensus was not achieved. Results Among the 25 recommendations selected, the main ones are the following: (1) Intra-articular injections of PRP are an effective symptomatic treatment for early to moderate knee osteoarthritis. This recommendation was considered appropriate with a relative agreement (Median = 8; rank = 6–9). Level of evidence 1A. (2) A PRP treatment sequence in knee osteoarthritis may include 1–3 injections. This recommendation was considered appropriate with a strong agreement (Median = 9; rank = 7–9). Level of evidence 1A. (3) Leucocytes-poor PRP should be preferred in knee osteoarthritis. This recommendation was considered appropriate with a relative agreement (Median = 8; rank = 5–9). Level of evidence 5. (4) Intra-articular PRP knee injections should be performed under ultrasound or fluoroscopic guidance. This recommendation was considered uncertain with no consensus (Median = 8; rank = 3–9). Level of evidence 5. (5) PRP should not be mixed with an anesthetic or intra-articular corticosteroid. This recommendation was considered appropriate with a relative agreement (Median = 9; rank = 6–9). Level of evidence 5 Conclusion Those 25 recommendations should standardize and facilitate the use of IA PRP injections, which are considered by experts as an effective treatment especially in early or moderate knee OA. Although a strong or relative agreement from the experts was obtained for most of the recommendations, many of them had a very low level of evidence (Level 5) and were principally based on the clinical experience of the experts.

Platelet-Rich Plasma: New Performance Understandings and Therapeutic Considerations in 2020

“…The importance of neutrophils in PRP is unclear. Systematic reviews identified LP-PRP as the preferred PRP formulation to achieve effective treatment outcomes for joint OA [ 33 ]. However, Lana et al [ 34 ] opposed the use of LP-PRP in knee OA treatment, suggesting that particular leukocytes play an important role in the inflammatory process preceding tissue regeneration due to their release of both pro and anti-inflammatory molecules.…”

Platelet-Rich Plasma: New Performance Understandings and Therapeutic Considerations in 2020

“…The importance of neutrophils in PRP is unclear. Systematic reviews identified LP-PRP as the preferred PRP formulation to achieve effective treatment outcomes for joint OA (25). However, Lana et al (26) opposed the use of LP-PRP in knee OA treatment, suggesting that particular leukocytes play an important role in the inflammatory process preceding tissue regeneration due to their release of both pro and anti-inflammatory molecules.…”

Clinical outcome and risk factor predictive for failure of autologous PRP injections for low-to-moderate knee osteoarthritis

“…A recent consensus 29 described the low to moderate knee OA as proper indication for PRP injections. A careful patient selection is recommended because severe radiographic changes appeared to be correlated to poor clinical outcome.…”

“…This was not confirmed for hyaluronic acid injections as no differences were found. It's well known that corticosteroids have a catabolic activity of PRP and Eymand et al 29 recommend a delay if steroids are injected before PRP. Nevertheless, Camurcu et al 36 demonstrated that single steroid injection followed by PRP 1 week later improve the clinical response in patients with low or moderate knee OA.…”

“…The heterogeneity of available PRP products (number of platelets and leukocytes, amount of growth factors and proor anti-inflammatory cytokines) and unstandardized protocols both leads to variable clinical results and contrasting findings. 29,37 A precise, stepwise and detailed description of the preparation protocol is mandatory to provide the reproducibility and the efficacy of this therapeutic strategy.…”