Platelet-rich Plasma May Benefit Early Knee OA
Platelet-rich plasma (PRP), a therapy used to help heal surgical wounds and tendon injuries, may also relieve symptoms of early knee osteoarthritis (OA), according to a new study out of the Hospital for Special Surgery (HSS) in New York. Researchers there say patients with knee OA reported significantly improved pain and function for 12 months after a single PRP injection. The findings, published online in Clinical Journal of Sports Medicine, also suggest that PRP may slow joint damage if administered early in the course of the disease. "The results are very exciting," says Brian Halpern, MD, chief of the Primary Care Sports Medicine Service at HSS and lead author of the study. "This suggests that PRP may have the potential not only to relieve symptoms but also to delay progression of OA, although we don't know if that will continue year after year." Dr. Halpern is also a clinical associate professor at Weill Cornell Medical College in New York. PRP is a preparation of platelets derived from a person's own blood. It's obtained by spinning a small amount of blood in a centrifuge to separate the platelets from red and white blood cells. The concentrated platelets are then injected into problem areas where they are thought to release growth factors and stimulate the healing process. In the HSS study, researchers injected 22 patients with 6 milliliters of PRP and followed them for one year. All participants had diagnosed knee OA and had arthritis-related pain for an average of 14 months. The patients were clinically evaluated at baseline and periodically throughout the year for knee pain, function, stiffness and the ability to perform tasks of daily living, such as climbing stairs. Study participants also underwent magnetic resonance imaging (MRI) to evaluate joint cartilage at baseline and at one year – something not done in previous PRP studies. Although questionnaires used in the study – the visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) – are validated tools routinely used to assess pain and function in people with OA, they are subjective. An MRI, on the other hand provides an objective picture of changes in the joint. Seventeen patients completed the study and full MRI data was available for 15. For the majority of patients, clinical outcomes were encouraging. On the VAS pain scale, pain was reduced 56.2 percent at 6 months and nearly 60 percent at one year. WOMAC scores showed similar reductions in pain and stiffness. Activities of daily living (ADL) scores also improved significantly: 46.8 percent at 6 months and 55.7 percent at one year. What's more, most study participants showed no further cartilage loss a year after the PRP injection. Previous studies have found that people with knee OA tend to lose around 5 percent of cartilage per year. Dr. Halpern stresses that the positive results occurred in people with early OA. "You're not going to be able to do a lot in the regenerative sense for people with bone-on-bone arthritis. By then, the horse is already out of the barn," he says. "But in the earlier stages, you can improve symptoms and the environmental milieu enough to delay or maybe even prevent knee replacement. But that's a long way off and we need to look at a lot more numbers [before we can say that with certainty]." Still, Dr. Halpern says the study results have prompted HSS to create a registry that will track future osteoarthritis patients over time. Researchers will be able to compare outcomes for various OA treatments, such as exercise, weight control, bracing and hyaluronic acid injections as well as PRP. And for the first time, imaging tests will be used to detect changes in joint cartilage.
It's hoped that the HSS data will help answer some of the many questions that arise as PRP treatments become more common. "Many more folks are doing it now, especially sports medicine orthopaedists, and they are learning more about why it can and can't work," says Dr. Halpern, noting that he has injected more than 400 patients with PRP over the last five years and all had outcomes consistent with the study results. "One example is that it appears the platelet concentration has an effect on efficacy, but we don't know what the optimum [level] is right now. That's another thing that has to be explored,” he says. “By definition, PRP formulations have to be two to five times greater than the platelet concentration in the blood. But it seems that if platelet concentration gets as high as eight times greater, it can actually have a deleterious effect." Dr. Halpern stresses that PRP is not a panacea. "It certainly won't help everybody with everything," he notes. "This is an evolving field, and we need to learn much more." Eric L. Matteson, MD, chair of rheumatology at the Mayo Clinic in Rochester, Minnesota, agrees that PRP needs more study. "The real issue from a biological standpoint is whether PRP contains factors that can somehow stimulate cartilage and in so doing improve arthritis. There has to be some demonstration of actual effect. If there is improvement in cartilage, we should be able to see it, but this study didn't show that,” says Dr. Matteson. “And if MRI didn't show an improvement, then what accounts for the decrease in pain? Perhaps the placebo effect. We really have no idea. We need studies that show the biological plausibility of this treatment." Orthopaedic surgeon Jason Scopp, MD, director of the Joint Preservation Center at Peninsula Orthopaedic Associates in Salisbury, Md., says that in addition to failing to show biological plausibility, the HSS study has other shortcomings. "This is a very small sample size, which means the study is underpowered, and there is no control group for comparison. Other studies of PRP have enrolled more patients, are better powered and compare PRP to viscosupplementation [hyaluronic acid injections]," he notes. Still, despite what he sees as the limitations of this study, Dr. Scopp is a fan of PRP. "PRP is a great product, and several studies have shown it to be superior to cortisone and even viscosupplementation, but there is still no consensus on the best preparation, best volume of injections and number of injections," he says.