Knee Osteoarthritis

1CliniCal MediCine insights: arthritis and MusCuloskeletal disorders 2015:8

Open Access: Full open access to this and thousands of other papers at http://www.la-press.com.

Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders

Background Knee osteoarthritis (OA) is a chronic progressive disease affecting more than 20% of people older than 45 years.1 According to the survey of the causes of productive work time

loss in the United States, OA is the second most common cause of work performance loss after low back pain.2 With an increase in life expectancy, it is estimated that the need for knee arthroplasty would rise more than six times by 2030,

Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial)

seyed ahmad raeissadat1, seyed Mansoor rayegani2, hossein hassanabadi3, Mohammad Fathi4, elham ghorbani5, Marzieh Babaee5 and kamran azma6 1Physical Medicine and Rehabilitation Department, Clinical Development Center of Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2Physical Medicine and Rehabilitation Department, PM & R Research Center of Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3Physical Medicine and Rehabilitation Department, Mashhad University of Medical Sciences, Mashhad, Iran. 4Anesthesiology Department, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 5Physical Medicine and Rehabilitation Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 6Physical Medicine and Rehabilitation Department, AJA University of Medical Sciences, Tehran, Iran.

ABstrAct IntroductIon: Knee osteoarthritis (OA) is the most common articular disease. Different methods are used to alleviate the symptoms of patients with knee OA, including analgesics, physical therapy, exercise prescription, and intra-articular injections (glucocorticoids, hyaluronic acid [HA], etc). New studies have focused on modern therapeutic methods that stimulate cartilage healing process and improve the damage, including the use of platelet-rich plasma (PRP) as a complex of growth factors. Due to the high incidence of OA and its consequences, we decided to study the long-term effect of intra- articular injection of PRP and HA on clinical outcome and quality of life of patients with knee OA. Method: This non-placebo-controlled randomized clinical trial involved 160 patients affected by knee OA, grade 1–4 of Kellgren–Lawrence scale. In the PRP group (n = 87), two intra-articular injections at 4-week interval were applied, and in the HA group (n = 73), three doses of intra-articular injection at 1-week interval were applied. All patients were prospectively evaluated before and at 12 months after the treatment by Western Ontario and McMaster Universities Arthritis Index (WOMAC) and SF-36 questionnaires. The results were analyzed using SPSS 16.1 software (RCT code: IRCT2014012113442N5). results: At the 12-month follow-up, WOMAC pain score and bodily pain significantly improved in both groups; however, better results were deter- mined in the PRP group compared to the HA group (P , 0.001). Other WOMAC and SF-36 parameters improved only in the PRP group. More improve- ment (but not statistically significant) was achieved in patients with grade 2 OA in both the groups. conclusIon: This study suggests that PRP injection is more efficacious than HA injection in reducing symptoms and improving quality of life and is a therapeutic option in select patients with knee OA who have not responded to conventional treatment.

Keywords: knee osteoarthritis, intra-articular injection, platelet-rich plasma, hyaluronic acid

CItAtIOn: raeissadat et al. knee osteoarthritis injection Choices: hyaluronic acid Versus Platelet rich Plasma. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 2015:8 1–8 doi: 10.4137/CMaMd.s17894.

ReCeIVed: June 12, 2014. ReSubmItted: october 4, 2014. ACCePted fOR PublICAtIOn: october 20, 2014.

ACAdemIC edItOR: Chuanju liu, editor in Chief

tYPe: original research

fundIng: authors disclose no funding sources.

COmPetIng InteReStS: Authors disclose no potential conflicts of interest.

COPYRIgHt: © the authors, publisher and licensee libertas academica limited. this is an open-access article distributed under the terms of the Creative Commons CC-BY-nC 3.0 license.

CORReSPOndenCe: ghorbani_egh@yahoo.com

Paper subject to independent expert blind peer review by minimum of two reviewers. all editorial decisions made by independent academic editor. upon submission manuscript was subject to anti-plagiarism scanning. Prior to publication all authors have given signed confirmation of agreement to article publication and compliance with all applicable ethical and legal requirements, including the accuracy of author and contributor information, disclosure of competing interests and funding sources, compliance with ethical requirements relating to human and animal study participants, and compliance with any copyright requirements of third parties. this journal is a member of the Committee on Publication ethics (CoPe).

Raeissadat et al

2 CliniCal MediCine insights: arthritis and MusCuloskeletal disorders 2015:8

causing significant economic burdens for pain control and rehabilitation of patients.3

The targets of OA treatment are pain decrement, func- tion and mobility increment, prevention or correction of the deformity, and slowing the progression of the disease. There are numerous conservative treatments for knee OA that have short-term efficacy and have their own benefits and disadvan- tages.4 For example, Non steroidal anti-inflammatory drugs (NSAIDs) and intra-articular corticosteroid are common treatments of arthritis. Despite their low cost and easy access, these treatments have systemic adverse effects and may cause joint cartilage destruction and flare up of the osteoarthritic pro- cess.5 Also common treatments for cartilage tissue repair rarely achieve an ideal level of functional capacity for the patient.6

Because of the high costs of knee OA management, ther- apeutic options that are effective on tissue healing have been taken into consideration in recent years in order to prevent the progression of OA.7 Among these are growth factors that have been studied both in vitro and in vivo as effective factors for the healing of cartilage in OA with promising results.8–10 Growth factors are effective in chemotaxis, differentiation of mesenchymal stem cells, chondrocyte proliferation, and syn- thetic activities of osseous and cartilaginous cells; therefore, they have important roles in healing and remodeling of carti- lage tissue.11

Platelet-rich plasma (PRP) is an autologous biologic treatment including patients’ own plasma, containing growth factors released from platelets and endogenous fibrin scaf- fold.12 The rationale for the use of PRP is to stimulate the natural healing cascade and tissue regeneration by a “supra- physiologic” release of platelet-derived factors directly at the site of treatment.4

Most studies believe that therapeutic PRP should have platelet concentrations four to six times greater than whole blood (200,000 mm−3). Some authors stated that the concen- trations less than or greater than this amount may be ineffective or inversely lead to suppression of the healing process.13 PRP is classified into four categories, depending on leukocyte and fibrin contents: pure platelet-rich plasma (P-PRP); leukocyte- and platelet-rich plasma (L-PRP); pure platelet-rich fibrin (P-PRF); and leukocyte- and platelet-rich fibrin (L-PRF).14

The applications of biologic treatments such as PRP in musculoskeletal disorders are growing significantly. Although comparing PRP with other intra-articular and soft tissue injections has led to conflicting results, it seems that PRP has useful effects on healing and functional improvement of injured tissues.15–17

Viscosupplementation is another conservative method in OA management, which was approved by Food and Drug Administration for knee therapy in 1997 and was suggested by American college of Rheumatology (ACR) guideline as a therapeutic choice for pain decrement in knee OA in 2000.18

Hyaluronic acid (HA) is a high molecular weight glu- cosamine comprising repeating units of acetyl glucosamine

and d-acid glucoronic synthetized by synoviocytes, fibroblasts, and chondrocytes. It is available in synovial fluid and extracel- lular matrix and is responsible for viscoelastic and lubricant features of synovial fluid.19 A normal adult knee joint has 2 mL of synovial fluid containing 2.5–4 mg/mL of HA with mean molecular weight of 5–7 × 106 kD. In the OA setting, both concentration and molecular weight of endogenous HA decrease due to synovial fluid dilution secondary to effusion, abnormal synoviocyte production, and molecular fragmenta- tion.16 Although the mechanism of intra-articular injection of HA in improving OA symptoms is not clearly known, it seems that it has some role in joint mechanical support…