Which patients might benefit from platelet-rich plasma?

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doi:doi: 10.12788/jfp.0607

Applied Evidence

Which patients might benefit from platelet-rich plasma?

J Fam Pract. 2023 June;72(5):192-199 | doi: 10.12788/jfp.0607

By

Gregory D. Bentz Jr, MD

Marvin H. Sineath Jr, MD

Megan S. Dannemiller, MD

PRP has become a popular form of regenerative medicine. This review looks at the evidence for its use in various musculoskeletal conditions.

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PRACTICE RECOMMENDATIONS

› Consider plateletrich plasma (PRP) for conservative management of knee osteoarthritis and lateral epicondylitis. B

› Consider giving multiple injections of PRP for longterm pain relief and expedited return to sport in patellar tendinopathy. B

› Do not use PRP for Achilles tendinopathy due to a lack of clinical evidence. B

Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Cecerska-Heryć E, Goszka M, Serwin N, et al. Applications of the regenerative capacity of platelets in modern medicine. Cytokine Growth Factor Rev. 2022;64:84-94. doi: 10.1016/j.cytogfr.2021.11.003

2. Le ADK, Enweze L, DeBaun MR, et al. Current clinical recommendations for use of platelet-rich plasma. Curr Rev Musculoskelet Med. 2018;11:624-634. doi: 10.1007/s12178-018-9527-7

3. Everts P, Onishi K, Jayaram P, et al. Platelet-rich plasma: new performance understandings and therapeutic considerations in 2020. Int J Mol Sci. 2020;21:7794. doi: 10.3390/ijms21207794

4. Di Martino A, Boffa A, Andriolo L, et al. Leukocyte-rich versus leukocyte-poor platelet-rich plasma for the treatment of knee osteoarthritis: a double-blind randomized trial. Am J Sports Med. 2022;50:609-617. doi: 10.1177/03635465211064303

5. Mariani E, Pulsatelli L. Platelet concentrates in musculoskeletal medicine. Int J Mol Sci. 2020;21:1328. doi: 10.3390/ijms21041328

6. Belk JW, Kraeutler MJ, Houck DA, et al. Platelet-rich plasma versus hyaluronic acid for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2021;49:249-260. doi: 10.1177/0363546520909397

7. Filardo G, Kon E, Della Villa S, et al. Use of platelet-rich plasma for the treatment of refractory jumper’s knee. Int Orthop. 2010;34:909-915. doi: 10.1007/s00264-009-0845-7

8. Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper’s knee. Injury. 2009;40:598-603. doi: 10.1016/j.injury.2008.11.026

9. Kanchanatawan W, Arirachakaran A, Chaijenkij K, et al. Short-term outcomes of platelet-rich plasma injection for treatment of osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2016;24:1665-1677. doi: 10.1007/s00167-015-3784-4

10. Cook J, Young M. Biologic therapies for tendon and muscle injury. UpToDate. Updated August 11, 2022. Accessed May 23, 2023. www.uptodate.com/contents/biologic-therapies-for-tendon-and-muscle-injury

11. Bendich I, Rubenstein WJ, Cole BJ, et al. What is the appropriate price for platelet-rich plasma injections for knee osteoarthritis? A cost-effectiveness analysis based on evidence from Level I randomized controlled trials. Arthroscopy. 2020;36:1983-1991.e1. doi: 10.1016/j.arthro.2020.02.004

12. Jones IA, Togashi RC, Thomas Vangsness C Jr. The economics and regulation of PRP in the evolving field of orthopedic biologics. Curr Rev Musculoskelet Med. 2018;11:558-565. doi: 10.1007/s12178-018-9514-z

13. Costa LAV, Lenza M, Irrgang JJ, et al. How does platelet-rich plasma compare clinically to other therapies in the treatment of knee osteoarthritis? A systematic review and meta-analysis. Am J Sports Med. 2023;51:1074-1086 doi: 10.1177/03635465211062243

14. Meheux CJ, McCulloch PC, Lintner DM, et al. Efficacy of intra-articular platelet-rich plasma injections in knee osteoarthritis: a systematic review. Arthroscopy. 2016;32:495-505. doi: 10.1016/j.arthro.2015.08.005

15. Shen L, Yuan T, Chen S, et al. The temporal effect of platelet-rich plasma on pain and physical function in the treatment of knee osteoarthritis: systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2017;12:16. doi: 10.1186/s13018-017-0521-3

16. Paget LDA, Reurink G, de Vos RJ, et al; PRIMA Study Group. Effect of platelet-rich plasma injections vs. placebo on ankle symptoms and function in patients with ankle osteoarthritis: a randomized clinical trial. JAMA. 2021;326:1595-1605. doi: 10.1001/jama.2021.16602

17. Evans A, Ibrahim M, Pope R, et al. Treating hand and foot osteoarthritis using a patient’s own blood: a systematic review and meta-analysis of platelet-rich plasma. J Orthop. 2020;18:226-236. doi: 10.1016/j.jor.2020.01.037

18. Ye Y, Zhou X, Mao S, et al. Platelet rich plasma versus hyaluronic acid in patients with hip osteoarthritis: a meta-analysis of randomized controlled trials. Int J Surg. 2018;53:279-287. doi: 10.1016/j.ijsu.2018.03.078.

19. Berney M, McCarroll P, Glynn L, et al. Platelet-rich plasma injections for hip osteoarthritis: a review of the evidence. Ir J Med Sci. 2021;190:1021-1025. doi: 10.1007/s11845-020-02388-z

20. Belk JW, Houck DA, Littlefield CP, et al. Platelet-rich plasma versus hyaluronic acid for hip osteoarthritis yields similarly beneficial short-term clinical outcomes: a systematic review and meta-analysis of Level I and II randomized controlled trials. Arthroscopy. 2022;38:2035-2046. doi: 10.1016/j.arthro.2021.11.005

21. Dadgostar H, Fahimipour F, Pahlevan Sabagh A, et al. Corticosteroids or platelet-rich plasma injections for rotator cuff tendinopathy: a randomized clinical trial study. J Orthop Surg Res. 2021;16:333. doi: 10.1186/s13018-021-02470-x

22. Kwong CA, Woodmass JM, Gusnowski EM, et al. Platelet-rich plasma in patients with partial-thickness rotator cuff tears or tendinopathy leads to significantly improved short-term pain relief and function compared with corticosteroid injection: a double-blind randomized controlled trial. Arthroscopy. 2021;37:510-517. doi: 10.1016/j.arthro.2020.10.037

23. A Hamid MS, Sazlina SG. Platelet-rich plasma for rotator cuff tendinopathy: a systematic review and meta-analysis. PLoS One. 2021;16:e0251111. doi: 10.1371/journal.pone.0251111

24. Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005;33:561-567. doi: 10.1177/0363546504270454

25. Dragoo JL, Wasterlain AS, Braun HJ, et al. Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med. 2014;42:610-618. doi: 10.1177/0363546513518416.

26. Rodas G, Soler-Rich R, Rius-Tarruella J, et al. Effect of autologous expanded bone marrow mesenchymal stem cells or leukocyte-poor platelet-rich plasma in chronic patellar tendinopathy (with gap >3 mm): preliminary outcomes after 6 months of a double-blind, randomized, prospective study. Am J Sports Med. 2021;49:1492-1504. doi: 10.1177/0363546521998725

27. Andriolo L, Altamura SA, Reale D, et al. Nonsurgical treatments of patellar tendinopathy: multiple injections of platelet-rich plasma are a suitable option: a systematic review and meta-analysis. Am J Sports Med. 2019;47:1001-1018. doi: 10.1177/0363546518759674

28. Scott A, LaPrade RF, Harmon KG, et al. Platelet-rich plasma for patellar tendinopathy: a randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline. Am J Sports Med. 2019;47:1654-1661. doi: 10.1177/0363546519837954

29. Kemp JA, Olson MA, Tao MA, et al. Platelet-rich plasma versus corticosteroid injection for the treatment of lateral epicondylitis: a systematic review of systematic reviews. Int J Sports Phys Ther. 2021;16:597-605. doi: 10.26603/001c.24148

30. Miller LE, Parrish WR, Roides B, et al. Efficacy of platelet-rich plasma injections for symptomatic tendinopathy: systematic review and meta-analysis of randomised injection-controlled trials. BMJ Open Sport Exerc Med. 2017;3:e000237. doi: 10.1136/bmjsem-2017- 000237

31. Ben-Nafa W, Munro W. The effect of corticosteroid versus platelet-rich plasma injection therapies for the management of lateral epicondylitis: a systematic review. SICOT J. 2018;4:11. doi: 10.1051/sicotj/2017062

32. Niemiec P, Szyluk K, Jarosz A, et al. Effectiveness of platelet-rich plasma for lateral epicondylitis: a systematic review and meta-analysis based on achievement of minimal clinically important difference. Orthop J Sports Med. 2022;10:23259671221086920. doi: 10.1177/23259671221086920

33. Li S, Yang G, Zhang H, et al. A systematic review on the efficacy of different types of platelet-rich plasma in the management of lateral epicondylitis. J Shoulder Elbow Surg. 2022;311533-1544. doi: 10.1016/j.jse.2022.02.017.

34. Madhi MI, Yausep OE, Khamdan K, et al. The use of PRP in treatment of Achilles tendinopathy: a systematic review of literature. Study design: systematic review of literature. Ann Med Surg (Lond). 2020;55:320-326. doi: 10.1016/j.amsu.2020.04.042

35. Loppini M, Maffulli N. Conservative management of tendinopathy: an evidence-based approach. Muscles Ligaments Tendons J. 2012;1:134-137.

36. Nauwelaers AK, Van Oost L, Peers K. Evidence for the use of PRP in chronic midsubstance Achilles tendinopathy: a systematic review with meta-analysis. Foot Ankle Surg. 2021;27:486-495. doi: 10.1016/j.fas.2020.07.009

37. Dai WL, Zhou AG, Zhang H, et al. Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials. Arthroscopy. 2017;33:659-670.e1. doi: 10.1016/j.arthro.2016.09.024

38. Bar-Or D, Rael LT, Brody EN. Use of saline as a placebo in intra-articular injections in osteoarthritis: potential contributions to nociceptive pain relief. Open Rheumatol J. 2017;11:16-22. doi: 10.2174/1874312901711010016

39. Phillips M, Bhandari M, Grant J, et al. A systematic review of current clinical practice guidelines on intra-articular hyaluronic acid, corticosteroid, and platelet-rich plasma injection for knee osteoarthritis: an international perspective. Orthop J Sports Med. 2021;9:23259671211030272. doi: 10.1177/23259671211030272

40. Finnoff JT, Awan TM, Borg-Stein J, et al. American Medical Society for Sports Medicine position statement: principles for the responsible use of regenerative medicine in sports medicine. Clin J Sport Med. 2021;31:530-541. doi: 10.1097/JSM.0000000000000973

Platelet-rich plasma (PRP) injections have become a popular treatment option in a variety of specialties including sports medicine, maxillofacial surgery, dermatology, cosmetology, and reproductive medicine.¹ PRP is an autologous blood product derived from whole blood, using a centrifuge to isolate a concentrated layer of platelets. The a-granules in platelets release transforming growth factor b 1, vascular endothelial growth factor, platelet-derived growth factor, basic fibroblast growth factor, epidermal growth factor, insulin-like growth factor 1, and other mediatorsthat enhance the natural healing process.²

When patients ask. Familiarity with the use of PRP to treat specific musculoskeletal (MSK) conditions is essential for family physicians who frequently are asked by patients about whether PRP is right for them. These patients may have experienced failure of medication therapy or declined surgical intervention, or may not be surgical candidates. This review details the evidence surrounding common intra-articular and extra-articular applications of PRP. But first, a word about how PRP is prepared, its contraindications, and costs.

Preparation and types of PRP

Although there are many commercial systems for preparing PRP, there is no consensus on the optimal formulation.² Other terms for PRP, such as autologous concentrated platelets and super-concentrated platelets, are based on concentration of red blood cells, leukocytes, and fibrin.³ PRP therapies usually are categorized as leukocyte-rich PRP (LR-PRP) or leukocyte-poor PRP (LP-PRP), based on neutrophil concentrations that are above and below baseline.² Leukocyte concentration is one of the most debated topics in PRP therapy.⁴

Common commercially available preparation systems produce platelet concentrations between 3 to 6 times the baseline platelet count.⁵ Although there is no universally agreed upon PRP formulation, studies have shown 2 centrifugation cycles (“double-spun” or “dual centrifugation”) that yield platelet concentrations between 1.8 to 1.9 times the baseline values significantly improve MSK conditions.^6-8

Familiarity with the use of platelet-rich plasma to treat specific musculoskeletal conditions is essential for FPs who frequently are asked by patients about whether it is right for them.

For MSK purposes, PRP may be injected into intratendinous, peritendinous, and intra-articular spaces. Currently, there is no consensus regarding injection frequency. Many studies have incorporated single-injection protocols, while some have used 2 to 3 injections repeated over several weeks to months. PRP commonly is injected at point-of-care without requiring storage.

Contraindications. PRP has been shown to be safe, with most adverse effects attributed to local injection site pain, bleeding, swelling, and bruising.⁹

Contraindications to PRP include active malignancy or recent remission from malignancy with the exception of nonmetastatic skin tumors.¹⁰ PRP is not recommended for patients with an allergy to manufacturing components (eg, dimethyl sulfoxide), thrombocytopenia, nonsteroidal anti-inflammatory drug use within 2 weeks, active infection causing fever, and local infection at the injection site.¹⁰ Since local anesthetics may impair platelet function, they should not be given at the same injection site as PRP.¹⁰

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