Multiple Injections of PRP/Steroid Combination Result in Better Clinical Outcames in Advanced Osteoarthritis: A Prospective Randomized Study

Abstract

Aim: The impact of PRP/steroid combination in advanced osteoarthritis is unclear. Multiple intraarticular injections are thought to sustain better clinical scores. The objective of this prospective study is to evaluate the effect after repeated injections of corticosteroid (CS) and platelet-rich plasma (PRP) treatment compared to single dose PRP/steroid injection in patients affected by advanced osteoarthritis. Material and Methods: A total of 98 patients affected by clinically and radiographically documented with grade 3 - 4 gonarthrosis according to the Kellgren- Lawrence classification were included in this study. The patients were randomized into 2 study groups. Forty-nine patients (Group 1) received three intra-articular injections of PRP (5mL) and steroid (1 cc – 5 mgr triamcinolone). Forty-nine patients (Group 2) received one intra-articular injection of PRP/steroid (5 mL). In multiple injection group, an unblinded physician performed the injection once a week for three weeks into the affected knee in both groups. All patients were evaluated with the VAS score and the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales before the infiltration, at 2 and 6 months after the first injection. Results: Two groups are similar concerning demographic variables (age, gender, BMI, stage of arthritis) were in both groups. The combination of intra-articular PRP with steroids resulted in a significantly superior clinical outcome, with sustained lower VAS (p<0.05) and improved KOOS subscales (p<0.05) except for KOOS sporting activity (at 2 months), KOOS quality of life (at 2 and 6 months). Conclusion: This prospective randomized trial demonstrated that multiple intraarticular injections of PRP/steroid combination are more effective in advanced osteoarthritis when compared to single injection with lower VAS scores and better KOOS scores at 6 months after injection therapy.

Keywords

• Platelet rich plasma
• corticosteroid
• intraarticular injection
• advanced arthritis

References

1. 1. Levy DM, Petersen KA, Vaught MS, Christian DR, Cole BJ. Injections for knee osteoarthritis: corticosteroids, viscosupplementation, platelet-rich plasma, and autologous stem cells. Arthrosc J Arthrosc Relat Surg. 2018;34(5):1730-43.
2. 2. Hermann W, Lambova S, Muller-Ladner U. Current treatment options for osteoarthritis. Curr Rheumatol Rev. 2018;14(2):108-16.
3. 3. Khurana A, Goyal A, Kirubakaran P, Akhand G, Gupta R, Goel N. Efficacy of Autologous Conditioned Serum (ACS), Platelet-Rich Plasma (PRP), Hyaluronic Acid (HA) and Steroid for Early Osteoarthritis Knee: A Comparative Analysis. Indian J Orthop. 2020;1-11.
4. 4. Balch H, Gibson J, El-Ghobarey A, Bain L, Lynch M. Repeated corticosteroid injections into knee joints. Rheumatology. 1977;16(3):137-40.
5. 5. Han S-B, Seo I-W, Shin Y-S. Intra-articular injections of hyaluronic acid or steroids associated with better outcomes than platelet-rich plasma, adipose mesenchymal stromal cells, or placebo in knee osteoarthritis: a network meta-analysis. Arthrosc J Arthrosc Relat Surg. 2021;37(1):292-306.
6. 6. Migliorini F, Driessen A, Quack V, Sippel N, Cooper B, El Mansy Y, et al. Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis: a Bayesian network meta-analysis. Arch Orthop Trauma Surg. 2020;1-18.
7. 7. Eymard F, Ornetti P, Maillet J, Noel É, Adam P, Legré-Boyer V, et al. Intra-articular injections of platelet-rich plasma in symptomatic knee osteoarthritis: A consensus statement from French-speaking experts. Knee Surg Sports Traumatol Arthrosc. 2020;1-16.
8. 8. Saltzman BM, Frank RM, Davey A, Cotter EJ, Redondo ML, Naveen N, et al. Lack of standardization among clinical trials of injection therapies for knee osteoarthritis: a systematic review. Phys Sportsmed. 2020;48(3):266-89.

9. 9. McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. Jama. 2017;317(19):1967-75.
10. 10. Zeng C, Lane N, Hunter D, Wei J, Choi H, McAlindon T, et al. Intra-articular corticosteroids and the risk of knee osteoarthritis progression: results from the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2019;27(6):855-62.
11. 11. Arthroscopy Association of Canada, Kopka M, Sheehan B, Degen R, Wong I, Hiemstra L, et al. Arthroscopy Association of Canada position statement on intra-articular injections for knee osteoarthritis. Orthop J Sports Med. 2019;7(7):2325967119860110.
12. 12. Görmeli G, Görmeli CA, Ataoglu B, Çolak C, Aslantürk O, Ertem K. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017;25(3):958-65.
13. 13. Vilchez-Cavazos F, Millán-Alanís JM, Blázquez-Saldaña J, Álvarez-Villalobos N, Peña-Martínez VM, Acosta-Olivo CA, et al. Comparison of the clinical effectiveness of single versus multiple injections of platelet-rich plasma in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Orthop J Sports Med. 2019;7(12):2325967119887116.
14. 14. Wang P, Li K, Jiang Z, Qiu B, Nie C, Luo H, et al. Impact of the numbers of injections of platelet rich plasma on the clinical outcomes in patients with knee osteoarthritis: A protocol for an updated network meta-analysis. Medicine (Baltimore). 2021;100(1).
15. 15. Mazzocca AD, McCarthy MBR, Chowaniec DM, Cote MP, Romeo AA, Bradley JP, et al. Platelet-rich plasma differs according to preparation method and human variability. JBJS. 2012;94(4):308-16.
16. 16. Khoshbin A, Leroux T, Wasserstein D, Marks P, Theodoropoulos J, Ogilvie-Harris D, et al. The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis. Arthrosc J Arthrosc Relat Surg. 2013;29(12):2037-48.
17. 17. Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Am J Sports Med. 2013;41(2):356-64.
18. 18. Yaradilmis YU, Demirkale I, Tagral AS, Okkaoglu MC, Ates A, Altay M. Comparison of two platelet rich plasma formulations with viscosupplementation in treatment of moderate grade gonarthrosis: A prospective randomized controlled study. J Orthop. 2020;20:240-6.
19. 19. Güvendi EU, Aşkin A, Güvendi G, Koçyiğit H. Comparison of efficiency between corticosteroid and platelet rich plasma injection therapies in patients with knee osteoarthritis. Arch Rheumatol. 2018;33(3):273.
20. 20. Concoff A, Sancheti P, Niazi F, Shaw P, Rosen J. The efficacy of multiple versus single hyaluronic acid injections: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2017;18(1):1-14.
21. 21. Smith C, Patel R, Vannabouathong C, Sales B, Rabinovich A, McCormack R, et al. Combined intra-articular injection of corticosteroid and hyaluronic acid reduces pain compared to hyaluronic acid alone in the treatment of knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2019;27(6):1974-83.
22. 22. Camurcu Y, Sofu H, Ucpunar H, Kockara N, Cobden A, Duman S. Single-dose intra-articular corticosteroid injection prior to platelet-rich plasma injection resulted in better clinical outcomes in patients with knee osteoarthritis: A pilot study. J Back Musculoskelet Rehabil. 2018;31(4):603-10.
23. 23. CA A-O, AN H-R, OR S-S, de la Garza-Castro S. Intraarticular injection of platelet-rich plasma in knee osteoarthritis: single versus triple application approach. Pilot study. Acta Reumatol Port. 2019;44(2).
24. 24. Kavadar G, Demircioglu DT, Celik MY, Emre TY. Effectiveness of platelet-rich plasma in the treatment of moderate knee osteoarthritis: a randomized prospective study. J Phys Ther Sci. 2015;27(12):3863-7.
25. 25. Görmeli G, Görmeli CA, Ataoglu B, Çolak C, Aslantürk O, Ertem K. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017;25(3):958-65.
26. 26. Munde S, Jha V, Malik J. Effectiveness of Platelet-Rich Plasma in the Treatment of Moderate Knee Osteoarthritis. Ann Int Med Dent Res. 2017;3(4):42.
27. 27. Rai SK, Raman VP, Varma R, Wani SS. Combined intra-articular injections (Hyaluronic acid, platelet-rich plasma, and corticosteroid) for osteoarthritis knee, an effective alternative treatment. J Orthop Traumatol Rehabil. 2018;10(1):57.