Platelet-Rich Plasma in the Management of Articular Cartilage Pathology

A Systematic Review

Andrew P. Dold, MD; Michael G. Zywiel, MD; Drew W. Taylor, MSc; Tim Dwyer, MBBS; John Theodoropoulos, MD

Disclosures

Clin J Sport Med. 2014;24(1):31-43. 

In This Article

Abstract and Introduction

Abstract

Objective: Using systematic review methodology, we endeavored to answer the following questions concerning the treatment of osteochondral pathology: (1) what pathologies have been treated in vivo with the use of platelet-rich plasma (PRP); (2) what methods of PRP preparation and delivery have been reported; (3) what assessment tools and comparison group have been used to assess its effectiveness; and (4) what are the clinical outcomes of its use.

Data Sources: A systematic literature search was performed of the OVID, EMBASE, and Evidence Based Medicine Reviews databases to identify all studies published up to October 2012 that assessed clinical outcomes of the use of PRP for the treatment of chondral and osteochondral pathology, excluding those including concomitant management of acute fractures or ligament reconstruction.

Data Extraction: The included studies were reviewed and the following data were extracted and tabulated: study authors' year and journal, study design and level of evidence, pathology treated, methods of PRP preparation and delivery, and clinical outcome scores.

Data Synthesis: Ten studies were included in the final analysis. The majority of studies assessed the use of PRP in the treatment of degenerative osteoarthritis of the knee or hip (representing 570 of a total of 662 joints). The majority of patients were treated with intra-articular injections, whereas 2 studies used PRP as an adjunct to surgical treatment. Significant improvements in joint-specific clinical scores (7 of 8 studies), general health scores (4 of 4 studies), and pain scores (4 of 6 studies) compared with baseline were reported up to 6-month follow-up, but few studies provided longer-term data. No studies reported worse scores compared with baseline at final follow-up. Three of 4 comparative studies reported significantly better clinical and/or pain scores when compared with hyaluronic acid injections at similar follow-up times.

Conclusions: Currently, there is a paucity of data supporting the use of PRP for the management of focal traumatic osteochondral defects. There is limited evidence suggesting short-term clinical benefits with the use of PRP for symptomatic osteoarthritis of the knee, but the studies published to date are of poor quality and at high risk for bias. Further high-quality comparative studies with longer follow-up are needed to ascertain whether PRP is beneficial, either alone or as an adjunct to surgical procedures, in the management of articular cartilage pathology.

Introduction

Articular cartilage pathology represents a spectrum of potentially debilitating conditions that can have substantial impact on patient well-being, with symptoms including persistent joint pain and decreased function. Both chondral and osteochondral lesions of a number of synovial joints are being diagnosed with increasing frequency.[1,2] The natural history of these lesions often includes progression to symptomatic osteoarthritis and functional impairment in otherwise young and active patients.[3,4] Several treatment modalities are available, including microfracture, autologous chondrocyte transplantation, and autograft and allograft osteochondral transplantation.[5] However, the reported results with these procedures have been variable and are not guaranteed to prevent symptomatic degenerative disease at long-term follow-up.[6]

Articular cartilage has limited inherent healing capacity due to its avascular and alymphatic nature.[7–9] In isolation from the systemic circulation, the normal inflammatory and reparative processes are unable to assist with repair of injured cartilage in a synovial joint, and adjacent healthy chondrocytes are prevented from migrating to the injured area by the extracellular matrix.[10] Although injuries that penetrate subchondral bone can stimulate underlying marrow cells to produce a systemic response to generate new tissue, the result is the formation of biomechanically inferior fibrocartilage consisting primarily of type 1 collagen.[11,12]

Autologous platelet-rich plasma (PRP) has been reported to release a number of cytokines and growth factors that stimulate the healing of bone and soft tissue and has been advocated in the treatment of a wide range of musculoskeletal pathologies.[13–17] Chondrocytes stimulated with PRP in vitro have been shown to increase their synthesis of proteoglycans and collagen,[18] with the repair tissue generated after PRP treatment demonstrating similar histological and biomechanical characteristics to normal hyaline cartilage.[13,19,20] Recently, PRP has been investigated as a biologic solution in the treatment of osteochondral pathology and osteoarthritis. Results from animal studies have identified the potential utility of PRP, both in isolation and as an adjunct to surgical procedures, to restore normal hyaline cartilage in articular injuries.[17,21,22] However, despite the theoretical basis for the use of PRP in the treatment of osteochondral pathology, ongoing controversy remains regarding its clinical efficacy in vivo.

The purpose of the present study was to systematically review the published literature to answer the following questions: (1) what osteochondral pathologies have been treated in vivo with the use of PRP; (2) what methods of PRP preparation and delivery have been used in the treatment of osteochondral pathology; (3) what assessment tools and comparison groups have been used to assess the effectiveness of the use of PRP in the treatment of osteochondral pathology; and (4) what are the clinical outcomes of treating chondral and osteochondral lesions with PRP.

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