Platelet Rich Plasma Therapy for Knee Osteoarthritis
Platelet Rich Plasma Treatment for the Knee
In this article, Ross Hauser MD discusses the use of Platelet Rich Plasma Therapy for the treatment of knee osteoarthritis, also know as PRP Knee Injections.
Platelet Rich Plasma (PRP) speeds the healing of many types of injuries including various conditions of the knee. When treating the knee, our medical team utilizes a Comprehensive Prolotherapy injection technique which may include a combination of healing factors. PRP is commonly used in conjunction with Dextrose Prolotherapy and Stem Cell Therapy. If stem cells are used, they would be drawn from the patient and then re-injected into the knee to stimulate tissue regrowth, such as in instances of knee osteoarthritis. This is to ensure that a more thorough treatment is given to the weakened area, versus a one-shot PRP approach. Please see this article for a discussion on the general treatment of osteoarthritis including a detailed description of the PRP therapy injections and for a comparison of types of knee osetoarthritis injection therapy.
PRP and Osteoarthritis of the knee
Dextrose Prolotherapy alone has been shown to improve the quality of life in patients with knee osteoarthritis, “suggesting that Prolotherapy may have a pain-specific disease-modifying effect.”1 With the addition of PRP the results are even more remarkable. The PRP affects repair of the damaged cartilage, and the Dextrose Prolotherapy strengthens the supportive structures such as the weakened ligaments and tendons that most likely led to the cartilage degeneration in the first place. The goal of this type of Comprehensive Prolotherapy treatment is to repair the entire knee.
Platelet Rich Plasma therapy is a very promising regenerative treatment. It must be utilized, however, by physicians who are experienced in its use. Some physicians may use PRP as a single dose treatment rather than as part of a comprehensive treatment program. Used this way PRP may not be as effective. For this reason, some researchers see the components, healing mechanisms, and outcomes of PRP as challenging, and though the treatment has repairative functions in osteoarthritis of the knee even with the single dose usage, they would like to see a standardized protocol.2
Testing whether or not Platelet-rich plasma (PRP) provides symptomatic relief in early knee osteoarthritis in athletes, researchers looked at 78 patients with bilateral knee osteoarthritis1. The patients were then divided randomly into three groups.
- Group A (52 knees) received a single injection of PRP
- Group B (50 knees) received 2 injections of PRP 3 weeks apart
- Group C (46 knees) received a single injection of normal saline
The three groups were compared with each other and no improvement was noted in group C as compared with groups A and B.
The next part is interesting: there was no difference between groups A and B, which means that a single dose of PRP is as effective as two injections to alleviate symptoms in early knee osteoarthritis. The results, however, deteriorate after six months. Both groups treated with PRP had better results than did the group injected with saline only.
Other than the fact that the PRP was found effective at alleviating symptoms of osteoarthritis in the knee is the subsequent findings. Two PRP injections were no more effective than one and that the results deteriorated after six months.3
Now these findings are somewhat in agreement with other recent research that suggests a single dose of PRP worked very well for a six-month time period but the results deteriorated.4
Platelet Rich Plasma for knee meniscus injuries
Meniscus tears are the most frequent cause of meniscus injury. Menisci heal poorly due to a very poor blood supply. Surgical treatments are common for meniscus injuries, but they also have a high failure rate. Even the American Academy of Orthopedic Surgeons was unable to come up with evidence to support the use of partial meniscectomy.
They looked at a study by Herrlin et al. comparing arthroscopic partial meniscectomy to a conservative exercise program. The authors reported no significant treatment benefits of meniscectomy and at the 6 month follow up there was no difference noted between the two groups, “in terms of reduced knee pain, improved knee function and improved quality of life.” 5 Not only was there no benefit, but it is important to note that surgical treatment for meniscal injuries can result in an acceleration of cartilage degeneration and an increased rate of osteoarthritis.
Platelet Rich Plasma is effective for meniscus repair
Due to the poor healing potential of meniscus tears and the degeneration caused by the injury or by surgery, researchers and clinicians have looked into ways to stimulate repair. One such way is Prolotherapy with Platelet Rich Plasma. Meniscus injuries are a frequent cause of knee pain, and as such we see many cases in our office, especially meniscal tears, one of the most common conditions where PRP to the knee is utilized.
Caring Medical has conducted research which shows the effectiveness of PRP Prolotherapy, including case reports of MRI-documented meniscus tears successfully treated with PRPP. 6 Other research demonstrates that PRP promotes significant healing of the meniscus.7
In our experience, using dextrose Prolotherapy with PRP together enhances the effectiveness of meniscal repair. When treating a meniscal tear with PRP Prolotherapy, the concentrated platelets (PRP) are placed at the site of the tear. Growth factors are released which will stimulate healing of the tear. The growth factors in the PRP will cause a proliferation and regeneration of the injured tissue. This boosts fibroblastic events involved in tissue healing causing these tears to heal.
PRP Prolotherapy is effective at healing meniscal injuries without the need for surgery
Caring Medical research has shown that improvement with dextrose Prolotherapy alone met the patients’ expectations in over 96% of the knees to the point where surgery was not needed.8 However, in cases where a stronger proliferating solution is necessary, and PRP is used in conjunction with Dextrose Prolotherapy, the results are outstanding. Prolotherapy with or without PRP is a first-line treatment consideration for meniscal injuries, and an effective alternative to surgery.
Patients with meniscal injuries as well as those with knee osteoarthritis are commonly led to believe that surgery is their only option. Conservative management is often overlooked in the quest to send patients for surgical referral. One researcher states, “Few conservative management options were tried before referral, indicating the need to enhance pre-surgical care for patients with knee osteoarthritis.”9
Interestingly, in a trial “involving patients with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.”10There are quite a few studies showing no benefit from this type of surgery compared to more conservative treatments.11 This study, however, clearly demonstrates NO benefit from arthroscopic partial meniscectomy compared to fake surgery. These results certainly raise some concern. On our website is a more detailed article on mensicus tears and treatment with PRP Stem Cell Therapy and Prolotherapy.
Can PRP Prolotherapy help the patient who has already undergone knee surgery?
Yes, PRP is effective at decreasing pain and improving symptoms and quality of life in patients with chronic knee pain after surgery. Surgery entails cutting and the removal of structures. The knee joint requires these structures for cushion and stability and proper functioning. Without them, knee instability occurs. Knee ligament instability is the main cause of knee pain before and after a total knee replacement. “Instability of the knee is one of the most common causes of failure in knee arthroplasty,” because of “intraoperative injuries or excessive release of important coronal stabilizers such as the medial collateral ligament.”12 Another researcher reports, “Ligament instability is the primary reason for revision total knee arthroplasty.”13
PRP Prolotherapy strengthens the weakened ligaments and tendons that are causing instability and stabilizes the knee. PRP Prolotherapy helps the body repair the weakened structures and tissue so the knee can function optimally.
PRP Knee Injection
1.Rabago D et al. Association between disease-specific quality of life and magnetic resonance imaging outcomes in a clinical trial of prolotherapy for knee osteoarthritis. Arch Phys Med Rehabil. 2013 Nov;94(11):2075-82. doi: 10.1016/j.apmr.2013.06.025. Epub 2013 Jul 10.
2. Chang KV, Hung CY, Aliwarga F, Wang TG, Han DS, Chen WS. Comparative Effectiveness of Platelet-Rich Plasma Injections for Treating Knee Joint Cartilage Degenerative Pathology: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2013 Nov 27. pii: S0003-9993(13)01212-4. doi: 10.1016/j.apmr.2013.11.006. [Epub ahead of print]
3. 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 Jan 8. [Epub ahead of print]
4. Halpern B, Chaudhury S, Rodeo SA, Hayter C, Bogner E, Potter HG, Nguyen J. Clinical and MRI Outcomes After Platelet-Rich Plasma Treatment for Knee Osteoarthritis. Clin J Sport Med. 2012 Dec 12. [Epub ahead of print]
5. Herrlin S, et al. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):393-401.
6. Hauser R, Phillips HJ, Maddela HS. Platelet Rich Plasma Prolotherapy as First-line Treatment for meniscal pathology.Practical Pain Management. 2010;July/August:53-64.
7. Wei LC, et al. A novel hypothesis: The application of platelet-rich plasma can promote the clinical healing of white-white meniscal tears. Med Sci Monit. 2012 Aug;18(8):HY47-50.
8. Hauser R, Phillips HJ, Maddela HS. The case for utilizing Prolotherapy as first-line treatment for meniscal pathology: a retrospective study shows Prolotherapy is effective in the treatment of MRI-documented meniscal tears and degeneration. Journal of Prolotherapy. 2010;2(3):416-437.
9. Klett MJ, Frankovich R, Dervin GF, Stacey D. Impact of a surgical screening clinic for patients with knee osteoarthritis: a descriptive study. Clin J Sport Med. 2012 May;22(3):274-7.
10. Sihvonen R, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013; 369:2515-2524.
11. Lowry F. Real knee surgery no better than sham for meniscal tear. Medscape Medical News. December 27, 2013.
12. Del Gaizo DJ, Della Valle CJ. Instability in primary total knee arthroplasty. Orthopedics. 2011 Sep 9;34(9):e519-21. doi: 10.3928/01477447-20110714-46.
13. Graichen H, et al. Ligament instability in total knee arthroplasty–causal analysis. Orthopade. 2007 Jul;36(7):650, 652-6.