Comparison of the short-term clinical effectiveness of 5% dextrose water, platelet rich plasma and corticosteroid injections for carpal tunnel syndrome: a systematic review and network meta-analysis of randomized controlled trials
Archives of physical medicine and rehabilitation. 2022
OBJECTIVE To compare the short-term effectiveness of corticosteroids, 5% dextrose(D5W), and platelet-rich plasma (PRP) injections for treating carpal tunnel syndrome (CTS). DATA SOURCES Four databases (MEDLINE (PubMed), Embase, the Cochrane Controlled Trials Register, and Web of Science (WOS)) were researched from inception to the 1st of April 2022. STUDY SELECTION Two authors independently screened the literature to identify the RCTs meeting the included criteria, which involved comparing corticosteroid, 5% dextrose water (D5W), and platelet-rich plasma (PRP) injection with each other or placebo-controlled for treating CTS. DATA EXTRACTION The two reviewers independently conducted information extraction, the outcomes included were the changes in Symptom Severity Scale (SSS), Function Status Scale (FSS), and Visual Analogue Scale (VAS) at short-term follow-up after drug injection treatment and any adverse events reported. DATA SYNTHESIS Twelve randomized controlled trials with 749patients (817 hands) were included. The results of this study suggested that PRP injection was the most likely to relieve symptoms, improve functions and alleviate pain, with the SUCRA being 91.5%, 92.7%, and 80.8%, respectively, followed by D5W injection (74.4%, 72.2%, 72.1%), and corticosteroid injection (33.7%, 31.9%, 46.2%). The injection of three drugs was significantly better than that of a placebo. CONCLUSION From the results of the network meta-analysis, PRP injection is the most recommended treatment among the injection of corticosteroid, D5W, and PRP. The protocol of this network meta-analysis has been registered in PROSPERO with registration number CRD42022325228.
A systematic review on efficacy of different types of Platelet-Rich Plasma in the management of lateral epicondylitis
Journal of shoulder and elbow surgery. 2022
BACKGROUND Platelet-rich plasma (PRP) is reported as an effective treatment for lateral epicondylitis (LE). Theoretically, different types of PRP have different therapeutic effects. However, there is controversy on the effects of different types of PRP in the treatment of LE. PURPOSE To systematically compare the pain relief, functional improvement and successful rates on treatment of two different types of PRP, by reviewing and summarizing the data available in the current literature on LE after PRP injection. METHODS The PubMed, Medline, Embase, Cochrane Library and Web of science were reviewed. A computerized literature search was performed for related studies published from inception to August 2021 by terms of lateral epicondylitis, tennis elbow, tendinopathy, lateral elbow pain, PRP. PRP involved in present study were divided into leukocyte-poor PRP and leukocyte-rich PRP groups according to different preparation methods. Outcomes of interest included characteristics of the subjects, types and preparations of PRP, clinical outcomes, successful rate and safety of treatment of short-term and long-term follow-up. RESULTS A total of 33 studies included 2420 LE patients. There were 19 studies with LP-PRP, 13 studies with LR-PRP and 1 study involved both LP-PRP and LR-PRP. Patients had significant improved clinical outcomes post-treatment compared to pre-treatment in both groups of PRP. The mean of VAS was ranged from 6.1 to 8.0 before the treatment, 1.5 to 4.0 at short-term and 0.6 to 3.3 at the long-term follow-up in LR-PRP group. The mean of VAS was ranged from 4.2 to 8.4 before the treatment, 1.6 to 5.9 at short-term and 0.7 to 2.7 in the long-term follow-up in LP-PRP group. The DASH score of LR-PRP and LP-PRP were ranged from 47.0 to 54.3 and 30.0 to 67.7 separately before the treatment and 20.0 to 22.0 and 5.5 to 19.0 separately at long-term follow-up. LR-PRP and LP-PRP groups reflected successful rate ranged from 70%-100% and 36%-100% respectively. The complication rate lower in LP-PRP group (3.9%) than LR-PRP group (6.4%), with the major complication was temporary pain after PRP treatment (P = 0.029). CONCLUSION PRP treatment demonstrated a significant improvement with pain relief and functional improvement on lateral epicondylitis regardless types of PRP. There was no significant difference between LR-PRP and LP-PRP in pain relief and functional improvement. The major complication was temporary pain after PRP injection and the complication rate in LP-PRP was lower than LR-PRP.
Failure to disclose industry funding impacts outcomes in randomized controlled trials of platelet-rich plasma
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2022
PURPOSE Platelet-rich plasma (PRP) represents a highly profitable biological therapy. Platelet-rich plasma is widely used to treat musculoskeletal disorders despite mixed evidence of its efficacy. As evidenced by literature from other domains, industry funding may influence the results of clinical trials. The objective of the current study was to determine the association between industry funding and positive results for randomized controlled trials (RCTs) assessing the efficacy of PRP in musculoskeletal disorders. METHODS A search of four databases was conducted. Included studies were RCTs comparing PRP to any non-PRP comparator in adults (18 years old or over) with musculoskeletal disorders and had full text available in English. Studies were excluded if they were published before 2016 or were non-human trials. A multivariate binomial logistic regression model was created to explore predictors of statistically significant findings. Covariates included the presence of industry funding, sample size, and length of study follow-up. 1440 records were screened with 87 trials included in the final analysis. RESULTS Of the 87 studies, 61 (70%) reported a statistically significant primary outcome. The presence of industry funding was not predictive of a statistically significant primary outcome [OR = 0.36, 95% CI 0.096-1.36, (n.s.)]. Studies that did not state whether industry funding was present had a higher chance of reporting a statistically significant primary outcome (OR = 3.61, 95% CI 1.1-11.9, p = 0.035). Sample size and length of follow-up were not predictive of a statistically significant primary outcome. CONCLUSION The results of the current study conclude that industry funding had no impact on the reporting of positive results for RCTs investigating PRP in musculoskeletal disorders. However, not disclosing sources of funding was associated with a higher likelihood of reporting positive results. The results of trials that fail to disclose funding sources should be interpreted with caution in the PRP literature. LEVEL OF EVIDENCE I.
Platelet-Rich Plasma in acute Achilles tendon ruptures: A systematic review and meta-analysis
Foot (Edinburgh, Scotland). 2022;53:101923
BACKGROUND Platelet Rich Plasma (PRP) is known to exert multi-directional biological effects favouring tendon healing. However, conclusions drawn by numerous studies on its clinical efficacy for acute Achilles tendon rupture are limited. We performed a systematic review and meta-analysis to investigate this and to compare to those without PRP treatment. METHODS The Cochrane Controlled Register of Trials, Pubmed, Medline and Embase were used and assessed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ('plasma' OR 'platelet-rich' OR 'platelet-rich plasma' or 'PRP') AND ('Achilles tendon rupture/tear' OR 'calcaneal tendon rupture/tear' OR 'tendo calcaneus rupture/tear'). Data pertaining to biomechanical outcomes (heel endurance test, isokinetic strength, calf-circumference and range of motion), patient-reported outcome measures (PROMs) and incidence of re-ruptures were extracted. Meta-analysis was performed for same outcomes measured in at least three studies. Pooled outcome data were analysed by random- and fixed-effects models. RESULTS After abstract and full-text screening, 6 studies were included. In total there were 510 patients of which 256 had local PRP injection and 254 without. The average age was 41.6 years, mean time from injury to treatment 5.9 days and mean follow-up at 61 weeks. Biomechanically, there was similar heel endurance, isokinetic strength, calf circumference and range of motion between both groups. In general, there were no differences in patient reported outcomes from all scoring systems used in the studies. Both groups returned to their pre-injured level at a similar time and there were no differences on the incidence of re-rupture (OR 1.13, 95% CI, 0.46-2.80, p = 0.79). CONCLUSION PRP injections for acute Achilles tendon ruptures do not improve medium to long-term biomechanical and clinical outcomes. However, future studies incorporating the ideal application and biological composition of PRP are required to investigate its true clinical efficacy.
Efficacy of platelet-rich plasma injection in the treatment of frozen shoulder: A systematic review and meta-analysis
Journal of back and musculoskeletal rehabilitation. 2022
BACKGROUND Frozen shoulder (FS) is characterized by progressive shoulder pain and a limited range of motion. Recently, platelet-rich plasma (PRP) injection is a newly developed treatment option for patients with FS and its efficacy needs to be examined. OBJECTIVE By conducting a systematic review and meta-analysis, this study attempted to evaluate the efficacy of PRP injection in the treatment of patients with FS. METHODS PubMed, EMBASE, Web of Science, Elsevier, The Cochrane Library, WanFang Data and CNKI databases were searched up to May 31, 2020. This study included randomized controlled trials as well as prospective cohort studies. Two reviewers independently screened the title, abstract and full text in order to extract data from qualified studies. The main outcome was pain visual analogue score (VAS) while the secondary outcome was range of motion (ROM) of the shoulder joint that consists of four parts: internal rotation, flexion, external rotation and abduction. RESULTES Three randomized controlled trials and one prospective cohort study met the inclusion criteria. Accordingly, a total of 359 cases were analyzed and followed up to 3 months. The control group included corticosteroids (CS), ultrasound therapy, and stellate ganglion block. Compared to other groups, VAS was statistically significant after 1 month and 3 months of treatment (SMD: -0.46, 95% CI: -0.75 to -0.18, P= 0.002; I=2 43.2%), (SMD: -0.87, 95% CI: -1.23 to -0.50, P= 0.00, I=2 61.9%). Compared to the control group, only flexion of the patients treated with PRP demonstrated no significant improvement at 1 month, whereas internal rotation, flexion, external rotation and abduction of the shoulder were found to be improved following 3 months of treatment. CONCLUSIONS The corresponding findings illustrate that compared to other non-operative treatments, local injection of PRP can effectively improve pain and shoulder motion in patients with FS. However, due to the short follow-up time and limitations regarding the quantity and quality of studies, the above conclusions require further elucidation by performing additional high-quality studies.
Transosseous-Equivalent/Suture Bridge Technique in Combination with Platelet-Rich Product Application Yield Optimal Clinical Outcomes in Arthroscopic Rotator Cuff Repair: A Bayesian Network Analysis of Randomized Controlled Trials
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2022
PURPOSE To assess the clinical evidence defining the optimal combination of arthroscopic suture technique and Platelet-Rich Products (PRP) application for arthroscopic rotator cuff repair (ARCR). METHODS All level of evidence (LOE) I randomized controlled trials (RCT) focusing arthroscopic suture technique and/or PRP application in ARCR were included. The exclusion criteria were: LOE II or worse; Studies with other interventions; Studies reported none of predetermined clinical outcomes; Studies unable to extract any precise data; Studies from the same patient group of included studies. A pair-wise meta-analysis and Bayesian network analysis were performed on each comparison. The intervention options were ranked by Bayesian network analysis. RESULTS 27 studies comprising 1, 947 individuals met the inclusion criteria. The application of transosseous equivalent/suture bridge repair (SB) with PRP (SB+PRP) significantly reduced retear rate (Risk Ratio [RR], 0.29; 95% confidence interval [CI], [0.15, 0.55].) and increased Constant score (Mean Difference, 1.90; 95% CI, [0.14, 3.74].), compared to SB repair. Single-row repair (SR) with PRP usage (SR+PRP) significantly reduced retear rate (RR, 0.27; 95% CI, [0.12, 0.55].) and pain visual analog scale (VAS) (Mean Difference, -0.84; 95% CI [-1.39, -0.46].), increased University of California, Los Angeles (UCLA) shoulder score (Mean Difference, 1.48; 95% CI [0.50, 2.58].) and Constant score (Mean Difference, 4.53; 95% CI [2.65, 6.38].), compared to SR repair. The ranking for outcomes demonstrated SB+PRP resulted in the best retear rate, UCLA shoulder score, with the second-best postoperative pain, Constant score, while SR+PRP resulted in the best postoperative pain, Constant score, with the second-best retear rate and UCLA score. CONCLUSION Arthroscopic rotator cuff repair utilizing SB+PRP yields optimal retear rate and UCLA shoulder score, with the second-best postoperative pain and Constant shoulder outcome score, while SR+PRP yields the best in these two parameters. LEVEL OF EVIDENCE Level I, Bayesian network analysis of level I RCT.
The Statistical Fragility of Platelet-Rich Plasma as Treatment for Chronic Noninsertional Achilles Tendinopathy: A Systematic Review and Meta-analysis
Foot & ankle orthopaedics. 2022;7(3):24730114221119758
BACKGROUND Randomized controlled trial (RCT) outcomes reaching statistical significance, frequently determined by P <.05, are often used to guide decision making. Noted lack of reproducibility of some RCTs has brought special attention to the limitations of this approach. In this meta-analysis, we assessed the robustness of RCTs evaluating platelet-rich plasma (PRP) for the treatment of chronic noninsertional Achilles tendinopathy (AT) by using fragility indices. METHODS The present study was a systematic review and meta-analysis of RCTs comparing outcomes after PRP injection vs alternative treatment in patients with AT. Representative data sets were generated for each reported continuous outcome event using summary statistics. Fragility indices refer to the minimal number of patients whose status would have to change from a nonevent to an event to turn a statistically significant result into a nonsignificant result, or vice versa. The fragility index (FI) and continuous FI (CFI) were determined for dichotomous and continuous outcomes, respectively, by manipulating each data set until reversal of significance (a=0.05) was achieved. The corresponding fragility quotient (FQ) and continuous FQ (CFQ) were calculated by dividing FI/CFI by sample size. RESULTS Of 432 studies screened, 8 studies (52 outcome events) were included in this analysis. The 12 dichotomous outcomes had a median FI of 4.5 (FQ: 0.111), and the 40 continuous outcomes had a median CFI of 5 (CFQ: 0.154). All 52 outcome events included lost-to-follow-up data, and 12 (23.1%) indicated a greater number of patients lost to follow-up than the FI or CFI. CONCLUSION Our findings suggest that RCTs evaluating PRP for AT therapy lack statistical robustness, because changing only a small number of events may alter outcome significance. LEVEL OF EVIDENCE Level II, therapeutic study.
The use of platelet-rich plasma in studies with early knee osteoarthritis versus advanced stages of the disease: a systematic review and meta-analysis of 31 randomized clinical trials
Archives of orthopaedic and trauma surgery. 2022
INTRODUCTION Reports have concluded that platelet-rich plasma (PRP) is an effective and safe biological approach to treating knee osteoarthritis (OA). However, the effectiveness of PRP in advanced stages of the disease is not entirely clear. The purpose of this study was to evaluate whether the use of PRP would be as effective in studies with early-moderate knee OA patients compared to studies including patients with end-stage OA, based on the Kellgren-Lawrence classification. MATERIALS AND METHODS A comprehensive search in MEDLINE, EMBASE, Scopus, and Web of Science databases was conducted to identify randomized controlled trials (RCTs) comparing the effect of PRP injections versus other intra-articular treatments on pain and functionality. A meta-analysis was conducted using a random-effects model and the generic inverse variance method. RESULTS We included 31 clinical trials that reported data of 2705 subjects. Meta-analysis revealed an overall significant improvement of both pain [MD, - 1.05 (95% CI - 1.41 to - 0.68); I(2) = 86%; P ≤ 0.00001] and function [SMD, - 1.00 (95% CI - 1.33, to - 0.66); I(2) = 94%; P ≤ 0.00001], favoring PRP. Subanalysis for pain and functional improvement showed a significant pain relief in studies with 1-3 and 1-4 Kellgren-Lawrence OA stages and a significant functional improvement in studies with 1-2, 1-3 and 1-4 knee OA stages, favoring PRP. CONCLUSION Our results indicate that including patients with advanced knee OA does not seem to affect the outcomes of clinical trials in which the effectiveness of the PRP in knee OA is assessed.
The Use of Intra-articular Platelet-Rich Plasma as a Therapeutic Intervention for Hip Osteoarthritis: A Systematic Review and Meta-analysis
The American journal of sports medicine. 2022;:3635465221095563
BACKGROUND There is a cohort of patients in whom hip preservation surgery is not indicated, because they have developed signs of early osteoarthritis (OA), and nor can they have a hip replacement, as they are too early in the disease process. Management of this cohort of patients is not standardised and both pharmacological and nonpharmacological measures are utilised to reduce pain. Interventions available for early OA include intra-articular injections of steroids, viscosupplementation and more recently platelet-rich plasma (PRP). However, the use of PRP in hip OA has not yet been studied systematically. PURPOSE To assess intra-articular PRP as a therapeutic intervention for hip OA, including the duration of efficacy, influence of dose and composition of PRP, and the incidence of adverse effects. STUDY DESIGN A systematic review and meta-analysis; Level of evidence, 4. METHODS We performed literature searches on the MEDLINE, EMBASE, CINAHL, WEB OF SCIENCE, COCHRANE, and SCOPUS databases, and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Data were pooled using random-effects meta-analysis. We assessed the quality of the included studies using the methodological index for non-randomized studies instrument, with an additional assessment for randomized controlled trials with the revised Cochrane risk of bias tool for randomized trials. This is the first study to concisely collate the available data on the use of PRP in hip OA. RESULTS Eight studies were included in the analysis, with data from a total of 331 patients. PRP significantly reduced pain compared with the baseline at multiple time points, with the greatest effect at the 1- to 2-month follow-up, but PRP significantly improved function only at the 1- to 2-month follow-up. A significantly larger reduction in pain was achieved with a single injection of PRP compared with multiple injections, a total injected dose of PRP <15 mL compared with ≥15 mL, and use of a leukocyte-poor PRP preparation compared with leukocyte-rich PRP. There were no lasting adverse effects. CONCLUSION Low- and moderate-quality evidence suggests that PRP reduces pain and improves function at the end-point follow-up of studies compared with the baseline. Moderate-quality evidence suggests that a larger reduction in pain is achieved with a single injection of PRP compared with multiple injections, and low-quality evidence attributes a larger reduction of pain with a total injected dose of PRP <15 mL compared with ≥15 mL and using leukocyte-poor PRP compared with leukocyte-rich PRP.
Comparison of the clinical effectiveness of activated and non-activated platelet-rich plasma in the treatment of knee osteoarthritis: a systematic review and meta-analysis
Clinical rheumatology. 2022
INTRODUCTION/OBJECTIVES Platelet-rich plasma (PRP) has shown to be clinically effective in the treatment of knee osteoarthritis (OA). Notwithstanding, some inconsistences remain due to methodological differences in PRP preparation such as the use (or not) of activation strategies. We aimed to evaluate whether the use of non-activated PRP would be as effective as activated PRP in patients with knee OA. METHOD All randomized, placebo-controlled trials were identified through a search in MEDLINE, EMBASE, Scopus, and Web of Science up to June 2022. Pre- and post-injection pain and function scores were collected. The meta-analysis was conducted with a random-effects model and generic inverse variance method. Effect sizes were estimated using standardized mean differences (SMD). RESULTS Fourteen clinical trials involving 1292 subjects were included for meta-analysis. Exogenous activation of PRP revealed a significant pain relief (SMD, - 1.05 [95% CI - 1.58 to - 0.52]; p = 0.0001) and a significant functional improvement (SMD, - 1.21 [95% CI - 1.75 to - 0.67]; p < 0.0001) unlike studies describing the use of a non-activated PRP. The sensitivity analysis indicated that the effect size for both outcomes was not influenced by a single study. CONCLUSIONS The results of this systematic review suggest that the use of an exogenously activated PRP is more effective in improving both pain and functional scores in patients with knee OA. Key Points • Results from meta-analysis suggest that exogenously activated PRP is clinically more effective than non-activated PRP. • The use of an activated PRP was more frequently reported by the included studies. • The most frequent method for activation was the use of calcium chloride (CaCl(2)).