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Reporting Bias is Highly Prevalent in Systematic Reviews and Meta-Analyses of Platelet Rich Plasma Injections for Hip Osteoarthritis
Kim, D., Bashrum, B. S., Kotlier, J. L., Mayfield, C. K., Thompson, A. A., Abu-Zahra, M., Hwang, M., Bolia, I. K., Petrigliano, F. A., Liu, J. N.
Arthroscopy, sports medicine, and rehabilitation. 2024;6(1):100851
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Editor's Choice
Abstract
PURPOSE To describe the incidence and types of spin in systematic reviews of platelet-rich plasma (PRP) injections for hip osteoarthritis (OA) and to determine whether patterns in study characteristics could be identified among studies with identifiable spin. METHODS The PubMed, Scopus, and SPORTDiscus databases were queried. Inclusion criteria were systematic reviews or meta-analyses that included an assessment of intra-articular PRP injections as a stand-alone treatment for hip OA. Two authors independently assessed the presence of spin in the included studies and recorded general study characteristics. The prevalence of the 15 different categories of spin was quantified using descriptive statistics. RESULTS Fifteen studies met inclusion criteria for this study. All studies contained at least two types of spin (range 2-9), with a median of 2. The most common type of spin was type 14 ("Failure to report a wide confidence interval of estimates"), which was observed in 10 studies. The second most common type of spin was type 13 ("Failure to specify the direction of the effect when it favors the control intervention"), found in 6 studies. CONCLUSIONS Spin is highly prevalent in abstracts of systematic reviews of PRP in the treatment of hip OA. Several associations were found between spin types and the study characteristics of AMSTAR 2 rating, Scopus CiteScore, journal impact factor, and PROSPERO preregistration. When present, spin in the abstracts of reviewed studies tended to favor the use of PRP in hip osteoarthritis. CLINICAL RELEVANCE It is important to understand the prevalence of spin in published abstracts, especially in areas of great impact or interest, so authors and readers can have a greater awareness of this potential form of bias.
PICO Summary
Population
Patients with hip osteoarthritis (15 systematic reviews).
Intervention
Systematic review to describe the incidence and types of spin bias in systematic reviews of platelet-rich plasma injections for hip osteoarthritis and to determine whether patterns in study characteristics could be identified among studies with identifiable spin.
Comparison
Outcome
All studies contained at least two types of spin (range 2-9), with a median of 2. The most common type of spin was type 14 ("Failure to report a wide confidence interval of estimates"), which was observed in 10 studies. The second most common type of spin was type 13 ("Failure to specify the direction of the effect when it favors the control intervention"), found in 6 studies. Several associations were found between spin types and the study characteristics of AMSTAR 2 rating, Scopus CiteScore, journal impact factor, and PROSPERO preregistration.
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Comparative effectiveness of intra-articular therapies in knee osteoarthritis: a meta-analysis comparing platelet-rich plasma (PRP) with other treatment modalities
Khalid, S., Ali, A., Deepak, F., Zulfiqar, M. S., Malik, L. U., Fouzan, Z., Nasr, R. A., Qamar, M., Bhattarai, P.
Annals of medicine and surgery (2012). 2024;86(1):361-372
Abstract
INTRODUCTION Knee osteoarthritis (KOA) is a progressive joint disease commonly treated with intra-articular injections, including platelet-rich plasma (PRP), hyaluronic acid (HA), or corticosteroids (CS). This updated meta-analysis aims to enhance the statistical power of the results and provide comprehensive clinical evidence that reflects the most current research. By doing so, the authors aim to suggest a reliable estimate for the development of guidelines, addressing the pressing need for effective and minimally invasive treatment options. METHODS PubMed, Scopus, clinicaltrials.gov, Cochrane Central were searched until March 2023, for randomized controlled trials (RCTs) comparing the effectiveness of intra-articular injectable therapies, including PRP, HA, CS, and placebo, in KOA. Data extraction involved baseline characteristics and outcome measures [Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, Visual Analog Scale (VAS) pain scores, KOOS, and IKDC scores] at 1, 3, 6 and 12 months. Statistical analysis, including subgroup analysis, assessment of heterogeneity, and publication bias, was conducted using Review Manager. RESULTS Our meta-analysis of 42 studies involving 3696 patients demonstrated that PRP treatment resulted in significant pain relief compared to HA injections, as evidenced by improved WOMAC pain (MD: -0.74; 95% CI: -1.02 to -0.46; P≤0.00001; I (2)=94%) and VAS pain (MD: -0.65; 95% CI: -1.24 to -0.06; P=0.03; I(2)=97%) outcomes. Similarly, PRP showed greater efficacy in reducing WOMAC pain (MD: -8.06; 95% CI: -13.62 to -2.51: P=0.004; I (2)=96%) and VAS pain (MD: -1.11; 95% CI: -1.64 to -0.59; P≤0.0001; I (2)=68%) compared to CS injections, with the most significant improvement observed at 6 months. CONCLUSIONS PRP is an effective treatment for KOA. It provides symptomatic relief, has the potential to reduce disease progression, and has sustained effects up to 12 months. PRP offers superior pain relief and functional enhancement compared to CS and HA injections.
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Platelet Rich Plasma, Bone Marrow Aspirate Concentrate and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis
Jawanda, H., Khan, Z. A., Warrier, A. A., Acuña, A. J., Allahabadi, S., Kaplan, D. J., Ritz, E., Jackson, G. R., Mameri, E. S., Batra, A., et al
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2024
Abstract
PURPOSE To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months. METHODS A literature search was conducted using the 2020 PRISMA guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient reported outcome scores for pain and function at baseline and at latest follow-up were extracted and the change in scores were converted to uniform 0-100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function. RESULTS Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%) followed by placebo (26.2%), PRP (21.5%), CS (8.8%) and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared to placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared to placebo. Surface under the cumulative ranking curves (SUCRA) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function with overall SUCRA scores of 91.54, 76.46, and 53.12 respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70. CONCLUSION At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared to placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared to BMAC, HA, and CS.
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Platelet rich plasma therapy versus other modalities for treatment of plantar fasciitis: A systematic review and meta-analysis
Herber, A., Covarrubias, O., Daher, M., Tung, W. S., Gianakos, A. L.
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons. 2024
Abstract
INTRODUCTION Plantar fasciitis (PF) is the most common cause of heel pain in adults. There are numerous non-operative treatments available including platelet rich plasma (PRP) injections. PPR has demonstrated effectiveness for a range of musculoskeletal conditions including plantar fasciitis. PURPOSE/OBJECTIVE To compare the effectiveness of PRP to other conservative treatment options for the management of PF. METHODS A systematic search of PubMed and Google Scholar was performed for randomized control trials (RCT) comparing PRP to other treatment modalities. Studies met inclusion criteria if mean and standard deviations for visual analog scale (VAS) pain scores, plantar fascia thickness (PFT), Foot Function Index (FFI), or American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score were reported. Mean differences (MD) were used to compare VAS pain, PFT, FFI, and AOFAS between PRP and other treatments. RESULTS Twenty-one RCTs which altogether included 1356 patients were included in the meta-analysis. PRP demonstrated significantly greater improvements in VAS pain scores compared to extracorporeal shock wave therapy (ESWT) (SMD: 0.86; CI: [0.30, 1.41]; p = 0.002), corticosteroid injections (CSI) (SMD: 1.08; CI: [0.05, 2.11]; p = 0.04), and placebo (SMD: 3.42; CI: [2.53, 4.31]; p < 0.00001). In terms of FFI, no significant differences existed among PRP, ESWT, CSI, dextrose prolotherapy (DPT), and meridian trigger points (MTP) in enhancing foot functionality. However, PRP demonstrated a marked advantage over phonophoresis, showing a substantial improvement in FFI scores (SMD: 3.07, 95% CI: 2.34-3.81). PRP did not demonstrate superiority over ESWT, CSI, or MTP for improving PFT, but it was notably more effective than phonophoresis (SMD: 3.18, 95% CI: 2.43-3.94). PRP demonstrated significantly greater improvements in AOFAS scores over CSI (SMD: 3.31, CI: [1.35, 5.27], p = 0.0009) and placebo (SMD: 3.75; CI: [2.81, 4.70]; p < 0.00001). CONCLUSION PRP is more effective than CSI, ESWT, and placebo in reducing VAS and more effective than CSI and placebo in improving AOFAS. PRP did not demonstrate a consistent advantage across all outcome measures, such as PFT and FFI. These findings underscore the complexity of PF treatment and call for a more standardized approach to PRP preparation and outcome measurement. LEVEL OF EVIDENCE Level I Meta-Analysis.
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Platelet-Rich Plasma Has Better Results for Long-term Functional Improvement and Pain Relief for Lateral Epicondylitis: A Systematic Review and Meta-analysis of Randomized Controlled Trials
Xu, Y., Li, T., Wang, L., Yao, L., Li, J., Tang, X.
The American journal of sports medicine. 2024;:3635465231213087
Abstract
BACKGROUND Corticosteroids (CS) have shown good short-term performance in terms of pain relief and functional improvement. However, the safety and long-term efficacy of this treatment remains controversial. Several studies have reported good results of platelet-rich plasma (PRP) in the treatment of tendinopathies. However, whether its use in the treatment of lateral epicondylitis (LE) is superior to that of CS remains controversial. PURPOSE To perform a systematic review and meta-analysis of original studies to determine whether the prognosis of LE patients treated with PRP is better than that of CS. STUDY DESIGN Meta-analysis; Level of evidence, 2. METHODS Two independent reviewers searched online databases from January 2000 to July 2022 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to evaluate prospective studies of PRP versus CS injection for LE. A third author addressed any discrepancies. Evidence quality was assessed using the Cochrane risk of bias tool. Risk ratios for dichotomous variables and mean differences (MDs) for continuous variables were used to compare clinical outcomes. P values <.05 were considered statistically significant. RESULTS Eleven randomized controlled trials with 730 patients were included in this review. PRP provided a significantly worse short-term (<2 months) improvement in the visual analog scale (VAS) pain score (MD, 0.93 [95% CI, 0.42 to 1.44]; I(2) = 85%; P = .0003) and Disabilities of the Arm, Shoulder and Hand (DASH) score (MD, 10.23 [95% CI, 9.08 to 11.39]; I(2) = 67%; P < .0001) but better long-term (≥6 months) improvement in the VAS score (MD, -2.18 [95% CI, -3.13 to -1.22]; I(2) = 89%; P < .0001), DASH score (MD, -8.13 [95% CI, -9.87 to -6.39]; I(2) = 25%; P < .0001), and Mayo Elbow Performance Score (MD, 16.53 [95% CI, 1.52 to 31.53]; I(2) = 98%; P = .03) than CS. The medium-term (2-6 months) reduction in the VAS score was not significantly different between the 2 groups. After sensitivity analysis, none of the results changed except for the short-term VAS scores (MD, 0.53 [95% CI, -0.13 to 1.19]; I(2) = 78%; P = .12). CONCLUSION Both PRP and CS injections are effective treatments for patients with LE. CS provides better short-term (<2 months) functional improvement and may be more advantageous in terms of short-term pain relief, while PRP provides better long-term (≥6 months) functional improvement and better performance regarding long-term pain relief.
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Randomized Controlled Trials on Platelet-Rich Plasma for Knee Osteoarthritis Poorly Adhere to the Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) Guidelines: A Systematic Review
Stone, A. V., Abed, V., Owens, M., Brunty, N., Skinner, M., Jacobs, C.
The American journal of sports medicine. 2024;:3635465231185289
Abstract
BACKGROUND Platelet-rich plasma (PRP) treatment for knee osteoarthritis has grown exponentially over the past decade; however, its scientific evaluation is highly variable. The American Academy of Orthopaedic Surgeons addressed the need for the standardization of orthobiologics studies by publishing the Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) guidelines in May 2017. In total, the MIBO guidelines are divided into 12 categories, encompassing 23 checklist items. HYPOTHESIS/PURPOSE The purpose of this study was to analyze how well randomized controlled trials (RCTs) on PRP interventions for knee osteoarthritis adhered to the MIBO guidelines. We hypothesized that most articles would report <80% of the MIBO criteria. STUDY DESIGN Systematic review; Level of evidence, 1. METHODS PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to perform a systematic review in the PubMed/MEDLINE and Web of Science databases. Inclusion criteria included English-language RCTs that assessed PRP interventions for knee osteoarthritis and reported beginning patient enrollment in June 2017 or later. The original 23 MIBO checklist items were separated and modified into a 44-point checklist. Adherence was determined by calculating the total percentage of checklist items that each article adequately and clearly reported from the 44-point checklist. RESULTS A total of 25 RCTs (2356 patients) were included in this study. The weighted mean age was 57.7 ± 4.4 years, with 42.9% being male. On average, only 53.1% ± 10.4% (range, 31.8%-77.3%) of the 44-point MIBO checklist items were reported per article. No articles had adherence rates ≥80%, 5 (20.0%) had rates between 60% and 79.9%, and 20 (80.0%) had rates ≤59.9%. Categories fluctuated in adherence, with "Intervention" having the greatest adherence (100.0%) and "Activation" having the lowest (14.0%). Additionally, 4 (33.3%) categories had adherence rates ≥80%, 0 had rates from 60% to 79.9%, and 8 (66.7%) had rates ≤59.9%. CONCLUSION The overall mean adherence to MIBO guidelines by RCTs on PRP interventions for knee osteoarthritis was 53.1%. To increase the reproducibility, improve transparency, and assess the treatment efficacy of future PRP studies, reporting of MIBO guidelines should be improved.
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Outcomes of platelet rich plasma injections in the adhesive capsulitis of the shoulder
Lum, Z. C., Guntupalli, L., Huish, E. G.
Journal of orthopaedics. 2024;48:42-46
Abstract
BACKGROUND Platelet rich plasma (PRP) injections have been utilized in an attempt to provide improved pain and functional outcomes to patients with a variety of orthopaedic ailments. Adhesive capsulitis, also known as frozen shoulder is a common debilitating condition that carries significant morbidity due to the painful and prolonged course. Various studies have investigated intra-articular PRP administration with different methodologies and outcomes. HYPOTHESIS/PURPOSE We sought to perform a meta-analysis on outcomes of adhesive capsulitis after PRP injection, determine effectiveness compared to corticosteroid, and compare adverse events. STUDY DESIGN Meta analysis. METHODS EMBASE, EBSCO, Pubmed and Google Scholar were used to extract titles and abstracts using keywords "adhesive capsulitis", "frozen shoulder", "PRP", "platelet rich plasma". 41 articles were found and after duplicates removed and full-text review, 7 studies investigating 385 patients undergoing PRP or corticosteroid injections were found. Age, gender, body mass index (BMI), and ASA scores were obtained. Patient reported outcomes (PROs) were obtained and all reported range of motion (ROM) were recorded and compared after PRP and steroid injections using random effects meta-regression pre-injection and post-injection. RESULTS Both intra-articular PRP and steroid injections resulted in improved outcomes for treatment of adhesive capsulitis at 3 months. PRP injections had significantly better range of motion in passive forward flexion (151° vs 144.1°, p = 0.024) and had improved Shoulder Pain and Disability Index (SPADI) scores (14.6° vs 18.6°, p = 0.009) compared to steroid, however these may not reach minimum clinical thresholds. PRP had significantly better active (60° vs 43. 5°, p = 0.038) and passive internal rotation (69.6° vs 52.7°, p = 0.017) compared to steroid which did reach minimum clinical thresholds. There were no differences detected between VAS pain, active forward flexion, extension, abduction, external rotation nor difference in adverse events. DISCUSSION Both injections decreased pain and improved range of motion in patients. Intra-articular PRP injections may result in improved internal rotation compared to corticosteroid. Improvement in SPADI and passive forward flexion may be statistically significantly but may not be clinically relevant. LEVEL OF EVIDENCE 3, Therapeutic.
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The efficacy of platelet-rich plasma injections compared to corticosteroids and physiotherapy in adhesive capsulitis: A systematic review and meta-analysis
Pretorius, J., Mirdad, R., Nemat, N., Ghobrial, B. Z., Murphy, C.
Journal of orthopaedics. 2024;47:35-44
Abstract
INTRODUCTION Adhesive Capsulitis is a common condition of the shoulder with significant morbidity and protracted disease. It is usually characterized by sudden onset with progressive symptoms of pain and loss of function. This systematic review compares platelet rich plasma (PRP) intra-articular injections with corticosteroids (CS) injections and physiotherapy. MATERIAL AND METHODS A literature search was performed using online databases (Pubmed, Cochrane, EMBASE, Medline and CINAHL) including all the studies performed on humans through April 2023. Prospective comparative studies were included in this review of patients with adhesive capsulitis assessing the use of PRP injections versus corticosteroid injections or physiotherapy. The standardized mean difference (SMD) with 95 % confidence interval in VAS/DASH/SPADI and ROM scores was calculated using a random effects model, comparing PRP to corticosteroids injections and physiotherapy across studies. RESULTS A total of 11 studies and 971 patients, with a mean age of 52.1, were included in this analysis with 7 being randomised trials and four cohort studies. The control group was corticosteroid injections in 8 studies and physiotherapy in the other three studies. Overall PRP lead to a statistically significant improved outcome at 3 and 6 months follow up for all outcome parameters. The outcome measures at three months includes VAS 0.73 (0.31, 1.16) SMD, DASH 0.66 (0.36, 0.96) SMD, SPADI 1.50 (0.43, 2.57) SMD, ER 1.47 (0.27, 2.66) SMD and Abduction 1.10 (0.21, 1.98) SMD. Six months assessment similarly favoured PRP with VAS 3.17 (1.26, 5.08) SMD and DASH 2.10 (1.66, 2.55) SMD scores. Furthermore, a subgroup analysis demonstrated that PRP was favourable to corticosteroids as control with significant improvement in pain (VAS) at 3 months 0.65 (0.29, 1.00) and 6 months 3.17 (1.26, 5.08) SMD. CONCLUSION This review demonstrated that intra-articular PRP injections for adhesive capsulitis produces favourable outcomes when compared to corticosteroid injections and physiotherapy. PRP produces improved pain and functional scores as well as range of motion, which is statistically significant from 3 to 6 months post intervention. PRP seems to be a safe and effective alternative non-invasive treatment modality for patients with adhesive capsulitis.
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Adipose Tissue-Derived Minimally Manipulated Products versus Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis: A Systematic Review of Clinical Evidence and Meta-Analysis
Veronesi, F., Andriolo, L., Salerno, M., Boffa, A., Giavaresi, G., Filardo, G.
Journal of clinical medicine. 2023;13(1)
Abstract
The use of minimally manipulated adipose tissue (MM-AT) products is gaining increasing interest for the treatment of knee osteoarthritis (OA). MM-AT represents an easy way to exploit adipose tissue properties, although clinical evidence is still limited, as well as their benefits with respect to more documented orthobiologics like platelet-rich plasma (PRP). A systematic review and meta-analysis were performed to evaluate the safety and efficacy of MM-AT products for knee OA management. The risk of bias of the included studies was evaluated using the Dawns and Black checklist for all the included studies and RoB-2.0 for randomized controlled trials (RCTs). Thirty-three clinical studies were included in the qualitative analysis: 13 prospective case series, 10 retrospective case series, 7 RCTs, 2 retrospective comparative studies, and 1 prospective comparative study. An overall clinical improvement and few minor adverse events were observed. Five RCTs comparing MM-AT and PRP injections were meta-analyzed, showing comparable results. The analysis also highlighted the limits of the literature, with only a few high-level trials and an overall low quality. Even though the current literature is still limited, the available evidence suggests the safety and overall positive results of the intra-articular injections of MM-AT products for knee OA treatment.
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Patients With Knee Osteoarthritis Who Receive Platelet-Rich Plasma or Bone-Marrow Aspirate Concentrate Injections Have Better Outcomes Than Patients Who Receive Hyaluronic Acid: Systematic Review and Meta-analysis
Belk JW, Lim JJ, Keeter C, McCulloch PC, Houck DA, McCarty EC, Frank RM, Kraeutler MJ
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2023
Abstract
PURPOSE To systematically review the literature in order to compare the efficacy and safety of platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and hyaluronic acid (HA) injections for the treatment of knee osteoarthritis (OA). METHODS A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I studies that compared the clinical efficacy of at least 2 of the following 3 injection therapies: PRP, BMAC, and HA for knee OA. The search phrase used was knee AND osteoarthritis AND randomized AND ("platelet rich plasma" OR "bone marrow aspirate" OR "hyaluronic acid"). Patients were primarily assessed based on patient-reported outcome scores (PROs) including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) score. RESULTS Twenty-seven studies (all Level I) met inclusion criteria, including 1,042 patients undergoing intra-articular injection(s) with PRP (mean age 57.7 years, mean follow-up 13.5 months), 226 patients with BMAC (mean age 57.0 years, mean follow-up 17.5 months), and 1,128 patients with HA (mean age 59.0 years, mean follow-up 14.4 months). Non-network meta-analyses demonstrated significantly better post-injection WOMAC (p < 0.001), VAS (p < 0.01), and Subjective IKDC scores (p < 0.001) in PRP patients when compared to HA patients. Similarly, network meta-analyses demonstrated significantly better post-injection WOMAC (p < 0.001), VAS (p = 0.03), and Subjective IKDC (p < 0.001) scores in BMAC patients when compared to HA patients. There were no significant differences in post-injection outcome scores when comparing PRP to BMAC. CONCLUSION Patients undergoing treatment for knee OA with PRP or BMAC can be expected to experience improved clinical outcomes when compared to HA patients. LEVEL OF EVIDENCE I, Meta-Analysis of Level I studies.