Main Article Content
OBJECTIVES: To compare and evaluate the efficacy of intraarticular platelet-rich growth factor (PRGF) versus intraarticular steroid injections.
MATERIAL AND METHODS: A prospective, blinded, randomized controlled trial was conducted by enrolling 650 patients with knee osteoarthritis (OA) who did not respond to the combination of oral medication and physiotherapy. After computer-based randomization and exclusion, the number of patients in our study was 557. Patients were divided into 2 groups. Group 1 (310 patients) received intraarticular PRGF injection and group 2 (247 patients) received intraarticular injection of 40-mg triamcinolone solution. The post-trial follow-up period ranged from 12 to 18.5 months. The primary endpoints were the International Knee Documentation Committee (IKDC) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and the secondary endpoints were the Visual Analog Scale (VAS) pain scores.
RESULT: The IKDC scores were measured at baseline, 2-, 4-, 6-, and 12-month follow-up after the injection. The IKDC scores of group 1 (PRGF treatment) were 39.48 ± 7.94, 48.47 ± 8.49, 51.04 ± 8.26, 51.54 ± 8.07, and 52.14 ± 9.86, and the IKDC scores of group 2 (steroid treatment) were 38.30 ± 7.26, 45.64 ± 9.45, 45.60 ± 10.24, 45.79 ± 9.96, and 43.14 ± 11.63, respectively. WOMAC scores were collected at the same period. The WOMAC scores of group 1 (PRGF treatment) were 56.91 ± 14.89, 42.54 ± 15.64, 38.13 ± 14.95, 36.41 ± 15.23, and 36.28 ± 17.86 and, for group 2 (steroid treatment), the scores were 56.73 ± 11.69, 45.22 ± 17.00, 46.37 ± 17.52, 46.47 ± 17.47, and 50.84 ± 20.29, respectively. Patients in group 1 and 2 both showed improvement after the treatment. The data showed significant statistical difference (p < 0.01) in almost all of the scoring, in favor of the PRGF injection, except no significance at the first 2 months (WOMAC, p = 0.053). The secondary outcome revealed a similar trend with significant statistical difference (p < 0.01) as the primary outcome did. PRGF was collected according to our novel Plasma Platelet Concentrate and Growth Factors (PP&GF) protocol. The average platelet concentration prepared by PP&GF protocol was 6 times (3-8.69) higher than the normal platelet concentration. There was no knee infection at the end of the follow up.
CONCLUSION: PRGF and intraarticular steroid injection result in good outcomes, however in terms of functional scoring (WOMAC and IKDC), PRGF treatment demonstrated significantly better clinical outcomes at 6- to 12-month follow-up. PRGF treatment can become an effective alternative treatment in knee OA. However, optimal preparation techniques are essential for improved clinical outcomes, and further investigation with long-term follow-up is recommended.
This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Centers for Disease Control and Prevention (CDC). Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation: United States, 2010–2012. MMWR Morb
Mortal Wkly Rep 2013;62:869-73.
Buckwalter JA, Brown TD. Joint injury, repair, and remodeling:Roles in post-traumatic osteoarthritis. Clin Orthop Relat Res2004;423:7-16.
Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.Arthritis Rheumatol 2020;72 220-33.
National institute for health and care excellence. Management of osteoarthritis NICE pathways 2020. (Accessed November15, 2020, at fhttps://pathways.nice.org.uk/pathways/osteoarthritis).
Chan FK, Goto S, Wu MS, et al. Burden of non-steroidalantiinflammatory and antiplatelet drug use in Asia: a multidisciplinary working party report: Clin Gastroenterol Hepatol 2012;10:753–60.
Turajane T, Wongbunnak R, Patcharatrakul T, et al. Gastrointestinal and cardiovascular adverse effects in nonselective NSAIDs and COX-2 Inhibitors in elderly patients with knee osteoarthritis. J Med Assoc Thai 2009; 92 Suppl 6: S19-26.
Johal H, Khan M, Yung SP, et al. Impact of Platelet-Rich Plasma use on pain in Orthopedic surgery: A Systematic
Review and Meta-analysis. Sport Health 2019;11(4):355-66.
Turajane T, SriratanavudhiC, Saengsirinavin P. PRGF (Platelet Rich Growth Factors): What is the Evidence Based?RCOST ICL4; 2018;4:236-45.
Jevsevar DS, Shores PB, Mullen K, et al. Mixed treatment comparisons for nonsurgical treatment of knee osteoarthritis:a network meta-analysis. J Am AcadOrthop Surg 2018;26:325-36.
Turjane T, Sriratanavudhi C , Saengsirinavin P, et al. Safety and clinical efficacy of platelet rich growth factors (Prgf) in management of knee osteoarthritis after failed conservative treatment: evidence from real practices. J South East Asia Med Res 2019:3(1):1- Available from: https://jseamed.org/index.php/jseamed/article/view/43.
Pourcho AM Smith J, Wisniewski SJ. MD, et al. Intraarticular Platelet-Rich Plasma Injection in the Treatment of Knee Osteoarthritis: Review and Recommendations. Am J Phys Med Rehabil 2014;93(11 Suppl 3):S108-21.
Sánchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. Int J Oral Maxillofac Implants 2003;18:93-103.
Mishra A, Tummala P, King A, et al. Buffered platelet-rich plasma enhances mesenchymal stem cell proliferation and chondrogenic differentiation. Tissue Eng Part C Methods 2009;15:431-5.
Wernecke C, Braun HJ, Dragoo JL. The effect of Intra-articular corticosteroids on articular cartilage: a systematic review. Orthop J Sports Med 2015;3(5):2325967115581163.
Jevsevar DS, Shores PB, Mullen K, et al. Mixed treatment comparisons for nonsurgical treatment of knee osteoarthritis: a network meta-analysis. J Am Acad Orthop Surg 2018;26:325-36.
Kon E, Buda R, Filardo G, et al. Platelet-rich plasma: Intraarticular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc 2010;18:472-9.
Güvendi EU, Aşkin A, Güvendi G, et al. Comparison of Efficiency Between Corticosteroid and Platelet Rich Plasma Injection Therapies in Patients With Knee Osteoarthritis. Arch
Vannabouathong C, Bhandari M, Bedi, et al Nonoperative treatments for knee osteoarthritis: an evaluation of treatment characteristics and the intra-articular placebo effect. JBJS Rev 2018;6(7):e5. doi:10.2106/JBJS.RVW.17.00167.
LaPrade RF, Dragoo JL, Koh JL, et al. AAOS ResearchSymposium Updates and Consensus: Biologic Treatment of Orthopaedic Injuries. J Am Acad Orthop Surg 2016;24:e62-e78.
Dohan Ehrenfest DM, Bielecki T, Del Corso M, et al. Shedding light in the controversial terminology for platelet-rich products: platelet-rich plasma (PRP), platelet rich fibrin (PRF), platelet-leukocyte gel (PLG), preparation rich in growth factors (PRGF), classification and commercialism. J Biomed
Mater Res A 2010;95:1280-2.
Vaquerizo V, Plasencia MA, Arribas I, et al. Comparison of intra-articular injections of plasma rich in growth factors (PRGF-Endoret) versus Durolane hyaluronic acid in the treatment of patients with symptomatic osteoarthritis: a randomized controlled trial. Arthroscopy 2013;29:1635-43.
Turajane T, Chaweewannakorn U, Larbpaiboonpong V, et al Combination of intra-articular autologous activated peripheral blood stem cells with growth factor addition/ preservation and hyaluronic acid in conjunction with arthroscopic microdrilling mesenchymal cell stimulation Improves quality of life and
regenerates articular cartilage in early osteoarthritic knee disease. J Med Assoc Thai 2013;96:580-93.
Turajane T, Thitiset T, Honsawek S, et al. Assessment of chondrogenic differentiation potential of autologous
activated peripheral blood stem cells on human early osteoarthritic cancellous tibial bone scaffold. Musculoskelet Surg 2014;98(1):35-43.
Padilla S, Orive G, Sanchez M, et al. Platelet-rich plasma in orthopaedic applications: evidence-based recommendations for treatment. J Am Acad Orthop Surg 2014;22:469-70.
Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF).Trends Biotechnol 2009;27:158-67.