Single-dose intra-articular corticosteroid injection prior to platelet-rich plasma injection resulted in better clinical outcomes in patients with knee osteoarthritis: A pilot study

Abstract

BACKGROUND:

The synergistic and protective effect of platelet-rich plasma (PRP) added to methlyprednisolone (MP) has been demonstrated via in-vitro studies. However, there is no report in the literature about this issue.

OBJECTIVE:

The aim of this study was to evaluate clinical outcomes of intra-articular (IA) MP injection prior to PRP injection in comparison with single-dose MP and PRP injections alone in patients with knee osteoarthritis (OA).

METHODS:

The treatment groups were “PRP group” ( $n=$ 37) who underwent single-dose IA PRP injection, “PRP $+$ MP group” ( $n=$ 40) who underwent MP injection one week prior to single-dose PRP injection, and “MP group” ( $n=$ 38) who underwent single-dose MP injection. Visual Analog Scale (VAS) and The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were applied at first admission and at 1 ${}^{\text{st}}$ , 3 ${}^{\text{rd}}$ , 6 ${}^{\text{th}}$ , and 12 ${}^{\text{th}}$ month follow-ups.

RESULTS:

At the end of the 1st month, WOMAC score in PRP $+$ MP group was significantly lower than PRP group. At the 3 ${}^{\text{rd}}$ month, WOMAC score in PRP $+$ MP group was significantly lower than PRP and MP groups. At the 6 ${}^{\text{th}}$ month, VAS and WOMAC score in PRP $+$ MP group was significantly lower than MP group. At the end of the 12 ${}^{\text{th}}$ month, no significant difference was observed among three groups in VAS and WOMAC scores.

CONCLUSION:

According to our results, IA MP injection prior to PRP injection resulted in significantly better clinical outcomes compared to PRP and MP injections alone in patients who had mild to moderate knee OA.

Keywords

Platelet-rich plasma intra-articular injection knee osteoarthritis corticosteroid

1. Introduction

Knee osteoarthritis (OA) is one of the most common disorders that can cause functional disability including cartilage damage with an inadequate healing capacity [1]. It has been reported that approximately 25% of adults over 55 years old suffer from knee pain at least one time a year, and nearly half of them are diagnosed as knee OA in years [2, 3].

Current treatment methods for knee OA include non-pharmacological, pharmacological, and surgical interventions. According to recent treatment guidelines, pharmacological treatment is highly recommended for middle-aged and older patients with the diagnosis of knee OA [4]. Intra-articular (IA) injection is a minimally invasive pharmacological treatment method, which consists of administering various agents into the knee joint to decrease pain and increase function when other pharmacological interventions failed [5].

Although IA use of corticosteroids is still controversial in literature, they are commonly used in orthopedic practice to relieve pain and improve function in patients with knee OA [6]. In the literature, there is strong evidence supporting IA corticosteroid injection for significant pain relief and functional improvement in OA [7]. Synovitis and effusion of the knee joint due to the inflammatory process are frequently presented in knee OA and correlate with pain as well as functional outcome [8]. In light of data from studies reporting the association between the inflammatory process and progression of knee OA, corticosteroids may still have a potential role in the pathophysiology of cartilage damage by reducing the inflammatory process in the knee joint [9]. Beneficial effects can be achieved with the application of IA corticosteroids at low doses; however, its negative effects on healthy cartilage have been shown in vitro and in vivo studies at high doses and durations [10].

On the other hand, IA use of autologous platelet-rich plasma (PRP) injections was indicated for chondral lesions of knee to modify inflammatory response, tissue repair, and regeneration in the knee joint [11]. According to recent systematic reviews in literature, IA PRP injection was suggested as a safe and effective option in the treatment of knee OA compared to hyaluronic acid (HA) viscosupplementation [12]. However, no consensus has been established in literature regarding the number of IA injections as well as ideal intervals between repeated applications [13].

Combination of PRP with local anesthetics and/or corticosteroids is another controversial issue in literature [14]. The synergistic and protective effect of PRP on tendon cell viability when added to methlyprednisolone (MP) has been demonstrated via in-vitro studies, however, the anti-inflammatory effect of PRP in combination with or without corticosteroids is still up for debate [15, 16, 17]. Platelet activation is a primary or secondary feature in rheumatic disorders remains to be elucidated; however, emerging data suggest that the release rate of activated platelets applied topically to the inflamed cartilage in arthritis may suppress the inflammation and facilitate tissue repair [18]. To our current knowledge, there is no study found in available literature comparing IA PRP injection with combined corticosteroid and PRP injection and corticosteroid injection alone for knee OA.

It was hypothesized that the IA MP injection prior to PRP injection would lead to improvements in clinical and pain scores due to synergistic effect. Therefore, the aim of this study was to evaluate clinical outcomes of IA MP injection prior to PRP injection in comparison with single-dose MP and PRP injections alone in patients with knee OA.

2. Materials and methods

2.1 Study population

Patients who admitted to our department between January 2016 and August 2016 and underwent IA injection of knee joint with the diagnosis of knee OA were evaluated in this prospective longitudinal study. The study was approved by Erzincan University, Clinical Researches Ethics Committee (ID No:33216249-604.01.02-E.42916) and conducted in compliance with the Helsinki Declaration. Written informed consent was obtained from all patients.

Patients’ age, gender, body mass index (BMI), past medical history, and clinical scores were noted at the first admission. Weight-bearing anteroposterior and lateral radiographs of both knees were evaluated for radiographic classification of the patients. Magnetic resonance imaging (MRI) of the affected knee was also evaluated for all patients to exclude knee pathologies that need surgical intervention.

Patients with a complete medical record, between 40 and 80 years of age, with a body mass index (BMI) lower than 30 kg/m ${}^{2}$ , with grade II or III knee OA according to Kellgren-Lawrence classification [19] were included in this study. The exclusion criteria were: 1) patients who were lost to follow-up, 2) patients with osteochondritis dissecans and synovitis according to MRI, as well as meniscal or ligamenteous pathologies with mechanical symptoms 3) past medical history of surgery or fracture from the affected extremity, 4) previous IA knee injection within 1 year.

Figure 1.

Flowchart diagram of the study. n: number of patients, IA: intraarticular, OA: osteoarthritis, PRP: platelet-rich plasma, MP: methylprednisolone.

One hundred and thirty-two patients who met the eligibility criteria were divided into three groups according to IA injection treatment method. Seventeen patients were lost to follow-up and 115 patients completed 12 months follow-up (Fig. 1). The treatment groups were “PRP group” ( $n=$ 37) who underwent single-dose IA PRP injection, “PRP $+$ MP group” ( $n=$ 40) who underwent MP injection one week prior to single-dose PRP injection, and “MP group” ( $n=$ 38) who underwent single-dose MP injection.

All injections were performed in the supine position after sterile preparation of skin. Intra-articular injections were performed through standard suprapatellar approach for IA injection of knee. Oral paracetamol was routinely prescribed for all patients.

2.2 PRP group

Firstly, 2 mL of anticoagulant was withdrawn into a 20 mL sterile injector. Then, 18 mL of peripheral venous blood was taken from patient and a total of 20 mL sample was transferred into the tube of the PRP kit. The tube was centrifuged at 1800 rpm for 8 minutes. Approximately 10 mL of plasma was obtained after centrifuging. The lower part of the plasma (3 mL PRP), which has richer platelet content, was transferred into another sterile injector to administrate into the knee joint. Single dose 3 mL of PRP was combined with 3 mL of prilocaine and injected into the knee joint through suprapatellar approach.

2.3 PRP plus MP group

One week prior to IA PRP injection, all patients in the PRP $+$ MP group received IA 1 mL/40 mg methylprednisolone combined with 3 mL prilocaine. IA PRP injection was performed in the same manner as PRP group one week after MP injection.

2.4 MP group

In the MP group, a single dose of 1 mL of methypre- dnisolone combined with 3 mL prilocaine was administrated into knee joint under sterile conditions through suprapatellar IA injection approach.

2.5 Outcome assessment

Patients’ demographics such as age, gender, BMI, and grade of knee OA were recorded for all patients at first admission. Visual Analog Scale (VAS) and The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were applied for all patients at first admission and at 1 ${}^{\text{st}}$ , 3 ${}^{\text{rd}}$ , 6 ${}^{\text{th}}$ , and 12 ${}^{\text{th}}$ month follow-ups. VAS score was primarily used to evaluate pain. Patients described pain on a scale from 0 (no pain) to 10 (worst pain). The WOMAC score consisted of 24 items divided into 3 subscales as: 1) pain, 2) stiffness, and 3) physical function. Adverse effects and complications were noted for all patients during follow-ups.

2.6 Statistical analysis

Statistical analysis was performed using the SPSS 20 software (SPSS Inc., IBM, NY, USA). Categorical variables were given with frequency and percentage; continuous numerical variables were given with median (minimum; maximum). The Pearson Chi-Square test was used to compare frequencies. Comparison of VAS and WOMAC scores between groups at first admission, as well as at 1 ${}^{\text{st}}$ , 3 ${}^{\text{rd}}$ , 6 ${}^{\text{th}}$ , 12 ${}^{\text{th}}$ month follow-ups were performed by non-parametric Kruskal-Wallis test. In addition to that, non-parametric pair wise comparison was performed. The differences between repeated measurements were compared by repeated measures one-way ANOVA test. $P$ values lower than 0.05 ( $p<$ 0.05) were considered statistically significant.

3. Results

The demographic data and baseline characteristics of the patients at the initial control were shown in Table 1. There was no statistically significant difference between three groups in terms of age, gender, BMI, Kellgren-Lawrence classifications or the initial VAS and WOMAC scores (Table 1).

Table 1
Demographics and baseline characteristics of the patients with $p$ values

	PRP		PRP $+$ MP		MP		$p$
	group		group		group		values
	( $n=$ 37)		( $n=$ 40)		( $n=$ 38)
Age (years)	61	(50;79)	63	(50;79)	63	(51;75)	$n.s.^{*}$
Gender
Female	31	(84%)	33	(82%)	32	(84%)	$n.s.^{**}$
Male	6	(16%)	7	(18%)	6	(16%)	$n.s.^{**}$
BMI (kg/m2)	28	(23;30)	29	(23;30)	28	(23;30)	$n.s.^{*}$
Kellgren-Lawrence classification
Grade 2	20	(54 %)	21	(53 %)	20	(53 %)	$n.s.^{**}$
Grade 3	17	(46%)	19	(47%)	18	(47%)	$n.s.^{**}$
Initial VAS score	8	(5;9)	7	(6;9)	7	(6;9)	$n.s.^{*}$
Initial WOMAC score
Pain	15	(14;17)	15	(14;18)	15	(14;18)	$n.s.^{*}$
Stiffness	7	(5;8)	6	(5;8)	6	(5;8)	$n.s.^{*}$
Physical	54	(53;65)	54	(53;66)	55	(53;66)	$n.s.^{*}$
function
Total	77	(73;88)	77	(73;88)	77	(73;88)	$n.s.^{*}$

n.s. not significant. ${}^{*}$ p value according to Kruskal-Wallis test. ${}^{**}$ p value according to Pearson Chi-Square test.

At the 1 ${}^{\text{st}}$ month, clinical improvements were obtained according to VAS and WOMAC scores within each group compared to the initial scores. When three groups were compared, the pain subscale of WOMAC score in PRP $+$ MP group was significantly lower than PRP group, and total WOMAC score in PRP $+$ MP group was significantly lower than PRP group (Table 2).

Table 2

Comparison of clinical scores of the groups at 1st, 3rd, 6th and 12th months after intraarticular injection

	VAS score	WOMAC score
		Pain	Stiffness	Physical function	Total
1st month
PRP group	3 (2;3)	7 (5;9)	3 (2;5)	19 (19;22)	29 (26;36)
PRP $+$ MP group	3 (2;3)	6 (5;9)	2 (1;4)	19 (18:22)	28 (26;35)
MP group	3 (2;3)	6 (5;8)	3 (2;5)	19 (18;25)	28 (25;36)
$p$ value (between groups)	$n.s.^{*}$	$0.021^{*}$	$n.s.^{*}$	$n.s.^{*}$	$0.014^{*}$
$p$ value (PRP vs PRP $+$ MP)	$n.s.^{**}$	$0.032^{**}$	$n.s.^{**}$	$n.s.^{**}$	$0.012^{**}$
$p$ value (PRP vs MP)	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$
$p$ value (PRP $+$ MP vs MP)	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$
3rd month
PRP group	3 (2;4)	8 (6;9)	3 (2;5)	22 (20;24)	33 (29;38)
PRP $+$ MP group	3 (2;4)	6 (5;9)	2 (2;5)	21 (20;25)	30 (28;38)
MP group	3 (2;5)	8 (5;10)	3 (2;6)	24 (20;40)	34 (27;54)
$p$ value (between groups)	$n.s.^{*}$	$<0.001^{*}$	$0.001^{*}$	$<0.001^{*}$	$<0.001^{*}$
$p$ value (PRP vs PRP $+$ MP)	$n.s.^{**}$	$<0.001^{**}$	$0.047^{**}$	$n.s.^{**}$	$0.002^{**}$
$p$ value (PRP vs MP)	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$
$p$ value (PRP $+$ MP vs MP)	$n.s.^{**}$	$<0.001^{**}$	$<0.001^{**}$	$<0.001^{**}$	$<0.001^{**}$
6th month
PRP group	6 (3;8)	9 (8;11)	4 (2;7)	29 (28;54)	44 (38;69)
PRP $+$ MP group	4 (3;8)	9 (5;10)	3 (2;7)	28 (22;66)	40 (32;81)
MP group	6 (3;9)	11 (7;15)	6 (3;7)	34 (29;50)	51 (41;69)
$p$ value (between groups)	$n.s.^{*}$	$<0.001^{*}$	$<0.001^{*}$	$<0.001^{*}$	$<0.001^{*}$
$p$ value (PRP vs PRP $+$ MP)	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$
$p$ value (PRP vs MP)	$n.s.^{**}$	$<0.001^{**}$	$<0.001^{**}$	$<0.001^{**}$	$0.001^{**}$
$p$ value (PRP $+$ MP vs MP)	$n.s.^{**}$	$<0.001^{**}$	$<0.001^{**}$	$<0.001^{**}$	$<0.001^{**}$
12th month
PRP group	7 (5;9)	16 (8;17)	7 (4;8)	54 (37;65)	76 (50;88)
PRP $+$ MP group	7 (6;9)	15 (8;17)	6 (4;8)	54 (30;70)	74 (43;93)
MP group	7 (6;9)	17 (14;18)	8 (5;9)	54 (34;66)	76 (53;89)
$p$ value (between groups)	$n.s.^{*}$	$0.038^{*}$	$0.027^{*}$	$n.s.^{*}$	$n.s.^{*}$
$p$ value (PRP vs PRP $+$ MP)	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$
$p$ value (PRP vs MP)	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$	$n.s.^{**}$
$p$ value (PRP $+$ MP vs MP)	$n.s.^{**}$	$0.041^{**}$	$0.031^{**}$	$n.s.^{**}$	$n.s.^{**}$

n.s. not significant. ${}^{*}$ p value according to Kruskal Wallis test. ${}^{**}$ p value according to pairwise comparison.

Figure 2.

The line chart of initial and follow-up (a) VAS and (b) WOMAC scores of the three groups.

At the 3 ${}^{\text{rd}}$ month, no significant difference was observed between groups in terms of VAS scores. However, all subscales and the total WOMAC score were significantly different among groups. The pain subscale of WOMAC in PRP $+$ MP group was significantly superior to other groups like 1 ${}^{\text{st}}$ month follow-up scores ( $p=<$ 0.001). Stiffness subscale of WOMAC was lowest in PRP $+$ MP group and a significant difference was observed when compared to MP group and PRP group ( $p=<$ 0.001 and $p=$ 0.047, respectively). Physical function component of WOMAC score in PRP $+$ MP group was significantly superior to MP group ( $p=<$ 0001). Total WOMAC score in PRP $+$ MP group was also significantly lower than PRP and MP groups ( $p=$ 0.002 and $p=<$ 0.001, respectively) (Table 2).

At the 6 ${}^{\text{th}}$ month, VAS score was lowest in PRP $+$ MP group however no significant difference was obtained among groups. Pain, stiffness, and physical function subscales and total of the WOMAC score in MP group were also significantly higher than other groups (Table 2).

At the end of the 12 ${}^{\text{th}}$ month, no significant difference was observed between the three groups with regard to VAS and total WOMAC scores. However, pain and stiffness subscales of WOMAC in PRP $+$ MP groups were significantly lower than MP group. No significant difference was obtained in physical function subscale of WOMAC scores among all groups (Table 2).

According to the results of repeated measures one-way ANOVA test, after IA injection VAS and WOMAC scores differed significantly between time points ( $p<$ 0.001). When groups were compared, the difference of VAS score between time points did not significantly differ between groups. The difference of total WOMAC score between time points was significantly different when PRP $+$ MP group was compared to MP group ( $p=$ 0.001) (Fig. 2a and b).

During the follow-up, no systemic complication was observed related to IA injections in the three groups. Besides, no septic reaction occurred after IA injections. Minor adverse reactions were defined as local reactions as pain, mild swelling, and warmth. Minor adverse reactions occurred in 5 of 37 patients (13.5%) in PRP group, in 2 of 40 patients (5%) in PRP $+$ MP group and in 0 of 38 patients (0%) in MP group.

4. Discussion

The most important finding of this study was PRP injection in combination with MP injection resulted in better improvements in clinical scores compared to both single-dose PRP and MP injections in patients who had mild to moderate knee OA. After combined IA injection of MP and PRP, significant improvements were observed in clinical scores compared to PRP alone within 3 months. Besides, significant differences were also detected in clinical scores compared to MP group at least 6 months.

Intra-articular PRP injection is considered as a viable treatment method for knee OA according to previous studies [20, 21]. In-vivo and in-vitro studies have shown increases in chondrocyte proliferation as well as decreases in inflammatory cascade after administration of PRP [22]. In an animal study comparing the effects of PRP and saline on full-thickness cartilage defect of knee in immature rabbits, Serra et al. reported no difference in tissue repair at 19 weeks of age [23]. Beitzel et al. reported increased tenocyte and chondrocyte proliferation after application of PRP in their in-vivo study; the authors observed that, although corticosteroid application alone decreased cell viability, this effect could reverse when a combination of PRP was applied [24]. Solchaga et al. also observed a decrease in cell proliferation after application of corticosteroid in a rat tendinopathy model, however, authors reported that histology demonstrated similar repair and they found no significant difference between PRP and corticosteroid in terms of biomechanical function and improvements of tendon [25]. In their in-vitro study on human rotator cuff derived cells, Muto et al. mentioned that PRP might be useful in combination with corticosteroid application to protect deleterious effects of corticosteroids [26]. Intra-articular PRP’s short standing effectiveness on pain modulation even in Grade IV knee OA may demonstrate its anti-inflammatory effect. On the other hand, decrease in clinical symptoms after IA PRP application may indicate its regulatory effect on biological tissue repairing mechanism due to rich content of growth factors.

To date, no study can be found in literature evaluating the clinical outcomes of PRP in combination with corticosteroid for knee OA. In literature, only limited number of studies exist about combination of HA and corticosteroid. Campos et al. compared the clinical outcomes of HA plus triamcinolone with HA alone; the authors reported that addition of triamcinolone improved first week VAS and WOMAC scores [27]. From this point of view, we hypothesized that IA PRP injection in combination with MP may provide a mutually beneficial effect. According to our results, IA injection of MP prior to PRP injection revealed superior clinical outcomes in comparison to PRP alone. However, this synergistic effect continued until the end of the 3 ${}^{\text{rd}}$ month. At the 6 ${}^{\text{th}}$ month follow-up, comparison of PRP and PRP $+$ MP groups showed no significant difference.

In the literature, the efficacy comparison of PRP and corticosteroid is still unclear. In their randomized clinical trial comparing single dose IA PRP and corticosteroid injection for Kellgren-Lawrence grade II or III knee OA, Forogh et al. reported that PRP was significantly superior to corticosteroid in terms of VAS score and knee clinical scores [28]. However, authors found no significant difference between PRP and corticosteroid when patients’ ranges of motions were compared [28]. Kon et al. reported that PRP injection yielded satisfactory clinical outcomes up to 6 ${}^{\text{th}}$ month and worsened at 12 ${}^{\text{th}}$ month follow-up [29]. Lomonte et al. and Buyuk et al. compared IA triamcinolone with MP in their studies; both authors reported that MP and triamcinolone are equally effective and significant improvement in pain and function according to WOMAC scores can be sustained for up to 6 months [30, 31]. Our results showed that no significant difference was observed between single-dose PRP and MP when the mean VAS scores were compared. However, patients total WOMAC scores were significantly lower in PRP group compared to MP group up to 6 months.

When we reviewed complications after IA injection, no systemic complications or septic condition occurred during follow-up in the three groups. Minor complications due to adverse reaction such as pain, mild swelling, and warmth of the indexed knee were not observed in MP group, where as it was highest in PRP group (13.5%) compared to PRP $+$ MP group (5%). Patel et al. reported 22% complication rate after single-dose PRP injection, moreover it was 44% after double-dose PRP injection with a 3-week interval [32]. The rate of adverse reactions related to PRP injection was consistent with current literature.

The main limitation of this study was comparison of non-randomized three groups. However, a relatively homogeneous patient population, with no significant difference in demographics and stages of diseases, was evaluated in this study. Besides, patients were followed up to the end of 12 months to evaluate clinical efficacy of single-dose PRP in comparison with PRP plus MP and MP alone. In the other hand, the main strength of this study was being the first study in literature reporting the clinical outcomes of IA PRP in combination with MP injection. We did not apply a priori calculation for the sample size; however, post hoc analysis was performed for each of the variables and the lowest statistical power was 0.96 with an alpha value of 0.05. This study may guide further prospective randomized well-controlled clinical trials about this issue, which was investigated widely in previous in-vitro studies.

5. Conclusion

According to our results, the combination therapy with MP and PRP revealed significantly better improvements at least 3 months compared to single PRP and at least 6 months compared to single MP injection in clinical scores of patients who had mild to moderate knee OA. Further clinical trials are needed to evaluate the synergistic effect of MP in addition with PRP for the treatment of knee OA.

Footnotes

Conflict of interest

None to report.

References

Neogi

. The epidemiology and impact of pain in osteoarthritis. Osteoarthritis Cartilage. 2013; 21(9): 1145.

Silverwood

Blagojevic-Bucknall

Jinks

Jordan

Protheroe

Jordan

. Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2015; 23(4): 507.

Peat

McCarney

Croft

. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis. 2001; 60(2): 91. Review.

Zhang

Moskowitz

Nuki

Abramson

Altman

Arden

, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008; 16(2): 137. Review.

Liu

Dubé

Driban

McAlindon

Eaton

Lapane

. Patterns of intra-articular injection use after initiation of treatment in patients with knee osteoarthritis: data from the osteoarthritis initiative. Osteoarthritis Cartilage. 2017; 25(10): 1607.

McAlindon

LaValley

Harvey

Price

Driban

Zhang

Ward

. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017; 317(19): 1967.

Cheng

Souzdalnitski

Vrooman

Cheng

. Evidence-based knee injections for the management of arthritis. Pain Med. 2012; 13(6): 740.

Baker

Grainger

Niu

Clancy

Guermazi

Crema

, et al. Relation of synovitis to knee pain using contrast-enhanced MRIs. Ann Rheum Dis. 2010; 69(10): 1779.

Roemer

Guermazi

Felson

Niu

Nevitt

Crema

, et al. Presence of MRI-detected joint effusion and synovitis increases the risk of cartilage loss in knees without osteoarthritis at 30-month follow-up: the MOST study. Ann Rheum Dis. 2011; 70(10): 1804.

10.

Wernecke

Braun

Dragoo

. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015; 3(5): 23259671155811 63.

11.

Gobbi

Lad

Karnatzikos

. The effects of repeated intra-articular PRP injections on clinical outcomes of early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2015; 23(8): 2170.

12.

Meheux

McCulloch

Lintner

Varner

Harris

. Efficacy of Intra-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review. Arthroscopy. 2016; 32(3): 495.

13.

Dai

Zhou

Zhang

. Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Meta-analysis of Randomized Controlled Trials. Arthroscopy. 2017; 33(3): 659.

14.

Pourcho

Smith

Wisniewski

Sellon

. 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. Review.

15.

Mazzocca

McCarthy

Intravia

Beitzel

Apostolakos

Cote

, et al. An in vitro evaluation of the anti-inflammatory effects of platelet-rich plasma, ketorolac, and methylprednisolone. Arthroscopy. 2013; 29(4): 675.

16.

Muto

Kokubu

Mifune

Inui

Sakata

Harada

, et al. Effects of platelet-rich plasma and triamcinolone acetonide on interleukin-1ß-stimulated human rotator cuff-derived cells. Bone Joint Res. 2016; 5(12): 602.

17.

Carofino

Chowaniec

McCarthy

Bradley

Delaronde

Beitzel

, et al. Corticosteroids and local anesthetics decrease positive effects of platelet-rich plasma: an in vitro study on human tendon cells. Arthroscopy. 2012; 28(5): 711.

18.

Gasparyan

Ayvazyan

Pretorius

Kitas

. Platelets in rheumatic diseases: friend or foe? Curr Pharm Des. 2014; 20(4): 552. Review.

19.

Kellgren

Lawrence

. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957; 16(4): 494.

20.

Görmeli

Ataoglu

Çolak

Aslantürk

Ertem

. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017; 25(3): 958.

21.

Campbell

Saltzman

Mascarenhas

Khair

Verma

Bach

Jr Cole

. Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior Outcomes Compared With Other Therapies in the Treatment of Knee Osteoarthritis? A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015; 31(11): 2213.

22.

Khoshbin

Leroux

Wasserstein

Marks

Theodoropoulos

Ogilvie-Harris

, et al. The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis. Arthroscopy. 2013; 29(12): 2037. Review.

23.

Serra

Soler

Carrillo

Sopena

Redondo

Cugat

. Effect of autologous platelet-rich plasma on the repair of full-thickness articular defects in rabbits. Knee Surg Sports Traumatol Arthrosc. 2013; 21(8): 1730.

24.

Beitzel

McCarthy

Cote

Apostolakos

Russell

Bradley

, et al. The effect of ketorolac tromethamine, methylprednisolone, and platelet-rich plasma on human chondrocyte and tenocyte viability. Arthroscopy. 2013; 29(7): 1164.

25.

Solchaga

Bendele

Shah

Snel

Kestler

Dines

Hee

. Comparison of the effect of intra-tendon applications of recombinant human platelet-derived growth factor-BB, platelet-rich plasma, steroids in a rat achilles tendon collagenase model. J Orthop Res. 2014; 32(1): 145.

26.

Muto

Kokubu

Mifune

Sakata

Nagura

Nishimoto

, et al. Platelet-rich plasma protects rotator cuff-derived cells from the deleterious effects of triamcinolone acetonide. J Orthop Res. 2013; 31(6): 976.

27.

de Campos

Rezende

Pailo

Frucchi

Camargo

. Adding triamcinolone improves viscosupplementation: a randomized clinical trial. Clin Orthop Relat Res. 2013; 471(2): 613.

28.

Forogh

Mianehsaz

Shoaee

Ahadi

Raissi

Sajadi

. Effect of single injection of platelet-rich plasma in comparison with corticosteroid on knee osteoarthritis: a double-blind randomized clinical trial. J Sports Med Phys Fitness. 2016; 56(7-8): 901.

29.

Kon

Buda

Filardo

Di Martino

Timoncini

Cenacchi

, et al. Platelet-rich plasma: intra-articular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc. 2010; 18(4): 472.

30.

Lomonte

de Morais

de Carvalho

Zerbini

. Efficacy of Triamcinolone Hexacetonide versus Methylprednisolone Acetate Intraarticular Injections in Knee Osteoarthritis: A Randomized, Double-blinded, 24-week Study. J Rheumatol. 2015; 42(9): 1677.

31.

Buyuk

Kilinc

Camurcu

Camur

Ucpunar

Kara

. Compared efficacy of intra-articular injection of methylprednisolone and triamcinolone. Acta Ortop Bras. [online]. 2017; 25(5): 206.

32.

Patel

Dhillon

Aggarwal

Marwaha

Jain

. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Am J Sports Med. 2013; 41(2): 356.

Single-dose intra-articular corticosteroid injection prior to platelet-rich plasma injection resulted in better clinical outcomes in patients with knee osteoarthritis: A pilot study

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Study population

2.3 PRP plus MP group

2.4 MP group

2.5 Outcome assessment

2.6 Statistical analysis

3. Results

Table 1 Demographics and baseline characteristics of the patients with p values

5. Conclusion

Footnotes

Conflict of interest

References

Table 1
Demographics and baseline characteristics of the patients with $p$ values