What are the recommendations for orthopedic conditions treated with plasma treatment, such as platelet-rich plasma (PRP) therapy?

Recommendations for Orthopedic Conditions Treated with Platelet-Rich Plasma (PRP) Therapy

Platelet-rich plasma (PRP) therapy is strongly recommended against in patients with knee and/or hip osteoarthritis due to concerns regarding heterogeneity, lack of standardization in preparations, and insufficient evidence of clinical benefit. 1

Current Guideline Recommendations for PRP in Orthopedic Conditions

Osteoarthritis

• The American College of Rheumatology/Arthritis Foundation 2019 guidelines strongly recommend against PRP treatment for knee and hip osteoarthritis 1
• The American Academy of Orthopaedic Surgeons (AAOS) 2022 guidelines acknowledge that PRP has some evidence (two high-quality studies and one moderate-quality study) showing reduced pain and improved function in knee osteoarthritis, but notes inconsistent results, particularly in severe knee osteoarthritis 1
• The AAOS 2014 guidelines made no recommendation for or against PRP use due to insufficient evidence at that time 1

Hip Osteoarthritis

• PRP therapy is specifically not recommended for hip osteoarthritis according to the 2019 ACR/AF guidelines 1
• Limited research exists for PRP in hip OA compared to knee applications 2

Tendinopathies and Other Conditions

• No clear recommendations exist for PRP in tendinopathies from major orthopedic guidelines 3
• For other orthopedic applications, the evidence remains limited and insufficient to make formal recommendations 4, 5, 6

Rationale Behind Recommendations

Concerns with PRP Therapy

• Lack of standardization in PRP preparation methods 1, 2
• Significant variability in:
  • Platelet concentration 2
  • Presence of leukocytes 2
  • Activation methods 2
  • Volume injected 2
  • Number of injections administered 2
• Difficulty identifying exactly what is being injected in each preparation 1
• Inconsistent results in clinical studies 1

Evidence Quality

• While some studies show benefit for knee osteoarthritis, the evidence is inconsistent 1
• PRP shows worse treatment response in patients with severe knee osteoarthritis 1
• Cost concerns exist relative to potential benefits 1

Alternative Recommended Treatments

First-line Treatments for Osteoarthritis

• Physical therapy and exercise programs 2
• Weight management for overweight patients 1, 2
• Oral NSAIDs (both selective and non-selective) 1, 2
• Topical NSAIDs where appropriate 2

Second-line Interventions

• Intra-articular corticosteroid injections (supported by considerable evidence with 19 high-quality and six moderate-quality studies) 1, 2
• Note that benefits from corticosteroid injections typically last only about 3 months 1

Clinical Decision Algorithm

1. Start with conservative management:

   • Physical therapy/exercise 2
   • Weight management 1
   • Oral/topical NSAIDs 1, 2

2. If inadequate response:

   • Consider intra-articular corticosteroid injections 1, 2

3. PRP should not be routinely offered due to:

   • Strong recommendations against use 1
   • Lack of standardization 2
   • Inconsistent evidence 1

Common Pitfalls and Caveats

• Despite growing popularity and direct-to-consumer marketing, PRP lacks standardization and consistent evidence of efficacy 1
• The complexity of tissue healing processes cannot be replicated simply by injecting a subset of growth factors 3
• PRP products vary widely in composition, making comparison between studies difficult 2
• Cost concerns exist as PRP is often not covered by insurance due to insufficient evidence 1
• The AAOS/NIH consensus recommendations identified knee OA as having more urgent need for clinical trial development for biologics than other conditions 1, 2

Research Needs

• High-quality multicenter randomized controlled trials with standardized PRP preparation protocols 2
• Studies should include biorepositories and standardized outcome measures 2
• Better characterization of PRP products to understand which components might be beneficial 1