SAFETY AND CLINICAL EFFICACY OF PLATELET RICH GROWTH FACTORS (PRGF) IN MANAGING KNEE OSTEOARTHRITIS AFTER FAILED CONSERVATIVE TREATMENT: EVIDENCE FROM REAL PRACTICES
Keywords:Osteoarthritis, Platelet rich plasma, Platelet rich growth factor, Knee arthroplasty, Total knee arthroplasty, Kellgren-Lawrence, Surgical intervention
Background: Platelet rich growth factors (PRGF) comprise a biological treatment of knee osteoarthritis (OA). Due to its limitation concerning the articular cartilage lesions’ healing potential, chondrocyte differentiation and external environment factors, clinical improvement of knee OA using PRGF treatment depends on preparation techniques.
Objectives: The study aimed to demonstrate clinical outcomes of PRGF treatment in real practices.
Methods: A prospective cohort study was conducted from February 2018 to 2019 at the Biomedical Technology Research and Development Center, Police General Hospital, Bangkok, Thailand. We enrolled patients above 60 years old with knee OA that failed conservative treatment. The exclusion criteria included meniscus and ligament injury and knee deformity of the tibiofemoral angle more than 5 degrees. The primary endpoint was safe PRGF while secondary endpoints included changes of weight bearing pain and delayed surgery until an appropriate time for intervention.
Results: A total of 240 patients with knee OA, Kellgren-Lawrence (KL) grades II, III or IV were enrolled including 90 males and 150 females. The average age was 68 (60-81) years. Mode of conservative treatment failure included 140 cases of oral medication, 60 cases of oral medication and steroid injection and 40 cases of oral medication, steroid and intra-articular hyaluronic injections (IA-HA). Based on the KL system, 194 were classified as grades II-III, and 46 patients were grade IV. The PRGF was collected according to the protocol. The average initial platelet concentration before and after centrifugation was 165x103 cells/µL (140-195x103 cells/µL) and 990x103 cells/µL (825-1,650x103 cells/µL), respectively. At average of 3.3 (3-8) months follow-up, no major complications were observed, but 17 cases (7.9%) had minor complications. Average VAS (visual-analog-scale for pain: 0-100) scores before and after injection were 71 (65-80) and 52 (50-72, respectively. Surgical intervention in KL II-III totaled 11 cases (5.6%) and KL IV totaled 5 cases (10.8%).
Conclusion: Our technique of adjusting platelet concentration, fibrin concentration, leukocyte population and activator status improved clinical efficacy of PRGF treatment. PRGF is a safe, simple and effective treatment for patients with knee OA experiencing conservative treatment failure.
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 Res 2004; 423: 7-16. DOI: https://doi.org/10.1097/01.blo.0000131638.81519.de
Chan FK, Goto S, Wu MS, Abola MT, Yeoh KG, Sutrisna B. Burden of non-steroidal anti-inflammatory and antiplatelet drug use in Asia: a multidisciplinary working party report: Clin Gastroenterol Hepatol 2012; 10: 753–60. DOI: https://doi.org/10.1016/j.cgh.2012.03.027
Turajane T, Wongbunnak R, Patcharatrakul T, Ratansumawong K, Poigampetch Y, Songpatanasilp T. 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.
Bannuru RR, Schmid CH, Kent DM, Vaysbrot EE, Wong JB, McAlindon TE. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med 2015; 162: 46-54. DOI: https://doi.org/10.7326/M14-1231
Sánchez M, Fiz N, Azofra J, Usabiaga J, Aduriz Recalde E, Garcia Gutierrez A, et al. A randomized clinical trial evaluating plasma rich in growth factors (PRGF-Endoret) versus hyaluronic acid in the short-term treatment of symptomatic knee osteoarthritis. Arthroscopy 2012; 28: 1070-8. DOI: https://doi.org/10.1016/j.arthro.2012.05.011
Zhang W, MoskowitzRW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis. Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16: 137-62. DOI: https://doi.org/10.1016/j.joca.2007.12.013
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, Lee B, Kraus M, Tse V, et al. Buffered platelet-rich plasma enhances mesenchymal stem cell proliferation and chondrogenic differentiation. Tissue Eng Part C Methods 2009; 15: 431-5. DOI: https://doi.org/10.1089/ten.tec.2008.0534
Turajane T, Chaweewannakorn U, Larbpaiboonpong V, Aojanepong J, Thitiset T, Honsawek S, 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 T1, Thitiset T, Honsawek S, Chaveewanakorn U, Aojanepong J, Papadopoulos KI. Assessment of chondrogenic differentiation potential of autologous activated peripheral blood stem cells on human early osteoarthritic cancellous tibial bone scaffold. Musculoskelet Surg 2014; 98: 35-43. DOI: https://doi.org/10.1007/s12306-013-0303-y
Padilla S, Orive G, Sanchez M, Anitua E, Hsu WK. 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. DOI: https://doi.org/10.1016/j.tibtech.2008.11.009
Jevsevar DS, Shores PB, Mullen K, Schulte DM, Brown GA, Cummins DS Mixed treatment comparisons for nonsurgical treatment of knee osteoarthritis: a network meta-analysis. J Am Acad Orthop Surg 2018; 26: 325-36. DOI: https://doi.org/10.5435/JAAOS-D-17-00318
Hsu WK, Mishra A, Rodeo SR, Fu F, Terry MA, Randelli P, et al. Platelet-rich plasma in orthopaedic applications: Evidence-based recommendations for treatment. J Am Acad Orthop Surg 2013; 21: 739-48. DOI: https://doi.org/10.5435/JAAOS-22-08-469
LaPrade RF, Dragoo JL, Koh JL, Murray IR, Geeslin AG, Chu CR. AAOS Research Symposium Updates and Consensus: Biologic Treatment of Orthopaedic Injuries. J Am Acad Orthop Surg 2016; 24: e62-e78. DOI: https://doi.org/10.5435/JAAOS-D-16-00086
Kon E, Buda R, Filardo G, Di Martino A, Timoncini A, Cenacchi A et al. Platelet-rich plasma: Intraarticular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc 2010; 18: 472-9. DOI: https://doi.org/10.1007/s00167-009-0940-8
Vaquerizo V, Plasencia MA, Arribas I, Seijas R, Padilla S, Orive G, 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. DOI: https://doi.org/10.1016/j.arthro.2013.07.264
Dohan EDM, Bielecki T, Del Corso M, Inchingolo F, Sammartino G. 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. DOI: https://doi.org/10.1002/jbm.a.32894
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