Platelet-rich therapies for musculoskeletal soft tissue injuries - PubMed (original) (raw)

Review

Platelet-rich therapies for musculoskeletal soft tissue injuries

Vinícius Y Moraes et al. Cochrane Database Syst Rev. 2014.

Abstract

Background: Platelet-rich therapies are being used increasingly in the treatment of musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies. These therapies can be used as the principal treatment or as an augmentation procedure (application after surgical repair or reconstruction). Platelet-rich therapies are produced by centrifuging a quantity of the patient's own blood and extracting the active, platelet-rich, fraction. The platelet-rich fraction is applied to the injured tissue; for example, by injection. Platelets have the ability to produce several growth factors, so these therapies should enhance tissue healing. There is a need to assess whether this translates into clinical benefit.

Objectives: To assess the effects (benefits and harms) of platelet-rich therapies for treating musculoskeletal soft tissue injuries.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (25 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL 2013 Issue 2), MEDLINE (1946 to March 2013), EMBASE (1980 to 2013 Week 12) and LILACS (1982 to March 2012). We also searched trial registers (to Week 2 2013) and conference abstracts (2005 to March 2012). No language or publication restrictions were applied.

Selection criteria: We included randomised and quasi-randomised controlled trials that compared platelet-rich therapy with either placebo, autologous whole blood, dry needling or no platelet-rich therapy for people with acute or chronic musculoskeletal soft tissue injuries. Primary outcomes were functional status, pain and adverse effects.

Data collection and analysis: Two review authors independently extracted data and assessed each study's risk of bias. Disagreement was resolved by discussion or by arbitration by a third author. We contacted trial authors for clarification of methods or missing data. Treatment effects were assessed using risk ratios for dichotomous data and mean differences (MD) or standardised mean differences (SMD) for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using the fixed-effect model for RR and MD, and the random-effects model for SMD. The quality of the evidence for each outcome was assessed using GRADE criteria.

Main results: We included data from 19 small single centre trials (17 randomised and two quasi-randomised; 1088 participants) that compared platelet-rich therapy with placebo, autologous whole blood, dry needling or no platelet-rich therapy. These trials covered eight clinical conditions: rotator cuff tears (arthroscopic repair) (six trials); shoulder impingement syndrome surgery (one trial); elbow epicondylitis (three trials); anterior cruciate ligament (ACL) reconstruction (four trials), ACL reconstruction (donor graft site application) (two trials), patellar tendinopathy (one trial), Achilles tendinopathy (one trial) and acute Achilles rupture surgical repair (one trial). We also grouped trials into 'tendinopathies' where platelet-rich therapy (PRT) injections were the main treatment (five trials), and surgical augmentation procedures where PRT was applied during surgery (14 trials). Trial participants were mainly male, except in trials including rotator cuff tears, and elbow and Achilles tendinopathies.Three trials were judged as being at low risk of bias; the other 16 were at high or unclear risk of bias relating to selection, detection, attrition or selective reporting, or combinations of these. The methods of preparing platelet-rich plasma (PRP) varied and lacked standardisation and quantification of the PRP applied to the patient.We were able to pool data for our primary outcomes (function, pain, adverse events) for a maximum of 11 trials and 45% of participants. The evidence for all primary outcomes was judged as being of very low quality.Data assessing function in the short term (up to three months) were pooled from four trials that assessed PRT in three clinical conditions and used four different measures. These showed no significant difference between PRT and control (SMD 0.26; 95% confidence interval (CI) -0.19 to 0.71; P value 0.26; I² = 51%; 162 participants; positive values favour PRT). Medium-term function data (at six months) were pooled from five trials that assessed PRT in five clinical conditions and used five different measures. These also showed no difference between groups (SMD -0.09, 95% CI -0.56 to 0.39; P value 0.72; I² = 50%; 151 participants). Long-term function data (at one year) were pooled from 10 trials that assessed PRT in five clinical conditions and used six different measures. These also showed no difference between groups (SMD 0.25, 95% CI -0.07 to 0.57; P value 0.12; I² = 66%; 484 participants). Although the 95% confidence intervals indicate the possibility of a poorer outcome in the PRT group up to a moderate difference in favour of PRT at short- and long-term follow-up, these do not translate into clinically relevant differences.Data pooled from four trials that assessed PRT in three clinical conditions showed a small reduction in short-term pain in favour of PRT on a 10-point scale (MD -0.95, 95% CI -1.41 to -0.48; I² = 0%; 175 participants). The clinical significance of this result is marginal.Four trials reported adverse events; another seven trials reported an absence of adverse events. There was no difference between treatment groups in the numbers of participants with adverse effects (7/241 versus 5/245; RR 1.31, 95% CI 0.48 to 3.59; I² = 0%; 486 participants).In terms of individual conditions, we pooled heterogeneous data for long-term function from six trials of PRT application during rotator cuff tear surgery. This showed no statistically or clinically significant differences between the two groups (324 participants).The available evidence is insufficient to indicate whether the effects of PRT will differ importantly in individual clinical conditions.

Authors' conclusions: Overall, and for the individual clinical conditions, there is currently insufficient evidence to support the use of PRT for treating musculoskeletal soft tissue injuries. Researchers contemplating RCTs should consider the coverage of currently ongoing trials when assessing the need for future RCTs on specific conditions. There is need for standardisation of PRP preparation methods.

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Conflict of interest statement

Vinícius Y Moraes ‐ none known Mário Lenza ‐ none known Marcel Jun Tamaoki ‐ none known Flávio Faloppa ‐ none known João Carlos Belloti ‐ none known

Figures

1

1

Study flow diagram

2

2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

1.1

1.1. Analysis

Comparison 1 PRT versus control: all conditions, Outcome 1 Function (all scores/instruments): short term (up to 3 months follow‐up).

1.2

1.2. Analysis

Comparison 1 PRT versus control: all conditions, Outcome 2 Function (all scores/instruments): medium term (over 3 months, under 1 year follow‐up).

1.3

1.3. Analysis

Comparison 1 PRT versus control: all conditions, Outcome 3 Functional (all scores/instruments): long term (1 year or more follow‐up).

1.4

1.4. Analysis

Comparison 1 PRT versus control: all conditions, Outcome 4 Pain (VAS: 0 to 10: worst pain): short term (up to 3 months follow‐up).

1.5

1.5. Analysis

Comparison 1 PRT versus control: all conditions, Outcome 5 Pain (VAS: 0 to 10: worst pain): medium term (over 3 months, under 1 year follow‐up).

1.6

1.6. Analysis

Comparison 1 PRT versus control: all conditions, Outcome 6 Pain (VAS: 0 to 10: worst pain): long term (1 year or more follow‐up).

1.7

1.7. Analysis

Comparison 1 PRT versus control: all conditions, Outcome 7 Adverse effects (any of PRT or placebo application).

2.1

2.1. Analysis

Comparison 2 PRT versus control: subgrouped by tendinopathies and augmentation procedures, Outcome 1 Function (all scores/instruments): short term (up to 3 months follow‐up).

2.2

2.2. Analysis

Comparison 2 PRT versus control: subgrouped by tendinopathies and augmentation procedures, Outcome 2 Function (all scores/instruments): medium term (over 3 months, under 1 year follow‐up).

2.3

2.3. Analysis

Comparison 2 PRT versus control: subgrouped by tendinopathies and augmentation procedures, Outcome 3 Functional (all scores/instruments): long term (1 year or more follow‐up).

2.4

2.4. Analysis

Comparison 2 PRT versus control: subgrouped by tendinopathies and augmentation procedures, Outcome 4 Pain (VAS: 0 to 10: worst pain): short term (up to 3 months follow‐up).

2.5

2.5. Analysis

Comparison 2 PRT versus control: subgrouped by tendinopathies and augmentation procedures, Outcome 5 Pain (VAS: 0 to 10: worst pain): medium term (over 3 months, under 1 year follow‐up.

2.6

2.6. Analysis

Comparison 2 PRT versus control: subgrouped by tendinopathies and augmentation procedures, Outcome 6 Pain (VAS: 0 to 10: worst pain): long term (1 year or more follow‐up).

2.7

2.7. Analysis

Comparison 2 PRT versus control: subgrouped by tendinopathies and augmentation procedures, Outcome 7 Adverse effects (any of PRT pr placebo application.

3.1

3.1. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 1 Function (Constant score): long term (1 year follow‐up).

3.2

3.2. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 2 Function (Constant score): long term (2 year follow‐up).

3.3

3.3. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 3 Function (UCLA score): long term (1 year follow‐up).

3.4

3.4. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 4 Function (Simple Shoulder Test (SST)): long term (1 year follow‐up).

3.5

3.5. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 5 Function (DASH score): long term (1 year follow‐up).

3.6

3.6. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 6 Function (DASH score): long term (2 year follow‐up).

3.7

3.7. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 7 Function (L'Insalata score): long term (1 year follow‐up).

3.8

3.8. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 8 Function (ASES score): long term (1 year follow‐up).

3.9

3.9. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 9 Function (all scores/instruments): long term (1 year follow‐up).

3.10

3.10. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 10 Pain (Analogue Scale): short term (7 day follow‐up).

3.11

3.11. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 11 Pain (Analogue Scale): long term (2 year follow‐up).

3.12

3.12. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 12 Pain (Analogue Scale): long term (1 year follow‐up).

3.13

3.13. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 13 Pain (Analogue Scale): short term (30 day follow‐up).

3.14

3.14. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 14 Rate of retear: long term (1 year follow‐up).

3.15

3.15. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 15 Rate of retear: long term (2 year follow‐up).

3.16

3.16. Analysis

Comparison 3 PRT versus control: Rotator cuff tears (surgical repair), Outcome 16 Patient satisfaction.

4.1

4.1. Analysis

Comparison 4 PRT versus control: Shoulder impingement syndrome (surgery), Outcome 1 Functional (self‐evaluation instability score: short term (6 week follow‐up).

4.2

4.2. Analysis

Comparison 4 PRT versus control: Shoulder impingement syndrome (surgery), Outcome 2 Functional instability after surgery: 6 week follow‐up.

4.3

4.3. Analysis

Comparison 4 PRT versus control: Shoulder impingement syndrome (surgery), Outcome 3 Pain (VAS): short term (6 week follow‐up).

5.1

5.1. Analysis

Comparison 5 PRT versus control: Elbow epicondylitis, Outcome 1 Function (PRTEE score): short term (3 month follow‐up).

5.2

5.2. Analysis

Comparison 5 PRT versus control: Elbow epicondylitis, Outcome 2 Function (PRTEE scores): medium term (6 month follow‐up).

5.3

5.3. Analysis

Comparison 5 PRT versus control: Elbow epicondylitis, Outcome 3 Function (Liverpool elbow score): short term (3 month follow‐up).

5.4

5.4. Analysis

Comparison 5 PRT versus control: Elbow epicondylitis, Outcome 4 Function (Liverpool elbow score): medium term (6 month follow‐up).

5.5

5.5. Analysis

Comparison 5 PRT versus control: Elbow epicondylitis, Outcome 5 Function (all scores/instruments): short term (3 months or less follow‐up).

5.6

5.6. Analysis

Comparison 5 PRT versus control: Elbow epicondylitis, Outcome 6 Pain (VAS): short term (6 week follow‐up).

5.7

5.7. Analysis

Comparison 5 PRT versus control: Elbow epicondylitis, Outcome 7 Pain (VAS): medium term (6 month follow‐up).

6.1

6.1. Analysis

Comparison 6 PRT versus control: ACL reconstruction (patellar tendon graft donor site), Outcome 1 Function (Tegner scores): medium term (6 month follow‐up).

6.2

6.2. Analysis

Comparison 6 PRT versus control: ACL reconstruction (patellar tendon graft donor site), Outcome 2 Function (Lysholm score): medium term (6 month follow‐up).

6.3

6.3. Analysis

Comparison 6 PRT versus control: ACL reconstruction (patellar tendon graft donor site), Outcome 3 Function (VISA score): long term (1 year follow‐up).

6.4

6.4. Analysis

Comparison 6 PRT versus control: ACL reconstruction (patellar tendon graft donor site), Outcome 4 Pain (VAS): first post‐op day.

7.1

7.1. Analysis

Comparison 7 PRT versus control: ACL reconstruction, Outcome 1 Function (IKDC scores): long term (1 year follow‐up).

7.2

7.2. Analysis

Comparison 7 PRT versus control: ACL reconstruction, Outcome 2 Function (IKDC categories A & B: normal/nearly normal): medium and long term follow‐up.

7.3

7.3. Analysis

Comparison 7 PRT versus control: ACL reconstruction, Outcome 3 Function (Lysholm score): long term (1 year follow‐up).

8.1

8.1. Analysis

Comparison 8 PRT versus control: Patellar tendinopathy, Outcome 1 Function (VISA scores): medium term (6 month follow‐up).

8.2

8.2. Analysis

Comparison 8 PRT versus control: Patellar tendinopathy, Outcome 2 Function (Tegner scores): medium term (6 month follow‐up).

8.3

8.3. Analysis

Comparison 8 PRT versus control: Patellar tendinopathy, Outcome 3 Function (Lysholm score): medium term (6 month follow‐up).

8.4

8.4. Analysis

Comparison 8 PRT versus control: Patellar tendinopathy, Outcome 4 Pain (VAS): medium term (6 month follow‐up).

8.5

8.5. Analysis

Comparison 8 PRT versus control: Patellar tendinopathy, Outcome 5 Quality of Life (SF‐12 score): medium term (6 month follow‐up).

9.1

9.1. Analysis

Comparison 9 PRT versus control: Achilles tendinopathy, Outcome 1 Function (VISA‐A scores): short term (6 week follow‐up).

9.2

9.2. Analysis

Comparison 9 PRT versus control: Achilles tendinopathy, Outcome 2 Function (VISA‐A score): medium term (6 month follow‐up).

9.3

9.3. Analysis

Comparison 9 PRT versus control: Achilles tendinopathy, Outcome 3 Function (VISA‐A scores): long term (1 year follow‐up).

9.4

9.4. Analysis

Comparison 9 PRT versus control: Achilles tendinopathy, Outcome 4 Satisfied patients: medium term (6 month follow‐up).

9.5

9.5. Analysis

Comparison 9 PRT versus control: Achilles tendinopathy, Outcome 5 Satisfied patients: long term (1 year follow‐up).

9.6

9.6. Analysis

Comparison 9 PRT versus control: Achilles tendinopathy, Outcome 6 Return to desired sports: medium term (6 month follow‐up).

9.7

9.7. Analysis

Comparison 9 PRT versus control: Achilles tendinopathy, Outcome 7 Return to desired sports: long term (1 year follow‐up).

10.1

10.1. Analysis

Comparison 10 PRT versus control: Acute Achilles tendon ruptures (surgical repair), Outcome 1 Function (heel‐raise index): medium term (6 month follow‐up).

10.2

10.2. Analysis

Comparison 10 PRT versus control: Acute Achilles tendon ruptures (surgical repair), Outcome 2 Function (heel‐raise index): long term (1 year follow‐up).

10.3

10.3. Analysis

Comparison 10 PRT versus control: Acute Achilles tendon ruptures (surgical repair), Outcome 3 Complications.

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References

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References to ongoing studies

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    1. Walters B. Effect of intraoperative application of autologous PRP on post operative morbidity in ACL reconstruction using autologous bone patellar tendon bone graft harvest. http://clinicaltrials.gov/show/NCT01765712 (accessed 26 August 2013).
NCT01812564 {published data only}
    1. Tol J. Use of platelet rich plasma in the management of acute hamstring muscle strain injury. http://clinicaltrials.gov/show/NCT01812564 (accessed 26 August 2013).
NCT01833598 {published data only}
    1. Voigt A. Percutaneous needle tenotomy (PNT) versus platelet rich plasma (PRP) with pnt in the treatment of chronic tendinosis. http://clinicaltrials.gov/show/NCT01833598 (accessed 26 August 2013).
NCT01851044 {published data only}
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References to other published versions of this review

Moraes 2012
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Moraes 2013
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