Effect of Intra-Articular Injection of Platelet-Rich Plasma in patients with Osteoarthritis knee

Candidate Dr. Shashank Misra JR,PMR,AIIMS

Chief Guide Dr. S. L. Yadav Professor Department of PMR AIIMS

CO-GUIDES
Dr. U Singh Handa Professor & Head Professor Professor Additional Dr. Sanjay Wadhwa Dr. Gita

Department of PMR
PMR AIIMS, New Delhi

Department of PMR
AIIMS, New Delhi

Department of
AIIMS, New Delhi

INTRODUCTION
Osteoarthritis (OA) is a chronic degenerative disorder of multifactorial etiology characterized by loss of articular cartilage, hypertrophy of bone at the margins, subchondral sclerosis and range of biochemical and morphological alterations of the synovial membrane and joint capsule Mechanical, biochemical, and genetic factors are all involved in pathogenesis of osteoarthritis Osteoarthritis (OA) is the second most common rheumatological problem and is most frequent joint disease with prevalence of 22% to 39% in India (Mention reference)

INTRODUCTION
Typical clinical symptoms are pain, particularly after prolonged activity and weight bearing; whereas stiffness is experienced after inactivity

Characteristics of osteoarthritis vary across patients, and several definite clinical patterns have been identified

The choice of a suitable treatment strategy for a patient depends on clinical history, contraindications to specific therapies, and overall tolerability and acceptability of the considered treatment

KNEE OSTEOARTHRITIS
Osteoarthritis of weight-bearing joints, such as knee osteoarthritis, is more a local mechanical driven disease than a generalized one

In order to reach a non-vascularized tissue, such as cartilage, local intraarticular administration of drugs has always been considered as a preferred treatment modality

CURRENT TREATMENT MODALITIES

At present, there are numerous, non-invasive treatment approaches with emphasis on pain management, improvement in function and the potential to modify the disease process and progress of cartilage degeneration. Conservative management options include analgesics, steroid and non-steroid anti-inflammatory drugs, glucosamine/chondroitin supplementation, physical therapy, and hyaluronic acid (HA) injections. Intra articular injection of glucocorticoids and viscosupplimentation with hyaluronic acid leads to short term pain relief that may last between a few weeks to few months

However, most of them have either been of short-term success, not addressing the biological pathology or have shown only minor benefits

NEW TREATMENT MODALITIES

Current research is aimed at investigating new methods of stimulating the repair of damaged cartilage

Most recent knowledge regarding tissue biology highlights the complex regulation of growth factors for the normal tissue structure and the reaction to tissue damage Platelet-rich plasma (PRP) therapy is a simple, low cost and minimally invasive method that allows a natural concentrate of autologous growth factors to be obtained from the blood

This therapy is widely experimented in different fields of medicine to test its potential to enhance tissue regeneration

PLATELET RICH PLASMA

Platelet-rich plasma is autologous blood plasma that has been enriched with platelets.

As a concentrated source of autologous platelets, PRP contains and releases through degranulation, several different growth factors and other cytokines that stimulate healing of bone and soft tissue

Platelet rich plasma is composed of enhanced concentration of platelets contained in whole blood depending on the extraction process; therefore, it contains a hyper physiological content of autologous growth factors

CLINICAL APPLICATIONS OF PRP

In humans, PRP has been investigated and used as clinical tool for several types of medical treatments, including nerve injury, tendonitis,

osteoarthritis, cardiac muscle injury, bone repair and regeneration, plastic

surgery, and oral surgery.

PRP has also received attention as a result of its use in treating sports
injuries in professional athletes

ROLE OF PRP IN OSTEOARTHRITIS

Recent studies support the application of platelet-rich plasma products as an effective and safe method in the treatment of the early stages of knee OA. Growth factors present in platelet-rich plasma products,including transforming growth factor , platelet derived growth factor, and insulin-like growth factor 1, contribute to the maintenance of a homeostatic balanced status between anabolism and catabolism on the articular cartilage. Others such as vascular endothelial growth factor and basic fibroblast growth factor show chondroinductive roles

REVIEW OF LITERATURE

REVIEW OF LITERATURE
Mechanism of action Platelets were thought to act solely in the clotting cascade. In addition to local hemostasis at sites of vascular injury, platelets contain an abundance of growth factors and cytokines that are crucial in soft tissue healing and bone mineralization (Anitua et al., 2006)

Platelets also discharge many bioactive proteins responsible for attracting macrophages, mesenchymal stem cells, and osteoblasts, which not only promote scavenging of necrotic tissue but also facilitate tissue regeneration and healing (Sampson, 2008)

REVIEW OF LITERATURE

The concept that application of PRP would result in improvement of cartilage repair is based on the physiological role of platelets in wound healing (Nurden et al., 2008)

There are classification schemes that categorize platelet concentrates based on relative concentrations of platelets, leukocytes, and fibrin, and, although it is important to recognize and understand that there are obvious differences between types of platelet concentrates that are being used (Dohan Ehrenfest et al., 2009)

REVIEW OF LITERATURE
Mishra et al. (2012) supports the thought that PRP can stimulate chondral anabolism, reduce catabolic processes, and may improve overall joint homeostasis reducing synovial membrane hyperplasia,demonstrating that stimulates mesenchymal stem cell proliferation in vitro

Dr Kisiday, et al concluded the study that suggests that single-spin PRP preparations may be the most advantageous for intra-articular applications, and that double-spin systems should be considered with caution

REVIEW OF LITERATURE
,

Baltzer et al., (1994) conducted A prospective, randomized patient- and observer-blinded, placebo controlled trial and demonstrated that autologous conditioned serum injections induced considerable improvement of the clinical signs and symptoms of osteoarthritis with results that are even superior to those of hyaluronic acid

Sanchez et al. (2008) showed interesting preliminary results using intra-articular injections of an autologous preparation rich in growth factors for treatment of knee osteoarthritis Their studies suggest that these potent biological regulators of chondrocytes have an important role in cartilage repair

REVIEW OF LITERATURE
Spakova, T et al.( 2012) demonstrated a statistically significantly better results in a group of patients who received PRP injections after a 3- and 6-mo follow-up compared to the hyaluronic acid injection group

Their findings support the application of autologous PRP as an effective and safe method in the treatment of the initial stages of knee osteoarthritis

In addition, platelet rich plasma and autologous blood have shown less potential for serious side effects, such as tendon rupture and fat necrosis, than corticosteroids

REVIEW OF LITERATURE

Kon et al. reported results of a large, prospective case series using intra articular platelet rich plasma injection in patients with degenerative chondral lesions of the knee, as seen on magnetic resonance image or clear osteoarthrosis on radiograph

The authors concluded that treatment with platelet rich plasma is safe and effective for improvement of pain, function, and quality of life in patients with degenerative articular pathology

RATIONALE OF STUDY
Pharmacological treatments options bear considerable risk of adverse cardiovascular events and gastrointestinal adverse effects observe for treatment of joint pain.

Chronic nature of the disease requires development of drugs suitable for chronic treatment with minimal side effects, which is a challenging goal.

Intra articular injection of drugs directly into the affected joint has always been an option for treatment of osteoarthritis which is already frequently used and has the potential to deliver the desired profile.

PRP can stimulate chondral anabolism by stimulating chondrogenic diffrentiation, increasing aggregan levels and promoting mesenchymal stem cell proliferation, reduce catabolic processes, and may improve overall joint homeostasis reducing synovial membrane hyperplasia

AIMS AND OBJECTIVES

Aims: To study the effect of intra- articular injections of platelet rich plasma produced by single spin on improvement of pain, function, and quality of life in patients with OA knee

Objectives: The objectives of this study are to assess 1) changes in pain intensity 2) improvement in functional outcome, and 3) improvement in quality of life in patients with OA knee

STUDY CHARACTERSTICS
Study Design: A prospective, double blind, single hospital based randomized control trial

Study Duration: The study shall commence after approval from the institutional review board and the ethical committee till the required sample size is attained and will strictly adhere to the ICMR and GCP guidelines
Study Location: The study will be conducted at the Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi

PATIENT PROFILE
Patient Selection: Patients with chronic pain of knee failing conservative treatment by other treatment options and imaging findings of degenerative changes of knee as classified by radiographic criteria ( Kellgren Lawrence grade I-III) after filling written consent forms and fulfilling the inclusion criteria will be recruited. All male patients greater than age of 35 years will be included in the study except those with significant co-morbidities Inclusion Criteria: 1) Male and female patients aged above 35 years 2) Diagnosed with OA of knee by radiograph

3) Radiologic severity kellgren lawrence scale less than grade 4

EXCLUSION CRITERIA
Exclusion Criteria:
1. Systemic autoimmune rheumatoid disease (connective tissue disease and systemic necrotizing vasculitis) 2. Uncontrolled diabetes mellitus 3. Blood dyscrasias 4. Undergoing immunosuppressive therapy 5. Patient with impaired cognitive function 6. Unwilling to participate

7. H/o NSAID use within 5 days prior to blood withdrawl for PRP preparation
8. Hb < 10gm/dl and platelet count < 1,50,000 /cu.mm

CLINICAL ASSESSMENT TEST

Mention all your tests and their small introduction

METHODOLOGY
Consent: Informed written consent prior to being enlisted in the study will be taken from each participant History: A detailed complete history of the subject will be taken Examination: The clinical examination will include determination of range of motion and crepitus in affected knee, any malalignment with a bony enlargement. Any erythema or warmth over the affected joint(s);or any bland effusion. To find out any limitation of joint motion or muscle atrophy around affected joint (please mention your interview scales with a better language here) Investigations: Haemoglobin/TLC/DLC/ESR levels, Blood Sugar (Fasting/ PP), Blood Urea/ Serum Creatinine/ Serum ALP levels. X ray both knee (anteroposterior and lateral views)

Preparation and safety of PRP

Platelet rich plasma is prepared by centrifuging autologous, anticoagulated whole blood.. Centrifugation separates the following: (1) plasma (top layer) from (2) platelets and white blood cells (buffy coat, middle layer) and (3) red blood cells (bottom layer) (Fig. 3.) as a result of differences in specific gravity. In order to further concentrate the preparation, a second centrifugation separates the platelet rich plasma from platelet-poor plasma. Of note, the use of 2 spins versus 1 spin is controversial. Although a second spin will certainly concentrate the platelets further, but it will deplete wbc which might be helpful in regeration of cartilage as suggested by Mishra et al

Platelet rich plasma preparation (type 1, single spin)

To prepare the PRP, 24 mL of peripheral blood will be extracted from each patient by venipuncture directly into 4 EDTA tubes .

The extracted blood will be centrifuged at 3500 rpm for 15 minutes at room temperature in a system centrifuge.
Once the blood tubes will be centrifuged, we will proceed to physically separate the plasma fractions by meticulous pipetting and under strictly sterile conditions. We will pipette only the 2 mL of plasma rich in platelets remaining above the red series and the buffy coat, (one sample must be sent for analysis of platelet concentration)

Before infiltration, all these 2-mL fractions will be put together in a single tube (total, 8 mL), with gentle inversion of the tube in a sterile glass container.

Pre-Intervention
Patients will be asked to discontinue corticosteroid use if possible for at least 1 week and as long as 3 weeks before the procedure. As for nonsteroidal anti-inflammatory drugs (NSAIDs) will be stopped for an extended period around the time of PRP administration and others for just 2 days preoperatively. Anti-inflammatories will not stop growth factor release which occurs almost instantly once PRP is introduced to the tissue or joint. Normal consideration will be given to patients use of other anticoagulant and antiplatelet agents as per their standard injection protocols.

We prepared PRP by single spin methods Single spin . We spinned the venous blood of 6 ml in EDTA vial at about 3800 rpm for about 20 minutes.We pipetted layer of about 2 ml above buffy coat. Through automated count machine ,platelet concentration was calculated which was about 5 times the base line level

The PRP Procedure (Intervention)

Clinical examination and imaging can help to characterize the precise location and extent of the injury and/or degenerative disease.

Ultrasound studies prior and post-therapy, document specific outcomes of PRP such as regeneration of tendons and evidence of tissue healing. PRP should always be performed under strict asepsis. Patients will be informed about the procedure and written consent will be obtain. Analgesia and/or anxiolytics may be administered as needed.
Materials for the injection (PRP, needles, gel) will be placed on a sterile table adjacent to the patient, who would have been positioned comfortably to enable access to the injection site.

After the patients skin will be cleaned and an aseptic field will be created, a small amount of local anesthesetic (2-3 mls) may be injected to provide analgesia for the PRP administration. A test local anesthetic injection also may be administered to confirm the source of pain and aid the physician in site selection for PRP injection (i.e. analgesia following local administration helps to confirm the site of pathology and the source of pain). Lidocaine will be used as the local anesthetic

Image-guided injection ( ultrasound) will be performed and will be recorded in real time

Post-Procedure
Patients should rest, ice the affected area and elevate the limb for 48 hours following injection. The pace and duration of rehabilitation depends on the nature and extent of the injury

and the patients overall health and condition.

Post-treatment, some patients may use a walker boot, knee brace and/or crutches for

the lower extremity or a sling for the upper extremity to immobilize the treated area.
Stretching and light resistance exercises and physical therapy may also be prescribed after 2-5 days.

OUTCOME MEASURES

STATISTICAL ANALYSIS