Comparison Between Hyaluronic Acid and Platelet-Rich Plasma,
Intra-articular Infiltration in the Treatment of Gonarthrosis. 

Cerza F, Carni S,
Carcangiu A, Di Vavo I, Schiavilla V, Pecora A, De Biasi G, & Ciuffreda M. Am
J Sports Med. 2012 vol. 40(12): 2822-2827.

Osteoarthritis (also
known as gonarthrosis) is characterized by structural and biochemical changes
throughout the entire joint.  Unfortunately,
osteoarthritis can be challenging to treat and no treatments have been
demonstrated to slow, halt, or reverse osteoarthritis progression. Recently, it
has been hypothesized that hyaluronic acid (HA), a key component of synovial
fluid, or platelet-rich plasma (PRP), which contains various growth factors
involved in the inflammatory/healing process, may be good therapies for
osteoarthritis.  Therefore, Cerza and colleagues
conducted a randomized trial to compare the clinical responses to HA and PRP
treatment in 2 groups of patients affected by knee osteoarthritis (Kellgren-Lawrence grades 1 – 3;
mild-moderate disease).  The study
included 120 patients that had only received physical therapy and
pharmacological treatment, excluding those that had previous knee operations,
infiltrative (intra-articular injections) treatment, or an autoimmune
syndrome.  Sixty patients received 4
weekly injections of a specific PRP, autologous conditioned plasma, which was
chosen because of its high content of growth factors and low content of white
blood cells.  The other sixty patients
received 4 weekly injections of HA.  All
patients were evaluated before the injection series was started and at 4, 12,
and 24 weeks using the Western Ontario and McMaster (WOMAC) osteoarthritis
index questionnaire (graded 0-96, higher score represents increased
debilitation).  Both groups were found to
have similar pretreatment WOMAC scores: 76.9 for the PRP group and 75.4 for the
HA group.  At weeks 4, 12, and 24, the PRP
group had better WOMAC scores of 49.6, 39.1, and 36.5, compared to the HA group
with scores of 55.2, 57.0, and 65.1.  The
differences found between the groups were significant at each time point, as
well as significantly better than the baseline results at each time point.  The grade of osteoarthritis did not influence
the results within the group treated with PRP, whereas within the HA group individuals
with grade 3 osteoarthritis showed less improvement compared to individuals
with grades 1 and 2 (milder disease) at weeks 12 and 24.

Many patients suffer
from knee osteoarthritis, some at an earlier age secondary to injuries suffered
as an athlete or the rising rate of obesity. 
With some providers having concerns about the long-term use of
corticosteroid injections on younger patients, other options for treatment such
as HA and PRP have been looked at more closely. 
This study had similar outcomes to an article reviewed in April 2012 looking
at PRP vs HA in talarosteochondral lesions.  Although both groups were found to have
improvements compared to baseline in this study, the PRP group continued to
show improvement at 24 weeks, while the HA group’s peak effect was at 4 weeks
and worsened after that.  It is important
to note that these results differ slightly from another recent article by Filardo et al (2012) that suggested the
two treatments overall had similar outcomes but there was some signs that among
those with milder disease PRP was favorable to HA. Although more research is
needed with larger numbers of patients and longer follow-up, these results are
promising and can be added to the list of PRP studies with positive
results.  As far as how this effects
treatment decisions, it would be helpful to have studies that also compares
corticosteroid injections to both PRP and HA. 
Corticosteroid injections are still the first-line treatment when using
intra-articular injections for knee osteoarthritis.  Until PRP is covered by health insurances, HA
injections will still likely be 2nd line for the general
population.  Do you have any experiences with
the use of PRP for knee osteoarthritis? 
The authors discuss PRP having an anti-inflammatory effect in this
setting when using a product with low white blood cells.  What are your thoughts regarding PRP
typically being understood as having a pro-inflammatory reaction when used for
tendinopathy treatment?

Written by: Kris
Fayock, MD
Reviewed by: Jeffrey
B. Driban

Related Post:

Cerza F, Carnì S, Carcangiu A, Di Vavo I, Schiavilla V, Pecora A, De Biasi G, & Ciuffreda M (2012). Comparison Between Hyaluronic Acid and Platelet-Rich Plasma, Intra-articular Infiltration in the Treatment of Gonarthrosis. The American Journal of Sports Medicine, 40 (12), 2822-7 PMID: 23104611