Can PRP help reduce the risk of rotator cuff re-injury?

Platelet-rich plasma does not improve clinical outcomes in patients with rotator cuff disease, but reduces relapse rates. A systematic review and meta-analysis

Feltri P, Gonalba GC, Boffa A, Candrian C, Menon A, Randelli PS, Filardo G. Knee Surgery Sports Traumatol Arthrosc. December 11, 2022. doi: 10.1007/s00167-022-07223-9. E-publishing prior to printing. PMID: 36496450.

Full text freely available

Take home message

Including platelet-rich plasma (PRP) with rotator cuff surgery reduced the number of relapses compared to surgery without PRP. However, PRP had no other apparent clinical benefits during conservative or surgical treatment.

Background

Rotator cuff injuries are common injuries that can be treated with numerous conservative or surgical treatment options; However, these options are not always effective and can lead to persistent symptoms or retreats. Platelet-rich plasma (PRP) has attracted interest due to its high concentration of proteins involved in the healing process and low rate of side effects. There is mixed evidence regarding the effectiveness of PRP in reducing pain, improving function, and reducing the risk of hernia. Therefore, a systematic review may shed light on the role of PRP in the treatment of people with rotator cuff disorders.

Study aim

The authors conducted a systematic review and meta-analysis to evaluate the efficacy of PRP in terms of functional improvement, pain reduction, and retrauma after conservative or surgical treatment of rotator cuff disorders.

Methods

An initial database search yielded 1,229 articles, and the authors subsequently identified 36 clinical trials eligible for the systematic review. The authors then used 18 of those studies for the meta-analysis. The inclusion criteria required a randomized trial (published in English) that included specific outcomes (functional scores, pain scores and retear rate) and the use of PRP among people receiving conservative or surgical treatment of rotator cuff disease. The authors extracted 1) publication information (e.g. authors, journal), 2) population characteristics (age, gender, type of lesion, tendon involved), 3) tear characteristics (type of lesion, tendon(s) involved), 4) PRP characteristics, 5) repair technique (if applicable), 5) follow-up [split into short term (<6.5 months) and long term (>12 months)]and 6) clinical outcomes.

Results

The 36 clinical trials included 2,443 participants (~49% female, ~54 years old, ~16 months follow-up). Of the 36 articles from the randomized control trial, 16 examined PRP within the context of conservative treatment, and 20 examined PRP within the context of surgical treatment. The authors could not perform a meta-analysis among the studies with conservative management because they varied too much in outcomes, number of PRP injections, PRP volume used, and alternative treatments offered (e.g., corticosteroids, saline, exercise, or physiotherapy). Overall, PRP had mixed results in pain and function compared with other conservative treatments. Nineteen of the twenty surgical studies were included in the meta-analysis. The authors found no differences in self-reported pain or function between participants who underwent surgery with or without PRP. The patients who received PRP and surgery had a recurrence rate of ~7%, while the control group had a recurrence rate of ~14%.

Viewpoints

PRP can be an effective treatment for rotator cuff surgery to reduce the risk of re-tear compared to surgery without PRP. Interestingly, the PRP failed to provide better self-reported pain or function than surgery alone. Unfortunately, it remains unclear whether PRP reduces pain and improves function in people treated conservatively. When a doctor reviews the various studies among people managed conservatively, the doctor must take into account what the other treatment group received, the PRP protocol, and follow-up visits. Clinicians should focus on the studies that reflect their PRP protocol (or what they can offer) and patient population, and also consider whether they want to see how their results compare to usual care, placebo, or an active intervention (e.g., corticosteroids) . Finally, it’s worth remembering that in a clinical trial you should focus on the differences between groups. This comparison is the only one that takes advantage of why we want to classify people into different groups. Results examining changes within a group over time may be influenced by placebo effects, regression to the mean, or other factors unrelated to treatment.

Clinical implications

The use of PRP may reduce the risk of re-tear if used in conjunction with surgery. If a patient is receiving conservative treatment, doctors may look for specific studies that simulate their practice and treatment goals to help patients decide. However, patients receiving conservative care should also understand that the evidence for PRP is murky, but the risk of side effects is low.

Questions for discussion

Have any of your patients received PRP injections? If so, what were their thoughts? Would you use or recommend PRP therapy?

related posts

1. Common medications can affect the effectiveness of PRP
2. The positive effects of various platelet-rich plasma methods on human muscle, bone and tendon cells
3. Platelet-rich plasma is inadequate compared to exercise therapy

Written by Jane McDevitt
Reviewed by Jeffrey Driban