O R I G I N A L R E S E A R C H

Indications and associated outcomes for

platelet-rich plasma injections performed in
an academic orthopaedic-specific hospital:
A patient satisfaction survey
Craig S. Melbourne, MD, Conor A. Smith, MD, Jaykumar Patel, BS, Brooks Platt, BS
and James L. Cook, DVM, PhD, OTSC
Downloaded from http://journals.lww.com/c-orthopaedicpractice by BhDMf5ePHKbH4TTImqenVBosEKX31uF96LySho9svi2ibrEVY+6fMo5xAl6H5izoN7dhBHa+sB0= on 10/22/2020

Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri

treatment of 67.9% (range, 1-100%). Factors that negatively

ABSTRACT influenced successful outcomes in the present study included
Background: patient age older than 45 yr and use of leukocyte-rich PRP, while
Platelet-rich plasma (PRP) is an autologous biologic product that has degree of improvement and return to full activity positively
become widely used in orthopaedic centers and at so-called influenced patient satisfaction with PRP treatment.
“regenerative medicine” or “pain” clinics. Although food Drug
Administration (FDA)-approved indications for use of PRP in Conclusions:
orthopaedics are for applications in which it is mixed with autograft The results of the present study suggest that PRP can be used to
or allograft bone, attention and clinical research have focused on its treat a variety of musculoskeletal conditions commonly diag-
off-label uses for treatment of osteoarthritis, musculotendinous nosed at an academic orthopaedic-specific hospital, with expect-
disorders, or joint pain. The present study aimed to document ations for 78% of patients reporting improvement and an overall
indications for PRP used by orthopaedic surgery faculty in an patient satisfaction level of 68%.
academic orthopaedic-specific hospital between 2011 and 2016,
characterize demographics of patients receiving these injections, and Level of Evidence:
assess associated 1-year or greater outcomes for these patients. Level IV.

Methods: Key Words

With institutional review board approval, this study retrospec- platelet-rich plasma injections, osteoarthritis, patient
tively identified 148 patients with osteoarthritis, augmentation demographics, patient outcomes, patient satisfaction
surgical treatments, tendon or ligament pathology, and sacroiliac
joint pain as indications for PRP treatment.

Results:
For respondents (n = 60), 78.3% (47 of 60) reported PRP-related INTRODUCTION

A
improvement in symptoms, with mean duration of effect of lthough Food and Drug Administration (FDA)-approved
800 days and an overall level of satisfaction with their PRP indications for use of platelet-rich plasma (PRP) in
orthopaedics are for applications in which it is mixed
with autograft or allograft bone, most of the recent attention and
Financial Disclosure: Dr. Cook discloses the following
clinical research has focused on its off-label uses for treatment
relationships outside of this work: Artelon, Arthrex, Inc,
ConforMIS, CONMED Linvatec; Coulter Foundation, DePuy
of osteoarthritis (OA), musculotendinous disorders, or joint
Synthes, A Johnson & Johnson Company, Eli Lilly, Merial, pain.1–14
Midwest Transplant Network, Musculoskeletal Transplant PRP is defined as a plasma-based product that contains a
Foundation, NIH, Purina, Schwartz Biomedical, Trupanion, concentration of platelets greater than the platelet concen-
U.S. DOD, Zimmer-Biomet. The other authors have no tration in whole blood and is categorized as leukocyte-rich (LR)
disclosures. The authors report no conflicts of interest in or leukocyte-poor (LP) based on white blood cell con-
regard to this work. centration.1 Platelets synthesize and release over 1500 proteins,
Correspondence to James L. Cook, DVM, PhD, OTSC, University of many of which have known roles in mitigating symptoms and/
Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave, or promoting healing of musculoskeletal tissues through their
Columbia, MO 65201
anabolic, antiinflammatory, antidegradative, analgesic and/or
Tel: +(573) 884-4689; fax: +(573) 882-1760;
e-mail: [email protected].
antibiotic mechanisms of action.
Supplemental Digital Content is available for this article. Direct URL citations The best current evidence suggests that LP-PRP is safe and
appear in the printed text and are provided in the HTML and PDF versions of effective for symptomatic treatment of mild to moderate knee
this article on the journal's website, www.c-orthopaedicpractice.com. OA, with a reported effect duration of 6 to 12 mo.1–3,6,7,9–14
1941-7551 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Although most peer-reviewed studies on musculoskeletal uses

Volume 31  Number 3  May/June 2020 Current Orthopaedic Practice 263

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264 | www.c-orthopaedicpractice.com Volume 31  Number 3  May/June 2020

of PRP have come from orthopaedic surgery centers, the vast

majority of procedures are performed at so-called “regenerative
medicine” or “pain” clinics, with out-of-pocket costs to patients
for the PRP ranging from $400 to $1400.12 A paucity of
evidence has been reported by these clinics, and although a
great deal of evidence from orthopaedic centers is now available
in the peer-reviewed literature, nearly all of these assess PRP
injections for single indications.1–14 Therefore, the objectives of
the present study were to document indications for PRP used by
orthopaedic surgery faculty in an orthopaedic-specific hospital,
characterize demographics of patients receiving these injec-
tions, and assess associated 1-year or greater outcomes for these
patients. The overall goal for this work was to identify potential FIGURE 1. Number of patients receiving at least one PRP injection for
risk factors related to patient demographics, PRP type, injection treatment of a musculoskeletal disorder at an academic orthopaedic-
site, or indications that may influence outcomes such that specific hospital from 2011 to 2016. LP-PRP, leukocyte-poor platelet rich
subsequent studies can be appropriately targeted. plasma; LR-PRP, leukocyte-rich platelet rich plasma.

MATERIALS AND METHODS RESULTS

From 2011 and 2016 at our academic orthopaedic-specific
Ethical Review and Study Design hospital, 148 patients received one or more PRP injections
This retrospective review of electronic medical record (EMR) from one of 18 different orthopaedic surgery faculty
data was approved by the institutional review board (MU IRB members (Figure 1). Of the 148 patients, 83 were males.
#2009382). A patient satisfaction survey was designed using Seventeen of the providers used LP-PRP for all injections,
this retrospective patient data, and informed consent was and one provider used LR-PRP for all injections, treating 59
obtained from the patients. patients included in the present study. For patients
consenting to and completing the outcomes questionnaire
Data Extracted with a minimum of 1-year follow-up (n = 60 respondents,
EMR data were collected for all patients who received at least response rate = 40.5%), 37 were males and 35 received
one PRP injection at our orthopaedic-specific hospital LP-PRP. Demographic and PRP type data are summarized in
between 2011 and 2016. This period of time was chosen Table 1.
because it encompasses the date of first implementation of OA and other joint-related indications were most com-
generalized use of PRP at our institution, with an end date mon. Other indications for PRP injection included augmen-
that allowed for adequate follow-up on patients. Based on the tation of healing after surgery, tendon or ligamentous
experimental design aimed at collecting all available data pathology (injury or inflammation), and sacroiliac (SI) joint
from all eligible patients previously treated during the pain. Of the 47 patients (31.8%) who received multiple
defined study period, prestudy power analysis to determine injections (range, 2-11 injections), SI joint pain (15 patients)
sample size was not relevant as sample size was determined was the most common indication. Injection site and
by the nature of the study. No exclusion criteria were applied indication data are summarized in Table 2.
for inclusion of subjects’ EMR data. The EMR was used to For the 60 respondents, 78.3% (n = 47) reported PRP-related
glean the following data: patient age, gender, body mass improvement in symptoms. For those noting improvement,
index (BMI) at time of first PRP injection, PRP type used, PRP time to first noticing improvement ranged from 1 to 365 days
injection site and indication, treating provider, and total (median = 7 days, mean = 30.4 days) and duration for improve-
number of injections. ment ranged from 7 to 3,022 days median = 365 days,
Attempts were made to contact all subjects by telephone in mean = 800 days) including 11 of 47 (23%) reporting improve-
order to obtain and document informed consent and complete ment to current day/complete resolution. For the respondent
a questionnaire (see Appendix, Supplemental Digital Content 1, cohort, 38.3% received multiple injections for the same
http://links.lww.com/COP/A32) to assess their perception of
outcomes associated with their PRP injection(s).
TABLE 1. Patient demographics and injection type
Statistical Analysis Mean age Mean
Data were collected, tabulated, and statistically analyzed. (range) BMI %
Descriptive statistics were calculated for all data collected. Group N yrs (range) LP-PRP
Outcomes data were analyzed for statistically significant All subjects 148 47 28.6 60%
differences in proportions to determine variables that may be (13-89) (18-49)
considered risk factors for specific outcomes using chi-square Respondents 60 50 29 58%
(M = 37; (18-81) (20-44)
or Fishers Exact test. Outcomes data were analyzed for F = 23)
important correlations using Spearman Correlation tests
with r > 0.4 considered moderately strong and important. BMI, body mass index; F, female; LP-PRP, leukocyte poor platelet-rich plasma;
M, male.
Significance was set at P < 0.05.

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Current Orthopaedic Practice www.c-orthopaedicpractice.com | 265

TABLE 2. Injection site and indications

PRP injection site Indication for PRP

OA/Joint Augment Tear, sprain,

Group N Joint Tendon SI Muscle Pain surgery strain Inflammation Tendinosis SI pain
All subjects 148 85 35 16 12 53 23 21 19 16 16
Respondents 60 33 12 8 7 19 11 12 6 4 8
OA, osteoarthritis; PRP, platelet-rich plasma; SI, sacroiliac.

indication (median = 3, mean = 3, range 1-8), with the most PRP, while degree of improvement and return to full activity
common indication for multiple injections being knee OA appeared to influence patient satisfaction with PRP treat-
(n = 10). Patients reported the additional injections being less ment. However, these associations and correlations between
effective (17%) equally effective (61%), or more effective (22%) variables need to be further investigated in a larger cohort of
than the first PRP injection. patients before any definitive conclusions can be made.
For the 60 respondents, 71.7% (n = 43) returned to full work The use of orthobiologics for nonsurgical treatment of
duty at 0 to 60 days after PRP treatment (median = 1 day, patients with musculoskeletal disorders is growing at a rapid
mean = 3.1 days). For those not returning to full work duty after pace, with most of the injections being performed at
PRP treatment, reasons included need for surgical treatment regenerative medicine or pain clinics while the majority of
(n = 3), retired/planned retirement (n = 6), unplanned retire- the research is performed by orthopaedic centers.1–14 To
ment (n = 1), pain (n = 3), or disability (n = 4). For this cohort, date, the majority of peer-reviewed evidence for use of PRP
73.3% (n = 44) returned to full activity at 0 to 243 days after in orthopaedics has been focused on single-indication
PRP treatment (median = 1 day, mean = 15.3 days). For those studies.1–14 As such, the authors wanted to provide an
not returning to full activity, reasons included pain (n = 12), overview assessment of our initial use of PRP after generalized
need for surgical treatment (n = 3), or disability (n = 1). implementation in our orthopaedic-specific hospital. The
Respondents reported an overall level of satisfaction with overall goal for this approach was to identify potential risk
their PRP treatment of 67.9% (range, 0-100%). factors related to patient demographics, PRP type, injection
When analyzing the data for variables that may be site, or indication that may influence outcomes such
considered risk factors for specific outcomes, multiple injections that subsequent studies can be appropriately targeted. The
were significantly (P = 0.001) and 129 times more likely to be authors suggest that this goal was met.
associated with the SI pain indication for PRP treatment. No Limitations of this study include the relatively small
variables assessed in this present study were significantly population of patients included as well as the response rate,
associated with a higher likelihood for PRP-related improve- the potential for recall bias, and potentially confounding
ment (P > 0.2). However, age older than 45 yr was significantly variables. Although the overall population was relatively small,
(P = 0.014) and 9.7 times more likely to be associated with lack it did include all patients treated by orthopaedic faculty at our
of improvement. No variables assessed in this present study hospital during the study period. Similarly, the data for
were significantly associated with a higher likelihood for return respondents closely matched the data for the total patient
to full work (P > 0.1). However, use of LR-PRP was significantly population, suggesting that outcomes data were likely repre-
(P = 0.048) and 2.7 times more likely to be associated with lack sentative of the entire cohort. Based on the study design and
of return to full time work. No variables assessed in this present time period, some respondents were unable to recall exact
study were significantly associated with a higher likelihood for timing of certain outcome variables, such that the potential for
return to full activity (P > 0.2) or lack of return to full activity recall bias must be considered. In addition, confounding
(P > 0.1). No variables assessed in the present study were variables such as physician specialty, patient compliance,
significantly associated with a higher likelihood for overall participation in physical therapy, and others may have
level of satisfaction greater than 90% or less than 90% (P > 0.1). significantly influenced outcomes. As such, the results of the
When analyzing the data for important correlations, an study must be considered primarily informative for design of
overall level of satisfaction of less than 90% showed a moderately targeted prospective studies for which it provides valuable
strong (r = 0.61) direct correlation with improvement and a information.
moderately strong (r = 0.47) correlation with return to activity.

CONCLUSIONS
DISCUSSION The results of the present study provide important informa-
The results of our study suggest that PRP can be used to treat tion regarding potential indications for use of PRP to treat
a variety of musculoskeletal conditions commonly diagnosed musculoskeletal disorders in an academic orthopaedic-specific
at an orthopaedic-specific hospital, with expectations for hospital. Based on these initial data, the authors recommend
78% of patients reporting improvement and an overall that providers counsel patients regarding realistic expectations
patient satisfaction level of 68%. Factors that may influence for improvement, potential for multiple injections, return to
outcomes associated with PRP injections identified in the work, return to activity, and overall satisfaction level. Patient
present study included patient age and use of leukocyte-rich age and use of leukocyte-rich PRP may influence specific

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266 | www.c-orthopaedicpractice.com Volume 31  Number 3  May/June 2020

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