Platelet-Rich Plasma Augmentation to Microfracture Provides a Limited Benefit for the Treatment of Cartilage Lesions: A Meta-analysis

Abstract

Background: Microfracture is the most common first-line option for the treatment of small chondral lesions, although increasing evidence shows that the clinical benefit of microfracture decreases over time. Platelet-rich plasma (PRP) has been suggested as an effective biological augmentation to improve clinical outcomes after microfracture. Purpose: To evaluate the clinical evidence regarding the application of PRP, documenting safety and efficacy of this augmentation technique to improve microfracture for the treatment of cartilage lesions. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed in PubMed, EBSCOhost database, and the Cochrane Library to identify comparative studies evaluating the clinical efficacy of PRP augmentation to microfracture. A meta-analysis was performed on articles that reported results for visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC), and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Risk of bias was documented through use of the Cochrane Collaboration Risk of Bias 2.0 and Risk of Bias in Non-randomized Studies of Interventions assessment tools. The quality assessment was performed according to the Grading of Recommendations Assessment, Development and Evaluation guidelines. Results: A total of 7 studies met the inclusion criteria and were included in the meta-analysis: 4 randomized controlled trials, 2 prospective comparative studies, and 1 retrospective comparative study, for a total of 234 patients. Of the 7 studies included, 4 studies evaluated the effects of PRP treatment in the knee, and 3 studies evaluated effects in the ankle. The analysis of all scores showed a difference favoring PRP treatment in knees (VAS, P = .002 and P < .001 at 12 and 24 months, respectively; IKDC, P < .001 at both follow-up points) and ankles (both VAS and AOFAS, P < .001 at 12 months). The improvement offered by PRP did not reach the minimal clinically important difference (MCID). Conclusion: PRP provided an improvement to microfracture in knees and ankles at short-term follow-up. However, this improvement did not reach the MCID, and thus it was not clinically perceivable by the patients. Moreover, the overall low evidence and the paucity of high-level studies indicate further research is needed to confirm the potential of PRP augmentation to microfracture for the treatment of cartilage lesions.

Microfracture for the Treatment of Symptomatic Cartilage Lesions of the Knee: A Survey of International Cartilage Regeneration & Joint Preservation Society

“…There is still considerable controversy surrounding the potential benefit of biologic augmentation since systematic reviews and meta-analysis report mixed results. 17,19 In a recent systematic review of basic science literature, Fice et al . 38 noted that a large majority of studies reveal that platelet-rich plasma has beneficial effects on the improvement of the histologic quality of cartilage; however, the lack of standardization of study methodology prevents comparison between studies.…”

“…Current cartilage restoration procedure options include reconstruction using allograft or autograft tissues, ex vivo amplification and reimplantation of chondrogenic cells using autologous chondrocyte implantation techniques, as well as the local application of exogenous growth factors and mesenchymal progenitor cell-based therapies. As a result, there has been a shift in the utilization of MFX as well as the emergence of biologic augmentation aimed at improving the quality tissue repair, referred to as “microfracture plus.” 17-19…”

Return-to-Sport Review for Current Cartilage Treatments

“…Early results are encouraging, but long-term data are currently limited and lacks large-scale RTS outcomes. 19 Given the limitations of the microfracture procedure with higher reoperation rates and decreased RTS outcomes, many surgeons are now turning to microfracture plus techniques for smaller articular lesions. These techniques appear to improve the potential for hyaline cartilage formation and improve outcomes of the microfracture procedure at 2 years, but the clinical significance is still being analyzed.…”

Frontiers in Orthobiologics for the Treatment of Osteochondral Lesions of the Ankle Joint

“…Additionally, patient characteristics, including age and body mass index (BMI), may result in different PRP compositions. There is also inconsistency regarding dosages, timing, and frequency of treatment [56]. The diversity of PRPs, as well as the wide heterogeneity of methodology in existing studies, make comparisons between studies and interpretation of results difficult.…”