What Is the Appropriate Price for Platelet-Rich Plasma Injections for Knee Osteoarthritis? A Cost-Effectiveness Analysis Based on Evidence From Level I Randomized Controlled Trials

Published:February 13, 2020DOI:


      To identify the price of treatment at which platelet-rich plasma (PRP) is cost-effective relative to hyaluronic acid (HA) and saline solution intra-articular injections.


      A systemized review process of the PubMed, Embase, and MEDLINE databases was undertaken to identify randomized controlled trials comparing PRP with HA and saline solution with up to 1 year of follow-up. Level I trials that reported Western Ontario and McMaster Universities Arthritis Index Likert scores were included. These scores were converted into utility scores. Cost data were obtained from Centers for Medicare & Medicaid Services fee schedules. Total costs included the costs of the injectable, clinic appointments, and procedures. The change in utility scores from baseline to 6 months and 1 year for the PRP, HA, and saline solution groups was divided by total cost to determine utility gained per dollar and to identify the price needed for PRP to be cost-effective relative to these other injection options.


      Nine randomized controlled trials met the inclusion criteria. A total of 882 patients were included: 483 in the PRP group, 338 in the HA group, and 61 in the saline solution group. Baseline mean utility scores ranged from 0.55 to 0.57 for the PRP, HA, and saline solution groups. The 6-month gains in utility were 0.12, 0.02, and –0.06, respectively. The 12-month gains in utility from before injection were 0.14, 0.03, and 0.06, respectively. The lowest total costs for HA and saline solution were $681.93 and $516.29, respectively. For PRP to be cost-effective, the total treatment cost would have to be less than $3,703.03 and $1,192.08 for 6- and 12-month outcomes, respectively.


      For patients with symptomatic knee osteoarthritis, PRP is cost-effective, from the payer perspective, at a total price (inclusive of clinic visits, the procedure, and the injectable) of less than $1,192.08 over a 12-month period, relative to HA and saline solution.

      Level of Evidence

      Level I, systematic review.
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        • Cross M.
        • Smith E.
        • Hoy D.
        • et al.
        The global burden of hip and knee osteoarthritis: Estimates from the global burden of disease 2010 study.
        Ann Rheum Dis. 2014; 73: 1323-1330
        • Nüesch E.
        • Dieppe P.
        • Reichenbach S.
        • Williams S.
        • Iff S.
        • Jüni P.
        All cause and disease specific mortality in patients with knee or hip osteoarthritis: Population based cohort study.
        BMJ. 2011; 342: d1165
        • Hawker G.A.
        • Croxford R.
        • Bierman A.S.
        • et al.
        All-cause mortality and serious cardiovascular events in people with hip and knee osteoarthritis: A population based cohort study.
        PloS One. 2014; 9 (e91286)
        • Woolf A.D.
        • Pfleger B.
        Burden of major musculoskeletal conditions.
        Bull World Health Organ. 2003; 81: 646-656
        • Skou S.T.
        • Roos E.M.
        • Laursen M.B.
        • et al.
        A randomized, controlled trial of total knee replacement.
        N Engl J Med. 2015; 373: 1597-1606
        • Li C.S.
        • Karlsson J.
        • Winemaker M.
        • Sancheti P.
        • Bhandari M.
        Orthopedic surgeons feel that there is a treatment gap in management of early OA: International survey.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 363-378
        • London N.J.
        • Miller L.E.
        • Block J.E.
        Clinical and economic consequences of the treatment gap in knee osteoarthritis management.
        Med Hypotheses. 2011; 76: 887-892
        • Hagedorn II, J.C.
        • Danilevich M.
        • Gary J.L.
        What orthopaedic surgeons need to know: The basic science behind opioids.
        J Am Acad Orthop Surg. 2019; 27: e831-e837
        • McAlindon T.E.
        • LaValley M.P.
        • Harvey W.F.
        • et al.
        Effect of Intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: A randomized clinical trial.
        JAMA. 2017; 317: 1967-1975
        • Kirkley A.
        • Birmingham T.B.
        • Litchfield R.B.
        • et al.
        A randomized trial of arthroscopic surgery for osteoarthritis of the knee.
        N Engl J Med. 2008; 359: 1097-1107
        • Richter D.L.
        • Schenck Jr., R.C.
        • Wascher D.C.
        • Treme G.
        Knee articular cartilage repair and restoration techniques: A review of the literature.
        Sports Health. 2016; 8: 153-160
        • Bourne R.B.
        • Chesworth B.M.
        • Davis A.M.
        • Mahomed N.N.
        • Charron K.D.
        Patient satisfaction after total knee arthroplasty: Who is satisfied and who is not?.
        Clin Orthop Relat Res. 2010; 468: 57-63
        • Parvizi J.
        • Nunley R.M.
        • Berend K.R.
        • et al.
        High level of residual symptoms in young patients after total knee arthroplasty.
        Clin Orthop Relat Res. 2014; 472: 133-137
        • Ferket B.S.
        • Feldman Z.
        • Zhou J.
        • Oei E.H.
        • Bierma-Zeinstra S.M.
        • Mazumdar M.
        Impact of total knee replacement practice: Cost effectiveness analysis of data from the Osteoarthritis Initiative.
        BMJ. 2017; 356: j1131
        • Fice M.P.
        • Miller J.C.
        • Christian R.
        • et al.
        The role of platelet-rich plasma in cartilage pathology: An updated systematic review of the basic science evidence.
        Arthroscopy. 2019; 35: 961-976.e3
        • Alcerro J.C.
        • Lavernia C.J.
        Stem cells and platelet-rich plasma for knee osteoarthritis: Prevalence and cost in South Florida.
        J Am Acad Orthop Surg. 2019; 27: 779-783
        • Dai W.L.
        • Zhou A.G.
        • Zhang H.
        • Zhang J.
        Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: A meta-analysis of randomized controlled trials.
        Arthroscopy. 2017; 33: 659-670.e1
        • Russell L.B.
        • Gold M.R.
        • Siegel J.E.
        • Daniels N.
        • Weinstein M.C.
        The role of cost-effectiveness analysis in health and medicine.
        JAMA. 1996; 276: 1172-1177
        • Grootendorst P.
        • Marshall D.
        • Pericak D.
        • Bellamy N.
        • Feeny D.
        • Torrance G.W.
        A model to estimate health utilities index mark 3 utility scores from WOMAC index scores in patients with osteoarthritis of the knee.
        J Rheumatol. 2007; 34: 534-542
      1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) website.
        (Accessed November 14, 2019)
        • Coleman B.
        • Khan K.
        • Maffulli N.
        • Cook J.
        • Wark J.
        Studies of surgical outcome after patellar tendinopathy: Clinical significance of methodological deficiencies and guidelines for future studies.
        Scand J Med Sci Sports. 2000; 10: 2-11
        • Cowan J.
        • Lozano-Calderón S.
        • Ring D.
        Quality of prospective controlled randomized trials: Analysis of trials of treatment for lateral epicondylitis as an example.
        J Bone Joint Surg Am. 2007; 89: 1693-1699
        • Rosen J.
        • Sancheti P.
        • Fierlinger A.
        • Niazi F.
        • Johal H.
        • Bedi A.
        Cost-effectiveness of different forms of intra-articular injections for the treatment of osteoarthritis of the knee.
        Adv Ther. 2016; 33: 998-1011
        • Duymus T.M.
        • Mutlu S.
        • Dernek B.
        • Komur B.
        • Aydogmus S.
        • Kesiktas F.N.
        Choice of intra-articular injection in treatment of knee osteoarthritis: Platelet-rich plasma, hyaluronic acid or ozone options.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 485-492
        • Buendía-López D.
        • Medina-Quiros M.
        • Fernandez-Villacanas Marin M.A.
        Clinical and radiographic comparison of a single LP-PRP injection, a single hyaluronic acid injection and daily NSAID administration with a 52-week follow-up: A randomized controlled trial.
        J Orthop Traumatol. 2018; 19: 3
        • Patel S.
        • Dhillon M.S.
        • Aggarwal S.
        • Marwaha N.
        • Jain A.
        Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: A prospective, double-blind, randomized trial.
        Am J Sports Med. 2013; 41: 356-364
        • Raeissadat S.A.
        • Rayegani S.M.
        • Hassanabadi H.
        • et al.
        Knee osteoarthritis injection choices: Platelet-rich plasma (PRP) versus hyaluronic acid (a one-year randomized clinical trial).
        Clin Med Insights Arthritis Musculoskelet Disord. 2015; 8: 1-8
        • Smith P.A.
        Intra-articular autologous conditioned plasma injections provide safe and efficacious treatment for knee osteoarthritis: An FDA-sanctioned, randomized, double-blind, placebo-controlled clinical trial.
        Am J Sports Med. 2016; 44: 884-891
        • Vaquerizo V.
        • Plasencia M.A.
        • Arribas I.
        • et al.
        Comparison of intra-articular injections of plasma rich in growth factors (PRGF-Endoret) versus Durolane hyaluronic acid in the treatment of patients with symptomatic osteoarthritis: A randomized controlled trial.
        Arthroscopy. 2013; 29: 1635-1643
        • Su K.
        • Bai Y.
        • Wang J.
        • Zhang H.
        • Liu H.
        • Ma S.
        Comparison of hyaluronic acid and PRP intra-articular injection with combined intra-articular and intraosseous PRP injections to treat patients with knee osteoarthritis.
        Clin Rheumatol. 2018; 37: 1341-1350
        • Yu W.
        • Xu P.
        • Huang G.
        • Liu L.
        Clinical therapy of hyaluronic acid combined with platelet-rich plasma for the treatment of knee osteoarthritis.
        Exp Ther Med. 2018; 16: 2119-2125
        • Raeissadat S.A.
        • Rayegani S.M.
        • Ahangar A.G.
        • Abadi P.H.
        • Mojgani P.
        • Ahangar O.G.
        Efficacy of intra-articular injection of a newly developed plasma rich in growth factor (PRGF) versus hyaluronic acid on pain and function of patients with knee osteoarthritis: A single-blinded randomized clinical trial.
        Clin Med Insights Arthritis Musculoskelet Disord. 2017; 10 (1179544117733452)
        • Bedard N.A.
        • Dowdle S.B.
        • Anthony C.A.
        • et al.
        The AAHKS Clinical Research Award: What are the costs of knee osteoarthritis in the year prior to total knee arthroplasty?.
        J Arthroplasty. 2017; 32: S8-S10.e1
        • Losina E.
        • Paltiel A.D.
        • Weinstein A.M.
        • et al.
        Lifetime medical costs of knee osteoarthritis management in the United States: Impact of extending indications for total knee arthroplasty.
        Arthritis Care Res (Hoboken). 2015; 67: 203-215
        • Shahid M.
        • Kundra R.
        Platelet-rich plasma (PRP) for knee disorders.
        EFORT Open Rev. 2017; 2: 28-34
        • Dhillon M.S.
        • Patel S.
        • John R.
        PRP in OA knee—Update, current confusions and future options.
        SICOT J. 2017; 3: 27
        • Riboh J.C.
        • Saltzman B.M.
        • Yanke A.B.
        • Fortier L.
        • Cole B.J.
        Effect of leukocyte concentration on the efficacy of platelet-rich plasma in the treatment of knee osteoarthritis.
        Am J Sports Med. 2016; 44: 792-800
        • Cole B.J.
        • Karas V.
        • Hussey K.
        • Pilz K.
        • Fortier L.A.
        Hyaluronic acid versus platelet-rich plasma: A prospective, double-blind randomized controlled trial comparing clinical outcomes and effects on intra-articular biology for the treatment of knee osteoarthritis.
        Am J Sports Med. 2017; 45: 339-346
        • Drummond M.F.
        • Sculpher M.J.
        • Claxton K.
        • Stoddart G.L.
        • Torrance G.W.
        Methods for the economic evaluation of health care programmes.
        Oxford University Press, Oxford2015
        • Hochberg M.C.
        • Altman R.D.
        • April K.T.
        • et al.
        American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
        Arthritis Care Res (Hoboken). 2012; 64: 465-474
        • Bruyere O.
        • Cooper C.
        • Pelletier J.P.
        • et al.
        An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: A report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).
        Semin Arthritis Rheum. 2014; 44: 253-263
        • The Non-Surgical Management of Hip & Knee Osteoarthritis Working Group
        VA/DoD clinical practice guideline for the non-surgical management of hip & knee osteoarthritis.
        Veterans Affairs/Department of Defense, Office of Quality and Performance, and Office of Evidence Based Practice, US Army Medical Command, Washington, DC2014
        • Jevsevar D.S.
        Treatment of osteoarthritis of the knee: Evidence-based guideline, 2nd edition.
        J Am Acad Orthop Surg. 2013; 21: 571-576
        • McAlindon T.E.
        • Bannuru R.R.
        • Sullivan M.C.
        • et al.
        OARSI guidelines for the non-surgical management of knee osteoarthritis.
        Osteoarthritis Cartilage. 2014; 22: 363-388
        • Juni P.
        • Hari R.
        • Rutjes A.W.
        • et al.
        Intra-articular corticosteroid for knee osteoarthritis.
        Cochrane Database Syst Rev. 2015; : CD005328
        • Johal H.
        • Khan M.
        • Yung S.-H.P.
        • et al.
        Impact of platelet-rich plasma use on pain in orthopaedic surgery: A systematic review and meta-analysis.
        Sports Health. 2019; (1941738119834972)
        • Stefano L.
        • Paolo L.
        • Russo S.
        Knee OA management: A cost-effectiveness analysis of platelet-rich-plasma versus hyaluronic acid for the intra-articular treatment of knee OA in France.
        Int J Clin Rheumatol. 2018; 13: 307-318