Purpose
To evaluate the clinical effects of hyaluronic acid (HA), steroids, platelet-rich
plasma (PRP), or adipose mesenchymal stromal cell (MSC) injections in the treatment
of knee osteoarthritis (OA).
Methods
Randomized controlled trials with OA of the knee that compared HA, steroids, PRP,
adipose MSC, or their combination with placebo or in head-to-head combination were
identified from the MEDLINE, EMBASE, Cochrane Library, Web of Science, and SCOPUS
databases up to June 30, 2019. We performed a network meta-analysis of the relevant
literature to determine whether there was benefit from HA, steroids, PRP, or adipose
MSC treatment as compared with placebo.
Results
A total of 43 trials covering 5554 patients were included. Steroids were ranked most
likely to be effective for the management of pain or function, with adipose MSC and
multiple PRP appearing least likely to be effective. Although no significant difference
was observed among the 6 interventions, except for single PRP with respect to adverse
effects, steroids and HA exhibited a lower rate of AEs compared with the placebo.
In view of severe adverse effects, only single PRP was superior to placebo. Direct
pairwise meta-analysis for pain relief showed that HA was superior to placebo or single
PRP, but steroids had a significantly worse effect than single PRP. In addition, direct
pairwise meta-analysis for adverse effects favored steroids in comparison to HA.
Conclusions
The ranking statistics like surface under the cumulative ranking curve values of our
network meta-analysis support the use of steroids and HA for appropriate patients
with knee OA. For pain relief and AEs, steroids are most likely the best treatment,
followed by HA. Single PRP, multiple PRP, and adipose MSC interventions do not result
in a relevant reduction of joint pain nor improvement of joint function compared with
placebo. However, treatment effect differences were small and potentially not clinically
meaningful, indicating that other factors, such as cost and patient preferences, may
be more important in patients with knee OA.
Level of Evidence
meta-analysis of non-homogenous randomized controlled trials, Level II
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Article info
Publication history
Published online: April 16, 2020
Accepted:
March 29,
2020
Received:
October 1,
2019
Footnotes
See commentary on page 297
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
This study was performed at Chuncheon Sacred Heart Hospital, Hallym University School of Medicine.
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© 2020 by the Arthroscopy Association of North America
