We have long used bone marrow derived stem cells and Platelet Rich Plasma injections as effective and reliable treatments for the patient with hip osteoarthritis. When a patient comes into our office, the realistic expectation of effectiveness of treatment is confirmed by a physical examination and a patient history. Following the consultation we sit down with the patient and present our recommendations for their hip pain treatments. How do we decide which treatment will be best? Many factors. For instance, a patient who wants to climb a mountain in a few months will need a different treatment program than someone who simply wants to walk up a flight of stairs without loss of stability and pain. Someone who needs to get back to work or not lose time from a physically demanding job will need a different program than a retired person with limited activity. In this article we will concentrate on when the choice is Platelet Rich Plasma Therapy injections as a primary treatment of hip osteoarthritis.
Platelet-Rich Plasma therapy is part of a group of treatments that come under the term “regenerative medicine.” PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. It is important to note that this treatment will not help everyone.
Research on PRP for Hip Osteoarthritis
A February 2021 study (1) gives a very optimistic assessment that the days of hip replacement may be coming to an end. Not soon, but they are coming. Here is what the study said: “Orthopedic surgeons are at an exciting crossroads in medicine, where hip biologic therapies are evolving and increasingly available. Time tested interventions such as arthroplasty have shown good results and still have a major role to play but newer, regenerative approaches have the potential to effectively delay or reduce the requirement for such invasive procedures.”
In 2018 a study (2) from the United Kingdom suggested: “Literature to date concludes that intra-articular platelet-rich plasma injections of the hip, performed under ultrasound guidance to treat hip osteoarthritis, are well tolerated and potentially efficacious in delivering long-term and clinically significant pain reduction and functional improvement in patients with hip osteoarthritis. Larger future trials including a placebo group are required to further evaluate these promising results.” Research into 2021 continues to suggest the effectiveness of PRP for hip osteoarthritis.
Before we look at other research that supports the use of PRP for hip osteoarthritis treatments, I want to explain the variations someone researching or getting this treatment may experience. In our opinion, regenerative medicine results are best seen when multiple PRP injections are given. In some research and in many doctor’s offices PRP is treated somewhat like a cortisone injection where one quick injection is considered the treatment. Your hip osteoarthritis did not occur overnight, it is the result of a slow degenerative process. It usually takes time and numerous treatments / injections to rebuild the soft tissue of that hip.
This was a recent study published in the Journal of pain research.(3) It hits upon some good points that describe how PRP works and when PRP may not work.
- Variability in treatment can lead to failure: “Despite great variability in pain outcomes, the application of autologous platelet-rich plasma (PRP) has become increasingly popular in attempts to reduce chronic pain. The variability in PRP efficacy raises the question of whether PRP actually has an analgesic capacity, and if so, can that capacity be made consistent and maximized. The best explanation for the variability in PRP analgesic efficacy is the failure during PRP preparation and application to take into account variables that can increase or eliminate its analgesic capabilities. This suggests that if the variables are reduced and controlled, a PRP preparation and application protocol can be developed leading to PRP inducing reliable, complete, and long-term pain relief.”
Research: The recommendation of PRP to treat degenerative joint disease
Doctors at the Department of Special Surgical Science, University of Florence published research (4) that has been well cited in the medical community, and used as the basis to support the recommendation of PRP to treat degenerative joint disease. Here is what the study said:
“. . . the growth factors in the PRP, or the platelet-rich plasma, obtained from a withdrawal of autologous (from the same patient) blood, concentrating the platelets, represents a safe, economical, easy to prepare and easy to apply source of growth factors.
Numerous growth factors are in fact within the platelets and in particular a large number of them have a specific activity on neo-proliferation (new creation of tissue), on cartilage regeneration and in particular also an antiapoptotic effect on chondroblasts (the prevention of cartilage cells from dying).”
- The research team also pointed out that the success of the PRP treatment was dependent on the severity of osteoarthritis.
- Further that three PRP treatments could significantly decreased the pain and increased range of motion and joint function in the hip.
In another paper that was cited by 145 other medical studies, doctors in Spain writing in the Oxford University journal Rheumatology (5) assessed the safety and symptomatic changes in 40 patients receiving platelet-rich plasma (PRP) to osteoarthritis of the hip.
In the research, each joint received three hip injections PRP, which were administered once a week.
- The treatment goal was meaningful pain relief, which was described as a reduction in pain intensity of at least 30% at 6-months post-treatment.
- Secondary goals included changes in the level of disability of at least 30% and the percentage of positive responders, i.e. the number of patients that achieved a >30% reduction in pain and disability.
- Results. Statistically significant reductions for pain and improved function were reported at 7 weeks and 6 months.
- Twenty-three (57.5%) patients reported a clinically relevant reduction of pain (45%), Sixteen (40%) of these patients were classified as excellent responders who showed an early pain reduction at 6-7 weeks, which was sustained at 6 months, and a parallel reduction of disability.
How does PRP help hip osteoarthritis?
A December 2018 paper from the Steadman Philippon Research Institute published in the journal Current reviews in musculoskeletal medicine (6) made these observations of the molecular and cellular repair PRP is capable of.
- PRP modulates the inflammatory and catabolic environment through a locally applied concentrate of platelets, leukocytes, and growth factors.
- What this suggests is that PRP acts as an anti-inflammatory, it turns a toxic joint, one that breaks down cartilage (catabolic – meaning eroding or breaking down) into a healing joint environment by bringing in healing cells and growth factors into the damaged joint that repairs the lesions and cracks in the cartilage. It also inspires the building of new cartilage.
Doctors at Weill Cornell Medicine at New York Presbyterian Hospital published research findings (7) into the effectiveness of Autologous Platelet-Rich Plasma for Osteoarthritis of the Hip
- Thirty-six patients aged 49-85 with chronic hip pain and had image-guided intra-articular hip PRP injection.
- Outcomes were measured at baseline, two weeks, three months, and up to six months using the visual analog scale (VAS) for pain and the Hip Disability and Osteoarthritis Outcome Score (HOOS).
At two weeks, there was a significant improvement of function in two Hip Disability and Osteoarthritis Outcome Score HOOS subscales:
- Symptoms and Activities of Daily Living.
- There was a significant improvement in all HOOS categories at six months.
- A significant improvement in VAS was observed at six months.
- Sixty-seven percent (24/36) of the patients reported more than 50% improvement in pain at three months; 58% (21/36) reported a more than 50% improvement in pain at six months.
In patients with mild/moderate hip osteoarthritis, PRP may provide pain relief and functional improvement for up to six months.
PRP helps stem cells work and act as an anti-inflammatory
In our practice, Stem Cell Therapy is a treatment for musculoskeletal disorders. Stem cells are “de-differentiated pluripotent” cells, which means that they continue to divide to create more stem cells; these eventually “morph” into the tissue needing repair — for our purposes, collagen, bone, and cartilage. However, there is also a native supply of stem cells in damaged joints that can be “turned on,” again and have them begin their healing process. PRP injections can be one way.
A 2016 study in the journal Tissue engineering. Part B, Reviews, (8) gives an account of the healing mechanisms of PRP.
- PRP modulates the repair and regeneration of damaged articular cartilage in the joints and delays the degeneration of cartilage by stimulation of mesenchymal stem cell migration, proliferation, and differentiation into articular chondrocytes.
- In addition to the symptomatic relief, PRP is a biological response modifier of inflammatory nuclear factor-κB signaling pathway and PRP reduces the pain by decreasing inflammation and angiogenesis of the synovial membrane where pain receptors are localized.
- PRP has the therapeutic potential not only to promote tissue regeneration, but also to contribute to articular cartilage lubrication by decreasing the friction coefficient and minimizing wear.
- Although further refinements and improvements are needed in standardized PRP preparations, PRP may modulate regeneration of articular cartilage and retards the progression of osteoarthritis by stimulating cell migration, proliferation, differentiation of progenitor/stem cells, joint homeostasis, and joint lubrication.
Do you combine hyaluronic acid with PRP?
This is the answer to a question usually posed by someone who has visited another office where the person was offered a combined hyaluronic acid / PRP injection. Do we offer this? Not for musculoskeletal disorders. While the combination of Hyaluronic based fillers (because of their ability to retain moisture in damaged skin) and PRP has been shown effective in cosmetic applications, we have not seen the benefit of applying both in a joint affected by degenerative disease.
A September 2022 paper (9) examined this question: “The aim of this study was to compare the effectiveness of intra articular injections of PRP, hyaluronic acid and a combination of PRP and hyaluronic acid in patients with hip osteoarthritis. Hyaluronic acid and PRP are two intra articular interventions that can be used in osteoarthritis in the preoperative stages. Due to the different mechanisms of action, these two are proposed to have a synergistic effect by combining.”
- In this study, patients with grade 2 and 3 hip osteoarthritis were included, and were randomly divided into three injection groups: PRP, hyaluronic acid and a combination of PRP and hyaluronic acid. In either group, two injections with 2 weeks’ interval were performed into the hip joint under ultrasound guidance. Patients were assessed before the intervention, 2 months and 6 months after the second injection, using the visual analog scale (VAS pain score), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC pain and disability), and Lequesne (severity of hip osteoarthritis) questionnaires.
All three groups, PRP, hyaluronic acid and a combination of PRP and hyaluronic acid, showed significant improvement in the pain and disability scores at 2 months and 6 months compared with baseline. “Although all 3 interventions were associated with improvement of pain and function in patients with hip osteoarthritis, the therapeutic effects of PRP and PRP and hyaluronic acid injections lasted longer (6 months), and the effects of these two interventions on patients’ performance, disability, and activities of daily living were superior to hyaluronic acid in the long run. Moreover, the addition of hyaluronic acid to PRP was not associated with a significant increase in the therapeutic results.”
Do you offer hyaluronic acid at all? No
If a patient came into our office with a recommendation from another doctor that they seek a combined PRP / Hyaluronic acid treatment, we would discuss with them about the possibilities of stem cells.
- PRP, as mentioned above contains growth factors which rebuild cartilage. PRP also contains anti-inflammatory factors.
- Hyaluronic acid is a key component of the synovial fluid that encapsulates joints and provides protective lubrication as well as shock absorbing characteristics that protect the joint.
- Stem cells provides the healing and growth factors found in PRP, in addition the stem cell treatments increase hyaluronic acid levels in arthritic joints. See my article Stem cell treatments increase hyaluronic acid levels in arthritic knees.
Do you have questions? Ask Dr. Darrow
Marc Darrow, MD. JD., discusses the treatment philosophy of the Darrow Stem Cell Institute. Transcript of video
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6 Kennedy MI, Whitney K, Evans T, LaPrade RF. Platelet-Rich Plasma and Cartilage Repair. Current reviews in musculoskeletal medicine. 2018 Sep 10:1-0.
7. Singh JR, Haffey P, Valimahomed A, Gellhorn A. The Effectiveness of Autologous Platelet-Rich Plasma for Osteoarthritis of the Hip: A Retrospective Analysis. Pain Medicine. 2019 Apr 8.
8 Sakata R, Reddi AH. Platelet-rich plasma modulates actions on articular cartilage lubrication and regeneration. Tissue Engineering Part B: Reviews. 2016 Oct 1;22(5):408-19.
9 Nouri F, Babaee M, Peydayesh P, Esmaily H, Raeissadat SA. Comparison between the effects of ultrasound guided intra-articular injections of platelet-rich plasma (PRP), high molecular weight hyaluronic acid, and their combination in hip osteoarthritis: A randomized clinical trial.