Platelet Rich Plasma Therapy Hip Osteoarthritis Treatments

Our office has been offering regenerative medicine injections since 1993 as a service to people who wish to try to avoid hip replacement surgery. As part of our comprehensive program, we offer Platelet Rich Plasma Therapy, or as we describe it Platelet Rich Plasma Prolotherapy. The difference in the treatment is in the comprehensive nature of the treatment. As you will see in the research below, and through our own 30 years of empirical and clinical observation, a single injection of PRP will likely not work as hoped for. For some, Platelet Rich Plasma therapy for treating hip osteoarthritis should be suggested as a multiple-treatment care procedure.

If you have come upon this page, it is likely that you have received a recommendation for Platelet Rich Plasma treatment for your hip pain and you are doing your research. We are going to try to offer help with that research, but first, we would like to take a moment to describe how we offer Platelet Rich Plasma injections in cases of degenerative hip disease.

  • In Platelet Rich Plasma treatment, your blood is drawn from your arm, it is spun to concentrate the blood platelets which contain concentrated healing elements. The concentrated plasma “rich in healing platelets” solution is then injected into your hip.
  • In general terms, there are two PRP preparations. Leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP). Leukocyte-rich PRP is a PRP preparation that will increase the inflammatory response (a pro-inflammatory) and Leukocyte-poor PRP will modulate the inflammatory response in situations where the attending care provider believes that less inflammation would be more beneficial (an anti-inflammatory version).

In another office, Platelet Rich Plasma treatment may have been explained to you as a one-time injection treatment.

  • Platelet Rich Plasma treatment may have been explained to you as a one-time injection treatment. You may have been told this one injection will help with your problems of hip joint degeneration and address the concern of irreversible hip damage.
    • This “one-time,” treatment explanation may offer confusion in that many patients assume PRP injections are cortisone-like in that it is one injection offered at the time of treatment. The single injection PRP causes an inflammatory response, the opposite of the cortisone injections effect of causing an anti-inflammatory effect. The effects of the two injections could not be more opposite. Patients are often confused when the inflammation gets worse after PRP and they believe the PRP injection did not work.
    • This “one time,” treatment may also confuse patients who have or had been suggested to Hyaluronic acid. This is typically seen in patients who ask about PRP injections “How long does this last?” Hyaluronic acid injections have a finite or limited beneficial effect and patients are typically told how long these types of injections will last. Please read this article comparing Hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis

The controversy surrounding PRP injections for hip osteoarthritis. When it does not work and when it does

Medical research is filled with seemingly contradictory findings and recommendations. In this article we will look at research that suggests PRP will not help hip osteoarthritis patients, and, PRP will help hip osteoarthritis patients.

We use PRP injections in our office to help facilitate healing. We rarely offer them as a single injection. In our office, we combine PRP injections with Prolotherapy injections as explained and documented below. First, let’s explore the controversial findings surrounding the use of PRP in hip osteoarthritis treatments.

A January 2021 paper published in the journal Clinical Rheumatology (1) questioned the effectiveness of platelet-rich plasma (PRP) injections for osteoarthritis. Calling the use of this treatment one that “is still controversial.” The researchers noted that “Previous research supports the use of intra-articular PRP injections to promote a favorable environment for joint tissue healing and to delay the progression of osteoarthritis.” (Some of those studies are noted below).  The purpose of this study according to the researchers was to investigate the effectiveness of PRP in the management of hip osteoarthritis by reviewing previously published patient data. A total of 4 trials (334 participants, 340 hips) were included. The findings: “PRP may be beneficial and safe for patients with hip osteoarthritis . . . however, its superiority over other procedures such as hyaluronic acid remains unclear.” See below for further comparisons.

In the image below:

PRP or any regenerative medicine injections including stem cells or Prolotherapy do not create brand-new hips. A hip sometimes will be too far gone and hip replacement is recommended to help the patient return to a good quality of life.

severely degenerated hip xray

PRP does not work for everyone. Your candidacy for treatment should be carefully evaluated

An August 2019 study comes to us from Weill Cornell Medicine, Department of Rehabilitation, New York-Presbyterian Hospital. It was published in the journal Pain Medicine (2). Here are the simple learning points of that paper:

“Platelet-rich plasma (PRP) is a minimally invasive treatment option to reduce pain and promote tissue healing. At the time this study was performed, there was limited published literature analyzing outcomes for patients treated with PRP for hip osteoarthritis.

How the study worked: Thirty-six patients aged 49-85 years with chronic hip pain who were deemed good candidates for this study’s purposes, underwent image-guided intra-articular hip PRP injection. Outcomes were measured at baseline, two weeks, three months, and up to six months using standard scoring and disability scales. The number of people who had more than a 50% improvement in pain reduction and functional ability was further assessed.

  • Results: At two weeks, there was a significant improvement of function in people divided into one of two Hip Disability and Osteoarthritis Outcome Score groups:
    • Symptoms and Activities of Daily Living.
    • Pain Symptoms
    • Sixty-seven percent (24/36) of the patients reported a more than 50% improvement in pain at three months;
    • 58% (21/36) reported a more than 50% improvement in pain at six months.
  • Conclusions: In patients with mild/moderate hip osteoarthritis, PRP may provide pain relief and functional improvement for up to six months.

The avalanche of new research.

This 2019 paper was cited in a November 2022 study published in the Journal of Clinical Medicine (3) which noted at the top that more than 50% of the research articles on PRP and other orthobiologic (the use of cells, mainly from your own body as a healing agent) had been published after 2019. The focus of this research was the retro examination of outcomes of 735 patients gleaned from 20 clinical studies, 12 on PRP injections, and eight on cell-based therapies (five from bone marrow, two from adipose tissue, and one from amniotic fluid). According to the researchers, “the available evidence suggests safety and overall promising results, with the treatment success being inversely proportional to the severity of osteoarthritis (the earlier in the disease, the better treatments can work).

PRP is a promising treatment but the evidence can be controversial

Let’s take a brief march through the last ten years of research. In a 2013 study from doctors at the University of Florence, researchers found that a majority of patients receiving PRP for hip osteoarthritis had significant pain reduction at 6-7 weeks, which was sustained at 6 months, with a better range of motion. (4)

Researchers from the Rizzoli Orthopedic Institute in Italy published their findings in the American Journal of Sports Medicine which showed intra-articular PRP injections offer a significant clinical improvement in patients with hip osteoarthritis without relevant side effects. (5)

An April 2021 paper (6) published in the World Journal of Stem Cells summarized the use of PRP this way:

“PRP therapy has advantages such as rapid preparation and technical simplicity; it is also a point-of-care procedure, and can be carried out in-office due to its minimal invasiveness, permitting intra-articular, intra-tendinous or even intra-osseous injection. As a result of its autologous origin, it exhibits a unique safety profile, lacking many drug-related side effects or interactions. In osteoarthritis), PRP can interfere in the catabolic and inflammatory cascade (work as an anti-inflammatory), in order to promote anabolic responses.

People started searching for PRP for knee and hip pain on Google

The acceptance of PRP and the results achieved led to more doctors exploring PRP usage. This led to suggestions to their patients that PRP be explored for them. This of course led to a search in search engine inquiries into PRP treatments.

In October 2021, researchers at Stanford University writing in The Journal of Arthroplasty (7) noted a drastic rise in Google searchers related to platelet-rich plasma injections for osteoarthritis of the hip and knee. The researchers noted: “Surgeons treating hip and knee osteoarthritis patients can expect continued interest in platelet-rich plasma, despite inconclusive clinical and basic science data.”

A previous paper from Stanford University published in the journal Current Reviews in Musculoskeletal Medicine (8) December 2018 suggested: “PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.”

One of the reasons for more searches is that doctors are recommending this treatment more and more and people are going on their phones to get more information. In December 2022 paper (9) led by authors from the David Geffen School of Medicine, University of California, Los Angeles noted: “The highest injection incidences (increase of usage) were observed in patients younger than 44 years of age. These findings show that PRP is increasingly being used as a treatment modality for hip and knee osteoarthritis. ”

The rise in popularity of the treatment had some doctors warn against PRP use.

The rise in popularity of the treatment had some doctors warn against PRP use. Doctors at the Keck School of Medicine of USC wrote in the journal Current Reviews in Musculoskeletal Medicine, (10) in December 2018, “PRP is a costly treatment not covered by insurance, and clinical trials have not demonstrated definitive efficacy, we recommend informing patients when providing PRP ‘off-label.” Like any medical treatment, PRP will not fix everything, for some patients, PRP will not work for their hip pain for various reasons, generally speaking, a condition of hip degenerative disease that is “too far gone.”

Further doctors stress that patients be evaluated for the realistic candidacy of treatment. PRP should only be offered when there is a realistic expectation that the patient is considered a good candidate for treatment success. A multinational team of researchers also writing in the journal Current Reviews in Musculoskeletal Medicine (11) June 2019 suggested: “Although PRP is safe to use and it can be easily applied in the clinics, case-specific considerations are needed to determine whether PRP could be beneficial or not. If the use of PRP is favored, then, the configuration/optimization of the preparation and administration/delivery strategy with or without a concomitant treatment may further enhance the clinical outcomes and patients’ experience.”

Comparative studies, some even in contradiction with each other

In  November 2021, doctors in Italy published a comparative study in the journal BioMed Central Musculoskeletal Disorders (12). This article is filled with comparative studies, some even in contradiction with each other. However, they did find benefits of PRP injections:

“Intra-articular hip injections can be a useful instrument to reduce pain and improve function in hip osteoarthrosis, however, structured studies of high quality about this topic are still lacking. Although this review does not allow us to provide strong recommendations, we can observe that there is a short-term efficacy of PRP for pain decrease and long-term effectiveness for the improvement of function in patients affected by hip osteoarthrosis. The association of hyaluronic acid and corticosteroid can give better results compared to hyaluronic acid alone, while the use of intra-articular ketorolac and saline solution requires more studies.”

As described above, many patients come in with preconceived notions suggested to them by their orthopedists that PRP treatment is a one-injection treatment, the effects will wear off, and when the PRP effects wear off, surgery can then be discussed.

Despite evidence that PRP can help patients with hip osteoarthritis by addressing and correcting the destructive hip instability, there is a belief among many in the medical community that PRP is only a stopgap to delay hip replacement surgery. By offering the patient that one-time treatment, they will be providing the patient with significant pain relief until they are ready for hip replacement.

There are numerous studies that show a lack of effectiveness in PRP treatments. These studies surround single-dose/injection treatment. It should make sense to anyone researching the use of PRP for hip osteoarthritis that it is unlikely that you can reverse years of degenerative hip disease with a single injection of anything. A degenerative disease does not happen overnight, nor does it reverse overnight.

PRP compared to other treatments

In this section, we will look further at research that compares PRP to other notable treatments.

Platelet-rich plasma, hyaluronic acid, corticosteroid

A May 2020 (13) study published in the journal Arthroscopy compared the clinical outcomes of platelet-rich plasma, hyaluronic acid, corticosteroid, and a combined treatment of hyaluronic acid plus platelet-rich plasma for effectiveness in patients with hip osteoarthritis. What they found was: “corticosteroid injections are recommended as the most efficient agent in hip osteoarthritis patients in the short term. Moreover, PRP is reported to have the highest rank (best effectiveness) for pain relief for up to 6 months.” Again this is one injection vs one injection study. One injection of PRP is not our treatment standard.

Hyaluronic acid versus platelet-rich plasma

In this March 2022 paper in the journal Therapeutic Advances in Musculoskeletal Disease (14), researchers reviewed  30 previously published articles involving 2733 patients. They compared outcomes of hyaluronic acid versus platelet-rich plasma and compared single injection treatment versus three injection treatments. Their results were a mixed bag. PRP treatment performed better when compared with hyaluronic acid in the improvement of the patient’s function. There was no significant difference in pain between the two groups. LP-PRP (the anti-inflammatory version) looked to be superior (maybe was superior) to LR-PRP (the inflammatory version) in functional recovery, but there appeared to be no significant difference in pain relief between them. There was no significant difference between single PRP and triple PRP in the subgroup analysis. (One shot at three visits).

Previously a November 2021 paper (15) made a first-time comparison of the effectiveness of Leukocyte-rich PRP (LR-PRP)  against treatment with PRP plus hyaluronic acid and found both treatments were effective in reducing average visual analog scale (VAS pain 0 – 10 scale), but not in significantly increasing outcomes (the higher the score the better) of the Harris hip score (pain, function, range of motion, deformity of the hip). The researchers concluded: “Both treatments are effective at reducing pain in the short to medium term. Leukocyte-rich PRP (LR-PRP) could be the treatment of choice due to a more marked effect over time.”

A combination injection treatment of PRP and hyaluronic acid

A September 2022 study in the journal BMC Musculoskeletal Disorders (16) sought to compare the effectiveness of intraarticular injections of PRP, hyaluronic acid, and a combination injection treatment of PRP and hyaluronic acid for patients with hip osteoarthritis. The researchers theorized that since hyaluronic acid injections and PRP injections work in different ways, combining the two may have a synergistic effect and work better than either application applied alone. Was this in fact the case? No.

  • In this study, the researchers followed patients with grade two and grade three osteoarthritis.
  • These patients were then randomly divided into three injection groups:
    • PRP injection treatments
    • hyaluronic acid injection treatments and
    • a combination of PRP and hyaluronic acid injection treatments.
    • In these groups, two injections with 2-week intervals were performed into the hip joint under ultrasound guidance.

All three groups, PRP injection treatments, hyaluronic acid injection treatments, and the combination of PRP and hyaluronic acid injection treatments, showed significant improvement in pain reduction and pain and disability scores at two months and six months compared with baseline. However, the researchers found: “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.”

Please see these articles for further comparisons

What are we seeing in this image?

In this x-ray comparison, we see a hip joint that has been subjected to numerous cortisone injections and has demonstrated accelerated and significant breakdown. The cortisone injections, as documented in research in this article, have contributed to the bone-on-bone situation.

In this x-ray comparison we see a hip joint that has been subjected to numerous cortisone injections and has demonstrated accelerated and significant breakdown. The cortisone injections, as documented in research in this article, has contributed to the bone on bone situation.

Extracorporeal shock wave therapy (ESWT) and intra-articular platelet-rich plasma (PRP) injection for Osteonecrosis of the femoral head

Osteonecrosis (Osteo – meaning bone, necrosis – meaning death) is a painful condition caused by disrupted blood flow to the joint. Avascular Necrosis, the loss, blockage, or lack of blood vessels in the hip joint is a type of osteonecrosis.

We have a very extensive article on our site Is treating avascular necrosis of the femoral head without hip replacement possible? That goes into great detail. We will summarize some of the treatment information here related to PRP.

Earlier research gave preliminary support to PRP in the treatment of hip necrosis situations.

In a 2012 case history in PM & R: The Journal of Injury, Function, and Rehabilitation (17) PRP was found very effective for advanced-stage degenerative AVN of the hip, with the patient demonstrating significant functional improvements and the ultimate outcome of being able to avoid surgery. It should be noted that this was a single case history and that not all patients achieved this outcome.

A February 2022 paper (18) looked for evidence that extracorporeal shock wave therapy (ESWT) and intra-articular platelet-rich plasma (PRP) injection might alleviate pain and improve joint function in individuals with osteonecrosis of the femoral head.

A total of 60 patients aged 40-79 with osteonecrosis of the femoral head in one hip in stages I, II, and III (III or third being worse) were randomly assigned to the PRP (30 patients) or the ESWT group (30 patients). Four treatment sessions were provided in both groups.

Pain and functional assessments were performed at baseline, and 1-, 3-, 6-, and 12-month.

The researchers found both treatments effective to a degree in pain and function between three and 12 months after treatment, however, the PRP treatments seemed superior. The researchers wrote: “This study supported the effectiveness and safety of both the PRP injection and extracorporeal shock wave therapy (ESWT) in treating osteonecrosis of the femoral head patients. For symptomatic patients with osteonecrosis of the femoral head, intra-articular PRP injection appeared superior to extracorporeal shock wave therapy (ESWT) in pain relief and functional improvement.”

Is PRP only a stopgap to delay hip replacement surgery

Some of the long-term PRP research suggest that PRP can help short-term but eventually hip replacement will be needed anyway. In many patients we see, PRP treatment can be very successful, however, if you do very physically demanding work, or, push yourself through pain in other activities, especially that work or activity that caused the hip degeneration in the first place, will continue to degenerate the hip. PRP does not make a brand-new hip.

In our experience in treating thousands of patients, PRP is much less effective as a single-dose treatment.

PRP treatments for hip pain will not help everyone. But because of the great variation in treatments, researchers suggest that it is difficult to tell who the treatment can help and who the treatment will not help.

Single PRP treatment is not how we see PRP treatments. We see PRP treatments in conjunction with Prolotherapy treatments (Prolotherapy is a simple injection technique that works to strengthen the hip ligaments and provide stability to the hip. In combination, we see these treatments as a means to not only delay the need for a hip replacement but to prevent the need for a hip by repairing and regenerating tissue in the hip. We see this as the best chance for success but again, there are some hips that are too far gone and we will recommend patients to hip replacement.

In our experience, when somebody has a degenerative hip disease and the cartilage is wearing away and being lost, you simply cannot repair the cartilage without addressing what is causing the cartilage damage. This is the joint erosion or irreversible joint damage you are hearing so much about. It manifests itself as instability in your hip, the feeling that your hip is giving way or is loose and wobbly.

  • It is important that anyone contemplating treatment with platelet-rich plasma therapy should address the instability issue by adding comprehensive Prolotherapy treatments to the PRP treatments. Please see our article The evidence that alternatives to hip replacement can work for you. This includes a more detailed discussion of the use of PRP in combination with hip osteoarthritis.

Prolotherapy utilizes hypertonic dextrose, among other simple ingredients that are individualized to each case, to initiate localized soft tissue repair. In the hip, the treatment is used to repair, tighten and strengthen the ligaments that hold the hip bones in place.

Video

Ross Hauser, MD demonstrates a hip pain treatment using Platelet Rich Plasma (PRP) Prolotherapy treatment in conjunction with Comprehensive (H3) Prolotherapy injections, as done at Caring Medical. Our Prolotherapists treat patients from around the globe with various regenerative injection therapies, including Platelet Rich Plasma Prolotherapy.

Because of the sensitive nature of the treatments in the video, you must sign into a youtube account to watch.

If you have questions about PRP for your hip pain, Get help and information from our Caring Medical staff

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This page was updated June 20, 2023

 

 

 

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