Autologous platelet rich plasma injection can be effective in the management of osteoarthritis of the knee: impact on IL-1 β, TNF-α, hs-CRP

Abstract

Objective

To analyze the clinical efficacy of autologous platelet rich plasma (PRP) injection in the treatment of knee osteoarthritis (KOA) and its influence on related biomarkers such as interleukin-1 beta (IL-1β), tumor necrosis factor-alpha (TNF-α), and high-sensitivity C-reactive protein (hs-CRP).

Method

150 study subjects are randomly selected from KOA patients received treatment in the Third Hospital of Bethune Hospital from January 2022 to January 2023. After enrollment, patients are randomly numbered 1–100. 75 patients with odd and even numbers are included in the control group and the observation group, respectively. The former is cured with etocoxib, while the latter is treated with autologous PRP injection based on this. The clinical efficacy, relevant biomarkers (IL-1β, TNF-α, hs-CRP), and Lysholm knee score scale and Fugl Meyer assessment (FMA) scores are compared and analyzed.

Results

The total effective rate of 94.67% (71/75) in the observation group was higher than 84.00% (63/75) in the other one group (P < 0.05). Before treatment, the comparison in IL-1β, TNF-α, hs-CRP, Lysholm knee joint score, and FMA scale score are with P > 0.05. When the treatment period is at 1 and 2 months, the IL-1β, TNF-α, hs-CRP levels within the group were lower than before treatment, while the Lysholm knee joint score and FMA scale score were higher than before treatment (P < 0.05). When the treatment period is at 1 and 2 months, the IL-1β, TNF-α, hs-CRP levels and the Lysholm knee joint and FMA scale scores in the observation group were lower and higher than those in the other one group, respectively (P < 0.05).

Conclusion

The application of autologous PRP injection therapy in KOA patients can significantly improve their levels of related biomarkers, effectively improve knee joint function and motor function, and have good clinical efficacy.

Background

Knee osteoarthritis (KOA) refers to a chronic joint disease featured by degenerative cartilage lesions of the knee, and its main clinical features are pain, swelling, dyskinesia and other symptoms of the knee joint, with a high incidence rate [1, 2]. Based on the World Health Organization (WHO) survey [3, 4], the global occurrence rate of KOA is about 10–15%, of which the elderly population accounts for more than 95%. With the increasing trend of aging in China, the proportion has begun to rise. For KOA patients, currently, anti-inflammatory and pain relief medication patches, oral medication, and surgical procedures are commonly used in clinical practice to treat patients, to reduce inflammatory reactions and promote their physical recovery.

With the gradual deepening of research on KOA, some scholars have proposed [5, 6] that there is a close relationship between this disease and IL-1β, TNF-α, hs-CRP, and it has an important impact on the pathogenesis and progression of KOA. In KOA, joint cartilage is damaged and worn, leading to a large release of IL-1β and TNF-α, leading to inflammatory reactions within the joint, leading to synovial (joint intima) inflammation, destruction of joint cartilage, and promoting bone hyperplasia, leading to joint pain, swelling, and dysfunction. In addition, when joints are damaged and inflamed, the liver produces more CRP, including an increase in hs-CRP levels, which become one of the indicators of inflammatory response. The increase of hs-CRP is related to the severity and progression of KOA, which reflects the activity of the disease and the degree of joint inflammation. The excessive production and persistence of these inflammatory factors and biomarkers leads to the worsening of joint inflammation and damage, ultimately leading to the exacerbation of symptoms and disease progression in KOA. For this reason, effective treatment can be performed on DF patients by adjusting hemorheological parameters and levels of VEGF and Omentin-1.

As the rapid growth of modern society, the medical technology in China has been increasing year by year. The treatment options for KOA patients have become increasingly diverse, and different treatment methods have independent advantages. Etoricoxib is a nonsteroidal anti-inflammatory drug (NSAID) that belongs to the selectiveCyclooxygenase-2 (COX-2) inhibitor. It can cut down the synthesis of prostaglandins by inhibiting the activity of COX-2 enzyme, thereby improving the inflammatory response and alleviating pain [7]. However, there are still certain drawbacks to this type of COX-2 inhibitor. Studies have shown that long-term or high-dose use of selective COX-2 inhibitors may raise the risk of cardiovascular events, and may also cause gastrointestinal adverse reactions such as gastric ulcers, bleeding, and gastrointestinal discomfort [8]. Autologous PRP injection therapy refers to the use of patients' own blood to extract platelet-rich plasma through special treatment of the blood, and then inject platelet-rich plasma into damaged tissues or injured areas to promote tissue repair and healing. However, the author of this article found through searching relevant literature that there are relatively few reports on the efficacy of PRP in treating KOA and its impact on IL-1β, TNF-α, hs-CRP. In view of this, this article conducts the following exploration and reports as follows.

Materials and methods

General materials

This study randomly selects study subjects from KOA patients who received treatment in the hospital from January 2022 to January 2023, and is organized under the support of ethics committee. The sample size is worked out using the sample size calculation equation $N=\frac{p(1-p)}{{\alpha }^2/Z^2+p(1-p)/E}$ [9], where the probability value p = 0.5 and the error value α = 0.05, statistic Z = 1.96, total E = 107. It is calculated that a total of 150 patients are contained. After enrollment, the patient's random number is 1–150, with 75 odd numbered patients and 75 even numbered patients each included in both groups, respectively. General information between the two groups of patients are with P > 0.05.

Inclusion and exclusion criteria

Inclusion criteria: (a) Comply with the KOA related diagnostic criteria provided in the 2019 ACR/AF Guidelines: Management of Hand, Hip, and KOA [10]; (b) Age ≥ 18 years old; (c) There are no allergic reactions or other contraindications to the treatment medication used in this study; (d) Having the ability to collect sufficient blood samples for PRP preparation; (e) Volunteer participants in this study.

Exclusion criteria: (a) Patients with severe cardiovascular or hemorrhagic diseases; (b) Patients with active infections; (c) Patients with abnormal blood coagulation function or undergoing anticoagulant therapy; (d) Patients with fractures, severe soft tissue injuries, or the need for surgery; (e) Patients with immune system diseases or impaired immune function.

Research method

Control group: Oral indomethacin tablets (manufacturer: Shanghai Xinyi Jiufu Pharmaceutical Co., Ltd.; national drug approval number: H20080510; specification: 25 mg/tablet) were used, 1 tablet/time, 1 time/day, for continuous treatment for 2 months.

Observation group: On the foundation of the control group, autologous PRP treatment is used. The concrete manners are as bellows: (a) blood samples are collected: a needle is inserted into the vein on the inner side of the forearm, which is the "cubital fossa" area, and 50 ml of blood is collected into a dedicated blood collection vessel or tube. The collected blood samples are originally added with anticoagulants, such as disodium glyoxate (EDTA) or citrate, to prevent blood clotting. (b) Centrifuge separation: The blood sample is placed in a centrifuge, then centrifuged at a speed of 1400 r/min for 10 min, and the lower layer of red blood cells is drawn to the interface for 3 mm. Centrifuging at a speed of 1400 r/min for 10 min can extract 3/4 of the upper layer of poor platelet plasma. The remaining is PRP, and finally it adds 0.2 mL of calcium chloride for activation. (c) Extract PRP: A dedicated syringe or straw is used to extract the separated PRP from the centrifuge tube. (d) Injection therapy: Before injection, the patient's joints are thoroughly disinfected, and then a disposable syringe is used to puncture the joint cavity, injecting 5 ml of PRP. Treatment is performed every 2 weeks, lasting for 6 months.

Observation indicators

The clinical efficacy was assessed based on the clinical efficacy evaluation criteria provided in the 2019 OARSI Guidelines [11]. After 2 months of treatment, the two groups ‘clinical efficacy is assessed, specifically as positive response (PR): pain relief, normal daily activities; preliminary improvement (PI): pain relief, limited daily activities; no improvement (NI): physical symptoms worsen and inability to participate in any physiological activities. Overall effective rate (OER) = (PR + PI)/total number of cases * 100%.

Biomarkers are measured before treatment, 1 and 2 months after treatment for two groups of IL-1 β, TNF-α, Hs-CRP levels. The test sample is 5 ml of fasting venous blood from the patient's elbow vein; Sample processing method: 3200 r/min, 10 cn centrifugation radius, and 10 min of processing time to obtain serum; Storage method: Store at – 20 °C; IL-1 β, TNF-α: ELISA is used; Hs-CRP: immunoradiometric assay.

Knee joint function is evaluated using the LKJ score scale [12] before treatment, 1 and 2 months after treatment. The scale includes 8 items such as pain, instability, and swelling, with a total score of 0–100 points. ≥ 95 points indicate excellence; 94–95 points indicate good; 65–84 points indicate acceptable; < 65 indicates poor performance. In this study, the Cronbach’sαcoefficient of the rating scale is 0.710–0.932, I-CVI is 0.830–0.919, and S-CVI is 0.956.

Motor function: before treatment, 1 month, and 2 months after treatment, the lower limb motor function of the two groups of patients is comprehensively evaluated using the FMA [13]. The scale includes four basic contents: reflex activity, joint movement, dissociative movement, and coordination/speed, with a total score of 0–34 points. The Cronbach’sαcoefficient of the rating scale is 0.747–0.830, I-CVI is 0.820–0.931, and S-CVI is 0.973.

Quality control

This study invites a blood transfusion doctor who participated in the study to assist in collecting research data. To ensure the authenticity of the study, the doctor is unaware of patient grouping, treatment methods, and other information during the data collection process.

Statistics method

The data in the study is entered using Excel spreadsheets and processed using statistical software SPSS 26.0. (x ± s) is utilized to describe econometric data, and independent sample t-tests are conducted between groups. The counting data are described with [n (%)]. A χ²-test is conducted between groups, and P < 0.05 means statistically significant difference.

Results

Comparison of patient general information

The comparison within the two groups patients’ general information were with P > 0.05 (Table 1).

Table 1.

Comparison of general information of patients [n (%), ($\overline{x}$ ± s)]

Group	Number of cases	Gender		Age (year)	Course of disease (year)	Location of onset
		Male	Female			One knee	Both knees
Control group	75	39 (52.00)	36 (48.00)	57.26 ± 5.95	3.35 ± 1.43	35 (46.67)	40 (53.33)
Observation group	75	41 (54.67)	34 (45.33)	57.53 ± 6.01	3.37 ± 1.40	37 (49.33)	38 (50.67)
t/X2		0.107		0.276	0.087	0.107
P		0.743		0.783	0.931	0.744

Clinical efficacy comparison

The total effective rate of the observation group was higher than that of the other one group (P < 0.05) (Table 2).

Table 2.

Comparison of total effective rates between two groups of patients [n (%)]

Group	Number of cases	PR	PI	NI	OER
Control group	75	40 (53.33)	23 (30.67)	12 (16.00)	63 (84.00)
Observation group	75	59 (78.67)	12 (16.00)	4 (5.33)	71 (94.67)
X2					4.478
P					0.034

Comparison of biomarkers

Before treatment, the comparison of the two groups of patients’IL-1β, TNF-α, hs-CRP levels were with P > 0.05; When the treatment period is at 1 and 2 months, those within the group were lower than before treatment (P < 0.05); compared between groups, those levels in the observation group were lower than those in the other one group when the treatment period is at 1 and 2 months (P < 0.05) (Table 3).

Table 3.

Comparison of biomarker levels ($\overline{x}$ ± s)

Group	Number of cases	IL-1β (ng/L)			TNF-α (ng/L)			hs-CRP (mg/L)
		Before treatment	Treatment for 1 month	Treatment for 2 months	Before treatment	Treatment for 1 month	Treatment for 2 months	Before treatment	Treatment for 1 month	Treatment for 2 months
Control group	75	182.21 ± 12.38	162.26 ± 13.75*	134.32 ± 10.26#	86.91 ± 7.34	80.84 ± 8.98*	67.40 ± 6.06#	13.46 ± 2.73	11.29 ± 1.29*	9.27 ± 2.45#
Observation group	75	183.30 ± 13.45	90.82 ± 7.38*	90.49 ± 8.25#	87.02 ± 7.29	59.01 ± 6.20*	34.11 ± 7.01#	13.59 ± 2.86	6.38 ± 1.36*	5.33 ± 1.26#
t		0.516	39.646	28.831	0.092	17.325	31.113	0.285	22.685	12.385
P		0.606	< 0.001	< 0.001	0.927	< 0.001	< 0.001	0.776	< 0.001	< 0.001

Compared with before treatment, */# P < 0.05 within the group

IL-1βlevel: F_{inter group}/F_time/F_interaction = 15.738/113.245/2.274, F_{inter group}/F_time/F_interaction = < 0.001/< 0.001/0.021

TNF-α level: F_{inter group}/F_time/F_interaction = 14.981/112.198/2.050, F_{inter group}/F_time/F_interaction = < 0.001/< 0.001/0.038

hs-CRP level: F_{inter group}/F_time/F_interaction = 16.845/111.471/2.286, F_{inter group}/F_time/F_interaction = < 0.001/< 0.001/0.020

Before treatment, the comparison of the two groups’IL-1β, TNF-α, hs-CRP levels were with P < 0.05. When the treatment period is at 1 and 2 months, these in the observation group were lower than those in the other one group (Fig. 1).

Fig. 1.

Comparison of IL-1 β, TNF-α, hs-CRP levels between two groups. Note: A shows IL-1β level; B shows TNF-α level; C shows the hs-CRP level; the green filled box represents the control group, while the orange filled box represents the observation groups and "*" respectively indicate without and with statistically significant difference, and the more "*", the more significant the difference

https://pubmed.ncbi.nlm.nih.gov/22171664/

Comparison of knee joint function and motor function levels

Before treatment, the comparison of Lysholm knee joint (LKJ) and FMA scores are with P > 0.05; When the treatment period is at 1 and 2 months, the LKJ score and FMA scale score within the group were higher than before treatment (P < 0.05); Comparison between groups: When the treatment period is at 1 and 2 month, the LKJ score and FMA scale score in the observation group were higher than those in the other one group (P < 0.05) (Table 4).

Table 4.

Comparison of knee joint and motor function levels ($\overline{x}$ ± s, points)

Group	Number of cases	LKJ			FMA scale score
		Before treatment	Treatment for 1 month	Treatment for 2 months	Before treatment	Treatment for 1 month	Treatment for 2 months
Control group	75	53.58 ± 6.35	54.35 ± 5.27*	68.89 ± 4.45#	15.33 ± 1.26	17.20 ± 2.75*	19.12 ± 1.08#
Observation group	75	53.66 ± 6.72	85.39 ± 4.57*	91.57 ± 3.34#	15.41 ± 1.35	20.76 ± 2.86*	28.81 ± 1.47#
t		0.075	38.537	35.301	0.375	7.771	46.005
P		0.940	< 0.001	< 0.001	0.708	< 0.001	< 0.001

Compared with before treatment, */# P < 0.05 within the group

LKJ score: F_{inter group}/F_time/F_interaction = 15.315/107.753/1.995, F_{inter group}/F_time/F_interaction = < 0.001/< 0.001/0.044

FMA scale score: F_{inter group}/F_time/F_interaction = 11.348/109.214/1.985, F_{inter group}/F_time/F_interaction = 0.001/< 0.001/0.045

Before treatment, the LKJ and FMA scale scores has no significant difference. The level of LKJ and FMA scale scores in the observation group when the treatment period is at 1 and 2 months were higher than those in the other one group (Fig. 2).

Fig. 2.

Comparison of knee joint function and motor function levels between two groups. Note: A and B denote the LKJ score level and the FMA scale score level, respectively; the green filled box represents the control group, while the orange filled box represents the observation group; ns means no statistically significant difference, while "*"denotes a statistically significant difference

Discussion

Osteoarthritis (OA) disease imposes a huge economic burden and pressure on the global healthcare system, and limited clinical treatment currently makes it impossible to eradicate the causes of OA [14–16]. OA is a disease that commonly occurs in middle-aged people in clinical practice. Due to its long course, the quality of life of its patients decreases and chronic pain persists [17]. As a common degenerative joint disease in clinical practice, during the onset of KOA, when joint cartilage is damaged, the patient's body will initiate an inflammatory reaction to clear the damaged tissue and initiate the repair process. During this process, white blood cells and other inflammatory cells (such as macrophages and T cells) are attracted to the joint and produce inflammatory cytokines, including IL-1β, TNF-α, and as the joint cartilage deteriorates, metabolites are released in the intracellular and extracellular matrix, which may activate or stimulate inflammatory reactions, leading to an increase in IL-1β, TNF-α levels [18, 19]. At the same time, the increase in intracellular oxidative reactions can promote the formation of oxidative stress, generating excessive free radicals, and causing certain damage to cells and tissues. In addition, IL-1β and TNF-α themselves can also promote inflammatory reactions through active self-sustaining cycling mechanisms. When the level increases, it may further activate the inflammatory response, promote the synthesis and release of hs-CRP, and lead to the production of more inflammatory factors, forming a vicious cycle [20].

The research background of PRP injection therapy can be traced back to the 1970s [21]. PRP is the main source of molecules involved in tissue repair and regeneration, and can exert effects through the typical nuclear factor kB signaling pathway in various cell types, with anti-inflammatory properties [22]. Initially, PRP was mainly used in the dental and oral fields to promote the repair of periodontal tissue. With the deepening understanding of the potential benefits of PRP, research has gradually expanded to the fields of orthopedics and sports medicine, and has received widespread attention in joint degenerative diseases. Research has shown that [23, 24], PRP is rich in growth factors and has a positive effect on regulating and inhibiting inflammatory responses. When PRP is injected into the patient's knee joint, its growth factors may inhibit the production of inflammatory cytokines, alleviate joint inflammatory response and lower the level of inflammatory cytokines. At the same time, it promotes the proliferation and synthesis of chondrocytes, improves the activity of chondrocytes, improves the structure and function of damaged cartilage, and reduces the degradation of articular cartilage, laying the foundation for cartilage repair and regeneration, further cut down the production of inflammatory factors [25]. The results of this article show that, it was found that the hs-CRP of the observation group were obviously lower than those of the other one group. Therefore, it can be concluded that autologous PRP injection therapy can have a good influence on the systemic inflammatory state of patients, which can significantly reduce hs-CRP levels by utilizing the comprehensive effects of inhibiting inflammatory reactions, promoting tissue repair and regeneration, and regulating the systemic inflammatory state.

In addition, autologous PRP injection therapy can fully utilize the growth factor function rich in PRP, promote cartilage repair, increase the water content and elasticity of cartilage tissue, alleviate joint inflammation response, and improve joint pain; Moreover, autologous PRP injection therapy also has the effects of increasing blood supply and nutrition, improving the repair ability of damaged tissues, enhancing the stability of the knee joint, improving the knee joint function level of KOA patients, and strengthening motor function [26].

Conclusions

In summary, autologous PRP injection therapy can significantly improve the levels of death related biomarkers in KOA patients, effectively improve knee joint function and motor function levels, and have good clinical efficacy.

Author contributions

JQ, XG, LZ, HZ and XH analyzed data and writing, participated in collection of data and experimental operations, participated in design testing and supervision testing. All authors read and approve the manuscript version final.

Funding

Not applicable.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

The study was approved by the local ethics committee of the Shanxi Bethune Hospital. All experiments were performed in accordance with relevant guidelines and regulations such as the Declaration of Helsinki and the patients signed the informed consent form and agreed to be published.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.