Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis

BackgroundClinical outcomes between the use of platelet-rich plasma (PRP), autologous blood (AB) and corticosteroid (CS) injection in lateral epicondylitis are still controversial.Materials and methodsA systematic review and network meta-analysis of randomized controlled trials was conducted with the aim of comparing relevant clinical outcomes between the use of PRP, AB and CS injection. Medline and Scopus databases were searched from inception to January 2015. A network meta-analysis was performed by applying weight regression for continuous outcomes and a mixed-effect Poisson regression for dichotomous outcomes.ResultsTen of 374 identified studies were eligible. When compared to CS, AB injection showed significantly improved effects with unstandardized mean differences (UMD) in pain visual analog scale (VAS), Disabilities of Arm Shoulder and Hand (DASH), Patient-Related Tennis Elbow Evaluation (PRTEE) score and pressure pain threshold (PPT) of −2.5 (95 % confidence interval, −3.5, −1.5), −25.5 (−33.8, −17.2), −5.3 (−9.1, −1.6) and 9.9 (5.6, 14.2), respectively. PRP injections also showed significantly improved VAS and DASH scores when compared with CS. PRP showed significantly better VAS with UMD when compared to AB injection. AB injection has a higher risk of adverse effects, with a relative risk of 1.78 (1.00, 3.17), when compared to CS. The network meta-analysis suggested no statistically significant difference in multiple active treatment comparisons of VAS, DASH and PRTEE when comparing PRP and AB injections. However, AB injection had improved DASH score and PPT when compared with PRP injection. In terms of adverse effects, AB injection had a higher risk than PRP injection.ConclusionsThis network meta-analysis provided additional information that PRP injection can improve pain and lower the risk of complications, whereas AB injection can improve pain, disabilities scores and pressure pain threshold but has a higher risk of complications.Level of evidenceLevel I evidence

[1]  Douglas G Altman,et al.  Validity of indirect comparison for estimating efficacy of competing interventions: empirical evidence from published meta-analyses , 2003, BMJ : British Medical Journal.

[2]  R. Christensen,et al.  Treatment of Lateral Epicondylitis With Platelet-Rich Plasma, Glucocorticoid, or Saline , 2013, The American journal of sports medicine.

[3]  G. Lu,et al.  Combination of direct and indirect evidence in mixed treatment comparisons , 2004, Statistics in medicine.

[4]  L. Bouter,et al.  Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial , 2002, The Lancet.

[5]  J. Calandruccio,et al.  Autologous blood injections for refractory lateral epicondylitis. , 2003, The Journal of hand surgery.

[6]  L. Bouter,et al.  Effectiveness of physiotherapy for lateral epicondylitis: a systematic review , 2003, Annals of medicine.

[7]  P. Kannus,et al.  Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. , 1991, The Journal of bone and joint surgery. American volume.

[8]  Alex J. Sutton,et al.  Contour-Enhanced Funnel Plots for Meta-Analysis , 2008 .

[9]  L. Bouter,et al.  Corticosteroid injections for lateral epicondylitis: a systematic overview. , 1996, The British journal of general practice : the journal of the Royal College of General Practitioners.

[10]  F. Durbin.  Tennis elbow. , 1966, Nursing times.

[11]  J. Verhaar.  Tennis elbow. Anatomical, epidemiological and therapeutic aspects. , 1994, International orthopaedics.

[12]  Rachelle Buchbinder,et al.  Corticosteroid injections for lateral epicondylitis: a systematic review , 2002, Pain.

[13]  J. Ioannidis,et al.  The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration , 2009, Annals of Internal Medicine [serial online].

[14]  C. Dojode.  A randomised control trial to evaluate the efficacy of autologous blood injection versus local corticosteroid injection for treatment of lateral epicondylitis , 2012, Bone & joint research.

[15]  N. Rushton,et al.  Tennis elbow. A clinicopathologic study of 22 cases followed for 2 years. , 1990, Acta orthopaedica Scandinavica.

[16]  A. Panahi,et al.  Autologous Blood Versus Corticosteroid Local Injection in the Short-Term Treatment of Lateral Elbow Tendinopathy: A Randomized Clinical Trial of Efficacy , 2010, American journal of physical medicine & rehabilitation.

[17]  黄玉霞,et al.  Tennis elbow , 2010 .

[18]  Thomas R. Riley,et al.  A Randomized Double-blind Placebo-controlled Trial , 2004 .

[19]  T. Gosens,et al.  Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis , 2011, The American journal of sports medicine.

[20]  R. Brooks,et al.  The effect of platelet-rich plasma on clinical outcomes in lateral epicondylitis. , 2013, Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association.

[21]  L. Sedighipour,et al.  Is Platelet-rich plasma superior to whole blood in the management of chronic tennis elbow: one year randomized clinical trial , 2014, BMC Sports Science, Medicine and Rehabilitation.

[22]  I Harvey,et al.  Adjusted indirect comparison may be less biased than direct comparison for evaluating new pharmaceutical interventions. , 2008, Journal of clinical epidemiology.

[23]  D. Poon,et al.  Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. , 2005, Annals of internal medicine.

[24]  Douglas G Altman,et al.  Interaction revisited: the difference between two estimates , 2003, BMJ : British Medical Journal.

[25]  N. Rushton,et al.  Lateral epicondylitis: a review of pathology and management. , 2013, The bone & joint journal.

[26]  R. Buchbinder,et al.  Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis , 2013, The American journal of sports medicine.

[27]  D. A. van der Windt,et al.  Tennis elbow in primary care , 2006, BMJ : British Medical Journal.

[28]  M. Ramsey,et al.  Efficacy of Platelet-Rich Plasma for Chronic Tennis Elbow , 2013, The American journal of sports medicine.

[29]  M. Ibrahim,et al.  Local injection of autologous platelet rich plasma and corticosteroid in treatment of lateral epicondylitis and plantar fasciitis: Randomized clinical trial , 2012 .

[30]  M. Curtis,et al.  Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections , 2011, British Journal of Sports Medicine.

[31]  B. Morrey.  Platelet-Rich Plasma Versus Autologous Whole Blood for the Treatment of Chronic Lateral Elbow Epicondylitis: A Randomized Controlled Clinical Trial , 2012 .

[32]  T. Gosens,et al.  Positive Effect of an Autologous Platelet Concentrate in Lateral Epicondylitis in a Double-Blind Randomized Controlled Trial , 2010, The American journal of sports medicine.

[33]  L. Sedighipour,et al.  Effect of Platelet-Rich Plasma (PRP) versus Autologous Whole Blood on Pain and Function Improvement in Tennis Elbow: A Randomized Clinical Trial , 2014, Pain research and treatment.

[34]  Alex J Sutton,et al.  Contour-enhanced meta-analysis funnel plots help distinguish publication bias from other causes of asymmetry. , 2008, Journal of clinical epidemiology.

[35]  A. Singh.  Autologous blood versus corticosteroid local injection for treatment of Lateral Epicondylosis: A Randomized Clinical Trial , 2013 .

[36]  Eira Viikari-Juntura,et al.  Prevalence and determinants of lateral and medial epicondylitis: a population study. , 2006, American journal of epidemiology.