There has been increased interest in non-surgical treatments for osteoarthritis in recent years. One of the reasons for this is the Covid-19 pandemic, which resulted in disruption to normal treatment for osteoarthritis and patients experiencing longer delays for joint replacement surgery.
Even before the pandemic, people with the condition were encouraged to wait for as long as possible before undergoing surgery to minimise the risk of needing a revision joint replacement (surgery at a later date to replace a worn-out implant). This remains the advice for people with osteoarthritis which means that patients need to manage their symptoms in the short to medium-term using non-surgical treatments.
The British Orthopaedic Association Guidance
According to Versus Arthritis, the charity that supports patients with arthritis, there has been growing numbers of calls from patients about using injectable orthobiologics to treat osteoarthritis symptoms.
The British Orthopaedic Association responded by producing an information document outlining the different orthobiologic treatments currently available and looking at studies into their efficacy and safety. The report’s aim was to help patients make informed decisions about their medical care. In this blog we will summarise some of the key findings.
What is osteoarthritis and how common is it?
Osteoarthritis is a degenerative condition that affects the joints, causing the cartilage to deteriorate. As the condition worsens, it causes pain, stiffness, loss of mobility, swelling of the joint and a deteriorating quality of life.
What are injectable orthobiologic treatments for osteoarthritis?
Orthobiologic treatments are obtained from a human source and used in the treatment of musculoskeletal conditions like arthritis. Autologous orthobiologic treatments are prepared from the patient’s own blood, bone marrow or fat before being prepared and injected into an affected body part, such as the hip or knee.
Donor orthobiologic treatments are prepared from another person’s (donor) blood, bone marrow or fat. These treatments are not the same as biologics used to treat inflammatory conditions like rheumatoid arthritis and ankylosing spondylitis.
Most orthobiological treatments (with the exception of Platelet Rich Plasma in certain circumstances) are not available on the NHS.
Are stem cells used in injectable orthobiologic treatments?
While the term ‘stem cells’ might be used in describing some of these treatments, The British Orthopaedic Association is keen to clarify that very few, if any, true stem cells are present in injected orthobiologic treatments and that the cells injected do not have the ability to turn into new tissue in the way that stem cells might.
What injectable orthobiologic treatments are available?
Different injectable orthobiologic treatments are currently available, details of which are outlined below:
(1) Platelet Rich Plasma (PRP) – This uses the patient’s own blood, which contains cells known as platelets that are rich in molecules and cell messenger chemicals, which can promote healing and reduce inflammation. PRP is available on the NHS for certain conditions. It is the most widely-studied orthobiologic injectable, with more than 25 clinical trials comparing it with other injections. The British Orthopaedic Association says there is some evidence that PRP can provide relief from symptoms in the short-term (1-2 years) but says there is no evidence that it can restore cartilage or slow the progression of osteoarthritis. The National Institute for Health and Clinical Excellence (NICE) published a guideline concluding that PRP is reasonably safe but states there is not enough evidence to be sure how well it will work as a treatment.
(2) Autologous Anti-Inflammatories (AAIs) – Autologous conditioned serum (ACS) is a cell-free serum that contains anti-inflammatory factors released from white blood cells that have been activated. Autologous Protein Solution (APS) is produced by processing PRP, rich in white blood cells, to concentrate anti-inflammatory factors. Initial studies demonstrate AAIs have the potential to improve pain in the short-term and it appears to be reasonably safe but more evidence is needed before it can be widely used as a treatment for osteoarthritis.
(3) Cell-Based Therapies – These treatments often use Mesenchymal Stromal Cells (MSCs) which are present in bone marrow, fat and other tissues. The British Orthopaedic Association cautions against believing these cells can act like stem cells and become new cartilage cells. It states there is no evidence for this, but believes these cell-based treatments may have anti-inflammatory effects and provide some short-term pain relief. There are cell-based therapies that are delivered immediately after the cells are harvested (for example, Bone Marrow Aspirate Concentrate – BMAC, Stromal Vascular Fraction – SVF, and Microfragmented Adipose Tissue – MFAT). Other cell-based therapies require a delay for processing and growing cells in a laboratory. These are called cultured preparations and include Culture Derived Mesenchymal Stromal Cells – MSCS.
Do injectable orthobiologic treatments work?
The British Orthopaedic Association notes that short-term relief from symptoms has been reported by some studies into injectable orthobiologic treatments but cautions that not all of the studies have sufficient scientific rigour and there is not conclusive evidence that such improvements are due to the treatments themselves. It advises that further research is needed.
The Association is also critical of misleading claims about certain treatments, in particular the reference to stem cells. This leads it to conclude that there is not currently sufficient evidence to support the use of such therapies as a routine treatment for osteoarthritis. However, patients may wish to carry out their own research before making a decision about their own treatment using injectable orthobiologics.
You can read the NICE guidance on PRP injections for osteoarthritis here and further information from The British Association of Orthopaedics here.
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