Background The effectiveness of platelet-rich plasma (PRP) injections in chronic tendinopathies remains debated. Although the product's characteristics play a role, the impact of postinjection recommendations remains poorly investigated.Objective To establish principles and guidelines for post-PRP injection rehabilitation and return to activity/sports.Design We conducted a Delphi survey based on a "recommendations by formal consensus" methodology. Three clinicians and researchers of the GRIIP (International Research Group on Platelet Injections), experts in sports medicine and rehabilitation, performed a comprehensive literature review of MEDLINE, searching for (1) rehabilitation protocols after PRP injection for chronic tendinopathy and (2) fundamental studies of tendon healing. This review highlighted the main points to be clarified to establish a standardized post-PRP injection protocol. Fourteen points were identified, grouped into three dimensions (immediate postprocedure, rehabilitation, and follow-up and resumption of sports/activity). With a modified Delphi method, the propositions were submitted to a panel of 23 experts from five French-speaking countries. The recommendations were classified as appropriate or not appropriate, with strong or relative agreement, or uncertain when consensus was not reached.Results Ten recommendations (postprocedure avoidance of nonsteroidal anti-inflammatory drugs, rehabilitation principles and timeline, follow-up) were classified as appropriate: six with strong and four with relative agreement; four propositions regarding immediate postprocedure were deemed uncertain.Conclusion Agreement was reached for 10 of the 14 recommendations but with low level of evidence, mainly based on experts' opinion. This work should help standardize a post-PRP injection protocol for chronic tendinopathies, which will minimize bias due to variations in rehabilitation protocols in further studies.

PURPOSE:Platelet-rich plasma (PRP) could be a vector for certain diseases, and its composition may vary by pathologic condition. The main comorbidities that could affect PRP composition are infectious, oncologic and haematologic. In addition to potential alteration of clinical response, these pathologies could have a significant impact on the local tolerance of PRP as well as a risk of disease dissemination to the injection site. To date, there are few specific recommendations related to these comorbidities to guide clinicians. Therefore, the International Research Group on Platelet Injections (GRIIP) supported a consensus project to develop these recommendations. METHODS:Following the 'recommendations by formal consensus' methodology, a steering committee performed a literature review and drafted an initial set of recommendations. They were evaluated by an international rating group (15 specialists in musculoskeletal [MSK] diseases, five haematologists, four oncologists, three infectiologists and four scientists specialising in platelet physiology). From this rating, the first set of recommendations was discussed in a plenary meeting and then modified by the steering committee. Finally, four overarching principles and 23 recommendations were re-evaluated by the rating group. Recommendations were classified as appropriate or not, with strong or relative agreement, or uncertain. RESULTS:From the 23 recommendations, 10 concerned infectious diseases (viral and bacterial infections; dialysis; immunosuppressive drugs; dental care…), five oncologic diseases (local tumour; cured, active or in remission cancer…) and eight haematologic diseases (cytopenia; cured, active or stabilised cured hemopathy; monoclonal gammopathy…). All were considered appropriate by the experts (median = 9; range = 8-9), with strong or relative agreement. Due to the paucity of literature data, the recommendations are mainly based on expert opinion (Grade D). CONCLUSION:This consensus project provides four overarching principles and 23 recommendations related to contraindications of PRP injections in case of infectious, oncologic or hematologic diseases, validated by an international expert group. LEVEL OF EVIDENCE:Level I.

Platelet-rich plasma (PRP) is now one of the most widely used orthobiologics in musculoskeletal medicine, with knee osteoarthritis (KOA) as its main indication. PRP represents a spectrum of autologous preparations with differing cellular and protein content. In this narrative review, we frame current knowledge as a "research ecosystem" spanning mechanistic biology, product characterization, randomized controlled trials (RCTs), systematic reviews and meta-analyses, methodological evaluations, expert consensus, and precision medicine. We highlight the diverse biological roles of PRP components, including the immunomodulatory activity of platelets, the dual regenerative and inflammatory effects of leukocytes, and emerging neutrophil-macrophage crosstalk. Advances in classification systems and deep learning-based quality control are also discussed. Across RCTs, PRP generally outperforms corticosteroids and hyaluronic acid in early to moderate KOA, with benefits lasting several months to a year. Methodological evaluation adds nuance: fragility index analysis confirmed PRP's advantage but showed individual trials were only modestly robust, while spin in systematic reviews often overstated benefits, underscoring the need for more rigorous RCTs and transparent reporting. Leukocyte and platelet concentrations do not explain outcomes, highlighting the importance of patient-specific factors such as metabolic status, inflammation, and structural phenotype. Progress remains hampered by inconsistent reporting, lack of a standardized classification system, and inadequate stratification. We propose a roadmap linking product characterization, standardized reporting, precision patient selection, and objective outcome measures, aiming to shift PRP from a generic injection toward a tailored regenerative therapy.

Objective: Viscosupplementation (VS) by intra-articular injections of hyaluronic acid (HA) is a commonly used treatment of knee osteoarthritis. However, there are no clear recommendations for its use in clinical situations not usually addressed in therapeutic guidelines. Design: Members of the European Viscosupplementation Consensus Group (EUROVISCO), made up of rheumatologists, orthopedic surgeons, and rehabilitation physicians from seven European countries, were asked to make a therapeutic decision on 30 clinical scenarios based on their clinical experience and data from the literature, using the Delphi method. For each scenario, the strength of agreement and the level of consensus were calculated by the chairman of the group. Results: The expert panel reached consensus on 18 of the 30 clinical scenarios proposed. According to the experts, the factors that most influence the decision to use VS with HA to treat knee osteoarthritis are the nature and severity of symptoms, the presence of comorbidity, the absence of therapeutic alternatives, and the patient’s refusal to undergo knee arthroplasty. Obesity and an advanced radiological degree of osteoarthritis have been identified as the two main factors for poor response to VS with HA and should be considered before any decision is made to viscosupplement. Conclusion: This set of recommendations, based on common clinical scenarios, is intended to help practitioners make decisions about HA VS in patients with osteoarthritis of the knee.

Intra-articular injections of platelet-rich plasma (PRP) are increasingly utilized in the management of knee osteoarthritis (KOA) and various other medical specialties. However, the efficacy of PRP remains a contentious issue; some experts consider it to be a placebo, while others advocate for its therapeutic value. Evidence from controlled clinical trials and meta-analyses has often yielded contradictory results, frequently failing to demonstrate a clear clinical benefit despite favorable outcomes observed in real-world settings. Several factors may contribute to these inconsistencies, with the lack of standardization in PRP preparation and the heterogeneity of KOA phenotypes being the most significant. Phenotyping is more effectively accomplished in specialized clinical environments, which may elucidate the improved outcomes associated with better patient selection. After delineating the specific characteristics of PRP injections and the primary sources of variability, we emphasize the necessity for comprehensive characterization of the injected product and accurate phenotyping of KOA. Additionally, we examine the methodological biases that impede the interpretation of clinical results and propose a treat-to-target approach as a more suitable evaluation strategy. These methodological challenges should not undermine the potential of regenerative medicine, which offers considerable promise. Compared to conventional therapies, regenerative medicine is generally more compatible with human physiology, better tolerated, and potentially less expensive. However, the advancement of this field necessitates strict scientific rigor and objectivity. This involves a meticulous recognition of biases and methodological limitations, as well as a deeper understanding of the underlying mechanisms of action, to refine and optimize therapeutic protocols.

BACKGROUND:Platelet-rich plasma (PRP) is one of the most frequently used orthobiologic products for the injection treatment of patients affected by knee osteoarthritis (OA). Some preliminary evidence supports the influence of platelet concentration on patients' clinical outcomes. PURPOSE:To analyze if platelet concentration can influence the safety and clinical efficacy of PRP injections for the treatment of patients with knee OA. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:This study consisted of 253 patients with knee OA (142 men, 111 women; mean ± SD age, 54.8 ± 11.4 years; Kellgren-Lawrence grades 1-3) who were treated with 3 intra-articular injections of 5 mL of autologous leukocyte-rich or leukocyte-poor PRP. All patients were prospectively evaluated at baseline and at 2, 6, and 12 months. Patients were clinically assessed thorough the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and the International Knee Documentation Committee (IKDC) Subjective score. Platelet concentration was correlated with clinical outcome. Further analysis was performed by stratifying patients into 3 groups (homogeneous for OA severity) based on platelet concentration (high, medium, and low). All complications and adverse events were reported, as well as failures. RESULTS:An overall statistically significant improvement in all clinical scores was documented from baseline to each follow-up evaluation. Platelet concentration positively correlated with clinical outcome. KOOS Pain improved more with higher platelet concentration at 2 months (P = .036; rho = 0.132), 6 months (P = .009; rho = 0.165), and 12 months (P = .014; rho = 0.155). The same trend was shown by the other KOOS subscales and by the IKDC Subjective score, as well as by the comparison of the groups of high-, medium-, and low-platelet PRP. The highest failure rate (15.0%) was found in the low-platelet group as compared with the medium-platelet group (3.3%) and the high-platelet group (3.3%). No differences were observed among the 3 groups in terms of adverse events. CONCLUSION:This study demonstrated that platelet concentration influences the clinical outcome of PRP injections in knee OA treatment. PRP with a higher platelet concentration provides a lower failure rate and higher clinical improvement as compared with PRP with a lower platelet concentration, with overall better results up to 12 months of follow-up in patients with knee OA.

Objectives Viscosupplementation with hyaluronic acid (HA) is a commonly used intra-articular treatment for osteoarthritis (OA). We performed a Delphi consensus process to formulate guidelines for the use of intra-articular hyaluronic acid (IAHA) knee injection according to the patient’s characteristics. Methods The EUROVISCO group consists of 12 members who had expertise in clinical and/or research in the field of OA and IAHA treatment. This group drafted issues through an iterative process and subsequently voted according to a Delphi process on their level of agreement (LoA) on these recommendations. The scores were pooled to generate a median agreement score for each recommendation. The strength of the recommendation (SOR) was classified as strong if the median agreement score was ≥8. The level of consensus (LOC) was also obtained. The level of evidence was given for each recommendation. Results: A total of 34 statements were evaluated by the expert group. A unanimous or high LoA was obtained in 16. IAHA can be considered irrespective of the age in patients with symptomatic knee OA. It can be used in patients with diabetes and/or moderate to severe obesity. It can also be used in knee OA patients with a history of gout, meniscocalcinosis and with mild-to-moderate varus/valgus malalignment. The group recommended against the use of VS in pregnant women and in OA flare. Conclusion In summary, the working group provided strong recommendations for the use of IAHA injection that will facilitate individualized treatment decision algorithms in the management of knee OA.

Musculoskeletal corticosteroid injections are widely performed, although the exact practice varies greatly due to advances in knowledge and techniques. This justifies updating and drawing up good practice recommendations. Using a consensus model formalized by the French National Authority for Health (HAS) and based on a literature review that resulted in a “white book”, 13 recommendations were developed by a group of experts. These recommendations were then sent online to 48 specialists for evaluation, 27 of whom were rheumatologists and 15 of whom were general practitioners. These recommendations were also presented at the 34th annual meeting of the French Society for Rheumatology (SFR) (Paris, December 2021) at a symposium attended by a hundred or so rheumatologists, who voted on these recommendations in person. The results are presented as an overall score out of 10, a median out of 10 and as tertiles. The agreement was excellent for 10 of these 13 recommendations, with mean values of 8.5 to 9.1 out of 10, median values of 9 or 10 out of 10 and agreement of 91.7% to 97.9%, which corresponds to a consensus. The 3 other recommendations were broadly supported but were the subject of more debate. One relates to patient information (mean 7.3/10, median 8/10, upper tertile 72.9%) with discussion about the waiting period. Another related to the summary report (mean 8.4/10, median 9, upper tertile 91.7%) with discussions about its content and the need to specify the lot number of the injected product. The last one related to periprosthetic injections and the need to consult and get approval from a specialist (mean 8.0/10, median 8, upper tertile 83.3%) with mostly the general practitioners having reservations. In all, there is a very strong consensus among the musculoskeletal corticosteroid injection experts and specialists consulted, which justifies them being taken into consideration to improve our daily practice.

Les infiltrations ostéoarticulaires de corticostéroïdes sont certes très largement répandues, mais de pratiques très diverses, dans un contexte d’évolution des connaissances et des techniques, qui justifient une mise au point et l’élaboration de recommandations de bonne pratique. Sur un modèle de consensus formalisé de la Haute Autorité de Santé en France (HAS), et à partir d’une revue de la littérature qui a abouti à la réalisation d’un « livre blanc », 13 recommandations ont été élaborées et discutées par un groupe d’experts. Puis ces recommandations ont été envoyées en ligne à 48 spécialistes qui avaient donné leur accord pour les évaluer, dont 27 rhumatologues et 15 médecins généralistes. Ces recommandations ont été également présentées au 34e congrès de la Société Française de Rhumatologie (Paris, décembre 2021) à un panel d’une centaine de rhumatologues présents, qui ont pu voter en présentiel sur ces recommandations. Les résultats ont été présentés sous forme d’une évaluation globale sur 10, d’une médiane sur 10, et sous forme de tertiles. Dix de ces 13 recommandations ont un degré d’agrément excellent, avec des moyennes de 8,5 à 9,1 sur 10, des médianes à 9 ou 10/10, et des degrés d’agrément de 91,7 % à 97,9 %, c’est-à-dire consensuelles. Les 3 autres restent largement validées, mais ont fait l’objet de discussions. L’une a trait à l’information (moyenne 7,3/10, médiane 8/10, tertile supérieur 72,9 %), avec des discussions quant au délai de réflexion ; une autre porte sur le compte-rendu (moyenne 8,4/10, médiane 9, tertile supérieur 91,7 %), avec des discussions sur son contenu et la nécessité de préciser le numéro du lot injecté ; une dernière sur les injections en péri-prothétique, et la nécessité de concertation et d’obtention de l’assentiment du clinicien spécialiste (moyenne 8,0/10, médiane 8, tertile supérieur 83,3 %) avec des réserves essentiellement de la part des médecins généralistes. Au total, il existe un très fort consensus de la part des experts et des spécialistes des injections de corticostéroïde ostéoarticulaires consultés, qui justifie qu’on les prenne en compte pour en améliorer la pratique au quotidien.

Rationale Viscosupplementation (VS) with hyaluronic acid is widely used in the management of knee osteoarthritis. There is no clear recommendation on the decision-making to achieve VS. Design Based on extensive research of the literature and expert opinion, the members of the EUROVISCO (European Viscosupplementation Consensus Group) task force were asked to give their degree of agreement with 60 issues, using a Delphi method. Results The expert panel achieved unanimous agreement in favor of the following statements: It is recommended to assess pain on a visual or 10-point numeric scale before considering VS. VS can be considered for patients with pain scores between 3 and 8. A standard x-ray must be obtained before the decision of VS. If the x-ray is normal, osteoarthritis must be confirmed by MRI or computed tomography (CT) arthrogram before considering VS. The aims of VS are relieving pain, improving function, and reducing non-steroidal anti-inflammatory drug (NSAID) consumption. The use of VS must not be considered for treating an osteoarthritis flare. VS can be envisaged as a first-line pharmacological treatment in patients having a contra-indication to NSAIDs or analgesics. VS can be considered in patients with contra-indications to arthroplasty. In the case of severe comorbidities (diabetes, hypertension, gastrointestinal disorders, renal failure), VS can avoid the use of potentially dangerous treatments. VS can be considered in patients receiving antiplatelet agents, vitamin K antagonists, and direct factor Xa or thrombin inhibitors. Five other statements obtained a high level of consensus. Conclusion These recommendations, illustrated in a decision algorithm, have been established to help practitioners in the decision-making of knee VS.

Objectives This work studied if and how current clinical practice agrees with European Viscosupplementation Consensus Group (EUROVISCO) recommendations and how this agreement might be different according to physician’s specialization. In addition, this work aimed to identify key decision factors that practitioners consider in their decision to retreat or not a patient with hyaluronic acid viscosupplementation. Methods Practitioners have been invited by e-mail to participate in an online exercise on viscosupplementation retreatment. They received a fictional patient case at random among a set of predefined fictional cases. The platform asked the practitioner if he/she would retreat the patient with viscosupplementation or not. To take a decision, the practitioner could select questions among a list of predefined questions. Among them, some were related to criteria used in the EUROVISCO decision tree and others served as confounding factors. Results A total of 506 practitioners participated to the exercise, of which 399 gave their decision about the case assigned to them by the platform. The observed agreement between practitioner decisions and EUROVISCO recommendations was 58.89 ± 4.95% (95% confidence interval [CI]). Overall, the decision to retreat was taken in 47.87% of the cases, while the EUROVISCO guidelines follow-up would have led to 55.89% retreatment for the same cases ( P = 0.03). Conclusions In current practice, physicians tended to reinject their patients less than recommended, although EUROVISCO guidelines for viscosupplementation retreatment consider decision criteria that clearly correspond to those of practitioners in real life. These include the patients’ willingness to be treated or the patients’ perception of the effectiveness of the treatment.

Viscosupplementation (VS) is a symptomatic treatment for knee and other joint osteoarthritis (OA). Despite a long history of use, conflicting opinions remain on the best clinical indications and the most appropriate patients to be treated with intra-articular hyaluronic acid (IA-HA), the optimal dosing regimen and the modalities of retreatment. A multidisciplinary committee of European experts on OA (EUROVISCO) was constituted to formulate recommendations, aimed at helping physicians in the decision-making and the optimal achievement of VS. Before each session members were tasked to collate an exhaustive literature review. Level of evidence and strength of recommendation were based on the level of agreement for each item according to the Delphi method. In 2015, a consensus position was proposed for 24 statements. Among those that obtained a consensual agreement, the working group stressed that VS is effective in mild/moderate knee OA but is not an alternative to surgery in advanced OA, and that dosing regimen must be supported by controlled trials. In 2018, two decision algorithms for the retreatment with IA-HA in knee OA were published. Among the key recommendations, the experts recommended to re-treat every year patients with high risk of OA progression, even if not symptomatic. In 2020, EUROVISCO published two sets of recommendations for the design of clinical trials on the disease-modifying effect of VS and for optimizing the results of VS. The working group underlined that an accurate analysis of radiological features and symptoms and a careful clinical examination may improve the chances of success of VS, as well as good technique of injection and the use of imaging guidance. Based on the exhaustive analysis of the literature and their own clinical experience, the EUROVISCO experts offer a wide range of recommendations intended to help practitioners, particularly in certain cases where the specific characteristics of the patients make the therapeutic decision difficult.

The article Intra‑articular injections of platelet‑rich plasma in symptomatic knee osteoarthritis: a consensus statement from French‑speaking experts, written by Florent Eymard, Paul Ornetti, Jérémy Maillet, Éric Noel, Philippe Adam, Virginie Legre-Boyer, Thierry Boyer, Fadoua Allali, Vincent Gremeaux, Jean-Francois Kaux, Karine Louati, Martin Lamontagne, Fabrice Michel, Pascal Richette, Hervé Bard on behalf of the GRIP (Groupe de Recherche sur les Injections de PRP, PRP Injection Research Group), was originally published electronically on the publisher’s internet portal on 24 June 2020 without open access.

La hanche abarticulaire bénéficie maintenant d’une imagerie performante qui permet de mieux préciser la structure en cause et le degré de sa lésion, ce qui débouche sur une prise en charge thérapeutique plus efficace. Mais cette imagerie très largement pratiquée montre aussi des lésions asymptomatiques rendant plus que jamais indispensable la corrélation radioclinique, ce qui implique de ne pas sauter l’étape fondamentale de l’examen clinique, même si celui-ci peut être compliqué par l’intrication de plusieurs pathologies, situation assez fréquente dans la région de la hanche. Les tendinopathies du moyen et du petit glutéal, mieux diagnostiquées et qui dominent en fréquence la pathologie périarticulaire de hanche, ont ainsi pris le pas sur les bursopathies qui les accompagnent. D’autres tendons et bourses autour de la hanche ne doivent pas être méconnus, comme le tractus iliotibial avec l’enthésopathie proximale du tractus iliotibial sur la crête iliaque et sa pathologie péritrochantérienne récemment mise en évidence; l’iliopsoas et la pathologie de sa bourse; le droit fémoral, non seulement par son tendon direct, mais aussi son tendon indirect; et les tendons proximaux des ischiojambiers dont la pathologie ne concerne pas seulement les sportifs, mais aussi les sujets âgés où ces tendinopathies sont volontiers méconnues. Enfin, un nouveau syndrome, le conflit ischiofémoral vient enrichir cette pathologie péri-articulaire trop longtemps axée sur la face antérieure et latérale de la hanche au détriment de cette région postérieure d’analyse clinique difficile. Le développement de la chirurgie prothétique de hanche aux résultats le plus souvent remarquables génère cependant une pathologie péri-articulaire que le rhumatologue doit connaître, aidé aussi par une imagerie en progrès.

La radioprotection a fait l’objet d’une réévaluation par l’autorité de sûreté nucléaire (ASN) suite à une enquête de pratiques sur le terrain montrant d’importantes insuffisances de précautions, et pour se mettre en accord avec les nouvelles directives européennes. Les rhumatologues sont de moins en moins impliqués avec le choix de la nouvelle génération de jeunes rhumatologues de privilégier l’approche échographique, tant à visée diagnostique qu’interventionnelle. Cependant, les rayonnements X resteront de mise pour visualiser le tissu osseux et pratiquer des gestes interventionnels à ce niveau, et l’absorptiométrie, bien qu’extrêmement peu irradiante, est également concernée, tout comme la pratique de synoviorthèses isotopiques. Enfin, les rhumatologues restent des prescripteurs d’examens ou d’actes interventionnels réalisés sous contrôle visuel grâce aux rayonnements X. Ceux qui seront exposés aux rayonnements ionisants devront respecter les nouvelles réglementations, acquérir un matériel adéquat, respecter des procédures préétablies, et valider une formation de radioprotection vis-à-vis des patients d’une journée tous les 7 ans en France.

OBJECTIVES:The 3 aims of the work were to identify population subgroups that can benefit the most from viscosupplementation (VS), to provide recommendations on injection techniques, and to discuss VS appropriateness in clinical situations that are commonplace in daily practice.METHODS:The task force members voted on their degree of agreement on 27 statements, 36 recommendations, and 22 clinical scenarios using a 9-point scale. The strength of agreement/appropriateness/recommendation (SOA/SOR) was classified as strong if the median agreement score was ≥8. The level of consensus (LOC) was also obtained.RESULTS:Among the assumed predictors for VS failure, obesity, radiographic severity, large synovial fluid effusion, severe patellofemoral involvement, major malalignment, and gross joint instability received a large majority of agreements. The lateral mid-patellar approach was recommended for knee injection. Imaging guidance was unanimously recommended for hip and ankle. Agreement was achieved to strictly respect the dosing regimen proven by controlled trials. There was agreement for treating with VS patients with mild to moderate knee and hip OA, with normal weight or moderate overweight, insufficiently improved by first-line therapies, or who do not wish get oral treatment or who have contraindications to pain killers. The group considered the patient's wishes as a key element in therapeutic decision making.CONCLUSION:Based on literature data and clinical experience, the EUROVISCO group proposed a set of recommendations for optimizing the results of VS, aimed to help practitioners, especially in some cases in which the patients' specificities make the therapeutic decision difficult.