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Meta-analysis
ACE Report #5364

Small-medium sized rotator cuff tears may benefit from PRP application


Study Type:Meta analysis
OE Level Evidence:1
Journal Level of Evidence:N/A

Are Platelet-Rich Products Necessary during the Arthroscopic Repair of Full-Thickness Rotator Cuff Tears: A Meta-Analysis

PLoS One. 2013 Jul 12;8(7):e69731. doi: 10.1371/journal.pone.0069731. Print 2013

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Synopsis

Seven studies were included in this meta-analysis which aimed to determine the effect of the application of platelet-rich products (PRP) in arthroscopic rotator cuff repair. Pooled analyses of functional outcome measurements indicated no beneficial effect of PRP at a minimum of 12 months postoperatively, and overall no decrease in retear rate. However, an analysis of small to medium tears, exclusively, indicated a lower rate of retear when PRP had been applied.

Publication Funding Details +
Funding:
Non-funded
Conflicts:
None disclosed

Risk of Bias

9.5/10

Reporting Criteria

19/20

Fragility Index

N/A

Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

4/4

Introduction

4/4

Accessing Data

4/4

Analysing Data

4/4

Results

3/4

Discussion

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Healing following arthroscopic rotator cuff repair remains an issue for a number of patients. The relatively high rate of retear has led to interest in techniques and products that may aid in the healing process. Recently, popularity has surrounded biological augmentation with platelet-rich products (PRP). Despite numerous studies advocating the promising results of PRP, as well as FDA approval, there still remains limited high quality evidence to support its application into standard clinical practice.

What was the principal research question?

In a meta-analysis of studies of Level I and II evidence, did rotator cuff repair augmented with PRP provide any advantageous clinical or radiological outcome compared to repair without PRP?

Study Characteristics -
Data Source:
A search of PubMed, the Cochrane Library, and EMBASE databases was conducted for articles published from database inception to April 20, 2013. Bibliographies of identified articles were also manually search for additional publications.
Index Terms:
Search terms included "rotator cuff", "platelet rich plasma", "PRP", "platelet rich fibril matrix", "PRFM", and "platelet".
Study Selection:
Selection for article inclusion was made based on if the study represented Level I or II evidence which compared rotator cuff repair with and without the application of PRP. Studies must have also performed follow-up for at least 12 months, and reported outcome on at least one of the following measures: American Shoulder and Elbow Surgeons (ASES) Score, Constant Score, UCLA Score, Simple Shoulder Test, or radiographic (MRI and/or USG) findings. Selection was performed independently by two investigators.
Data Extraction:
Data extraction was performed independently by two reviewers, with disagreement resolved through discussion and consensus.
Data Synthesis:
Review Manager 5.1 (Cochrane Collaboration) software was used for pooling and statistical analysis. Weighted mean differences (WMD) were calculated for continuous variables, and risk ratios (RR) for dichotomous outcomes, with associated 95% confidence intervals. Heterogeneity was assessed via the Q statistic (significance P<0.10) and I^2 statistic (significance >50%), with a random-effects model used in the presence of significant heterogeneity. Otherwise, a fixed-effects model was used for the analysis. A funnel plot was used to identify publication bias.

What were the important findings?

  • A total of 7 studies were selected for inclusion in this meta-analysis: 6 randomized controlled trials and 1 prospective cohort study.
  • Three studies were able to be pooled each for the Constant Score, ASES Score, and UCLA Score. All three of these functional outcome measures demonstrated no significant difference between groups who received PRP and groups that did not (Constant: MD 0.73 (95%CI -1.87 to 3.27); P=0.58) (ASES: MD -2.89 (95%CI -6.31 to 0.53); P=0.10) (UCLA: MD -0.79 (95%CI -2.20 to 0.63); P=0.28).
  • Pooling of SST scores indicated a borderline significant finding in favor of control treatment over PRP application (MD 0.34 (95%CI -0.01 to 0.69); P=0.05).
  • Retear rate among 5 studies revealed no significant difference between repair with and without PRP application (RR 0.71 (95%CI 0.48-1.05); P=0.08). However, a separate analysis considering small-medium tears exclusively found a significantly lower rate of retear of those treated with PRP (RR 0.33 (95%CI 0.12-0.91); P=0.03). The difference remained non-significant in large-massive tears only (RR 0.86 (95%CI 0.60-1.23); P=0.42).

What should I remember most?

The application of platelet-rich products in arthroscopic rotator cuff repair did not improve functional outcome at a minimum of 12 months when compared to non-augmented repair. Patients with small to medium tears and treated with PRP experienced significantly fewer incidences of retear.

How will this affect the care of my patients?

Platelet-rich plasma does not appear to provide any additional benefit concerning functional outcome following rotator cuff repair. Further investigation into the use of PRP-like products in small to medium tears may be warranted, considering the lower rate of retear noted among groups that were treated with PRP application. This may suggest that the severity of the rotator cuff tear may contribute as a prognostic factor in the efficacy of PRP, but these results should be considered as hypothesis-generating only.

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