Comparative effectiveness of nonsurgical interventions in the treatment of patients with knee osteoarthritis: A PRISMA-compliant systematic review and network meta-analysis

Abstract

Background: To find out, based on the available recent randomized controlled trials (RCTs), if the nonsurgical interventions commonly used for knee osteoarthritis patients are valid and quantify their efficiency.

Methods: The database of MEDLINE and EMBASE were searched for RCTs evaluating nonsurgical treatment strategies on patients with mild to moderate knee osteoarthritis. A Bayesian random-effects network meta-analysis was performed. The primary outcome was the mean change from baseline in the Western Ontario and McMaster university (WOMAC) total score at 12 months. Raw mean differences with 95% credibility intervals were calculated. Treatments were ranked by probabilities of each treatment to be the best.

Results: Thirteen trials assessed 7 strategies with WOMAC at 12 months: injection of platelet rich plasma (PRP), corticosteroids, mesenchymal stem cells (MSCs), hyaluronic acid, ozone, administration of nonsteroidal anti-inflammatory drugs with or without the association of physiotherapy. For treatment-specific effect size, a greater association with WOMAC decrease was found significantly for MSCs (mean difference, -28.0 [95% CrI, -32.9 to -22.4]) and PRP (mean difference, -19.9 [95% CrI, -24.1 to -15.8]). Rank probabilities among the treatments indicated that MSCs had a much higher probability (P = .91) of being the best treatment compared with other treatments, while PRP ranked as the second-best treatment (P = .89).

Conclusion: In this systematic review and network meta-analysis, the outcomes of treatments using MSCs and PRP for the management of knee osteoarthritis were associated with long-term improvements in pain and function. More high quality RCTs would be needed to confirm the efficiency of MSCs and PRP for the treatment of patients with knee osteoarthritis.

Figure 1

Trial selection process.

Figure 2

Curves showed the total scores variation of knee OA strategies from baseline to the last follow-up visit according to Western Ontario and McMaster university (WOMAC). OA = osteoarthritis.

Figure 3

Network plot for the primary outcome. The area of every circle is proportional to the number of randomly assigned patients and indicates the sample size. The width of the lines is proportional to the number of trials that directly compared the 2 strategies.

Figure 4

Forest plot for the strategies’ effects compared with the reference treatment for primary outcome (WOMAC score at 12 months). Estimates are expressed on a 0 to 100 scale. Point estimates refer to the posterior mean. The bars indicate 95% credibility intervals (CrIs). WOMAC = Western Ontario and McMaster university.

Figure 5

Plots of treatments rank probabilities for primary outcome. A darker area indicates the probability of being a higher rank, thus the black areas show the probabilities of being the best treatment.