Efficacy of ultrasound-guided intra-articular injections for pain relief and functional improvement in early-to-mid stage knee osteoarthritis: a network meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

GUO Yuqi ¹ , LI Jiacheng ² , LU Bowen ¹ , ZHANG Jiahao ¹ ,  LI Gang ³

1. The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan 250014, P. R. China;
2. Orthopedic Center, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250014, P. R. China;
3. The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250014, P. R. China;

Corresponding?author：

LI Gang, Email: sdszylg@163.com

Keywords：

Knee osteoarthritis; Ultrasound guidance; Intra-articular injection; Comparative drug efficacy; Network meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.202507181

Video：

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Objective To systematically review the effectiveness of different pharmacologic agents administered via ultrasound-guided intra-articular injection for pain relief and functional improvement in early-to-mid stage knee osteoarthritis. Methods The PubMed, Web of Science, Cochrane Library, Embase, CNKI, VIP, WanFang Data, SinoMed, ClinicalTrials.gov, and the WHO international clinical trials registry platform were electronically searched to collect randomized controlled trials (RCTs) related to the objectives from inception to May 8, 2025. Two reviewers independently screened literature, extracted data and assessed the risk of bias of the included studies. The network meta-analysis was then performed by using R 4.4.3 software. Results A total of 23 RCTs involving 1 587 participants and nine intervention strategies were included. The results revealed: (1) For pain relief, platelet-rich plasma combined with ultrasound guidance ranked highest; (2) In terms of functional improvement, platelet-rich plasma demonstrated consistent advantages across multiple dimensions of joint function, stiffness, and total score; (3) Hypertonic dextrose and autologous adipose tissue injections showed potential benefits in specific outcome dimensions; (4) Interventions such as traditional blind injections, corticosteroids, and ozone ranked moderately; (5) Safety: Based on limited reports, current evidence indicates that adverse events were predominantly mild and transient local reactions, with no serious events directly attributable to the interventions. Conclusion Current evidence shows that platelet-rich plasma under ultrasound guidance demonstrated a consistent advantage across multiple outcome measures, characterized by favorable safety, targeting precision, and clinical applicability.

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2.	Ren JL, Yang J, Hu W. The global burden of osteoarthritis knee: a secondary data analysis of a population-based study. Clin Rheumatol, 2025, 44(4): 1769-1810.
3.	Cui A, Li H, Wang D, et al. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. EClinicalMedicine, 2020: 29-30.
4.	He Y, Jiang W, Wang W. Global burden of osteoarthritis in adults aged 30 to 44 years, 1990 to 2019: results from the global burden of disease study 2019. BMC Musculoskelet Disord, 2024, 25(1): 303.
5.	Lv Y, Sui L, Lv H, et al. Burden of knee osteoarthritis in China and globally from 1992 to 2021, and projections to 2030: a systematic analysis from the global burden of disease study 2021. Front Public Health, 2025, 13: 1543180.
6.	Madry H. Surgical therapy in osteoarthritis. Osteoarthritis Cartilage, 2022, 30(8): 1019-1034.
7.	Bergstein VE, Weinblatt AI, Taylor WL, et al. Total knee arthroplasty survivorship and outcomes in young patients: a review of the literature and 40-year update to a longitudinal study. Arch Orthop Trauma Surg, 2024, 144(9): 4077-4083.
8.	Phillips M, Bhandari M, Grant J, et al. A systematic review of current clinical practice guidelines on intra-articular hyaluronic acid, corticosteroid, and platelet-rich plasma injection for knee osteoarthritis: an international perspective. Orthop J Sports Med, 2021, 9(8): 23259671211030272.
9.	Qiao X, Yan L, Feng Y, et al. Efficacy and safety of corticosteroids, hyaluronic acid, and PRP and combination therapy for knee osteoarthritis: a systematic review and network meta-analysis. BMC Musculoskelet Disord, 2023, 24(1): 926.
10.	Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American college of rheumatology/arthritis foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken), 2020, 72(2): 149-162.
11.	Uson J, Rodriguez-García SC, Castellanos-Moreira R, et al. EULAR recommendations for intra-articular therapies. Ann Rheum Dis, 2021, 80(10): 1299-1305.
12.	Amirsaadat S, Amirazad H, Hashemihesar R, et al. An update on the effect of intra-articular intervention strategies using nanomaterials in osteoarthritis: possible clinical application. Front Bioeng Biotechnol, 2023, 11: 1128856.
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16.	Khateri S, Nejad FB, Kazemi F, et al. The effect of dextrose prolotherapy on patients diagnosed with knee osteoarthritis: a comprehensive systematic review and meta-analysis of interventional studies. Health Sci Rep, 2024, 7(6): e2145.
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18.	Sterne JAC, Savovi? J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ, 2019, 366: l4898.
19.	丁一航. 阿是超聲波治療儀聯合膝關節腔注射富血小板血漿治療早中期膝骨關節炎患者的臨床效果觀察. 反射療法與康復醫學, 2025, 6(7): 58-61.
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21.	何龍, 江昊, 林鵬, 等. 超聲引導關節腔注射自體富白細胞血小板血漿與透明質酸鈉治療膝骨關節炎患者的療效比較. 中華疼痛學雜志, 2023, 19(5): 752-757.
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23.	柳曦, 錢林學, 胡向東, 等. 超聲引導下注射富血小板血漿治療中度膝骨關節炎的臨床療效觀察. 臨床和實驗醫學雜志, 2023, 22(5): 539-543.
24.	孟勇, 莊全魁, 陳勇, 等. 可視化自體富血小板血漿關節腔注射對輕中度膝骨關節炎患者疼痛及關節功能影響. 臨床軍醫雜志, 2024, 52(4): 390-392.
25.	卿海洋, 朱明楠. 超聲引導下膝關節腔內注射富血小板血漿(PRP)治療中度膝骨關節炎的臨床效果. 中文科技期刊數據庫(文摘版)醫藥衛生, 2024, (7): 88-91.
26.	Ahmad HS, Farrag SE, Okasha AE, et al. Clinical outcomes are associated with changes in ultrasonographic structural appearance after platelet-rich plasma treatment for knee osteoarthritis. Int J Rheum Dis, 2018, 21(5): 960-966.
27.	Aslan SG, de Sire A, K?ylü SU, et al. The efficacy of ultrasonography-guided oxygen-ozone therapy versus corticosteroids in patients with knee osteoarthritis: a multicenter randomized controlled trial. J Back Musculoskelet Rehabil, 2024, 37(6): 1455-1466.
28.	Babaei-Ghazani A, Najarzade S, Madani P, et al. A comparison of ultrasound guided corticosteroid injection versus ozone injection in grade 3 knee osteoarthritis. Tehran University Med J, 2019, 77(6): 373-381.
29.	Babaei-Ghazani A, Najarzadeh S, Mansoori K, et al. The effects of ultrasound-guided corticosteroid injection compared to oxygen-ozone (O2-O3) injection in patients with knee osteoarthritis: a randomized controlled trial. Clin Rheumatol, 2018, 37(9): 2517-2527.
30.	Baria M, Barker T, Durgam S, et al. Microfragmented adipose tissue is equivalent to platelet-rich plasma for knee osteoarthritis at 12 months posttreatment: a randomized controlled trial. Orthop J Sports Med, 2024, 12(3): 23259671241233916.
31.	Baria M, Pedroza A, Kaeding C, et al. Platelet-rich plasma versus microfragmented adipose tissue for knee osteoarthritis: a randomized controlled trial. Orthop J Sports Med, 2022, 10(9): 23259671221120678.
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34.	Kianmehr N, Hasanzadeh A, Naderi F, et al. A randomized blinded comparative study of clinical response to surface anatomy guided injection versus sonography guided injection of hyaloronic acid in patients with primary knee osteoarthritis. Int J Rheum Dis, 2018, 21(1): 134-139.
35.	Louis ML, Magalon J, Jouve E, et al. Growth factors levels determine efficacy of platelets rich plasma injection in knee osteoarthritis: a randomized double blind noninferiority trial compared with viscosupplementation. Arthroscopy, 2018, 34(5): 1530-1540.
36.	McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA, 2017, 317(19): 1967-1975.
37.	Nabi BN, Sedighinejad A, Mardani-Kivi M, et al. Comparing the effectiveness of intra-articular platelet-rich plasma and corticosteroid injection under ultrasound guidance on pain control of knee osteoarthritis. Iran Red Crescent Med J, 2018, 20(3): 1-13.
38.	Rahimzadeh P, Imani F, Faiz SHR, et al. The effects of injecting intra-articular platelet-rich plasma or prolotherapy on pain score and function in knee osteoarthritis. Clin Interv Aging, 2018, 13: 73-79.
39.	Sibbitt WL, Band PA, Kettwich LG, et al. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol, 2011, 17(8): 409-415.
40.	Teymouri A, Birang N, Fakheri M, et al. Comparison of the efficacy of ultrasound-guided dextrose 25% hypertonic prolotherapy and intra-articular normal saline injection on pain, functional limitation, and range of motion in patients with knee osteoarthritis; a randomized controlled trial. BMC Musculoskelet Disord, 2025, 26(1): 313.
41.	Zhang Y. Platelet-rich plasma therapy in refractory knee osteoarthritis combined with infection. Int J Clin Exp Med, 2018, 11(5): 4801-4807.
42.	Puhan MA, Schünemann HJ, Murad MH, et al. A GRADE working group approach for rating the quality of treatment effect estimates from network meta-analysis. BMJ, 2014, 349: g5630.
43.	Bacevich BM, Smith RDJ, Reihl AM, et al. Advances with platelet-rich plasma for bone healing. Biologics, 2024, 18: 29-59.
44.	Tanzadehpanah H, Nobari S, Hoseini AJ, et al. Effect of platelet-rich plasma on angiogenic and regenerative properties in patients with critical limb ischemia. Regen Ther, 2025, 28: 517-526.
45.	Lai F, Kakudo N, Morimoto N, et al. Platelet-rich plasma enhances the proliferation of human adipose stem cells through multiple signaling pathways. Stem Cell Res Ther, 2018, 9(1): 107.
46.	Li XH, Xiao HX, Wang ZX, et al. Platelet concentrates preconditioning of mesenchymal stem cells and combined therapies: integrating regenerative strategies for enhanced clinical applications. Cell Transplant, 2024, 33: 9636897241235460.
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1. Yang D, Xu J, Xu K, et al. Skeletal interoception in osteoarthritis. Bone Res, 2024, 12(1): 22.
2. Ren JL, Yang J, Hu W. The global burden of osteoarthritis knee: a secondary data analysis of a population-based study. Clin Rheumatol, 2025, 44(4): 1769-1810.
3. Cui A, Li H, Wang D, et al. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. EClinicalMedicine, 2020: 29-30.
4. He Y, Jiang W, Wang W. Global burden of osteoarthritis in adults aged 30 to 44 years, 1990 to 2019: results from the global burden of disease study 2019. BMC Musculoskelet Disord, 2024, 25(1): 303.
5. Lv Y, Sui L, Lv H, et al. Burden of knee osteoarthritis in China and globally from 1992 to 2021, and projections to 2030: a systematic analysis from the global burden of disease study 2021. Front Public Health, 2025, 13: 1543180.
6. Madry H. Surgical therapy in osteoarthritis. Osteoarthritis Cartilage, 2022, 30(8): 1019-1034.
7. Bergstein VE, Weinblatt AI, Taylor WL, et al. Total knee arthroplasty survivorship and outcomes in young patients: a review of the literature and 40-year update to a longitudinal study. Arch Orthop Trauma Surg, 2024, 144(9): 4077-4083.
8. Phillips M, Bhandari M, Grant J, et al. A systematic review of current clinical practice guidelines on intra-articular hyaluronic acid, corticosteroid, and platelet-rich plasma injection for knee osteoarthritis: an international perspective. Orthop J Sports Med, 2021, 9(8): 23259671211030272.
9. Qiao X, Yan L, Feng Y, et al. Efficacy and safety of corticosteroids, hyaluronic acid, and PRP and combination therapy for knee osteoarthritis: a systematic review and network meta-analysis. BMC Musculoskelet Disord, 2023, 24(1): 926.
10. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American college of rheumatology/arthritis foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken), 2020, 72(2): 149-162.
11. Uson J, Rodriguez-García SC, Castellanos-Moreira R, et al. EULAR recommendations for intra-articular therapies. Ann Rheum Dis, 2021, 80(10): 1299-1305.
12. Amirsaadat S, Amirazad H, Hashemihesar R, et al. An update on the effect of intra-articular intervention strategies using nanomaterials in osteoarthritis: possible clinical application. Front Bioeng Biotechnol, 2023, 11: 1128856.
13. Fang WH, Chen XT, Vangsness CT. Ultrasound-guided knee injections are more accurate than blind injections: a systematic review of randomized controlled trials. Arthrosc Sports Med Rehabil, 2021, 3(4): e1177-e1187.
14. Saha P, Smith M, Hasan K. Accuracy of intraarticular injections: blind vs. image guided techniques-a review of literature. J Funct Morphol Kinesiol, 2023, 8(3): 93.
15. Sconfienza LM, Adriaensen M, Albano D, et al. Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part V, knee. Eur Radiol, 2022, 32(3): 1438-1447.
16. Khateri S, Nejad FB, Kazemi F, et al. The effect of dextrose prolotherapy on patients diagnosed with knee osteoarthritis: a comprehensive systematic review and meta-analysis of interventional studies. Health Sci Rep, 2024, 7(6): e2145.
17. Page MJ, Moher D, Bossuyt PM, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ, 2021, 372: n160.
18. Sterne JAC, Savovi? J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ, 2019, 366: l4898.
19. 丁一航. 阿是超聲波治療儀聯合膝關節腔注射富血小板血漿治療早中期膝骨關節炎患者的臨床效果觀察. 反射療法與康復醫學, 2025, 6(7): 58-61.
20. 高獻忠, 管華, 陸偉萍, 等. 膝關節腔注射富血小板血漿對老年患者膝關節骨性關節炎疼痛的影響. 臨床麻醉學雜志, 2020, 36(12): 1157-1160.
21. 何龍, 江昊, 林鵬, 等. 超聲引導關節腔注射自體富白細胞血小板血漿與透明質酸鈉治療膝骨關節炎患者的療效比較. 中華疼痛學雜志, 2023, 19(5): 752-757.
22. 吉冬梅, 徐小青, 史傳崗. 超聲引導膝關節腔注射對患者滿意度、關節功能和生活質量的影響. 介入放射學雜志, 2021, 30(10): 1040-1044.
23. 柳曦, 錢林學, 胡向東, 等. 超聲引導下注射富血小板血漿治療中度膝骨關節炎的臨床療效觀察. 臨床和實驗醫學雜志, 2023, 22(5): 539-543.
24. 孟勇, 莊全魁, 陳勇, 等. 可視化自體富血小板血漿關節腔注射對輕中度膝骨關節炎患者疼痛及關節功能影響. 臨床軍醫雜志, 2024, 52(4): 390-392.
25. 卿海洋, 朱明楠. 超聲引導下膝關節腔內注射富血小板血漿(PRP)治療中度膝骨關節炎的臨床效果. 中文科技期刊數據庫(文摘版)醫藥衛生, 2024, (7): 88-91.
26. Ahmad HS, Farrag SE, Okasha AE, et al. Clinical outcomes are associated with changes in ultrasonographic structural appearance after platelet-rich plasma treatment for knee osteoarthritis. Int J Rheum Dis, 2018, 21(5): 960-966.
27. Aslan SG, de Sire A, K?ylü SU, et al. The efficacy of ultrasonography-guided oxygen-ozone therapy versus corticosteroids in patients with knee osteoarthritis: a multicenter randomized controlled trial. J Back Musculoskelet Rehabil, 2024, 37(6): 1455-1466.
28. Babaei-Ghazani A, Najarzade S, Madani P, et al. A comparison of ultrasound guided corticosteroid injection versus ozone injection in grade 3 knee osteoarthritis. Tehran University Med J, 2019, 77(6): 373-381.
29. Babaei-Ghazani A, Najarzadeh S, Mansoori K, et al. The effects of ultrasound-guided corticosteroid injection compared to oxygen-ozone (O2-O3) injection in patients with knee osteoarthritis: a randomized controlled trial. Clin Rheumatol, 2018, 37(9): 2517-2527.
30. Baria M, Barker T, Durgam S, et al. Microfragmented adipose tissue is equivalent to platelet-rich plasma for knee osteoarthritis at 12 months posttreatment: a randomized controlled trial. Orthop J Sports Med, 2024, 12(3): 23259671241233916.
31. Baria M, Pedroza A, Kaeding C, et al. Platelet-rich plasma versus microfragmented adipose tissue for knee osteoarthritis: a randomized controlled trial. Orthop J Sports Med, 2022, 10(9): 23259671221120678.
32. Cole BJ, Karas V, Hussey K, et al. Hyaluronic acid versus platelet-rich plasma: a prospective, double-blind randomized controlled trial comparing clinical outcomes and effects on intra-articular biology for the treatment of knee osteoarthritis. Am J Sports Med, 2017, 45(2): 339-346.
33. Dório M, Pereira RMR, Luz AGB, et al. Efficacy of platelet-rich plasma and plasma for symptomatic treatment of knee osteoarthritis: a double-blinded placebo-controlled randomized clinical trial. BMC Musculoskelet Disord, 2021, 22(1): 822.
34. Kianmehr N, Hasanzadeh A, Naderi F, et al. A randomized blinded comparative study of clinical response to surface anatomy guided injection versus sonography guided injection of hyaloronic acid in patients with primary knee osteoarthritis. Int J Rheum Dis, 2018, 21(1): 134-139.
35. Louis ML, Magalon J, Jouve E, et al. Growth factors levels determine efficacy of platelets rich plasma injection in knee osteoarthritis: a randomized double blind noninferiority trial compared with viscosupplementation. Arthroscopy, 2018, 34(5): 1530-1540.
36. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA, 2017, 317(19): 1967-1975.
37. Nabi BN, Sedighinejad A, Mardani-Kivi M, et al. Comparing the effectiveness of intra-articular platelet-rich plasma and corticosteroid injection under ultrasound guidance on pain control of knee osteoarthritis. Iran Red Crescent Med J, 2018, 20(3): 1-13.
38. Rahimzadeh P, Imani F, Faiz SHR, et al. The effects of injecting intra-articular platelet-rich plasma or prolotherapy on pain score and function in knee osteoarthritis. Clin Interv Aging, 2018, 13: 73-79.
39. Sibbitt WL, Band PA, Kettwich LG, et al. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol, 2011, 17(8): 409-415.
40. Teymouri A, Birang N, Fakheri M, et al. Comparison of the efficacy of ultrasound-guided dextrose 25% hypertonic prolotherapy and intra-articular normal saline injection on pain, functional limitation, and range of motion in patients with knee osteoarthritis; a randomized controlled trial. BMC Musculoskelet Disord, 2025, 26(1): 313.
41. Zhang Y. Platelet-rich plasma therapy in refractory knee osteoarthritis combined with infection. Int J Clin Exp Med, 2018, 11(5): 4801-4807.
42. Puhan MA, Schünemann HJ, Murad MH, et al. A GRADE working group approach for rating the quality of treatment effect estimates from network meta-analysis. BMJ, 2014, 349: g5630.
43. Bacevich BM, Smith RDJ, Reihl AM, et al. Advances with platelet-rich plasma for bone healing. Biologics, 2024, 18: 29-59.
44. Tanzadehpanah H, Nobari S, Hoseini AJ, et al. Effect of platelet-rich plasma on angiogenic and regenerative properties in patients with critical limb ischemia. Regen Ther, 2025, 28: 517-526.
45. Lai F, Kakudo N, Morimoto N, et al. Platelet-rich plasma enhances the proliferation of human adipose stem cells through multiple signaling pathways. Stem Cell Res Ther, 2018, 9(1): 107.
46. Li XH, Xiao HX, Wang ZX, et al. Platelet concentrates preconditioning of mesenchymal stem cells and combined therapies: integrating regenerative strategies for enhanced clinical applications. Cell Transplant, 2024, 33: 9636897241235460.
47. Zhuo F, Li J, Wang YH, et al. Platelet-rich plasma inhibits inflammation, apoptosis, and the NLRP3/C aspase-1 pathway and induces matrix metalloproteinases and proliferati on of IL-1β-induced articular chondrocytes by downregulating T-box tra nscription factor 3. Eur J Inflam, 2022, 20: 1-13.
48. Qiao J, Guo X, Zhang L, et al. Autologous platelet rich plasma injection can be effective in the management of osteoarthritis of the knee: impact on IL-1 β, TNF-α, hs-CRP. J Orthop Surg Res, 2024, 19(1): 703.
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Chinese Journal of Evidence-Based Medicine

Latest ArticlesEfficacy of ultrasound-guided intra-articular injections for pain relief and functional improvement in early-to-mid stage knee osteoarthritis: a network meta-analysis

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