Plasma Rico em Plaquetas (PRP) e Terapias de Injeção Folheto
O que você está sentindo
Você pode notar dor no joelho, cotovelo ou ombro. Esse desconforto frequentemente se intensifica após a prática de atividades físicas. Ele também pode acordá-lo à noite se você dormir do lado afetado. Tarefas simples, como alcançar as costas para fechar um sutiã ou guardar uma camisa dentro da calça, podem se tornar difíceis.
Na osteoartrite por desgaste do joelho, você pode sentir rigidez ou dor que limita seus movimentos. Seu cirurgião pode recomendar pelo menos duas injeções de Plasma Rico em Plaquetas (PRP) para ajudar. São aplicações que utilizam o próprio plasma sanguíneo para reduzir a inflamação. O alívio proporcionado por essas injeções geralmente dura pelo menos 24 semanas.
Se você tiver cotovelo de tenista (epicondilite lateral), a dor geralmente ocorre na parte externa do cotovelo. Você pode sentir fraqueza ao segurar objetos. A quantidade de alívio dos sintomas obtida frequentemente depende da concentração do PRP utilizado. Doses mais altas tendem a proporcionar um alívio mais significativo em comparação com outros tratamentos.
A dor no ombro decorrente de problemas no manguito rotador pode tornar doloroso levantar o braço. Se você já teve cirurgia, seu cirurgião pode utilizar um tipo específico de PRP chamado PRP pobre em leucócitos. Esse tipo ajuda a reduzir o risco de o tendão se romper novamente após o reparo.
Para dor no tendão de Aquiles ou na síndrome da dor trocantérica maior (dor no quadril), as evidências atuais não apoiam o uso de PRP. Ela não é mais eficaz do que um placebo para essas condições. Você deve evitar esses tratamentos até que novos estudos de alta qualidade forneçam respostas melhores.
Seu cirurgião decidirá se o PRP é adequado para você com base na sua lesão específica. Ele é frequentemente considerado para atletas com artrite grave em grandes articulações ou lesões musculares agudas. No entanto, os resultados variam. Algumas pessoas obtêm grande alívio, enquanto outras podem permanecer insatisfeitas. Sempre discuta os benefícios e limitações potenciais com sua equipe de saúde antes de iniciar o tratamento.
O que está realmente acontecendo
Seu corpo utiliza plaquetas para curar lesões. Essas células se reúnem no local da lesão e liberam proteínas que auxiliam na reparação tecidual. A terapia com plasma rico em plaquetas (PRP) coleta seu próprio sangue, o centrifuga para concentrar essas células de cura e as injeta de volta na área problemática. Isso fornece ao seu corpo um sinal mais forte para corrigir o dano.
Na osteoartrite do joelho, o revestimento liso nas extremidades dos ossos se desgasta. Trata-se da osteoartrite por desgaste. A articulação perde sua capacidade de amortecimento. Seu cirurgião pode recomendar pelo menos duas injeções de PRP para essa condição. O objetivo é reduzir a dor e melhorar a função. Para muitos pacientes, esses efeitos duram pelo menos 24 semanas. No entanto, a ciência ainda está em evolução. Alguns estudos apresentam problemas metodológicos, por isso interpretamos os resultados com cautela. Precisamos de mais dados a longo prazo para ter certeza de quão eficaz esse tratamento é para todos.
Para problemas tendíneos, como a epicondilite lateral (cotovelo de tenista), as fibras tendíneas, semelhantes a cordas, ficam danificadas. Pesquisas mostram uma ligação direta entre a concentração de PRP utilizada e a quantidade de alívio dos sintomas obtida. Doses mais altas frequentemente proporcionam melhores resultados do que doses mais baixas. Este tratamento pode ser mais eficaz do que outras estratégias para essa condição específica. Além disso, ajuda a refutar a ideia de que o PRP é apenas um placebo para a tenossinovite crônica.
Em lesões do ombro, os tendões do manguito rotador atuam como cordas que mantêm seu braço no lugar. Após a cirurgia, esses tendões podem se romper novamente. O uso de PRP pobre em leucócitos durante o reparo pode reduzir esse risco de ruptura. Leucócitos são glóbulos brancos. A remoção de parte deles pode criar um ambiente de cicatrização mais favorável.
Para outras condições, as evidências são mistas ou negativas. O PRP não é recomendado para a tendinopatia do tendão de Aquiles. Não é mais eficaz do que um placebo para essa condição. O uso rotineiro para a síndrome da dor trocantérica também não é respaldado. Em contextos esportivos, o PRP pode ajudar em lesões musculares agudas, mas os protocolos precisam de padronização. Para a osteoartrite de grandes articulações em atletas, ela deve ser oferecida sistematicamente.
Em última análise, seu cirurgião decidirá se o PRP é adequado para você com base na sua lesão específica e nas evidências mais recentes.
O que esperar
O seu prognóstico depende fortemente da condição específica que está a tratar. Para a artrose por desgaste do joelho, o seu cirurgião provavelmente recomendará pelo menos duas injecções de PRP. Estes tratamentos podem ajudar a gerir os sintomas durante pelo menos 24 semanas. Isto significa que pode experimentar alívio durante cerca de seis meses antes de considerar cuidados adicionais.
Se for um atleta com artrose de grandes articulações, a terapia com PRP pode ser uma parte útil do seu plano de gestão. Pode ajudá-lo a manter-se ativo durante as épocas de competição. No entanto, para lesões musculares agudas, a evidência é menos clara. Embora o PRP possa ajudar em alguns contextos desportivos, os protocolos ainda não estão padronizados. Deve discutir se esta é a escolha certa para o seu tipo específico de lesão.
Para outras questões comuns, os resultados variam. Nos casos de tenossinovite crónica (inflamação da bainha do tendão), demonstrou-se que o PRP funciona melhor do que um placebo. No entanto, para a epicondilite lateral (cotovelo de tenista), as evidências são contraditórias. Alguns estudos mostram que doses mais elevadas proporcionam um melhor alívio dos sintomas, enquanto outros não apoiam a sua utilização. Da mesma forma, o uso rotineiro para a síndrome da dor trocantérica (dor no quadril) não é apoiado pelos dados atuais.
Seja cauteloso com as expectativas para a tendinopatia do tendão de Aquiles. As evidências atuais mostram que o PRP não é mais eficaz do que um placebo para esta condição. Geralmente, não é recomendado até que novos estudos de alta qualidade forneçam respostas diferentes. Se estiver a realizar uma reparação do manguito rotador, o seu cirurgião pode utilizar PRP pobre em leucócitos para ajudar a reduzir o risco de o tendão se romper novamente.
No geral, o PRP não é uma cura garantida. É uma opção de tratamento que funciona bem para algumas pessoas e condições, mas não para todas. O seu cirurgião ajudá-lo-á a decidir se os benefícios potenciais superam os custos e o esforço para a sua situação específica.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Overview
- At least two PRP injections are recommended for treating knee osteoarthritis, with effects lasting for at least 24 weeks [1].
- Conclusions regarding the clinical utility of PRP should be interpreted with caution due to major methodological concerns, including lack of PRP characterization and short-term follow-up [2].
- Future studies should prioritize long-term outcomes to guide clinical decision-making more effectively [2].
- Both leukocyte-rich (L-PRP) and leukocyte-poor (LP-PRP) platelet-rich plasma are effective treatment options with comparable efficacy based on current evidence [3].
- Findings refute claims of PRP equivalence to placebo and support its efficacy over placebo in chronic tenosynovitis [4].
- PRP therapy should be systematically offered for competition sports practitioners [5].
- The authors argue that they fulfilled the reporting requirements for the injected PRP product as defined by MIBO [6].
- Findings do not support PRP as a recommended treatment for lateral epicondylitis [7].
- PRP is no more effective than placebo for treating Achilles tendinopathy and should not be used for this indication until new, large, high-quality RCTs upend current knowledge [8].
- Rigorous basic, translational, and clinical research remains fundamental to realize the promise of PRP treatment for musculoskeletal disease [9].
- Current evidence supports the selective use of PRP in sports settings, though standardization in protocols and outcomes is needed [11].
- Routine use of PRP for the treatment of greater trochanteric pain syndrome is not supported [13].
- Studies evaluating the outcomes and procedures of the use of PRP in the setting of lateral epicondylitis have poor adherence to MIBO guidelines [14].
How It Works
- The clinical utility of PRP should be interpreted with caution due to major methodological concerns in some studies, including lack of PRP characterization and short-term follow-up [2].
- Both leukocyte-rich PRP (L-PRP) and leukocyte-poor PRP (LP-PRP) are effective treatment options with comparable efficacy based on current evidence [3].
- PRP therapy is recommended for competition sports practitioners [5].
- Authors argue that they fulfilled the reporting requirements for the injected PRP product as defined by MIBO [6].
- A direct, linear relationship was observed between the concentration factor of PRP used and the magnitude of patient-reported symptom relief after PRP injection, with high-dose PRP showing significant efficacy over alternative treatment strategies [10].
- Corticosteroids resulted in greater short-term improvement, while PRP demonstrated superior longer-term outcomes at 6 and 12 months for lateral elbow tendinopathy [12].
- The application of PRP following small-diameter core decompression results in significant pain relief, improved short-term functional outcomes, and enhanced quality of life compared to core decompression alone in early osteonecrosis of the femoral head [15].
- The goal of characterization studies is to discern key molecular mediators between leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) derived from the same patient with equivalent platelet concentrations [16].
- Optimizing osteoarthritis treatment involves tailoring PRP protocols to disease stage, with low platelet, high leukocyte PRP recommended for early OA due to its anti-inflammatory effects and high platelet, low leukocyte PRP preferred for advanced OA to promote tissue repair and regeneration [17].
What the Evidence Shows
Efficacy by Condition
- At least two PRP injections are recommended for knee osteoarthritis, with effects lasting for at least 24 weeks [1].
- Intra-articular PRP injection is an effective treatment for improving overall function in patients with primary osteoarthritis, particularly in younger individuals [23].
- PRP injections are a safe and effective conservative treatment method for reducing pain symptoms and increasing functionality in patients with lateral epicondylitis [22].
- Current evidence supports the selective use of PRP in sports settings for acute muscle injuries, though standardization in protocols and outcomes is needed [11].
- PRP can effectively improve pain and functional impairment in patients with tendinopathy, and its midterm efficacy is superior to that of corticosteroids [20].
- Corticosteroids resulted in greater short-term improvement than PRP, while PRP demonstrated superior longer-term outcomes at 6 and 12 months for lateral elbow tendinopathy [12].
- Current evidence is of insufficient quality to determine if anterior cruciate ligament reconstruction (ACLR) augmented with PRP provides a clinically meaningful improvement in postoperative outcomes over ACLR without PRP [26].
Product Composition and Preparation
- Both leukocyte-rich (L-PRP) and leukocyte-poor (LP-PRP) are effective treatment options with comparable efficacy for knee osteoarthritis based on current evidence [3].
- Leukocytes did not affect the safety and efficacy of intra-articular PRP injections for the treatment of patients with knee osteoarthritis in a double-blind randomized controlled trial [19].
- A direct, linear relationship was observed between the concentration factor of PRP used and the magnitude of patient-reported symptom relief after PRP injection for lateral epicondylitis, with high-dose PRP showing significant efficacy over alternative treatment strategies [10].
- The findings refute claims of PRP equivalence to placebo and support its efficacy over placebo for chronic tenosynovitis [4].
Combination Therapies
- For patients with knee osteoarthritis, PRP combined with hyaluronic acid (PRP + HA) therapy is safe and yields better outcomes in pain relief and functional improvement compared to PRP monotherapy [21].
- The combination of PRP with non-crosslinked hyaluronic acid in mono-injection was found to be non-inferior to crosslinked hyaluronic acid regarding the percentage of responders over 6 months for knee osteoarthritis [25].
Reporting Quality and Methodological Concerns
- The authors' conclusions regarding the clinical utility of PRP should be interpreted with caution due to major methodological concerns, including lack of PRP characterization and short-term follow-up; future studies should prioritize long-term outcomes to guide clinical decision-making more effectively [2].
- Spin bias is highly prevalent in the abstracts of systematic reviews and meta-analyses of intra-articular PRP to treat knee osteoarthritis, with identified spin tending to favor the use of PRP [24].
- Studies evaluating the outcomes and procedures of the use of PRP in the setting of lateral epicondylitis have poor adherence to Minimum Information for Studies Evaluating Biologics in Orthopedics (MIBO) guidelines [14].
Specific Recommendations
- The authors recommend systematically offering PRP therapy for competition sports practitioners [5].
Practical Considerations
- Both leukocyte-rich (L-PRP) and leukocyte-poor (LP-PRP) are effective treatment options with comparable efficacy based on current evidence [3].
- A direct, linear relationship was observed between the concentration factor of PRP used and the magnitude of patient-reported symptom relief after PRP injection [10].
- High-dose PRP shows significant efficacy over alternative treatment strategies [10].
- Corticosteroids resulted in greater short-term improvement compared to PRP for lateral elbow tendinopathy [12].
- PRP demonstrated superior longer-term outcomes at 6 and 12 months compared to corticosteroids for lateral elbow tendinopathy [12].
- Leukocyte-poor platelet-rich plasma reduces retear risk after arthroscopic rotator cuff repair [18].
- The economic value of LP-PRP is conditional rather than uniform and depends on revision probability and preparation cost [18].
Key Evidence
- [L3] At least two PRP injections are recommended, with effects lasting for at least 24 weeks. [1] (10.1186/s13018-025-05756-6)
- [L5] The authors' conclusions regarding the clinical utility of PRP should be interpreted with caution due to major methodological concerns, including lack of PRP characterization and short-term follow-up; future studies should prioritize long-term outcomes to guide clinical decision-making more effectively. [2] (10.1016/j.arth.2025.05.007)
- [L1] Both L-PRP and LP-PRP are effective treatment options with comparable efficacy based on current evidence. [3] (10.1186/s13018-026-06689-4)
- [L1] These findings refute claims of PRP equivalence to placebo and support its efficacy over placebo. [4] (10.1186/s12891-025-09339-8)
- [L4] The authors recommend systematically offering PRP therapy for competition sports practitioners. [5] (10.1186/s12891-025-08663-3)
- [Paper] The authors argue that they fulfilled the reporting requirements for the injected PRP product as defined by MIBO. [6] (10.1177/03635465231203202)
- [L1] These findings do not support PRP as a recommended treatment for this condition. [7] (10.1177/03635465251383039)
- [L1] PRP is no more effective than placebo for treating Achilles tendinopathy and should not be used for this indication until new, large, high-quality RCTs upend current knowledge. [8] (10.1097/corr.0000000000003478)
- [Paper] Rigorous basic, translational, and clinical research remains fundamental to realize the promise of PRP treatment for musculoskeletal disease. [9] (10.1177/03635465251395284)
- [L1] A direct, linear relationship was observed between the concentration factor of PRP used and the magnitude of patient-reported symptom relief after PRP injection, with high-dose PRP showing significant efficacy over alternative treatment strategies. [10] (10.1016/j.jisako.2025.100442)
- [L2] Current evidence supports the selective use of PRP in sports settings, though standardization in protocols and outcomes is needed. [11] (10.1177/23259671251399907)
- [L1] Corticosteroids resulted in greater short-term improvement, while PRP demonstrated superior longer-term outcomes at 6 and 12 months. [12] (10.1177/23259671251386862)
- [L1] As a result, we do not support the routine use of PRP for the treatment of this condition. [13] (10.2106/jbjs.24.00763)
- [L2] This review demonstrated that studies evaluating the outcomes and procedures of the use of PRP in the setting of LE have poor adherence to MIBO guidelines. [14] (10.5397/cise.2024.01060)
- [L3] The application of PRP following CD results in significant pain relief, improved short-term functional outcomes, and enhanced quality of life compared to CD alone. [15] (10.1186/s12891-024-08243-x)
- [L5] The goal of the study was to discern key molecular mediators between leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) derived from the same patient with equivalent platelet concentrations. [16] (10.1177/03635465231206930)
- [L1] Optimizing OA treatment involves tailoring PRP protocols to disease stage, with low platelet, high leukocyte PRP recommended for early OA due to its anti-inflammatory effects and high platelet, low leukocyte PRP preferred for advanced OA to promote tissue repair and regeneration. [17] (10.1186/s13018-025-06026-1)
- [L1] The economic value of LP-PRP is conditional rather than uniform and depends on revision probability and preparation cost. [18] (10.1016/j.jse.2026.02.018)
- [L1] This double-blind randomized controlled trial demonstrated that leukocytes did not affect the safety and efficacy of intra-articular PRP injections for the treatment of patients with knee OA. [19] (10.1177/03635465241283500)
- [L1] PRP can effectively improve pain and functional impairment in patients with tendinopathy, and its midterm efficacy is superior to that of corticosteroids. [20] (10.1186/s12891-025-08566-3)
- [L1] This meta-analysis reveals that, for patients with KOA, PRP + HA therapy is safe and yields better outcomes in pain relief and functional improvement compared to PRP monotherapy. [21] (10.1186/s13018-024-05429-w)
- [L4] PRP injections are a safe and effective conservative treatment method for reducing pain symptoms and increasing functionality in patients with lateral epicondylitis. [22] (10.1177/2325967125s00169)
- [L1] Intra-articular PRP injection is an effective treatment for improving overall function in patients with primary OA, particularly in younger individuals. [23] (10.1186/s12891-026-09486-6)
- [L1] Spin bias is highly prevalent in the abstracts of systematic reviews and meta-analyses of intra-articular PRP to treat knee osteoarthritis, with identified spin tending to favor the use of PRP. [24] (10.1002/arj.70027)
- [L1] The combination of PRP with non-crosslinked HA in mono-injection was found to be non-inferior to crosslinked HA, with regards to the percentage of responders over 6 months (WOMAC pain). [25] (10.1186/s12891-026-09625-z)
- [L1] Current evidence is of insufficient quality to determine if ACLR augmented with PRP application provides a clinically meaningful improvement in postoperative outcomes over ACLR without PRP. [26] (10.1186/s13018-026-06714-6)
References
[1] Efficacy of multiple autologous apheresis platelet-rich plasma injections for treating knee osteoarthritis and its influencing factors: a retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05756-6
[2] Letter Regarding “Platelet-Rich Plasma Injections are Inferior to Corticosteroid Injections for Short-Term Pain Relief: A Prospective, Double-Blinded, Randomized Controlled Trial”. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.05.007
[3] Leukocyte-rich versus leukocyte-poor platelet-rich plasma and hyaluronic acid for knee osteoarthritis: a systematic review and network meta-analysis. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06689-4
[4] Time-dependent growth factor kinetics, platelet concentration, and clinical response following platelet-rich plasma versus saline in chronic tenosynovitis: a randomized controlled trial. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09339-8
[5] Platelet-rich plasma treatment for large joint osteoarthritis: retrospective study highlighting a possible treatment protocol with long-lasting stimulation of the joint with an adequate dose of platelets. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08663-3
[6] Improving Injectable Orthobiologics Reporting Guidelines Adherence: Response. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231203202
[7] Platelet-Rich Plasma Does Not Improve Pain or Function in Patients With Lateral Epicondylitis as Compared With Placebo: A Meta-analysis of Randomized Clinical Trials. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465251383039
[8] Editor’s Spotlight/Take 5: Is Platelet-rich Plasma Effective in Treating Achilles Tendinopathy? A Meta-analysis of Randomized Clinical Trials. Clinical Orthopaedics & Related Research. 2025. DOI: 10.1097/corr.0000000000003478
[9] Platelet-Rich Plasma in the Treatment of Musculoskeletal Disease in 2025 and Beyond. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465251395284
[10] Platelet Concentration Factor Explains Variability in Outcomes of Platelet-rich Plasma for Lateral Epicondylitis: High Dose Critical for Positive Response. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100442
[11] Platelet-Rich Plasma in Acute Muscle Injuries: An Umbrella Review and Meta-analysis of Return to Sport and Reinjury Outcomes. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251399907
[12] A Randomized Controlled Trial of 1-Year Clinical Outcomes of a Single Platelet-Rich Plasma Injection Versus Corticosteroid for the Treatment of Lateral Elbow Tendinopathy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251386862
[13] Efficacy of Platelet-Rich Plasma Versus Placebo for the Treatment of Greater Trochanteric Pain Syndrome. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00763
[14] Adherence rates to the Minimum Information for Studies Evaluating Biologics in Orthopedics guidelines for clinical studies on platelet-rich plasma for the treatment of lateral epicondylitis: a systematic review. Clinics in Shoulder and Elbow. 2026. DOI: 10.5397/cise.2024.01060
[15] Efficacy of small-diameter core decompression with platelet-rich plasma in early osteonecrosis of the femoral head: a retrospective study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08243-x
[16] The Accurate Characterization of Platelet-Rich Plasma Enables Its Classification and Comparison: Response. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231206930
[17] The efficacy of platelet-rich plasma preparation protocols in the treatment of osteoarthritis: a network meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06026-1
[18] Leukocyte-poor platelet-rich plasma reduces retear risk after arthroscopic rotator cuff repair: a meta-analysis with mechanistic and economic evaluation. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.018
[19] Leukocytes Do Not Influence the Safety and Efficacy of Platelet-Rich Plasma Injections for the Treatment of Knee Osteoarthritis: A Double-Blind Randomized Controlled Trial. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465241283500
[20] Platelet-rich plasma and corticosteroid injection for tendinopathy: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08566-3
[21] RETRACTED ARTICLE: A meta-analysis and systematic review of the clinical efficacy and safety of platelet-rich plasma combined with hyaluronic acid (PRP + HA) versus PRP monotherapy for knee osteoarthritis (KOA). Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-024-05429-w
[22] Poster 58: Decreased Pain After Platelet-Rich Plasma Injection in Lateral Epicondylitis Patients in the Early Follow-up Period. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00169
[23] Investigating the therapeutic impact of platelet-rich plasma on knee, hip, and traumatic osteoarthritis: a meta-analysis and systematic review. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09486-6
[24] Statistically Significant Results Favored in Abstracts of Platelet Rich Plasma Treatment of Knee Osteoarthritis: A Systematic Review and Spin Analysis. Arthroscopy. 2026. DOI: 10.1002/arj.70027
[25] Efficacy and safety of a combination of platelet-rich plasma with non-crosslinked hyaluronic acid versus a crosslinked hyaluronic acid, in single-injection for knee osteoarthritis. Randomized, controlled, multicenter, non-inferiority trial. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09625-z
[26] The impact of platelet-rich plasma augmentation on postoperative clinical outcomes in patients undergoing anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06714-6




