The effects of local platelet rich plasma delivery on diabetic fracture healing

Platelet rich concentrate: basic science and current clinical applications

Improvements in resuscitation, dissemination of ATLS protocols, and growth of regional and local trauma centers has increased the survivability after severe traumatic injuries. Furthermore, advances in medical management have increased life expectancy and also patients with orthopaedic injuries. While mechanical stabilization has been a hallmark of orthopaedic fracture care, orthobiologics are playing an increasing role in the management of these patients with complex injuries. Platelet-rich concentrate is an autologous concentration of platelets and growth factors, including transforming growth factor-beta (TGF-beta), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF). The enhancement of bone and soft tissue healing by the placement of supraphysiologic concentration of autologous platelets at the site of tissue injury or surgery is supported by basic science and clinical studies. Due to the increased concentration and release of these factors, platelet-rich plasma can potentially enhance the recruitment and proliferation of tenocytes, stem cells, and endothelial cells. A better understanding of platelet function and appropriate clinical use is essential in achieving the desired outcomes of platelet-rich concentrate in orthopaedic clinical applications.

Platelet gel supplementation in long bone nonunions treated by external fixation

OBJECTIVE

The aim of the present study was to evaluate the use of previously frozen, thawed platelet gel supplementation to accelerate the healing of long bone nonunions treated by external fixation.

DESIGN

Prospective case series with historical controls.

SETTING

University Hospital.

PATIENTS

Twenty patients affected by tibial, humeral, or forearm atrophic nonunions were treated by percutaneous stabilization with unilateral external fixators and injection of autologous platelet gel. The healing time was compared to the result obtained in a historical control group treated without platelet gel supplementation.

MAIN OUTCOME MEASUREMENTS

Consolidation rate and radiographic healing time of nonunions in the 2 groups were assessed by independent blinded observers. The nonunion was judged to be healed when bridging callus formation on both radiographic views was observed on at least 3 of 4 cortices.

RESULTS

The healing rate of nonunion was 90% (18/20) in platelet gel cases and 85% (17/20) in controls, respectively (P = 0.633). The mean time until radiographic consolidation in nonunions supplemented with platelet gel (147 +/- 63 days) was not different to the result in the control group (153 +/- 61 days; P = 0.784). Analyzing the mean healing time for separate segments, no differences were noted between study and control group-that is, tibia: 112 +/- 43 and 130 +/- 5 days, respectively (P = 0.382); humerus, 225 +/- 36 and 202 +/- 70 days, respectively (P = 0.530).

CONCLUSION

The present study failed to show the clinical usefulness of isolated percutaneous platelet gel supplementation in long bone nonunions treated by external fixation; however, caution should be exercised in interpreting this result because the actual numbers are small and the statistical power is limited.

Inhibition of fracture healing

This paper reviews the current literature concerning the main clinical factors which can impair the healing of fractures and makes recommendations on avoiding or minimising these in order to optimise the outcome for patients. The clinical implications are described.

Benefit of percutaneous injection of autologous platelet-leukocyte-rich gel in patients with delayed union and nonunion

This article reports the efficacy of percutaneous autologous platelet-leukocyte-rich gel (PLRG) injection as a minimally invasive method alternative to open grafting techniques. Each of 32 participants was followed on a regular basis with clinical examinations, roentgenograms, dual-energy X-ray absorptiometry examinations. In the delayed union group, the average time to union was 9.3 weeks after PLRG injection and the union was achieved in all cases. In the nonunion group, the union was observed in 13 of 20 cases and the average time to union was 10.3 weeks after PLRG injection. Interestingly, in patients in whom union was not achieved, the average time from the fracture and/or from the last operation was >11 months. This is our initial experience with the use of PLRG as biologic treatment for delayed union or nonunion. Our investigation showed that percutaneous PLRG injection in delayed union is a sufficient method to obtain union, which is less invasive procedure than bone marrow injection. Percutaneous PLRG grafting can be also an effective method for the treatment of selected cases of nonunion. The essential factor is the average time from the initial surgery to PLRG injection for nonunion; <11 months seems to be critical for good outcomes.

Autologous platelet gel and fibrin sealant enhance the efficacy of total knee arthroplasty: improved range of motion, decreased length of stay and a reduced incidence of arthrofibrosis

In this study we describe the potential role of autologous platelet gel and fibrin sealant in unilateral total knee arthroplasty to improve the postoperative range of motion and to reduce the incidence of arthrofibrosis. Total knee arthroplasty is often associated with a considerable amount of post-operative blood loss. Persistent limited motion directly after surgery may ultimately result in arthrofibrosis. To counteract these effects we investigated whether the use of autologous derived platelet gel and fibrin sealant would reduce postoperative blood loss, decrease the impaired range of motion and the incidence of arthrofibrosis. All patients were consecutively operated and assigned to the study or control groups. Study group patients (n = 85) were treated with the application of autologous platelet gel and fibrin sealant at the end of surgery. Eighty patients were operated without the use of platelet gel and fibrin sealant, and served as the control group. The postoperative hemoglobin decrease, range of motion and length of hospitalization were recorded. During a 5-month postoperative period patients were followed to observe the incidence of arthrofibrosis. In patients in the treatment group the hemoglobin concentration in blood decreased significantly less when compared to the control group. They also showed a superior postoperative range of motion when compared to those of the control group (P < 0.001). The incidence of arthrofibrosis and subsequent forced manipulation was significantly less (P < 0.001) in patients managed with platelet gel and fibrin sealant. We conclude that peri-operatively applied platelet gel and fibrin sealant may improve the range of motion after total knee arthroplasty, decreases the length of stay and may reduce the incidence of arthrofibrosis.

The use of autologous platelet-leukocyte gels to enhance the healing process in surgery, a review

BACKGROUND

The therapeutic use of autologously prepared, platelet-leukocyte-enriched gel (PLG) is a relatively new technology for the stimulation and acceleration of soft tissue and bone healing. The effectiveness of this procedure lies in the delivery of a wide range of platelet growth factors mimicking the physiologic wound healing and reparative tissue processes. Despite an increase in PLG applications, the structures and kinetics of this autogenously derived biologic material have not been observed.

METHODS

A review of the most recent literature was performed to evaluate the use of PLG in various surgical disciplines.

RESULTS

The review showed that the application of PLG has been extended to various surgical disciplines including orthopedics, cardiac surgery, plastic and maxillofacial surgery, and recently also endoscopic surgery.

CONCLUSION

This review demonstrates the usefulness of PLG in a wide range of clinical applications for improvement of healing after surgical procedures.

Reviewing the Structural Features of Autologous Platelet-Leukocyte Gel and Suggestions for Use in Surgery

The therapeutic use of autologously prepared platelet-leukocyte gel (PLG) is a relatively new technology which might stimulate and accelerate soft-tissue and bone healing. The effectiveness of this procedure lies in the exogenous delivery of a wide range of platelet growth factors, intentionally released from autologously prepared PLG. The rationale to employ this technique is to mimic physiological wound healing and reparative tissue processes. Despite an increase in clinical PLG applications, the structures and kinetics of this biological material have not been completely examined. Electron microscopic imaging was performed to evaluate platelet-leukocyte gel structures. Furthermore, directions for PLG application are presented, based on results from published articles in various surgical disciplines. In conclusion, PLG can be useful in a wide range of clinical applications to enhance healing following surgical procedures, since exogenous applied PLG releases instantly platelet growth factors, in the presence of leukocytic cells.

Autologous iliac crest bone graft: should it still be the gold standard for treating nonunions?

Nonunion is a common complication following long-bone fracture, with a prevalence that ranges from 2.5-46%, depending on the location and severity of the injury to the bone, soft tissue, and vascular structures. The treatment of nonunions involves addressing the biology of fracture repair and the mechanical stability of fracture fixation, which are interrelated. Nonunion treatment has traditionally included the addition of autograft from the iliac crest to enhance healing. However, there an associated morbidity with the harvesting of the graft, and alternatives such as bone marrow aspirate, platelet-rich plasma, allograft, and ceramics have also been studied. In addition, new advances in the understanding of the cellular and molecular mechanisms of fracture repair have led to the use of growth factors, such as bone morphogenetic proteins, to accelerate bone healing. This article reviews the benefits of iliac crest bone graft relative to those of other modalities in the treatment of nonunions.

Influence of platelet-rich plasma on osteogenic differentiation of mesenchymal stem cells and ectopic bone formation in calcium phosphate ceramics

Platelet-rich plasma (PRP) contains a mixture of growth factors that play an important role in wound and fracture healing. While PRP enhanced bone formation by autogenous cancellous bone grafts, its influence in combination with different bone substitutes remained unknown. This study evaluated the effect of PRP on osteogenic differentiation and ectopic bone formation of human mesenchymal stem cells (MSC) in distinct resorbable calcium phosphate ceramics. Calcium-deficient hydroxyapatite (CDHA) blocks with a large specific surface area (48 m2/g) and beta-tricalcium phosphate (beta-TCP) with a low specific surface area (<0.5 m2/g) were loaded with 2 x 10(5) bone marrow-derived MSC. Half of the specimens were treated with 5-fold concentrated PRP. Biocomposites were implanted subcutaneously into SCID mice or kept under osteogenic culture conditions for 2 weeks before implantation. The addition of PRP increased the specific alkaline phosphatase (ALP) activity (p = 0.012) in undifferentiated MSC/CDHA composites but not in MSC/beta-TCP composites. Osteogenic preinduction was ineffective for CDHA and reduced ALP activity of beta-TCP composites significantly at explantation. Ectopic bone formation was stronger in MSC/CDHA (7/32) compared to MSC/beta-TCP (2/30) composites, but no influence of PRP was evident. In conclusion, the effect of PRP depended on the type of ceramic and the differentiation status of the MSC, and enhanced ALP activity of MSC on the high surface scaffold CDHA only, but PRP did not improve osteogenesis in our setting.

Diabetic fracture healing

Patients with diabetic ankle fractures consistently are at greater risk of sustaining a complication during treatment than nondiabetics.other medical comorbidities, especially Charcot neuroarthropathy and peripheral vascular disease, play distinct roles in increasing these complication rates. Many options for nonoperative and operative treatment exist, but respect for soft tissue management and attention to stable, rigid fixation with prolonged immobilization and prolonged restricted weight bearing are paramount in trying to minimize problems and yield functions.

Fracture healing in the elderly patient

Clinical experience gives rise to the impression that there are differences in fracture healing in different age groups. It is evident that fractures heal more efficiently in children than in adults. However, minimal objective knowledge exists to evaluate this assumption. Temporal, spatial, and cellular quantitative and qualitative interrelationships, as well as signaling molecules and extracellular matrix have not been comprehensively and adequately elucidated for fracture healing in the geriatric skeleton. The biological basis of fracture healing will provide a context for revealing the pathophysiology of delayed or even impaired bone regeneration in the elderly. We will summarize experimental studies on age-related changes at the cellular and molecular level that will add to the pathophysiological understanding of the compromised bone regeneration capacity believed to exist in the elderly patient. We will suggest why this understanding would be useful for therapeutics focused on bone regeneration, in particular fracture healing at an advanced age.