Clinical Effectiveness of Platelet-Rich Plasma for Long-Bone Delayed Union and Nonunion: A Systematic Review and Meta-Analysis

Bioregenerative autologous scaffold made from bone marrow aspirate concentrate, cancellous bone autograft, platelet-rich plasma, and autologous fibrin to treat non-unions of the femur, humerus, and forearm bones: a case series

AIM

To evaluate the effectiveness of a bioregenerative scaffold created from bone marrow aspirate, cancellous bone autograft, platelet-rich plasma, and autologous fibrin in treating complicated non-unions of the supracondylar femur, humeral shaft, and radius and ulna.

METHODS & MATERIALS

Three patients with non-unions resulting from multiple surgical failures underwent bone stabilization along with the application of a novel bioregenerative scaffold. X-rays and subjective assessments were collected prior to surgery and at 6- and 12-months post-surgery.

RESULTS

All non-unions demonstrated healing with adequate callus formation, as confirmed by radiological assessments. By 12 months, all patients were able to resume full weight-bearing activities or regain full range of motion and physical strength without pain. Statistical analysis revealed improvements across all assessment scales compared to pre-surgical values.

CONCLUSION

This approach offers a viable option for treating complex long bone non-unions after multiple surgical interventions.

Management of Forefoot Nonunions: A Brief Overview with Case Example

Forefoot nonunions present significant challenges in clinical practice due to their complex etiology and the essential role of the forefoot in weight-bearing and ambulation. Risk factors such as poor vascular supply, diabetes, smoking, poor nutritional status, non-compliance, and infection exacerbate the condition. Diagnosis primarily relies on clinical evaluation and imaging modalities. The effective management of forefoot nonunions requires a multifaceted approach that integrates accurate diagnosis, appropriate conservative or surgical treatment, and thorough postoperative care and long-term follow- up. Understanding the underlying causes and appropriately managing patient comorbidities can significantly enhance treatment outcomes and patients' quality of life.

Single/ Multiple Dose Percutaneously Injected LR-PRP Enhances Union Rate in Fracture Delayed Unions: A Prospective Case Series

Background

Average bone healing times of common fractures in adults ranges from 3 to 12 weeks and is location dependent. Platelet Rich Plasma (PRP) stimulates natural healing process through growth factors contained in platelets and has been employed for the same in delayed unions.

Methods

All patients > 18 years and documented delayed union were included in the study. Patients were followed up monthly after each Leucocyte-rich PRP (LR-PRP) injection and a decision for repeat PRP injection was taken on basis of visible impression in radiograph after previous injection.

Results

Total 36 patients were studied in which 5 patients were lost to follow-up. Union was achieved in 28/31 (90.3%). 20 (71.4%) patients required only single PRP injections. 4 (14.3%) patients required 2 PRP injections, 3 (10.7%) patients required 3 PRP injections and 1 (3.6%) patient required 4 PRP injection. There was no significant correlation of number of PRPs to time from 1st PRP-union or time from last PPR- union.

Conclusion

Single/multiple dose percutaneously administered LR-PRP can be used as a fruitful alternative to catalyze union in patients having delayed union irrespective of site of injury.

Effects of Autologous Conditioned Serum on Non-Union After Open Reduction Internal Fixation Failure: A Case Series and Literature Review

Background and Objectives: Non-union is a severe complication of traumatic fracture that often leads to disability and decreased quality of life, with treatment remaining complex due to a lack of standardized protocols. This study examines the effectiveness of autologous conditioned serum (ACS) for non-union in patients who have a failed open reduction internal fixation (ORIF). Materials and Methods: Eleven patients with confirmed non-union at least 9 months post-ORIF or total hip replacement were enrolled. These patients received ACS treatment on the lesion sites once to three times monthly and were followed up. Efficacy was monitored through monthly X-rays to assess callus formation and bone union. Results: Seven patients received ACS three times, three patients received it twice, and the one who underwent total hip replacement received it once. Ten patients achieved union at the last follow-up visit, indicating the effectiveness of ACS in non-union cases unresponsive to ORIF. ACS demonstrated promising results in facilitating bone union in these challenging cases. Conclusions: ACS has the potential as an alternative or adjective treatment for non-union and is worthy of being investigated further for the benefits of patients.

Evidence-based orthobiologic practice: Current evidence review and future directions

The field of orthopedic and regenerative medicine is rapidly evolving with the increasing utilization of orthobiologic. These biologically derived therapies, including platelet-rich plasma, mesenchymal stem cells, bone marrow aspirate concentrate, stromal vascular fraction (SVF), and autologous chondrocyte implantation, are gaining traction for their potential to enhance the body's natural healing processes. They offer a promising alternative to traditional surgical interventions for musculoskeletal injuries and degenerative conditions. Current evidence suggests significant benefits of orthobiologics in treating conditions like osteoarthritis, tendon injuries, and spinal disorders, yet inconsistencies in treatment protocols and outcomes persist. The global market for orthobiologics is projected to grow substantially, driven by advancements in biologic therapies such as adipose-derived stem cells and SVF, and the demand for minimally invasive treatments. Despite their promise, regulatory and ethical challenges, as well as the need for high-quality, standardized research, remain significant obstacles. Future directions in the field include advancements in delivery systems, personalized medicine approaches, and the exploration of novel sources like induced pluripotent stem cells, aiming for more targeted and effective treatments. Collaborative efforts are crucial to overcoming these challenges and ensuring the safe and effective application of orthobiologics in clinical practice.

Orthobiologics in delayed union and non-union of adult long bones fractures: A systematic review

Background

Fracture healing poses a significant challenge in orthopedics. Successful regeneration of bone is provided by mechanical stability and a favorable biological microenvironment. This systematic review aims to explore the clinical application of orthobiologics in treating aseptic delayed union and non-union of long bones in adults.

Methods

A systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Three databases were explored, with no date restrictions, using keywords related to orthobiologics and delayed union and non-union. Eligible studies included human clinical studies in English, with available full texts, examining orthobiologics such as platelet-rich plasma (PRP), mesenchymal stem cells (MSCs), and bone morphogenetic protein (BMPs) for treating aseptic delayed unions and non-unions in adults. Animal studies, in vitro research, and studies on non-unions due to congenital defects, tumors or infections were excluded.

Results

The initial search identified 9417 studies, with 20 ultimately included in the review. These studies involved 493 patients affected by non-union and 256 patients affected by delayed union, with an average age respectively of 40.62 years and 41.7 years. The mean follow-up period was 15.55 months for non-unions and 8.07 months for delayed unions. PRP was the most used orthobiologic, and outcomes were evaluated through time to union, functional scores, and clinical examinations. The results indicated that orthobiologics, especially PRP, tended to yield better outcomes compared to surgical procedures without biological factors.

Conclusion

This systematic review suggests that orthobiologics, such as PRP, BMPs, and MSCs, can be effective and safe in the management of delayed union and non-union fractures. These biological treatments have the potential to improve union rates, reduce healing times, and enhance functional outcomes in patients with non-union fractures. Further research is essential to refine treatment protocols and determine the most suitable orthobiologic for specific patient populations and fracture types.

Osteogenic effects and safety of human induced pluripotent stem cell-derived megakaryocytes and platelets produced on a clinical scale

Introduction

Platelet-rich plasma obtained by centrifuging peripheral blood can promote osteogenesis owing to its abundant growth factors but has drawbacks, including rapid growth factor loss and inconsistent effects depending on donor factors. To overcome these issues, we were the first in the world to use freeze-dried human induced pluripotent stem cell-derived megakaryocytes and platelets (S-FD-iMPs) and found that they have osteogenesis-promoting effects. Since turbulence was found to activate platelet biogenesis and iPS cell-derived platelets can now be produced on a clinical scale by a device called VerMES, this study examined the osteogenesis-promoting effect and safety of clinical-scale FD-iMP (V-FD-iMPs) for future human clinical application.

Method

We administered either S-FD-iMPs, V-FD-iMPs, or saline along with artificial bone to the lumbar spine of 8-week-old male Sprague-Dawley rats (n = 4 each) and evaluated bone formation by computed tomography (CT) and pathology. Next, we administered V-FD-iMPs or saline along with artificial bone to the lumber spines of 5-week-old male New Zealand White rabbits (n = 4 each) and evaluated the bone formation by CT and pathology. Rats (n = 10) and rabbits (n = 6) that received artificial bone and V-FD-iMPs in the lumbar spine were also observed for 6 months for adverse events, including infection, tumor formation, and death.

Results

Both V-FD-iMPs and S-FD-iMPs significantly enhanced osteogenesis in the lumber spines of rats in comparison with the controls 8 weeks postoperatively, with no significant differences between them. Furthermore, V-FD-iMPs vigorously promoted osteogenesis in the lumber spines of rabbits 8 weeks postoperatively. In rats and rabbits, V-FD-iMPs showed no adverse effects, including infection, tumor formation, and death, over 6 months.

Conclusion

These results suggest that V-FD-iMPs promote safe osteogenesis.

A Comprehensive Review of Platelet-Rich Plasma and Its Emerging Role in Accelerating Bone Healing

This comprehensive review delves into the emerging role of platelet-rich plasma (PRP) in accelerating bone healing. PRP, a blood-derived product rich in platelets and growth factors, has garnered attention for its regenerative potential. The review begins by defining PRP and providing a historical background, highlighting its significance in expediting bone healing. PRP's composition and preparation methods, including centrifugation techniques and commercial kits, are explored. Mechanistically, PRP operates by releasing growth factors, chemotaxis, and angiogenesis, elucidating its cellular effects. Applications in fracture healing and orthopaedic surgeries, such as joint arthroplasty and spinal fusion, are discussed, emphasising the promising outcomes in clinical trials. Safety considerations, patient selection criteria, and the need for PRP preparation and application standardisation are underscored. The review outlines ongoing research trends, potential technological advancements, and unexplored areas in paediatric applications and inflammatory bone disorders. The implications for clinical practice involve informed decision-making, optimised protocols, and interdisciplinary collaboration. In conclusion, the future of PRP in bone healing holds exciting prospects, with the potential for precision medicine, integration with emerging therapies, expanded applications, and enhanced technological innovations shaping its trajectory in orthopaedics and regenerative medicine.

Long-term outcomes of atrophic/oligotrophic non-unions in dogs and cats treated with autologous iliac corticocancellous bone graft and circular external skeletal fixation: 19 cases (2014-2021)

OBJECTIVES

To determine the short- and long-term outcomes and complications in dogs and cats undergoing surgical treatment for viable oligotrophic and nonviable atrophic non-unions using circular external skeletal fixation and autologous corticocancellous bone graft.

MATERIALS AND METHODS

In this case series, the medical records and radiographs of all dogs and cats with radius/ulna and tibia/fibula viable oligotrophic and nonviable atrophic non-unions treated with corticocancellous bone graft and circular external skeletal fixation at two referral veterinary hospitals between 2014 and 2021 were retrospectively reviewed. The long-term follow-up was 1 year or greater.

RESULTS

Thirteen dogs and six cats with 19 non-union fractures met the inclusion criteria for the study. Eighteen non-union fractures (94.7%) healed and one did not. Five patients (26%) had minor perioperative period complications (<3 months). The patient that did not achieve bone union underwent revision surgery with internal fixation (plate and screws) and autologous cancellous bone graft. Fifteen (78.9%) cases returned to full function and three (15.8%) cases returned to acceptable function in the long-term follow-up period.

CLINICAL SIGNIFICANCE

The use of circular external skeletal fixation associated with autologous corticocancellous bone graft for the treatment of radius/ulna and tibia/fibula atrophic/oligotrophic non-union fractures in dogs and cats was considered successful in the majority of patients and was free of major or catastrophic complications.

Harnessing Healing Power: A Comprehensive Review on Platelet-Rich Plasma in Compound Fracture Care

This comprehensive review explores the applications of platelet-rich plasma (PRP) in the context of compound fracture care, providing a thorough examination of its biological mechanisms, preparation techniques, and clinical implications. The analysis highlights PRP's potential in accelerating bone healing, enhancing soft tissue repair, reducing inflammation and infection risks, and managing pain during fracture recovery. The review underscores the importance of ethical and regulatory considerations in integrating PRP into orthopaedic practice, emphasising informed consent, transparent patient communication, and ongoing monitoring of ethical concerns. Looking ahead, the implications for the future of compound fracture care suggest a transformative shift with the potential for personalised medicine approaches and emerging technologies. However, the conclusion calls for a balanced perspective, acknowledging the promising applications of PRP while emphasising the need for responsible and ethical use. The collaborative efforts of healthcare professionals, researchers, and regulatory bodies are crucial in navigating this evolving landscape and harnessing the healing power of PRP to redefine orthopaedic care for individuals with compound fractures.

Antimicrobial Effects of Platelet-Rich Plasma and Platelet-Rich Fibrin: A Scoping Review

Platelet-rich plasma (PRP), derived from the centrifugation and subsequent separation of whole blood, results in an unusually high concentration of platelets. A newer form of platelet concentrate, platelet-rich fibrin (PRF), has also been developed. There has been significant research into the therapeutic effects of PRP, particularly in enhancing wound healing and preventing infections in surgical wounds. This scoping review aims to thoroughly evaluate preclinical and clinical evidence regarding the antimicrobial effects of PRP and PRF. In conducting this review, 612 records were examined, and 36 articles were selected for inclusion. The studies reviewed include preclinical research, such as in-vitro and in-vivo studies, and clinical trials involving human participants. The current clinical evidence suggests a notable trend towards the antimicrobial capabilities of PRP and PRF, underscoring their potential benefits in treating wounds. The application of PRP and PRF in wound management shows encouraging outcomes, but further investigation is needed to optimize their use as antimicrobial agents. Additional research, particularly randomized controlled trials, is essential to substantiate their antimicrobial effectiveness in specific diseases and types of wounds, considering their potential impact on clinical results.

The Efficiency and Safety of Platelet-Rich Plasma Dressing in the Treatment of Chronic Wounds: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Recently, many clinical trials have applied platelet-rich plasma (PRP) dressings to treat wounds that have stopped healing, which are also called chronic wounds. However, the clinical efficiency of PRP dressings in treating chronic wounds is still controversial. Therefore, we conducted this study to compare PRP dressings with normal saline dressings in treating chronic wounds. Relevant randomized controlled trials focusing on utilizing PRP dressings in treating chronic wounds were extracted from bibliographic databases. Finally, 330 patients with chronic wounds, reported in eight randomized controlled trials, were included in this study. In total, 169 out of 330 (51.21%) were treated with PRP dressings, and 161 out of 330 (48.79%) were treated with normal saline dressings. The pooled results showed that the complete healing rate of the PRP group was significantly higher than that of saline group at 8 weeks and 12 weeks, respectively. In addition, there were no significant differences in wound infection and adverse events. Compared with normal saline dressing, the PRP dressing could effectively enhance the prognosis of chronic wounds. Furthermore, the PRP did not increase wound infection rate or occurrence of adverse events as an available treatment for chronic wounds.

Multiple Injections of Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Current Evidence in Randomized Controlled Trials

In recent years, various clinical trials have focused on treating knee osteoarthritis (KOA) with multiple injections of platelet-rich plasma (PRP). However, compared with the multiple hyaluronic acid (m-HA) injections, the clinical efficacy of multiple PRP (m-PRP) injections for KOA still remains controversial among these studies. Therefore, we aimed to compare the clinical effectiveness of m-PRP injections with m-HA injections in the treatment of KOA in this systematic review. Relevant clinical trials were searched via bibliographic databases, including Medline, PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials, to compare the m-PRP and m-HA injections in the treatment of KOA. Finally, fourteen randomized controlled trials, including 1512 patients, showed the postoperative VAS, WOMAC, IKDC, or EQ-VAS scores and were enrolled in this systematic review. Compared with the group of intra-articular m-HA injections, the group of intra-articular m-PRP injections was lower in the VAS scores at 3-month (WMD = −0.25; 95%CI, −0.40 to −0.10, p = 0.0009) and 12-month (WMD = −0.64; 95%CI, −0.79 to −0.49, p < 0.00001) follow-ups. In addition, the group of intra-articular m-PRP injections was also lower in the WOMAC scores at 1-month (WMD = −1.23; 95%CI, −2.17 to −0.29, p = 0.01), 3-month (WMD = −5.34; 95%CI, −10.41 to −0.27, p = 0.04), 6-month (WMD = −11.02; 95%CI, −18.09 to −3.95, p = 0.002), and 12-month (WMD = −7.69; 95%CI, −12.86 to −2.52, p = 0.004) follow-ups. Furthermore, compared with the group of intra-articular m-HA injections, the group of intra-articular m-PRP injections was higher in the IKDC scores at 3-month (WMD = 7.45; 95%CI, 2.50 to 12.40, p = 0.003) and 6-month (WMD = 5.06; 95%CI, 1.94 to 8.18, p = 0.001) follow-ups. However, the long-term adverse side of m-PRP injections for KOA still needs more large-scale trials and long-term follow-ups.

The levels of TGFβ1, VEGF, PDGF-BB, and PF4 in platelet-rich plasma of professional soccer players: a cross-sectional pilot study

Background

Regenerative therapy using platelet-rich plasma (PRP), a rich source of growth factors, has become popular in orthopedic sports medicine. Elite athletes prefer PRP therapy for their injured muscles and tendons primarily to avoid the possible risks of surgical treatment. However, the clinical effectiveness of PRP therapy in elite athletes compared to that in non-athletes remains unknown. Therefore, to investigate the effectiveness of PRP therapy in professional athletes (pro-athletes), we focused on the quality of PRP preparations and compared the levels of bioactive molecules between pro-athletes and non-athletes.

Methods

PRP was prepared from healthy, non-smoking male professional soccer players (pro-athletes) (n = 22) and non-athletes (VEGF: n = 34, others: n = 38). The levels of TGFβ1, PDGF-BB, VEGF, and PF4 were determined using ELISA kits. Polyphosphate was probed with 4’,6-diamidino-2-phenylindole and monitored using a fluorometer. The body composition of the donors was determined using a bathroom weighing scale.

Results

The levels of TGFβ1 and VEGF were significantly lower in pro-athletes than in non-athletes, whereas PF4 levels were significantly higher in pro-athletes. No significant difference was found in PDGF-BB levels between these groups. Biomolecule levels were not correlated with polyphosphate levels.

Conclusion

TGFβ1, VEGF, and PDGF-BB levels in pro-athletes were not higher than those in non-athletes. These findings suggest that growth factor levels in PRP may not be a predominant determinant of the clinical effectiveness of PRP therapy in pro-athletes. Increased PF4 levels in pro-athletes suggest an immunological function of PRP that may positively influence tissue regeneration.

Therapeutic Efficacy and Safety of Osteoinductive Factors and Cellular Therapies for Long Bone Fractures and Non-Unions: A Meta-Analysis and Systematic Review

BACKGROUND

Long bone fractures display significant non-union rates, but the exact biological mechanisms implicated in this devastating complication remain unclear. The combination of osteogenetic and angiogenetic factors at the fracture site is an essential prerequisite for successful bone regeneration. The aim of this study is to investigate the results of the clinical implantation of growth factors for intraoperative enhancement of osteogenesis for the treatment of long bone fractures and non-unions.

METHODS

A systematic literature review search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the PubMed and Web of Science databases from the date of inception of each database through to 10 January 2022. Specific inclusion and exclusion criteria were applied in order to identify relevant studies reporting on the treatment of upper and lower limb long bone non-unions treated with osteoinductive or cellular factors.

RESULTS

Overall, 18 studies met the inclusion criteria and examined the effectiveness of the application of Bone Morphogenetic Proteins-2 and -7 (BMPs), platelet rich plasma (PRP) and mesenchymal stem cells (MSCs). Despite the existence of limitations in the studies analysed (containing mixed groups of open and close fractures, different types of fractures, variability of treatment protocols, different selection criteria and follow-up periods amongst others), their overall effectiveness was found significantly increased in patients who received them compared with the controls (I2 = 60%, 95% CI = 1.59 [0.99-2.54], Z =1.93, p = 0.05).

CONCLUSION

Administration of BMP-2 and -7, PRP and MSCs were considered effective and safe methods in fracture treatment, increasing bone consolidation, reducing time to repair and being linked to satisfactory postoperative functional scores.