Delayed union of humeral shaft fractures: comparison of autograft with and without platelet-rich plasma treatment: a randomized, single blinded clinical trial

Comparison of the Effect of Platelet-rich Plasma (PRP) and Fat Graft on Autologous Bone Grafting in a Randomized-controlled Experimental Skull Model

Gold standard method for the treatment of critical-sized bone defects is the autogenous bone grafting procedure. A number of new and potentially useful adjuncts currently are being investigated to enhance the success of bone grafting. We propose to evaluate the effect of the most known and easily obtained 2 biological materials, fat graft and platelet-rich plasma (PRP), on bone graft healing. Twenty-seven New Zealand male rabbits were included in this randomized, controlled study. Two-sided 15-mm diameter bone defects were created in the parietal bones and the bones taken were replaced right-to-left and vice versa with 1 control group, 1 fat graft applied group, and the last one PRP applied group. Histologic evaluation and 3-dimensional maxillofacial computerized tomography were performed and bone density was calculated. In radiologic analysis, bone density was significantly different in the PRP group compared with the control and fat graft group in the 12th week ( P <0.05). In histologic scoring analysis, the PRP group had a better score than the control and fat graft group, while the fat graft group was worse than the control group in the 6th week ( P <0.05). The addition of PRP had a positive effect whereas fat graft had a negative effect on bone graft healing compared with the control group.

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.

Individualized herbal prescriptions for delayed union: A case series

Background Bone fractures are important clinical events for both patients and professionals. Active treatment options are limited for delayed unions and for nonunions; surgery is common but not entirely risk-free. This report describes three cases of delayed union successfully treated with herbal decoction. Participants Three patients had trapezoid and 3rd metacarpal bone fractures, 2nd, and 5th metatarsal bone fractures, respectively. All three patients were diagnosed with delayed union by an independent orthopedic surgeon based on computed tomography (CT) scan/radiographic imaging and fracture duration without a healing process. Patients took herbal decoction, Jeopgol-tang, with individually added herbs based on symptom manifestations, twice daily for 56, 85 and 91 days with no additional interventions except for a splint that they had been wearing since fracture diagnosis. Outcomes Improvement of delayed union was evaluated using radiographic imaging or CT during treatment with Jeopgol-tang. Results After taking herbal medicine, callus and bony bridging were confirmed on follow-up imagings and the patients described their experience with pain reduction at an interview after recovery. Conclusions This case series suggests that the herbal decoction Jeopgol-tang warrants further investigation to establish its role as a complementary and integrative medicine treatment option for delayed unions.

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.

Efficacy of adjuvant treatment for fracture nonunion/delayed union: a network meta-analysis of randomized controlled trials

Background

Fracture nonunion/delayed union seriously affects physical and mental health and quality of life. The aim of this study was to evaluate the relative efficacy of different adjuvant treatments for nonunion/delayed union by network meta-analysis.

Methods

A comprehensive search was performed to identify randomized controlled trials (RCTs) evaluating adjuvant treatment in the management of nonunion/delayed union. A network meta-analysis reporting on healing rate, healing time, and adverse effect (AE) outcomes was conducted to assess and compare different interventions.

Results

Thirty studies were included in the analysis. For the healing rate outcome, bone marrow aspirate (BMA) + autologous cancellous bone (ACB) was found to be significantly better than ACB alone (odds ratio: 0.12; 95% confidence interval: 0.03, 0.59). In the ranking results, BMA+ platelet-rich plasma (PRP) (96%), BMA + ACB (90%), and BMA alone (82%) showed relative advantages in the healing rate. Low-intensity pulsed ultrasonography (LIUS) intervention significantly shortened the healing time compared with ACB (SMD: -9.26; 95% CI: − 14.64, − 3.87). LIUS (100%), BMA + PRP (74%), and bone morphogenetic proteins (BMPs) (69%) have relative advantages. Compared with the control, electromagnetic field (EMF) (OR: 13.21; 95% CI: 1.58, 110.40) and extracorporeal shock wave (ESWT) (OR: 4.90; 95% CI: 1.38, 17.43) had a higher AE risk.

Conclusions

Among the current intervention strategies, BMA in combination with PRP and ACB can improve the healing rate of nonunion/delayed union. LIUS can significantly shorten the healing time. EMF and ESWT may have a high risk of AE. However, large-scale, well-designed studies are still needed to confirm the results.

Trial registration

Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05407-5.

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

Background

More recently, there was a series of clinical studies focusing on local administration of platelet-rich plasma (PRP) in long-bone fracture patients suffering from delayed union and nonunion. Therefore, we performed a systematic review to evaluate the effectiveness of PRP injection for treatment of patients with long-bone delayed union and nonunion.

Methods

Relevant clinical trials were selected by the main bibliographic databases, including Medline, PubMed, Embase, Web of Science, and the Cochrane library, to evaluate the effectiveness of PRP for long-bone fracture patients diagnosed with delayed union or nonunion by two reviewers independently. The main outcomes included healing rate, healing duration, pain relief, functional outcome, and complications.

Results

Finally, thirteen studies including four hundred and fifty-nine participants met the selection criteria and were included in this systematic review. These articles included three randomized controlled studies, one prospective study, and nine retrospective studies. 146 out of 155 (94.19%) patients treated with PRP during operation, and 144 out of 183 (78.69%) patients treated with PRP injection alone, exhibited bone consolidation. The healing rate of the PRP group (85.80%) was higher than that of the control group (60.76%). The mean bony union time of patients treated and untreated with PRP, were, respectively, 4.64 and 5.15 months. Four papers reported that PRP was effective in pain relief of patient with delayed union and nonunion. Complications, including small subcutaneous hematoma, subcutaneous swelling, and postoperative infection, were also reported in enrolled studies.

Conclusions

PRP is a promising alternative treatment for patients with long-bone delayed union and nonunion. PRP could successfully promote the healing rate and relieve the pain of patients with delayed union and nonunion. However, the long-term adverse side and functional outcome in application of PRP still need further large-scale trials and long-term follow-up.

Systematic Review Registration

https://www.researchregistry.com/browse-the-registry#home/registrationdetails/61dbd2f837e948001e68d5c5/, The identifying number is research registry 7525.

The role of Platelet Rich Plasma and other orthobiologics in bone healing and fracture management: A systematic review

BACKGROUND

Treatment of large bone defects and fracture healing complications (delayed and non-union) presents a substantial challenge for orthopaedic surgeons. Given that bone healing requires mechanical stability as well as a favourable biological microenvironment, orthobiologics such as Platelet-Rich Plasma (PRP) may have a significant clinical role to play.

AIMS

To perform a systematic review of the available literature to assess the clinical effect of PRP, with or without other orthobiologics, on bone healing.

METHOD

Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical studies of any evidence, assessing effect of PRP with or without other orthobiologics on bone healing, were included. A qualitative analysis was carried out on the clinical and radiological outcomes reported.

RESULT

27 articles with 1631 patients (mean age = 43.56, 57.1% male, mean follow-up = 17.27 months) were included in the qualitative. Of the 27 studies, 13 dealt with fracture complications (delayed or non-unions), 7 with acute fracture healing, 4 with tibial osteotomies and lengthening procedures and 3 with lumbar spine pathology. 18/27 studies showed a clinical benefit of PRP, 8/27 showed no significant effect, and 1/27 showed a worse outcome with PRP.

CONCLUSION

Our review suggests PRP may play a clinical role in bone healing but further randomised controlled trials (RCTs) using standardised outcomes should be performed to establish its efficacy.

Platelet-Rich Plasma Combined With Autologous Grafting in the Treatment of Long Bone Delayed Union or Non-union: A Meta-Analysis

Background: Platelet-rich plasma (PRP) has been suggested as an emerging treatment for bone defects. However, whether PRP could enhance the therapeutic efficacy of autologous bone grafting for long bone delayed union or non-union remains unknown. A meta-analysis of randomized and non-randomized controlled trials (RCT and NRCT) was performed to summarize current evidence. Methods: Relevant RCTs and NRCTs comparing the influences of autologous bone grafting on healing of long bone delayed union or non-union with and without PRP were obtained by searching PubMed, Embase, Cochrane's Library, China National Knowledge Infrastructure, and WanFang databases from inception to September 10, 2020. A random-effect model was applied to pool the results with the incorporation of the potential heterogeneity. Subgroup analysis according to study design was also performed. Results: Six RCTs and two NRCTs with 420 patients were included. Compared to patients allocated to autologous bone grafting alone, those allocated to combined treatment with PRP and autologous bone grafting were not associated with higher rates of radiographic bone healing [risk ratio (RR): 1.06, 95% confidence interval (CI): 0.99-1.13, P = 0.09; I ² = 24%] or excellent/good posttreatment limb function (RR: 1.14, 95% CI: 0.95-1.37, P = 0.37; I ² = 0%) but was associated with a shorter healing time (mean difference: -1.35 months, 95% CI: -1.86 to -0.84, P < 0.001; I ² = 58%). Subgroup analysis according to study design showed similar results for the above outcomes (P-values for subgroup difference all >0.10). Conclusions: Combined treatment with PRP and autologous bone grafting may be effective to accelerate the healing of long bone delayed union or non-union compared to autologous bone grafting alone.

Use of Osteobiologics for Fracture Management: The When, What, and How

Osteobiologics are defined as a group of natural and synthetic materials used to augment bone healing. The selection of the most appropriate osteobiologic from the growing list of available options can be a challenging task. In selecting a material, surgeons should weigh a variety of considerations, including the indication for their use (the when), the most suitable substance (the what), and the correct mode of application (the how). This summary reviews these considerations and seeks to provide the surgeon with a basis for informed clinical evidence-based decision-making in their choice of a successful option.

Application of platelet-rich plasma in traumatic bone infections

Introduction: Traumatic bone infection represents a clinical challenge for orthopedic surgeons. Traditional treatments include surgical debridement and antibiotic, but prolonged use of antibiotic may lead to colonization of resistant bacteria and other adverse reactions.Areas covered: Platelet-rich plasma (PRP), a biological product extracted from the peripheral blood of patients, has been widely used in the field of tissue repair in recent years. Because if its structural and antibacterial properties, PRP is an innovative option for the prevention and treatment of infections. This review assesses the recent scientific literature on PRP, specifically its in the treatment of infections. To this end, a literature review was conducted using the PubMed and Web of Science databases with the following keywords 'platelet-rich plasma (PRP)'; 'PRP AND traumatic bone infections'; 'PRP AND bone defect'; 'PRP AND antibiotics'; and 'PRP AND wound healing'.Expert opinion: This review focuses on the mechanism of action, preparation methods, clinical applications and other aspects related to PRP to provide a reference for its use in the treatment of traumatic bone infections, thereby enhancing the therapeutic effectiveness and improving the prognosis of patients.

Comparison of Shape Memory Staple and Gelled Platelet-Rich Plasma versus Shape Memory Staple alone for the Treatment of Waist Scaphoid Nonunion: A Single-Center Experience

Purpose  The aim of this study was to analyze the results of two different methods of surgical treatment of waist scaphoid nonunions (SNUs). We retrospectively analyzed data from 87 patients referred to our department from January 2010 to December 2017 who were surgically treated for waist SNU.

Methods  The mean period of time passed from trauma was 11.2 (±5.6) months. Patients were divided into two groups based on surgical treatment received: volar exposure osteosynthesis with shape memory staple (SMS) (group A) and volar exposure osteosynthesis with SMS and gelled platelet-rich plasma (GPRP) application at the bone defect level (group B). A cast (thumb excluded) was maintained for 4 weeks. Healing was checked clinically (pain, QuickDASH [Disabilities of the Arm, Shoulder, and Hand] score, Mayo Wrist Score) and radiologically (standard X-ray).

Results  Union was achieved in 40 patients in group A (95.2%) and in all patients in group B (45 patients; 100%). A statistically significant difference was observed in the improvement of the Mayo Wrist Score, QuickDASH score, and pain (measured through the visual analog scale) after 3 months from surgery ( p  = 0.02).

Conclusion  SMS is effective in treating waist SNU at more than 6 months from trauma. GPRP application can improve bone healing and upper limb function.

Level of Evidence  This is a retrospective observational Level III study.

No effect of platelet-rich plasma as adjuvant to bone marrow stimulation for the treatment of chondral defects in a large animal model

BACKGROUND

Bone marrow stimulation (BMS) remains a dominant treatment strategy for symptomatic full thickness articular cartilage defects. Autologous platelet-rich plasma (PRP), may improve biological cartilage repair as an adjunct to BMS.

OBJECTIVES

To assess the histological quality of cartilage repair after BMS with and without repeated local injections of PRP for the treatment of full-thickness focal chondral defects of the knee.

METHODS

Two full-thickness chondral defects (Ø = 6 mm) were surgically performed in the medial and lateral trochlea of each knee in skeletally mature Göttingen minipigs. The two treatment groups with 12 defect for each groups were (1) BMS with one weekly PRP injection for 4 weeks, and (2) BMS alone. The animals were euthanized after 6 months. Samples of both whole blood and PRP were analysed with an automated hematology analyzer to determine the concentrations of platelets and nucleated cells. The composition of cartilage repair tissue was assessed using gross appearance assessment, histomorphometry and semi-quantitative scoring (ICRS II).

RESULTS

The average fold increase in platelets was 10.2 ± 2.2. Leukocyte concentration increased in PRP samples by an average fold change of 7.2 ± 1.3. Our macroscopic findings showed that the defects in the BMS + PRP-treated group, were filled with an irregular, partially rough tissue similar to the BMS-treated group. No significant difference in amount of hyalin cartilage, fibrocartilage or fibrous tissue content and ICRS II scores was found between the groups.

CONCLUSIONS

Four repeated local injections of leukocyte-rich PRP after BMS in the treatment of full-thickness cartilage injuries demonstrated no beneficial effects in terms of macroscopic and histological cartilage repair tissue quality.

PRP and BMAC for Musculoskeletal Conditions via Biomaterial Carriers

Platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) are orthobiologic therapies considered as an alternative to the current therapies for muscle, bone and cartilage. Different formulations of biomaterials have been used as carriers for PRP and BMAC in order to increase regenerative processes. The most common biomaterials utilized in conjunction with PRP and BMAC clinical trials are organic scaffolds and natural or synthetic polymers. This review will cover the combinatorial strategies of biomaterial carriers with PRP and BMAC for musculoskeletal conditions (MsCs) repair and regeneration in clinical trials. The main objective is to review the therapeutic use of PRP and BMAC as a treatment option for muscle, bone and cartilage injuries.

Effects of autologous platelet-rich plasma on endometrial expansion in patients undergoing frozen-thawed embryo transfer: A double-blind RCT

Background

Adequate endometrial growth is principal for implantation and pregnancy. Thin endometrium is associated with lower pregnancy rate in assisted reproductive technology. Some frozen-thawed embryo transfer cycles are cancelled due to inadequate endometrial growth.

Objective

To assess the effectiveness of autologous platelet-rich plasma (PRP) intrauterine infusion for the treatment of thin endometrium.

Materials and Methods

A total of 72 patients who had a history of cancelled frozen-thawed embryo transfer cycle due to the thin endometrium ( < 7mm) were assessed for the eligibility to enter the study between 2016 and 2017. Twelve patients were excluded for different reasons, and 60 included patients were randomly assigned to PRP or sham-catheter groups in a double-blind manner. Hormone replacement therapy was administered for endometrial preparation in all participants. PRP intrauterine infusion or shamcatheter was performed on day 11-12 due to the thin endometrium and it was repeated after 48 hr if necessary.

Results

Endometrial thickness increased at 48 hr after the first intervention in both groups. All participants needed second intervention due to an inadequate endometrial expansion. After second intervention, endometrial thickness was 7.21 ± 0.18 and 5.76 ± 0.97 mm in the PRP group and sham-catheter group, respectively. There was a significant difference between the two groups. (p < 0.001). Embryo transfer was done for all patients in PRP group and just in six cases in the sham-catheter group. Chemical pregnancy was reported in twelve cases in the PRP group and two cases in the sham-catheter group.

Conclusion

According to this trial, PRP was effective in endometrial expansion in patients with refractory thin endometrium.

Experimental investigation of effects of platelet-rich plasma on early phases of orthodontic tooth movement

INTRODUCTION

The aim of this study was to evaluate the effects of platelet-rich plasma on orthodontic tooth movement in rats.

METHODS

We divided 48 Wistar male albino rats into 3 groups: control group, platelet-rich plasma group, and platelet-poor plasma group. The rats in all study groups had orthodontic tooth movement of their maxillary right first molars. Either platelet-rich plasma or platelet-poor plasma was injected into the animals in the platelet-rich plasma and platelet-poor plasma groups, respectively; the rats in the control group had no injection. Distances between the maxillary molar and incisor were measured on days 0, 1, 3, 7, and 14. Active osteoblast numbers in tension sites and osteoclast numbers in compression sites were examined histologically. Immunohistochemical evaluations of tartrate-resistant acid phosphatase (TRAP), transforming growth factor-β (TGF-β), and alkaline phosphatase (ALP) expressions were also performed.

RESULTS

The rats in the platelet-rich plasma group showed less tooth movement than those in the control group at day 3. At day 14, maximum tooth movement was observed in all groups. However, there was no statistical significance among the groups at day 14. In terms of osteoclast and osteoblast cells, no significant differences were observed in any group or at any time. Also, there were no significant differences in TRAP, ALP, and TGF-β expressions in the groups.

CONCLUSIONS

The application of platelet-rich plasma was not beneficial as an adjunct to orthodontic treatment.

Epidemiology of clavicle fractures in a level 1 trauma center in Belgium

PURPOSE

In the last 10 years, there has been an increasing tendency toward operative fixation of clavicle fractures. In this retrospective analysis, we will demographically assess all patients who sustained a clavicle fracture and were treated in our university hospital between 2004 and 2014.

METHODS

We retrospectively updated our database and analyzed all adult patients who were diagnosed with a clavicle fracture in our hospital. The following parameters were included in the database: age, gender, Robinson classification, date of trauma, injury mechanism, time until surgery, and reason for delayed surgery. Descriptive statistics were used to describe differences between patient groups and linear regression was performed to identify trends over time.

RESULTS

667 patients were included for analysis. The mean age was 43 ± 17.7 years. The majority of clavicle fractures occurred due to bicycle injuries (35.3%) and these increased from 2004 until 2014 (r = 0.738, R² = 0.545, p = 0.009). Patients with a midshaft clavicle fracture were increasingly treated primarily surgically (r = 0.928, R² = 0.861, p < 0.0001). There was an increased ratio of delayed surgery in relation to age from the age of 16 (9.1%) until the age of 70 years (37.2%).

CONCLUSIONS

There is an increasing number of fractures sustained by bicycle accidents and an increasing number of patients undergoing operative treatment. Middle-aged patients more often had delayed surgery compared with young adult patients. This could be due to an increased activity level of the elder population and the concomitant demand for a faster return to activities.

LEVEL OF EVIDENCE

III, retrospective comparative study.