Investigating the effect of intra-articular PRP injection on pain and function improvement in patients with distal radius fracture

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Elbow and Upper Extremity: An Orthoregeneration Network Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the elbow and upper extremity, including the tendons (lateral epicondylitis, medial epicondylitis, biceps tendonitis, triceps tendonitis), articular cartilage (osteoarthritis, osteochondral lesions), and bone (fractures, nonunions, avascular necrosis, osteonecrosis). Promising and established treatment modalities include hyaluronic acid; botulinum toxin; corticosteroids; leukocyte-rich and leukocyte-poor platelet-rich plasma; autologous blood; bone marrow aspirate comprising mesenchymal stromal cells (alternatively termed medicinal signaling cells and frequently mesenchymal stem cells [MSCs]) and bone marrow aspirate concentrate; MSCs harvested from adipose and skin (dermis) sources; vascularized bone grafts; bone morphogenic protein scaffold made from osteoinductive and conductive β-tricalcium phosphate and poly-ε-caprolactone with hydrogels, human MSCs, and matrix metalloproteinases; and collagen sponge. Autologous blood preparations such as autologous blood injections and platelet-rich plasma show positive outcomes for nonresponsive tendinopathy. In addition, cellular therapies such as tissue-derived tenocyte-like cells and MSCs show a promising ability to regulate degenerative processes by modulating tissue response to inflammation and preventing continuous degradation and support tissue restoration.

Advances with Platelet-Rich Plasma for Bone Healing

Despite significant advances in the understanding and delivery of osteosynthesis, fracture non-union remains a challenging clinical problem in orthopaedic surgery. To bridge the gap, basic science characterization of fracture healing provides a platform to identify and target biological strategies to enhance fracture healing. Of immense interest, Platelet-rich plasma (PRP) is a point of care orthobiologic that has been extensively studied in bone and soft tissue healing given its relative ease of translation from the benchtop to the clinic. The aim of this narrative review is to describe and relate pre-clinical in-vitro and in-vivo findings to clinical observations investigating the efficacy of PRP to enhance bone healing for primary fracture management and non-union treatment. A particular emphasis is placed on the heterogeneity of PRP preparation techniques, composition, activation strategies, and delivery. In the context of existing data, the routine use of PRP to enhance primary fracture healing and non-union management cannot be supported. However, it is acknowledged that extensive heterogeneity of PRP treatments in clinical studies adds obscurity; ultimately, refinement (and consensus) of PRP treatments for specific clinical indications, including repetition studies are warranted.

Efficacy of Platelet-Rich Plasma in the Treatment of Fractures: A Meta-Analysis

Background

Although numerous studies have reported the effectiveness of platelet-rich plasma (PRP) in promoting and enhancing bone healing, many orthopedic physicians remain skeptical of platelet-rich plasma in the treatment of fractures. The objective of this meta-analysis was to assess the efficacy of PRP in the treatment of fractures.

Methods

We search for research on PRP treatment of fractures in Pubmed, Embase, Medline, and Cochrane libraries. Two independent reviewers assessed included studies and met to develop a consensus on included studies. We also assessed the risk of bias using Review Manager 5.3 software.

Results

The present meta-analysis included 10 randomized controlled trials (RCT) containing 652 patients. In the fixed-effect meta-analysis of 10 RCTs, 8 RCTs found that fracture patients benefited from PRP treatment. The use of PRP reduced the time of fracture healing in 4 RCTs. Three RCTs found that PRP adjuvant therapy enhanced bone mineral density in the fracture trace and reduced the time of bone regeneration in mandibular fractures patients (standardized mean difference (SMD) = −1.99, 95%confidence interval (CI) = −2.64–−1.35). And 3 RCTs found that PRP adjuvant therapy decreased the risk of revision surgery in fracture patients (SMD = 1.83, 95%CI = 1.10–3.04).

Conclusion

PRP adjuvant therapy is beneficial for the treatment of fracture patients, particularly those with mandibular fractures, and decreased the risk of revision surgery in fracture patients.

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.

Clinical Cohort Study in Canine Patients, to Determine the Average Platelet and White Blood Cell Number and Its Correlation with Patient's Age, Weight, Breed and Gender: 92 Cases (2019-2020)

Due to its easy preparation and that it is well tolerated, the use of autologous platelet-rich plasma (PRP) has become increasingly popular in regenerative medicine. However, there are still no clear guidelines on how it should be classified or whether the individual canine patient’s clinical status can influence its quality. Objective: This study aims to show if the weight, age, sex, neutered status or breed of canine patients have any correlation with the composition of PRP. Design: A blinded count of the platelets and white blood cells (WBC) was performed from 111 samples from 92 client owned dogs undergoing treatment for degenerative joint disease (DJD). The results were analysed using Pearson correlation test, ANOVA test or Student T-test. Results: There is a positive correlation between the number of platelets and WBC in canine patients of different breeds, but there was no significant difference on the platelet number and WBC number among the different breeds. The weight of the patient is also directly correlated to the platelet number (p = 0.003) but not WBC number. WBC number was negatively correlated to the weight of the patient. The sex and age of the patient did not affect platelets and WBC number, although WBC number is increased in non-neutered male population (p = 0.003). However, it would be interesting to investigate whether the growth factors released from the platelet granules are affected by patient variables in a canine population. Conclusions: Our results show that it is possible to obtain good quality autologous PRP, irrespective of age, sex, neutered status or weight of the patient, for PRP regenerative therapy.

Platelet-Rich Plasma for Bone Fracture Treatment: A Systematic Review of Current Evidence in Preclinical and Clinical Studies

Background: Recently, there is an increasing interest in the therapeutic potential of platelet-rich plasma (PRP) for bone fracture treatment. Nevertheless, the effect of PRP for bone fracture treatment remains controversial and is still a matter of discussion. Therefore, we performed a systematic review to evaluate the efficacy and safety of PRP injection for treatment of bone fracture. Methods: The main bibliographic databases, including Medline, PubMed, Embase, Web of Science, and the Cochrane library, were comprehensively searched for studies focusing on the application of platelet-rich plasma (PRP) on bone fracture treatment. All relevant articles were screened for eligibility and subdivided into the preclinical and clinical studies. Data were extracted and presented systematically. Results: Finally, twenty-six in vitro preclinical studies (basic studies), nine in vivo preclinical studies (animal studies), and nine clinical studies, met the selection criteria, and were included in the present systematic review. Preclinical studies showed an overall positive effect of PRP on osteoblast-like cells in vitro and bone healing in animal models. The most used treatment for bone fracture in animal and clinical studies is fixation surgery combined with PRP injection. The clinical studies reported PRP shortened bony healing duration, and had no positive effect on improving the healing rate of closed fractures. However, the results of functional outcomes are controversial. Additionally, compared with control group, PRP would not increase the rate of postoperative wound infection. Conclusion: The present systematic review confirmed the continuing interests of PRP as an additional treatment for bone fracture. Preclinical studies highlighted the potential value of PRP as promising therapy for bone fracture. However, the preclinical evidence did not translate into a similar result in the clinical studies. In addition, types of fractures and procedures of PRP preparation are heterogeneous in enrolled studies, which might result in controversial results. Meanwhile, characteristics of PRP, such as platelet concentration, the numbers of leukocytes, still need to be determined and further research is required.

Effect of platelet-rich plasma on fracture healing

Bone has the ability to completely regenerate under normal healing conditions. Although fractures generally heal uneventfully, healing problems such as delayed union or nonunion still occur in approximately 10% of patients. Optimal healing potential involves an interplay of biomechanical and biological factors. Orthopedic implants are commonly used for providing the necessary biomechanical support. In situations where the biological factors that are needed for fracture healing are deemed inadequate, additional biological enhancement is needed. With platelets being packed with granules that contain growth factors and other proteins that have osteoinductive capacity, local application of platelet concentrates, also called platelet-rich plasma (PRP) seems an attractive biological to enhance fracture healing. This review shows an overview of the use PRP and its effect in enhancing fracture healing. PRP is extracted from the patient's own blood, supporting that its use is considered safe. Although PRP showed effective in some studies, other studies showed controversial results. Conflicts in the literature may be explained by the absence of consensus about the preparation of PRP, differences in platelet counts, low number of patients, and absence of a standard application technique. More studies addressing these issues are needed in order to determine the true effect of PRP on fracture healing.

Orthobiologics in Hand Surgery

Orthobiologic agents are used as innovative adjuvant therapy to treat common upper-extremity pathology, including carpal tunnel syndrome, de Quervain tenosynovitis, and distal radius fractures. In this article, we perform a narrative review and evaluate current literature on orthobiologics in the upper extremity. Orthobiologics evaluated include bone morphogenetic proteins, platelet-rich plasma, bone marrow aspirate concentrate, mesenchymal stem cells, and amniotic membrane. Studies selected include randomized control trials, case studies, and animal studies. Although there is some clinical evidence regarding the use of orthobiologic agents in the treatment of shoulder, elbow, and sports injuries, there is a paucity of literature regarding their use to treat pathology of the hand and wrist. Further investigation is necessary to determine their effectiveness and therapeutic value in treatment of upper extremity injuries.

Differential Effects of Platelets Selectively Activated by Protease-Activated Receptors on Meniscal Cells

BACKGROUND

Meniscal injury is very common, and injured meniscal tissue has a limited healing ability because of poor vascularity. Platelets contain both pro- and anti-angiogenic factors, which can be released by platelet selective activation.

HYPOTHESIS

Platelets release a high level of vascular endothelial growth factor (VEGF) when they are activated by protease-activated receptor 1 (PAR1), whereas the platelets release endostatin when they are activated by protease-activated receptor 4 (PAR4). The PAR1-treated platelets enhance the proliferation of meniscal cells in vitro and promote in vivo healing of wounded meniscal tissue.

STUDY DESIGN

Controlled laboratory study.

METHOD

Platelets were isolated from human blood and activated with different reagents. The released growth factors from the activated platelets were determined by immunostaining and enzyme-linked immunosorbent assay. The effects of the platelets with different treatments on meniscal cells were tested by an in vitro model of cell culture and an in vivo model of wounded meniscal healing.

RESULTS

The results indicated that platelets contained both pro- and antiangiogenic factors including VEGF and endostatin. In unactivated platelets, VEGF and endostatin were contained inside of the platelets. Both VEGF and endostatin were released from the platelets when they were activated by thrombin. However, only VEGF was released from the platelets when they were activated by PAR1, and only endostatin was released from the platelets when they were activated by PAR4. The rat meniscal cells grew much faster in the medium that contained PAR1-activated platelets than in the medium that contained either PAR4-activated platelets or unactivated platelets. The wounds treated with PAR1-activated platelets healed faster than those treated with either PAR4-activated platelets or unactivated platelets. Many blood vessel-like structures were found in the wounded menisci treated with PAR1-activated platelets.

CONCLUSION

The PAR1-activated platelets released high levels of VEGF, which increased the proliferation of rat meniscal cells in vitro, enhanced the vascularization of menisci in vivo, and promoted healing of wounded menisci.

CLINICAL RELEVANCE

Our results suggested that selective activated platelets can be used clinically to enhance healing of wounded meniscal tissue.

Platelet-rich plasma in osteoarthritis treatment: review of current evidence

Platelet-rich plasma (PRP) is defined as a volume of plasma with a platelet concentration higher than the average in peripheral blood. Many basic, preclinical and even clinical case studies and trials report PRP’s ability to improve musculoskeletal conditions including osteoarthritis, but paradoxically, just as many conclude it has no effect. The purpose of this narrative review is to discuss the available relevant evidence that supports the clinical use of PRP in osteoarthritis, highlighting those variables we perceive as critical. Here, recent systematic reviews and meta-analyses were used to identify the latest randomized controlled trials (RCTs) testing a PRP product as an intra-articular treatment for knee osteoarthritis, compared with an intra-articular control (mostly hyaluronic acid). Conclusions in the identified RCTs are examined and compared. In total, five recent meta-analyses and systematic reviews were found meeting the above criteria. A total of 19 individual trials were identified in the five reviews but only 9 were level of evidence I RCTs, and many had moderate or high risks of bias. At present, results from these RCTs seem to favor PRP use over other intra-articular treatments to improve pain scales in the short and medium term (6–12 months), but the overall level of evidence is low. As a result, clinical effectiveness of PRP for knee osteoarthritis treatment is still under debate. This is, prominently, the result of a lack of standardization of PRP products, scarceness of high quality RCTs not showing high risks of bias, and poor patient stratification for inclusion in the RCTs.

An overview of platelet products (PRP, PRGF, PRF, etc.) in the Iranian studies

Aim

The aim of the study was to carry out a review of published studies on various platelet products in Iranian studies.

Materials & methods

Electronic databases were searched for relevant articles. Two review authors independently extracted data via a tested extraction sheet, and disagreements were resolved by a meeting with a third review author.

Results

Bone disorders (25%), wound and fistula (16%), dental and gingival disorders (14%) and osteoarthritis (11%) have more relative frequency based on different fields.

Conclusion

The necessity of pursuing standard protocols in the preparation of platelet products, stating the precise content of platelets and growth factors, and long-term follow-up of study subjects were the most important points in Iranian studies.

Biologic Approaches to Problems of the Hand and Wrist

Orthobiologics are not used as frequently in the hand and wrist as in other sites. The most frequently reported is the use of bone morphogenetic protein for the treatment of Kienböck disease. Animal studies have described improved tendon healing with the use of platelet-rich plasma (PRP), but no clinical studies have confirmed these results. PRP has been reported to produce improvements in the outcomes of distal radial fractures and osteoarthritis of the trapeziometacarpal in small numbers of patients. The use of orthobiologics in the hand and wrist are promising, but clinical trials are necessary to establish efficacy and safety.

Effectiveness of Teriparatide on Fracture Healing: A Systematic Review and Meta-Analysis

Purpose

Nowadays, the efficacy of teriparatide in treating osteoporosis was widely accepted, but the discussion about using teriparatide to enhance fracture healing hasn’t come to an agreement. This meta-analysis was conducted to evaluate the effectiveness of teriparatide for fracture healing.

Methods

We searched PubMed, the Cochrane Library, and Embase in August 2016 for randomized controlled trials (RCTs) which concerned the treatment of teriparatide for fracture healing.

Results

Finally, a total of 380 patients were randomly assigned in the 5 trials included in this meta-analysis. There was a significant effectiveness with regards to function improvement in patients following fracture, however, there was no significant effectiveness with regards to time of radiographic fracture healing, fracture healing rate and reduction in pain.

Conclusions

This analysis showed that administration of teriparatide following fracture lacked the effectiveness for fracture healing. Moreover, teriparatide administration had no apparent adverse effects. These results should be interpreted with caution because of some clear limitations. If we want to confirm whether teriparatide improves fracture healing, more high-quality randomized controlled trials are needed.

Investigating the Effect of Intra-articular Platelet-Rich Plasma Injection on Union: Pain and Function Improvement in Patients with Scaphoid Fracture

Introduction Fracture of the scaphoid bone is the most common fracture of the carpus. However, the fracture union occurs late or may not heal. Sometimes, fracture healing requires prolong immobilization. Because of potential for joint stiffness, muscle atrophy, or the inability to use the hand during and after prolonged immobilization, there is great incentive to develop therapies that will accelerate bone healing and allow a quick return to work. To date, the effect of platelet-rich plasma (PRP) on scaphoid fracture has not been studied. We aimed to assess the effect of intra-articular PRP injection on union: pain, range of motion, and function in patients with scaphoid fracture. Hypothesis Union: pain reduction and functional improvement can be noticed after PRP use in scaphoid fracture. Materials and Methods A randomized controlled trial was designed with 14 patients with scaphoid fractures (Herbert type B2). Casting was done for them. Seven patients received intra-articular autologous PRP. Patients were followed up 2 weeks after casting using radiography and then at 2 months using radiography and computed tomography (CT) scan to check bone healing. Then patients were followed up for 3 and 6 months and after evaluation of healing by CT scan, the patient-rated wrist evaluation questionnaire was completed and the range of motion of the wrist was measured. Results Analysis revealed significant improvement in pain at rest, as well as during specific and usual activities following PRP injection in the case group. However, no statistically significant difference in wrist motion including radial and ulnar deviation, flexion, and extension was found in 6 months follow-up except some improvement in ulnar deviation after 3 months. However, this study showed that scaphoid union occurred earlier in the case group, but it was not statistically significant. Conclusion PRP may have a significant effect on pain reduction at rest and amount of difficulty in functions including specific and usual activities in patients with scaphoid fractures. Level of Evidence This is a level III, therapeutic trial.

Platelet-rich plasma for the treatment of bone defects: from pre-clinical rational to evidence in the clinical practice. A systematic review

PURPOSE

The treatment of large bone defects represents a significant challenge for orthopaedic surgeons. In recent years, biologic agents have also been used to further improve bone healing. Among these, platelet-rich plasma (PRP) is the most exploited strategy. The aim of the present study was to systematically review the available literature to identify: 1) preclinical in-vivo results supporting the rational of PRP use for bone healing; 2) evidence from the clinical practice on the actual clinical benefit of PRP for the treatment of fractures and complications such as delayed unions and non-unions.

METHODS

A systematic review of the literature was performed on the application of PRP in bone healing, using the following inclusion criteria: pre-clinical and clinical reports of any level of evidence, written in English language, published in the last 20 years (1996-2016), on the use of PRP to stimulate long-bone defect treatment, with focus on fracture and delayed/non-unions healing.

RESULTS

The search in the Pubmed database identified 64 articles eligible for inclusion: 45 were preclinical in-vivo studies and 19 were clinical studies. Despite the fact that the overall pre-clinical results seem to support the benefit of PRP in 91.1 % of the studies, a more in depth analysis underlined a lower success rate, with a positive outcome of 84.4 % in terms of histological analysis, and even lower values considering radiological and biomechanical results (75.0 % and 72.7 % positive outcome respectively). This was also mirrored in the clinical literature, where the real benefit of PRP use to treat fractures and non-unions is still under debate.

CONCLUSION

Overall, the available literature presents major limitations in terms of low quality and extreme heterogeneity, which hamper the possibility to optimize PRP treatment and translate it into a real clinical benefit despite positive preclinical findings on its biological potential to favour bone healing.