25 expert zone cover theme polytrauma management

Platelet-rich plasma for bone healing

to use or not to use?
Sebastian Lippross, Mauro Alini
Introduction At the beginning of the 21st century, the clini-
cal application of platelet-rich plasma (PRP) was considered a
breakthrough in the stimulation and acceleration of bone and
soft tissue healing. Since then, its use has been predominantly
in maxillofacial surgery as an autologous additive to bone
grafts and soft tissue transplants, although other indications
such as chronic diabetic ulcers and some standard orthopedic
procedures have been suggested. This article will clarify the
rationale behind the clinical application of PRP by reviewing
the literature and outlining some of our own observations in
basic research.
Platelets and the growth factors they release are essential for
regulating the cellular events that follow tissue damage. They
adhere, aggregate, form a fibrin mesh, and subsequently re-
lease a large variety of growth factors and cytokines. At least
15 different factors are known to be contained within plate-
lets [13], including platelet derived growth factor (PDRF-bb,
-ab und -aa isoforms), transforming growth factor-beta (TGF-
beta, -beta1 and -beta2 isoforms), platelet factor 4 (PF4), in-
terleukin 1 (IL-1), platelet-derived angiogenesis factor (PDAF),
vascular endothelial growth factor (VEGF), epidermal growth
factor (EGF), llatelet-derived endothelial growth factor
(PDEGF), epithelial cell growth factor (ECGF), insulin-like
growth factor (IGF), osteocalcin (Oc), osteonectin (On), fi-
brinogen (Fg), vitronectin (Vn), fibronectin (Fn) und throm-
bospontin-1 (TSP-1). The impact on bone and tissue regenera-
tion of most of these factors has been recognized by many
authors [413]. As opposed to an artificial composition of re-
combinant proteins, PRP maintains the natural concentra-
tions within a cocktail of growth factors acting on multiple
pathways [14]. Furthermore, artificial recombinant growth
factors require further synthetic or animal proteins as carri-
ers. PRP in contrast serves as a natural carrier itself [15].
Thereby PRP can mimic the highly efficient in vivo situation
much more closely than a custom designed protein prepara-
tion.
As platelet concentrates can be prepared from whole blood
within a short time using relatively simple methods, they have
the potential to be an immunogenically inert additive to pro-
mote rapid healing and tissue regeneration. Preparation of
platelet concentrates usually requires a two step centrifuga-
tion procedure [16]. In the first step full blood is divided into
a platelet-containing and a cell-containing fraction [17]. Dur-
ing the second step, which is high speed centrifugation, plate-
lets can be sedimented and rediluted to the desired volume of
plasma (usually 1/10 of the initial blood volume) yielding
platelet concentrations of more than 1,000,000 platelets/l
[15, 17]. To release the growth factors and cytokines, platelets
need to be activated. In vivo this happens through platelet
agonists like thrombin, collagen, ADP, serotonin, and throm-
boxane A2. For experimental purposes, bovine thrombin and
CaCl2 are the most commonly used agents. In our own studies
26 AODIALOGUE 1 | 07
we have demonstrated equal efficacy for freeze-thaw-activa-
tion of PRP [18]. In clinical practice PRP is used as a liquid,
made from 50100ml of full blood that quickly forms a gel
when applied with thrombin. Several companies have devel-
oped kits and devices for automatic preparation during surgi-
cal procedures.
Although the general concept seems plausible, controversy re-
mains about whether PRP and other platelet preparations
meet the high expectations set by the clinical demands. For
the practitioner it appears very difficult to obtain information
on the actions and the possible risks of using platelet concen-
trates.
Clinical safety considerations Clearly an autologous prepa-
ration does not bear the risks of transmissible diseases nor of
immunogenic reactions. If commercially available devices are
used, FDA approval will usually ensure that the preparation
process is carried out in a sterile and pyrogen free manner. We
are not currently aware of any serious adverse effects that
have occurred when PRP was used for wound healing and
bone grafting. Still, a possible risk arises from bovine throm-
bin that is used to activate PRP. Coagulopathies due to anti-
body formation against thrombin, Factor V, and Factor XI
have been reported after cardiac surgery [19, 20].
Basic researchin vitro and in vivo effects of autologous
platelet concentrates While there are numerous case stud-
ies and small clinical trials on the clinical applications, knowl-
edge about the underlying effects at the cellular level is limit-
ed. Nevertheless, PRP has been shown to stimulate cell
proliferation of osteoblasts and fibroblasts and to upregulate
osteocalcin in these cells [21, 22]. In a recent study by our
own group we demonstrated the differentiation of mesenchy-
mal stem cells (MSC) into bone forming cells in the presence
Application Type of study Study design Conclusion Reference
Treatment of intra-
bony defects
Comparative
controlled clini-
cal study
70 interproximal intrabony osseous
defects were treated with PRP and a
ceramic porous hydroxyapatite (HA)
scaffold or HA and saline
Treatment with PRP and HA led to
significantly more clinical im-
provement than HA and saline
[32]
Treatment of intra-
bony defects
Randomized
clinical trial
(split mouth,
double masked)
Bilateral periodontal intrabony de-
fects were matched in 13 individuals
and treated only with a bovine xeno-
graft or with PRP
PRP significantly increased the
clinical periodontal response of le-
sions treated with xenogenic bone
grafts
[33]
Treatment of
infrabony defects
Prospective case
series
Five similar bilateral paired infrabony
defects were treated with autologous
platelet concentrate (APC) or a biore-
sorbable barrier membrane (MEM)
Similar gain in clinical attachment
level and probing depths in APC
and MEM treated groups
[34]
Lumbar spine fusion Prospective re-
view compared
to historical
results
23 individuals underwent transforam-
inal lumbar interbody spinal fusion
(TLIF) with PRP compared to histori-
cal results
2-year minimum follow-up
showed faster healing in the PRP
group, but no significant differ-
ence in the pseudarthrosis rate
was observed
[35]
Total ankle replace-
ment
Comparative
Study
114 and 66 Agility total ankle replace-
ments were performed without and
with autologous concentrated growth
factors for distal syndesmosis fusion
Autologous concentrated growth
factors appeared to make a sig-
nificant positive difference in the
syndesmosis union rate in total
ankle replacements
[36]
Treatment of mandib-
ular continuity de-
fects in tumor cases
Prospective
study
44 individuals were treated with bone
graft and PRP and bone graft alone
Maturity index of bone grafts
with PRP was higher than in bone
grafts alone
[37]
Table 1 Application in bone healing
27 expert zone cover theme polytrauma management
of PRP [18]. An increase in growth and differentiation of PRP-
treated periodontal ligament cells has been shown by two
groups [10, 23]. Further investigation revealed stimulation of
the mitogenic (ie, transforming) response to PRP in human
trabecular and rat bone marrow cells [24, 25]. Additionally,
we were able to demonstrate a strong effect on the expansion
of endothelial progenitor cells by platelet-released growth fac-
tors [26].
In vivo studies do not support the positive actions of PRP. In
fact, in one of the most recent investigations PRP decreased
the osteoinductivity of demineralized bone matrix in nude
mice [27]. Other researchers performed trials on various ani-
mals and reported no beneficial effect of using PRP for bone
healing [28] or suggest a low regenerative potential for its use
in combination with xenogenic bone grafts [29]. Some studies
also show effective augmentation of porous biomaterial in rats
[30] and sheep [31]. Careful analysis of these studies reveals
that none are scientifically comparable. Therefore, we cannot
draw an overall scientific conclusion of PRP actions in animal
models.
Clinical trials and case studies Case reports and small clin-
ical trials have been reported in craniomaxillofacial surgery
as in other specialties. Table 1 and table 2 display a selection of
such studies which overall support the beneficial effect of PRP
and other platelet concentrates. As previously mentioned, in
animal studies the two main factors making it almost impos-
sible to compare any two of the studies published are the lack
of a standardized PRP preparation protocol (Table 3) and the
lack of commonly accepted evaluation criteria.
Application Type of study Study design Conclusion Reference
Treatment of chronic
ellbow tendinosis
Cohort study Out of a cohort of 150 patients with
chronic elbow tendinosis, 15 were
given one injection of PRP, and 5
were given one injection of bupiva-
caine
Pain was reduced in patients
treated with PRP compared to the
control group in this pilot study
[38]
Treatment of diabetic
foot ulcers
Prospective
randomized
controlled trial
40 individuals were randomized into
a PRP- and saline-gel group and fol-
lowed up for 12 weeks
Significantly more ulcers healed in
the PRP group
[39]
Treatment of diabetic
foot ulcers
Meta-analysis More than 25,000 cases of diabetic
foot ulcers were treated with and
without platelets
Ulcers treated with platelet con-
centrate were significantly more
likely to heal
[40]
Table 2 Other applications
Device Preparation time Platelet yield (whole blood) as stated
by manufacturer
Company
GPS
(gravitational platelet separation)
12 min Up to 8 Cell Factor Technologies
PCCS (platelet concentrate collec-
tion system)
20 min Up to 7 Implant Innovations
Symphony II 15 min Up to 6 DePuy
SmartPReP 15 min Up to 9 Harvest Technologies Corp
Magellan 15 min Up to 10 Medtronic
Table 3 Commercially available preparation systems
28 AODIALOGUE 1 | 07
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Sebastian Lippross, MD
Biomaterials and Tissue Engineering
Program
AO Research Institute, Davos
[email protected]
Mauro Alini, PhD
Head of Biomaterials and Tissue
Engineering Program
AO Research Institute, Davos
[email protected]
Summary and conclusions PRP preparation provides a
fairly simple method to deliver a variety of natural growth
factors to the patient. High concentrations of proteins acting
in concert through different pathways can be achieved by
commercially available systems that can be used in the oper-
ating room. The risks of contamination and immunogenic
response are considerably low when using FDA approved sys-
tems. The remaining risk of coagulopathies could be mini-
mized by using alternative activation methods to standard
bovine thrombin. On the whole, the beneficial effects of PRP
in clinical application remain doubtful. No appropriate clini-
cal investigations that meet all modern quality criteria have
been conducted up to now.
Based on our own and other groups in vitro findings, one
could hypothesize that PRP can be supportive of the healing
processes if used in the right manner. The appropriate use of
PRP has yet to be determined by larger randomized controlled
trials. Additional basic investigations on the mechanisms of
action could elucidate under which conditions PRP can act as
a tissue healing additive.
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