The biomechanical
and histological effects of platelet-rich plasma on fracture healing
and histological effects of platelet-rich plasma on fracture healing
Guzel Y, Karalezli N, Doral M, et al. Knee Surg Sports
Traumatol, Arthrosc. 2013 Oct 30 [Epub ahead of print].
Traumatol, Arthrosc. 2013 Oct 30 [Epub ahead of print].
Take Home
Message: The administration of platelet-rich plasma (PRP) using a standard preparation
technique may accelerate long bone fracture healing.
Message: The administration of platelet-rich plasma (PRP) using a standard preparation
technique may accelerate long bone fracture healing.
Platelets, which are naturally occurring in blood tissue,
secrete growth factors and cytokines that may enhance regenerative processes in
the body. Platelet-rich plasma (PRP) may be beneficial as an adjunct therapy
with spinal fusion surgery, prosthetic and periodontal therapy, and the
treatment of non-unions. However, there is still little known about the
biomechanical effects of PRP on the healing of fractures. The aim of this prospective,
randomized animal study was to determine the effect of PRP on the fracture
healing of long bones. The authors divided 70 female rats into one of three
groups: no PRP group, PRP-added group, and control group (no fracture, no PRP).
Rats from the no PRP (n=30) and PRP-added (n=30) groups underwent mid-diaphysis
transverse femur fractures and had their fractures fixed with 1-mm K-wires. Only
the PRP-added group then received an autologous PRP injection in the fracture
line prepared as per a standardized protocol (Anitua technique). The authors performed histological
assessments at four weeks and nine weeks post-surgery to determine the extent
of bone recovery. Some rats also underwent biomechanical testing in the ninth
week post-surgery to assess the structural integrity of the bone (No-PRP group:
8 rats, PRP-added group: 8 rats, and control group: 10 rats). The authors found
that rats in the PRP-added group demonstrated earlier weight-bearing,
accelerated fracture healing (e.g. osteochondral bone formation, reorganization
of the cancellous bone), and were able to withstand more force when maximum
loading was applied to the bone, compared with rats that did not receive PRP. Interesting
to note, the femurs of the PRP-added group were as strong as the control
group’s femurs that were never fractured.
secrete growth factors and cytokines that may enhance regenerative processes in
the body. Platelet-rich plasma (PRP) may be beneficial as an adjunct therapy
with spinal fusion surgery, prosthetic and periodontal therapy, and the
treatment of non-unions. However, there is still little known about the
biomechanical effects of PRP on the healing of fractures. The aim of this prospective,
randomized animal study was to determine the effect of PRP on the fracture
healing of long bones. The authors divided 70 female rats into one of three
groups: no PRP group, PRP-added group, and control group (no fracture, no PRP).
Rats from the no PRP (n=30) and PRP-added (n=30) groups underwent mid-diaphysis
transverse femur fractures and had their fractures fixed with 1-mm K-wires. Only
the PRP-added group then received an autologous PRP injection in the fracture
line prepared as per a standardized protocol (Anitua technique). The authors performed histological
assessments at four weeks and nine weeks post-surgery to determine the extent
of bone recovery. Some rats also underwent biomechanical testing in the ninth
week post-surgery to assess the structural integrity of the bone (No-PRP group:
8 rats, PRP-added group: 8 rats, and control group: 10 rats). The authors found
that rats in the PRP-added group demonstrated earlier weight-bearing,
accelerated fracture healing (e.g. osteochondral bone formation, reorganization
of the cancellous bone), and were able to withstand more force when maximum
loading was applied to the bone, compared with rats that did not receive PRP. Interesting
to note, the femurs of the PRP-added group were as strong as the control
group’s femurs that were never fractured.
The results
of this study suggest that injection of PRP into a fracture site of a long bone
may speed recovery and increase the bone’s ability to withstand stress.
Although PRP injections have yet to be standardized into a most effective technique
and concentration, the Anitua technique used in this study shows promising
effects in the healing of fractures in long bones. However, clinicians should
keep in mind that this study was conducted on rats and not on human models. Furthermore,
this study did not look at the treatment of nonunions, a serious complication
in fracture healing, and so the effect of PRP on nonunions has yet to be
determined. Despite these limitations, these findings are intriguing and may
eventually prompt clinical trials to determine if PRP can accelerate fracture
healing or avoid nonunions in humans.
of this study suggest that injection of PRP into a fracture site of a long bone
may speed recovery and increase the bone’s ability to withstand stress.
Although PRP injections have yet to be standardized into a most effective technique
and concentration, the Anitua technique used in this study shows promising
effects in the healing of fractures in long bones. However, clinicians should
keep in mind that this study was conducted on rats and not on human models. Furthermore,
this study did not look at the treatment of nonunions, a serious complication
in fracture healing, and so the effect of PRP on nonunions has yet to be
determined. Despite these limitations, these findings are intriguing and may
eventually prompt clinical trials to determine if PRP can accelerate fracture
healing or avoid nonunions in humans.
Questions for Discussion: What is your
experience as a clinician with PRP? Aside from PRP, what other therapeutic
interventions have you used to promote the healing of long bone fractures? Have
you found one intervention to be superior in terms of return-to-play/functionality
or incidence of re-fracture?
experience as a clinician with PRP? Aside from PRP, what other therapeutic
interventions have you used to promote the healing of long bone fractures? Have
you found one intervention to be superior in terms of return-to-play/functionality
or incidence of re-fracture?
Written
by: Tiffany Kobordo
by: Tiffany Kobordo
Reviewed
by: Lisa Chinn and Jeffrey Driban
by: Lisa Chinn and Jeffrey Driban
Related
Posts:
Posts:
Guzel Y, Karalezli N, Bilge O, Kacira BK, Esen H, Karadag H, Toker S, Göncü RG, & Doral MN (2013). The biomechanical and histological effects of platelet-rich plasma on fracture healing. Knee Surgery, Sports Traumatology, Arthroscopy PMID: 24170188
I think the thought of using PRP to decrease healing time is a tool that could be used more in the future. It may be awhile before it is used at anywhere but elite levels of athletics. The increase in cost may not be worth it for insurance purposes if it only decreases healing time by a week or two. The increase in biomechanical strength shows that it can help in strengthening the bone. A case where I could see the possibility of PRP use could be Aaron Rodgers trying to return quickly from a fractured clavicle. The use of PRP could possibly help in the healing process and increase the strength of the bone for possibly stresses put on it during a football game.
Other rehab techniques that I have used are non-thermal ultrasound, and therapeutic exercise to help the bone heal along the lines of stress. Most fracture rehabs take more cautious approaches and make sure that the bone is in the remodeling phase before returning to play. I think the biggest issue that needs to be addressed is what stresses are put on the body for the sport that an athlete plays. If you understand the stresses that need to be put on the bone, you can use progressive introduction to physical activities to promote healing of bone density, mass, and strength due to tissue healing along the lines of stress.
Perhaps in the future, PRP will be used more often to decrease the time it takes for the bone to reach this stage of healing. The ratio of cost to time saved will determine if it is used anywhere but elite levels though.
I agree with Zach in that if the cost to benefit ratio can be justified for PRP then it can definitely be utilized more often. The use in elite athletes and in major Division I collegiate settings is growing and more widely known, but as far as athletic trainers everywhere using this as a go-to treatment with accelerating the healing process, we have a long way to go. I recall Tiger Woods openly speaking about PRP injections when he tore his ACL years ago and PRP becoming a hot topic because a lot of the general public was unfamiliar with the term and treatment. Any treatment or modality that can be shown to accelerate healing is of interest in the medical field, especially in sports medicine where safe return to play time is so crucial. Athletes, coaches, athletic directors, team owners, donors and fans all want key players to return quickly when injured, but the evidence should be substantial for healthcare providers to incorporate treatments more frequently that still lack a lot of high level evidence research.
I agree with Zach and Colby, that especially in the higher levels of competition (DI and professional sports), those one or two weeks earlier of a return to play become much more crucial. I also feel that more research needs to be conducted to fully understand the effect of PRP on fracture healing, especially on human bone, as this study was conducted on rats and not on human models. Agreeing again with Colby, I feel that health care providers and clinicians should first determine if there is a substantial base of evidence before trying new treatments that may not necessarily have yet been validated through research.
I agree with the previous comments that this could have a place within professional and DI college athletics. It is interesting to see that this research is being completed. Since the rats were injected and then no other intervention was taken, I would be curious to see how the bone would react if immobilization was applied. Right now, that is common practice for most long bone fractures. It would be interesting to see if there were changes in the strength of the bone if the stress was eliminated or if the stress helped to promote healing in conjunction with the PRP. This is a very interesting possibility in the future.
PRP may find its way into D1 college athletics in the future; however, more research will need to be done on it in the meantime. Currently it is an expensive treatment and only a small fraction of the population can afford it. While I think it is a useful technique, it will not find its way into common practice for a while.