Platelet rich therapies for long bone healing in adult

Broken bones (fractures) are a major cause of disability in adults. The time taken for a bone to heal (achieve "union") is an important factor in determining recovery after an injury. A minority of fractures fail to heal at all or in an appropriate period of time. This review set out to find out whether treatment with platelet rich therapy (PRT) accelerates bone healing and reduces complications. Typically, platelet treatment involves the donation of a single venous blood sample from which the active, platelet-rich, fraction is extracted usually by a process of centrifugation. Additional chemicals may be added to the active fraction to alter its biological and material handling properties.

Only one study, involving 21 participants, was included in this review. The study compared PRT and bone graft versus bone graft alone (control) in patients with osteoarthritis of the knee who had surgery where a wedge of bone was cut (osteotomy) from their tibia (shin bone) in order to change the pattern of weight bearing on the knee. As in a fracture, the time for the bone to heal is an important factor in determining recovery after an osteotomy. The study found no difference between the PRT and control groups in patient-reported or clinician-assessed functional outcomes at one year. However, based on radiographic (x-ray) measures of bone healing, the study found a higher proportion of bones had healed by one year in those participants who had completed the study. One adverse event was reported in a participant receiving platelet-rich therapy

From the limited evidence that is currently available, the review found that PRT had no effect on functional outcomes. PRT may be beneficial in accelerating and improving the incidence of union in osteotomies. The only complication reported was not necessarily related to the PRT treatment. No data were available regarding PRT in the treatment of acute fractures, non-united fractures or large bony defects. One other study involving hip fracture patients is currently underway, and will provide further evidence concerning the use of PRT in the future.

Authors' conclusions: 

While a potential benefit of platelet-rich therapies to augment long bone healing in adults cannot be ruled out, the currently available evidence from a single trial is insufficient to support the routine use of this intervention in clinical practice. Future trials should focus on reporting patient-reported functional outcomes from all trial participants for a minimum follow-up of one year.

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Background: 

The morbidity and socioeconomic costs associated with long bone healing are considerable. Platelet-rich therapies are autologous blood products with a greater concentration of platelets than physiological whole blood. Despite promising results from a number of in-vitro animal studies, clinical evidence to support the use of platelet-rich therapy in long bone healing is unclear.

Objectives: 

To assess the effects (benefits or harms) of platelet-rich therapies for treating long bone osteotomies, acute fractures, un-united fractures and defects in adults.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (8 November 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 4), MEDLINE (1948 to November Week 1 2011) and EMBASE (1980 to Week 44 2011). Trial registers and reference lists of articles were also searched.

Selection criteria: 

Randomised and quasi-randomised controlled clinical trials evaluating any type of platelet-rich therapy compared with either no additional treatment or a placebo in the management of long bone osteotomies, acute fractures, un-united fractures and defects in adults. Studies including participants over 18 years of age; reporting functional outcomes, time to union, non-union, secondary procedures such as for fixation failure or delayed or non-union, adverse effects, pain or costs were included.

Data collection and analysis: 

Two authors independently selected the studies for inclusion in the review. Studies were assessed for the risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Treatment effects for dichotomous outcomes were expressed with risk ratios (RR) and continuous measures with mean differences, together with 95% confidence intervals (CI).

Main results: 

Only one eligible study, involving 21 participants, was included. The study compared platelet-rich therapy and allogenic bone graft with allogenic bone graft alone in patients undergoing corrective osteotomy for medial compartment osteoarthrosis of the knee. The risk of bias associated with this study was substantial. There was no significant difference in patient-reported or clinician-assessed functional outcome scores between groups at one year. There was a statistically significant benefit from platelet-rich therapy in the proportion of bones that were united at one year (8/9 versus 3/9; RR 2.67; 95% CI 1.03 to 6.91). This benefit, however, was not maintained when assuming poor outcomes for participants who were lost to follow-up (8/11 versus 3/10; RR 2.42; 95% CI 0.88 to 6.68). One adverse event was reported in a participant receiving platelet-rich therapy.

One other eligible study involving hip fracture patients is currently underway.

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