Research: Can Platelet Rich Plasma improve bone healing in patients with osteoarthritis or nonunion healing?
Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C
In this article, we will examine the medical research concerning the effectiveness of platelet-rich plasma therapy on stimulating bone healing and repair. In situations of osteoarthritis, bone takes on unusual characteristics. You know these characteristics to be one of overgrowth and bone spurs and bone that can be significantly weaker. In osteoarthritis, the goal is to repair a damaged joint enough that abnormal bone growth is stopped. In cases of non-union, whether from an injury that never healed right or the result of a failed surgical fusion, the hope is that Platelet Rich Plasma injections can restart the bone healing process and influence the healing of the bone. So we have two distinct scenarios, one where we want to stop bone overgrowth and one where we want to restart bone growth. The difference of course is that in non-union problems, PRP is asked to focus on that area of the bone that needs to patch itself. In osteoarthritis, we are asking PRP to help the entire joint change from a destructive, degenerative joint environment to one that is more pro-healing and stops bone overgrowth.
Starting with non-unions
A few years back, interest in Platelet Rich Plasma as a means to help accelerate or restart repair in damaged bones picked up momentum. In 2013 doctors writing in the Scientific World Journal (1) wrote:
“Platelet-rich plasma (PRP) therapy is a recently developed technique that uses a concentrated portion of autologous blood to try to improve and accelerate the healing of various tissues. There is considerable interest in using these PRP products for the treatment used in bone deficiency healing. Because PRP products are safe and easy to prepare and administer, there has been increased attention toward using PRP in numerous clinical settings. The benefits of PRP therapy appear to be promising, and many investigators are exploring the ways in which this therapy can be used in the clinical setting.”
There is research that goes back even further but the idea that PRP can be beneficial in healing bone deficits or “non-unions” has been circulating among doctors for many years.
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
Bring the research currently, in February 2021 doctors writing in the journal Current Osteoporosis Reports (2) explain the progress in understanding PRP as a treatment for the management of non-union fractures.
“The treatment of non-union fractures represents a significant challenge for orthopedic surgeons. In recent years, biological agents have been investigated and utilized to support and improve bone healing. Among these agents, platelet-rich plasma (PRP) is an emerging strategy that is gaining popularity. . . The majority of published studies reported that PRP accelerated fracture healing; however, this evidence was predominantly level IV. (What this means is that the majority of the research is the patient outcome, how people felt or responded to treatment). The lack of randomized, clinical trials (level I-II evidence) is currently hampering the successful clinical translation of PRP as a therapy for non-union fractures. (There is not enough research to suggest in placebo or comparison treatment studies that can isolate the benefits of PRP). This is despite the positive reports regarding its potential to heal non-union fractures when used in isolation or in combination with other forms of treatment.”
In other words, like much of the research surrounding PRP for bone healing, there is a sense that this works and is beneficial for patients but there is not enough research for the scientific community to whole-heartedly embrace it.
Bone regeneration studies:
“After 18 months of follow-up, the non-union healed completely and the limb strength returned to normal. At the 2-year follow-up, the plate was removed.”
A February 2021 case history was published by doctors in the Nagoya Journal of Medical Science, (3) a journal produced by Japan’s Nagoya University School Of Medicine.
In this case history, a patient is presented with a non-union fracture of the ulnar bone and the PRP treatments the patient received. Let’s let the attending doctors take over from here:
“Non-union is a serious postoperative complication of fracture. Early detection and intervention can avoid revision surgery. Platelet-rich plasma releases many active tissue factors and has the potential to promote fracture healing. Percutaneous injection of platelet-rich plasma at the fracture site may avoid surgical treatment when non-union occurs. We present a case of atrophic (atrophied) non-union of an ulna fracture treated conservatively with percutaneous injection of platelet-rich plasma.
The case is of a 12-year-old boy who broke his arm during martial arts training. A surgery with plates and screw put the forearm back together. Six months after the surgery the patient and his parents reported “persistent weakness in the affected forearm. Radiologic images revealed no signs of healing of the ulna. . . atrophic ulna non-union was diagnosed. Because the patient had been playing jazz drums three times per week (1 hour per playing session) after surgery, (his doctors) suspected that the non-union was related to the patient’s overuse of the affected limb.”
The patient received PRP injections at the failed union site. “Following treatment, a plaster forearm splint was fixed for 4 weeks. The patient attended regular follow-up visits to assess fracture healing and evaluate any potential symptoms. After 18 months of follow-up, the non-union healed completely and the limb strength returned to normal. At the 2-year follow-up, the plate was removed.”
University researchers in Mexico have published findings on PRP’s ability to regenerate bone. (4) Researchers assess bone regeneration in mandibular (jaw) fractures, that were treated with PRP. The platelet-rich plasma treatments increased the bone intensity and density in the fracture trace allowing bone regeneration and recovery in a shorter time than another group of patients in which it was not used. The study showed bone growth at between 3 and 5 weeks.
Better than a nail
Doctors at leading Turkish research hospitals writing in the European Journal of Orthopaedic Surgery & Traumatology (5) evaluated the effects of platelet-rich plasma on healing rates and healing time in the treatment of long bone non-unions treated by an intramedullary nail previously.
Long bone non-unions are broken bones that failed to heal properly. Surgical intervention including the use of nails to reset the bone during surgery is a standard treatment. Sometimes this fails and turns into the problem of a non-union of a broken bone. The next step usually is “Exchange nailing” for the failed bone healing. Old nail out, bigger new nail in.
The Turkish team then took 14 patients scheduled for the nail exchange and gave them PRP injections instead. They also exchanged the nail in 15 other patients as control.
The PRP patients recovered faster and achieved greater bone union 92.8% of the cases in the PRP group to 80% of the nail exchange group.
Healing non-union during a nail exchange and other non-healing factors
A June 2020 paper in the journal Bone Reports (6) helps explain how PRP works.
“The biologic rationale for (PRP) use in bone healing involves the local delivery of cytokines (growth factors) that are released from a pool of degranulating (platelets that are releasing growth factors and other immune system cells in response to need to heal and injury) platelets.
Local injection of PRP aims to mimic and augment the biological (healing) function of the hematoma (the blood that collects at an injury site) at the fracture site. Specifically, the granules in platelets contain and release PDGF, transforming growth factor-beta 1 (TGF-b1), VEGF, epidermal growth factor, fibroblast growth factor, and insulin-like growth factor which have been addressed to enhance the healing process of injured tissues.”
Here is a brief summary explanation:
- PDGF (Platelet-derived Growth Factor) initiates connective tissue and bone healing through the promotion of collagen and protein synthesis.
- Transforming Growth Factor (TGF) including TGF-b1 stimulates chondrocyte (Cartilage growth) and decreases the catabolic activity (breakdown of cartilage). There is also research to suggests that TGF-bi stimulates stem cell activity in the injured area.
- VEGF (Vascular Endothelial Growth Factor) creates new blood vessels for the healing factors to get to the site of the injury. Expanding the healing factors access to the injury.
The clinical significance of bone changes in osteoarthritis
In a study we often cite on this website Professor Tuhina Neog of Boston University School of Medicine, writing in the journal Therapeutic Advances in Musculoskeletal Disease (6) describes the “Clinical significance of bone changes in osteoarthritis.” Here are some of the points she made:
- Bone changes associated with osteoarthritis are common, so it is not all about cartilage. The bone changes include subchondral bone attrition (wasting away).
- Subchondral bone changes on MRIs show bone marrow lesions (swelling and deterioration of the bone marrow) are common.
Further in its desire to quickly repair and remodel itself to meet the challenges of degenerative joint disease, the bone increases its turnover rate and produces a far inferior bone with less mineralized than normal bone.
So we have a changing joint environment where the bone is degenerating and hurriedly being replaced by inferior bone. The whole joint degeneration process is in full process.
This is where researchers are now suggesting platelet-rich plasma therapy as a means to not only repair bone degeneration but also to help reverse the toxic healing environment.
Researchers publishing in the journal Expert Opinion on Biological Therapy (7) write:
- Successful healing of large bone defects is a complicated phenomenon because the body’s natural ability often fails to effectively repair the large bone defects. (The body cannot generate enough inflammation to repair the bone.)
The researchers here are calling for new treatments to increase the quality and accelerate bone healing. They conclude that: Platelet concentrates (PRP) in different forms can be considered an attractive option for such purpose because Platelets are a natural source of growth factors, and cytokines (the cells that comprise the healing signaling communication system), and other healing factors.
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Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated April 2, 2021