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25

Sebastian Lippross, Mauro Alini

Platelet-rich plasma for bone healing

to use or not to use?

Introduction

At the beginning of the 21st century, the clinical 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 release a large variety of growth factors and cytokines. At least
15 different factors are known to be contained within platelets [13], including platelet derived growth factor (PDRF-bb,
-ab und -aa isoforms), transforming growth factor-beta (TGFbeta, -beta1 and -beta2 isoforms), platelet factor 4 (PF4), interleukin 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), fibrinogen (Fg), vitronectin (Vn), fibronectin (Fn) und thrombospontin-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 recombinant proteins, PRP maintains the natural concentrations within a cocktail of growth factors acting on multiple
pathways [14]. Furthermore, artificial recombinant growth
factors require further synthetic or animal proteins as carriers. 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 preparation.
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 promote rapid healing and tissue regeneration. Preparation of
platelet concentrates usually requires a two step centrifugation procedure [16]. In the first step full blood is divided into
a platelet-containing and a cell-containing fraction [17]. During the second step, which is high speed centrifugation, platelets 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 thromboxane A2. For experimental purposes, bovine thrombin and
CaCl2 are the most commonly used agents. In our own studies

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we have demonstrated equal efficacy for freeze-thaw-activation 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 developed kits and devices for automatic preparation during surgical procedures.
Although the general concept seems plausible, controversy remains 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 concentrates.
Clinical safety considerations

Clearly an autologous preparation 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

Table 1

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 thrombin that is used to activate PRP. Coagulopathies due to antibody 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, knowledge about the underlying effects at the cellular level is limited. 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 mesenchymal stem cells (MSC) into bone forming cells in the presence

Application in bone healing

Application

Type of study

Study design

Conclusion

Reference

Treatment of intra-

Comparative

70 interproximal intrabony osseous

Treatment with PRP and HA led to

[32]

bony defects

controlled clini-

defects were treated with PRP and a

significantly more clinical im-

cal study

ceramic porous hydroxyapatite (HA)

provement than HA and saline

scaffold or HA and saline

Treatment of intra-

Randomized

Bilateral periodontal intrabony de-

PRP significantly increased the

bony defects

clinical trial

fects were matched in 13 individuals

clinical periodontal response of le-

(split mouth,

and treated only with a bovine xeno-

sions treated with xenogenic bone

double masked)

graft or with PRP

grafts

Treatment of

Prospective case

Five similar bilateral paired infrabony

Similar gain in clinical attachment

infrabony defects

series

defects were treated with autologous

level and probing depths in APC

platelet concentrate (APC) or a biore-

and MEM treated groups

[33]

[34]

sorbable barrier membrane (MEM)

Lumbar spine fusion

Prospective re-

23 individuals underwent transforam-

2-year minimum follow-up

view compared

inal lumbar interbody spinal fusion

showed faster healing in the PRP

to historical

(TLIF) with PRP compared to histori-

group, but no significant differ-

results

cal results

ence in the pseudarthrosis rate

[35]

was observed
Total ankle replace-

Comparative

114 and 66 Agility total ankle replace-

Autologous concentrated growth

ment

Study

ments were performed without and

factors appeared to make a sig-

with autologous concentrated growth

nificant positive difference in the

factors for distal syndesmosis fusion

syndesmosis union rate in total

[36]

ankle replacements
Treatment of mandib- Prospective

44 individuals were treated with bone

Maturity index of bone grafts

ular continuity de-

graft and PRP and bone graft alone

with PRP was higher than in bone

fects in tumor cases

study

grafts alone

[37]

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of PRP [18]. An increase in growth and differentiation of PRPtreated 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 factors [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 animals 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

Table 2

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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 clinical 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 impossible 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.

Other applications

Application

Type of study

Study design

Conclusion

Reference

Treatment of chronic

Cohort study

Out of a cohort of 150 patients with

Pain was reduced in patients

[38]

chronic elbow tendinosis, 15 were

treated with PRP compared to the

given one injection of PRP, and 5

control group in this pilot study

ellbow tendinosis

were given one injection of bupivacaine

Treatment of diabetic

Prospective

40 individuals were randomized into

Significantly more ulcers healed in

foot ulcers

randomized

a PRP- and saline-gel group and fol-

the PRP group

controlled trial

lowed up for 12 weeks

Meta-analysis

More than 25,000 cases of diabetic

Ulcers treated with platelet con-

foot ulcers were treated with and

centrate were significantly more

without platelets

likely to heal

Treatment of diabetic
foot ulcers

Table 3

[39]

[40]

Commercially available preparation systems

Device

Preparation time

Platelet yield (whole blood) as stated

Company

by manufacturer
GPS

12 min

Up to 8

Cell Factor Technologies

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

(gravitational platelet separation)

PCCS (platelet concentrate collection system)

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AODIALOGUE 1 | 07

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 operating room. The risks of contamination and immunogenic
response are considerably low when using FDA approved systems. The remaining risk of coagulopathies could be minimized by using alternative activation methods to standard
bovine thrombin. On the whole, the beneficial effects of PRP
in clinical application remain doubtful. No appropriate clinical 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.

Sebastian Lippross, MD

Biomaterials and Tissue Engineering

Program
AO Research Institute, Davos
sebastian.lippross@aofoundation.org

Mauro Alini, PhD

Head of Biomaterials and Tissue

Engineering Program
AO Research Institute, Davos
mauro.alini@aofoundation.org

Bibliography
1 Eppley BL, Woodell JE, Higgins J (2004) Platelet quantification
and growth factor analysis from platelet-rich plasma: implications for
wound healing. Plast Reconstr Surg; 114: 15021508.
2 Weibrich G, Kleis WK, Hafner G, et al (2002) Growth factor levels
in platelet-rich plasma and correlations with donor age, sex, and
platelet count. J Craniomaxillofac Surg; 30:97102.
3 Yazawa M, Ogata H, Nakajima T, et al (2003) Basic studies on the
clinical applications of platelet-rich plasma. Cell Transplant; 12:509
518.
4 Bostrom MP, Saleh KJ, Einhorn TA (1999) Osteoinductive growth
factors in preclinical fracture and long bone defects models. Orthop
Clin North Am; 30:647658.
5 Boyan BD, Ranly DM, Schwartz Z (2006) Use of growth factors to
modify osteoinductivity of demineralized bone allografts: lessons for
tissue engineering of bone. Dent Clin North Am; 50:21728, viii.
6 Einhorn TA (1995) Enhancement of fracture-healing. J Bone Joint
Surg Am; 77:940956.
7 Glowacki J (1998) Angiogenesis in fracture repair. Clin Orthop Relat
Res; S82S89.
8 Laurencin CT, Ambrosio AM, Borden MD, et al (1999) Tissue
engineering: orthopedic applications. Annu Rev Biomed Eng; 1:1946.
9 Logeart-Avramoglou D, Anagnostou F, Bizios R, et al (2005)
Engineering bone: challenges and obstacles. J Cell Mol Med; 9:7284.
10 Lucarelli E, Beccheroni A, Donati D, et al (2003) Platelet-derived
growth factors enhance proliferation of human stromal stem cells.
Biomaterials; 24:30953100.
11 Mistry AS, Mikos AG (2005) Tissue engineering strategies for bone
regeneration. Adv Biochem Eng Biotechnol; 94:122.
12 Salgado AJ, Coutinho OP, Reis RL (2004) Bone tissue
engineering: state of the art and future trends. Macromol Biosci;
4:743765.
13 Street J, Bao M, deGuzman L, et al (2002) Vascular endothelial
growth factor stimulates bone repair by promoting angiogenesis and
bone turnover. Proc Natl Acad Sci USA; 99:96569661.
14 Anitua E, Andia I, Ardanza B, et al (2004) Autologous platelets
as a source of proteins for healing and tissue regeneration. Thromb
Haemost; 91:415.
15 Marx RE (2001) Platelet-rich plasma (PRP): what is PRP and what is
not PRP? Implant Dent; 10:225228.
16 Weibrich G, Kleis WK, Kunz-Kostomanolakis M, et al (2001)
Correlation of platelet concentration in platelet-rich plasma to the
extraction method, age, sex, and platelet count of the donor. Int J Oral
Maxillofac Implants; 16:693699.
17 Barthelmai W (1969) [Isolation of thrombocytes from small blood
volumes]. Klin Wochenschr; 47:266270.
18 Meury T KLSTAM. Effect of platelet-rich-plasma on bone marrow
stromal cell differentiation. [abstract]. ASBMR 26th annual meeting.
2007.
19 Cmolik BL, Spero JA, Magovern GJ, et al (1993) Redo cardiac
surgery: late bleeding complications from topical thrombin-induced
factor V deficiency. J Thorac Cardiovasc Surg; 105:222227.

expert zone

cover theme polytrauma management

20 Spero JA (1993) Bovine thrombin-induced inhibitor of factor V and

bleeding risk in postoperative neurosurgical patients. Report of three
cases. J Neurosurg; 78:817820.
21 Graziani F, Ivanovski S, Cei S, et al (2006) The in vitro effect of
different PRP concentrations on osteoblasts and fibroblasts. Clin Oral
Implants Res; 17:212219.
22 Dolder JV, Mooren R, Vloon AP, et al (2006) Platelet-Rich
Plasma: Quantification of Growth Factor Levels and the Effect on
Growth and Differentiation of Rat Bone Marrow Cells. Tissue Eng.
23 Annunziata M, Oliva A, Buonaiuto C, et al (2005) In vitro celltype specific biological response of human periodontally related cells
to platelet-rich plasma. J Periodontal Res; 40:489495.
24 Gruber R, Varga F, Fischer MB, et al (2002) Platelets stimulate
proliferation of bone cells: involvement of platelet-derived growth
factor, microparticles and membranes. Clin Oral Implants Res; 13:529
535.
25 Oprea WE, Karp JM, Hosseini MM, et al (2003) Effect of platelet
releasate on bone cell migration and recruitment in vitro. J Craniofac
Surg; 14:292300.
26 Lippross S, Verrier S, Hoffmann A, et al (2007) Platelet released
growth factors boost expansion of endothelial progenitor cells
[abstract]. 53rd Annual Meeting of the Orthopaedic Research Society 2007;
Poster No 481.
27 Ranly DM, Lohmann CH, Andreacchio D, et al (2007) Plateletrich plasma inhibits demineralized bone matrix-induced bone
formation in nude mice. J Bone Joint Surg Am; 89:139147.
28 Pryor ME, Yang J, Polimeni G, et al (2005) Analysis of rat
calvaria defects implanted with a platelet-rich plasma preparation:
radiographic observations. J Periodontol; 76:12871292.
29 Sanchez AR, Sheridan PJ, Eckert SE, et al (2005) Regenerative
potential of platelet-rich plasma added to xenogenic bone grafts
in peri-implant defects: a histomorphometric analysis in dogs. J
Periodontol; 76:16371644.
30 Rai B, Oest ME, Dupont KM, et al (2007) Combination of plateletrich plasma with polycaprolactone-tricalcium phosphate scaffolds for
segmental bone defect repair. J Biomed Mater Res A.
31 Lucarelli E, Fini M, Beccheroni A, et al (2005) Stromal stem cells
and platelet-rich plasma improve bone allograft integration. Clin
Orthop Relat Res; 6268.
32 Okuda K, Tai H, Tanabe K, et al (2005) Platelet-rich plasma
combined with a porous hydroxyapatite graft for the treatment of
intrabony periodontal defects in humans: a comparative controlled
clinical study. J Periodontol; 76:890898.
33 Hanna R, Trejo PM, Weltman RL (2004) Treatment of intrabony
defects with bovine-derived xenograft alone and in combination
with platelet-rich plasma: a randomized clinical trial. J Periodontol;
75:16681677.
34 Papli R, Chen S (2007) Surgical treatment of infrabony defects with
autologous platelet concentrate or bioabsorbable barrier membrane: a
prospective case series. J Periodontol; 78:185193.

29

35 Hee HT, Majd ME, Holt RT, et al (2003) Do autologous growth

factors enhance transforaminal lumbar interbody fusion? Eur Spine J;
12:400407.
36 Coetzee JC, Pomeroy GC, Watts JD, et al (2005) The use of
autologous concentrated growth factors to promote syndesmosis
fusion in the Agility total ankle replacement. A preliminary study.
Foot Ankle Int; 26:840846.
37 Marx RE, Carlson ER, Eichstaedt RM, et al (1998) Platelet-rich
plasma: Growth factor enhancement for bone grafts. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod; 85:638646.
38 Mishra A, Pavelko T (2006) Treatment of chronic elbow tendinosis
with buffered platelet-rich plasma. Am J Sports Med; 34:17741778.
39 Driver VR, Hanft J, Fylling CP, et al (2006) Autologel Diabetic
Foot Ulcer Study Group. A prospective, randomized, controlled trial
of autologous platelet-rich plasma gel for the treatment of diabetic
foot ulcers. Ostomy Wound Manage; 52:6870, 72, 74.
40 Margolis DJ, Kantor J, Santanna J, et al (2001) Effectiveness of
platelet releasate for the treatment of diabetic neuropathic foot ulcers.
Diabetes Care; 24:483488.