Platelet Rich Plasma (PRP) Versus Conventional Ordinary Dressing In Management Of Diabetic Foot Ulcer & Wound

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1 Platelet Rich Plasma (PRP) Versus Conventional Ordinary Dressing In Management Of Diabetic Foot Ulcer & Wound Atef AbdelGhany Yousef, MD; Mohamed AbdelHakim Mansour, MD; Ahmed Khairy Allam, MD; Kareem Mohamed Ibrahim, M.B.B.Ch. Departments of General Surgery, Benha University, Benha, Egypt. Abstract Purposes: Find out advantages & efficacy of Platelet Rich Plasma versus conventional ordinary dressing in management of diabetic foot ulcer & wound. Background: Diabetic foot ulcer treatment places a considerable strain on the medical system, with long waiting time for healing in the public hospital system. Platelet Rich Plasma allows efficient treatment of many patients with hemostatic, anti-inflammatory and analgesic substance. Patients and methods: This prospective randomized controlled study was conducted on 60 diabetic patients having non-healing feet ulcers; Patients were randomly allocated by using a computer generated random number table into two groups according to the dressing method performed; Group A: Conventional ordinary dressing (N=30 (50%)), Group B: PRP dressing (N=30 (50%)). Follow-up period was for 3-monthes. Results: Most of ulcers were healed within the estimated time for this study (12 weeks) and There were satisfactory results (less complications) in PRP group (B); infection, exudates and Pain which were observed in 5 cases (16%), 3 cases (10%), 10 cases (33.3%) respectively as compared to group (A); 8 cases (26.6%), 12 cases (40%), 18 cases (60%) respectively. Also the rate of healing was good in group (B) with p-value <0.05. Conclusions: PRP is a powerful weapon for treating chronic ulcers, providing healing, reducing infection rates, besides its preventive action, which reduces amputation rates; So PRP is considered a very promising method for chronic ulcer dressing especially diabetic foot wounds than conventional ordinary dressing. 1

2 Key words: Platelet Rich Plasma, Conventional Ordinary Dressing, Diabetic Foot Wound, Outcomes. Introduction: About 15% of diabetic patients will develop chronic ulcer, and about 25% of those will have to undergo foot amputation (1, 2). In the non-healing diabetes mellitus (DM) ulcers, in addition to vascular and neurological disorders, the healing process is impaired in part due to deficiency of growth factors (3). Becaplermin, a recombinant human platelet-derived growth factor-bb (Regranex, PDGF-BB, Systagenix Wound Management, Gargrave, UK) is the only growth factor preparation approved by the FDA for treating DM ulcers, but it requires daily applications for weeks to months (4). Live skin equivalents, known as Apligraf and Dermagraft, accelerate wound healing, but also require frequent (weekly) applications, exhibit short shelf-life, and are expensive (5). The use of an adenovirus encoding human platelet-derived growth factor formulated in bovine collagen gel (GAM501) for treating small nonhealing diabetic foot ulcer has been reported Despite these advanced (6, 7). researches, a more practical and effective therapy for non-healing diabetic ulcer is clinically needed. Plasma samples with platelet concentration above base line values are referred to as platelet-rich plasma (PRP) (8, 9). The clinical efficacy of the PRP was discovered in early 1990s when new biological glues were being discovered. They are at present being extensively used in many clinical and surgical fields requiring tissue regeneration such as orthopedics, dentistry, wound healing, and maxillofacial surgeries (10). The therapeutic effect of PRP is attributed to the abundance of various growth factors such as platelet-derived growth factor (PDGF), transforming growth factor-β, fibroblast growth factor, insulin-like growth factor-1 (IGF-1), IGF-2, vascular endothelial growth factor, epidermal growth factor, and also some cytokines primarily stored in alpha granules (11). 2

3 PRP can be prepared either from autologous or allogenic source. Majority of studies documented have used autologous platelets preparations as they are more acceptable to the patient and carry lower risk of transmission of viral infections (12). PRP preparations are being extensively used in wound healing and tissue repair despite of insufficient evidence support (13). Blinded, multicentric, randomized controlled studies with large sample sizes to establish their therapeutic efficacy is the need of hour. There are no universally established standards for collection, quality control, and administration of the product (14, 15). Patients and methods: After local ethical committee of Benha university approval and obtaining written fully informed patients consent about the two methods of dressing benefits, risks, alternative interventions and possible complications., The current study was conducted at vascular unit, General surgery Department, Benha University hospital from November 2015 to November 2016 so as to allow 3 months follow-up period for the last case operated on. This prospective randomized controlled study was conducted on 60 diabetic patients having non-healing feet ulcers; Patients were randomly allocated by using a computer generated random number table into two groups according to the dressing method performed; Group A: Conventional ordinary dressing (N=30 (50%)), Group B: PRP dressing (N=30 (50%)). Patients included in this study were suffering from non-healing feet ulcers follow these criteria; Patients aged between years old, Diabetic patients from either type of diabetes type I (insulin dependent) or type II (non-insulin dependent) and they were in a controlled status with non-healed feet ulcers, ulcer for 3 to 6th month, The foot ulcer size ranges from 5 to 10 cm 2, Transcutaneous oxygen tension >30 mmhg, Patients hoped for revascularization surgery, Patients have normal peripheral platelet count (> /mm3) and Patient with screening serum albumin level of >2.5 g/dl or hemoglobin >10.5 g/dl. But patients excluded from this study who were Pregnant women, Patients with ischemic changes of foot (Transcutaneous oxygen tension<30), Patients with 3

4 radiological evidence of chronic osteomyelitis, Severe cardiovascular disorders, Patients are not hoped for revascularization surgery, Patients had received conventional skin grafting in the past, Critical ill patients with immunological disturbances, Patients who were receiving or had received radiotherapy or chemotherapy within 3 months before the study. All patients with non-healing feet ulcers should undergo formal assessment and investigations to Recognize the risk factors and treatment of diabetic foot disorders which require the skill of a specialized practitioner to diagnose, manage, treat, and counsel the patient. Integration of knowledge and experience through a multidisciplinary team approach promoted more effective treatment, thereby improving outcomes and limiting the risk of lower extremity amputation. Intervention: Sharp debridement of non-healing ulcer using scalpel, curette, scissors. Debridement converts a chronic or heavily infected wound to one that is acute by removing nonviable tissue that can stimulate excessive inflammation and bacterial growth. Simple incisions are used to open the infected area; Excision of necrotic tissue extends as deeply and proximally as necessary until healthy, bleeding soft tissue and bone are encountered. Any callus tissue surrounding the ulcer removed. Look for evidence of pus coming down tendon sheaths as this will indicate the need for more extensive debridement. Tendons are cut under tension to allow them to retract away from the open wound. The wounds should always be left open and inspected at 24 to 36h. Further debridement can be carried out as necessary until the wound is clean and healing is underway. In the presence of an adequate arterial supply, rapid healing can follow a thorough debridement. If healing does not occur, this is usually due to failure to drain all areas of infection, or unrecognized ischemia. The decision that a useful foot cannot be saved is one for the experienced surgeon. Some very odd shaped feet have served patients well for many years with 4

5 skilled orthotic input. If in doubt, all dead tissue should be excised and the wounds left open. Post Intervention dressing: Group A: this group of patients was treated by conventional ordinary dressing; surgical debridement had been done for all necrotic tissue and pus loculi were drained as discussed before, preparation of the material used for dressing, Irrigation of the ulcer with saline, selection of a dressing through matching the properties of the dressing (such as control of exudates) with the characteristics of the ulcer and the patient then packing the wound, Appropriate dressing types are determined by wound location, depth, amount of slough present, amount of exudates, condition of the wound margins and presence of infection; A broad spectrum of wound dressing materials used in some cases. Fig (1). A-Surgical debridement. B-Covering of the wound. Fig. (1): Daily Conventional ordinary dressing for Diabetic ulcer. Group B: this group of patients was treated by platelet rich plasma therapy, They had PRP as their dressing protocol, where PRP was applied to the diabetic foot after being prepared (within half an hour after preparation), followed by Vaseline gauze and then a dressing. The frequency of change of dressing was twice weekly with an interval of 3-4 days between every dressing. This protocol was 5

6 prospected to be performed for patients up to 12 weeks, or stopped whenever healing occurred. Each case sprayed with PRP in ulcers edges (sub dermal) and its floor(if deep). PRP prepared from their own blood (autologous PRP), Venous blood samples were drawn into 5 ml sterile tubes containing an anticoagulant (citrate dextrose-3.2% sodium citrate). to avoid platelet activation and degranulation (10 cc). Whole blood was centrifuged at 300 g during 5 minutes at 18 C. the first centrifugation is called soft spin (1007 g), which allows blood separation into three layers, namely bottommost red blood cell (RBC) layer (55% of total volume),topmost a cellular plasma layer called platelet-poor plasma (PPP; 40% of total volume) and an intermediate PRP layer (5% of total volume) called the buffy coat. The upper fraction (PRP1) was separated, without disturbing the buffy coat, and was transferred into a sterile tube and this can be done by Using a sterile syringe, the PPP, PRP and some RBCs (i.e. the upper two layers and very minimal unavoidable amount of bottom layer) were transferred into another tube without an anticoagulant. This tube underwent a second centrifugation (447 5 g) called hard spin. This allowed the platelets (PRP) to settle at the bottom of the tube with a very few RBCs. The a cellular plasma, PPP (80% of the volume), was found on the top. Most of the PPP was removed with a syringe and the remaining PRP was shaken well. PRP 1 was centrifuged at 700 g during 17 minutes at 18 C. The platelet pellet obtained from PRP 1 was resuspended in one ml PPP (PRP 2 ). Platelet activation was performed immediately by adding 0.5ml CaC l2. Application done immediately after activation in ulcers edges and floor. Photos taken with measurement of ulcers diameter. Dressing done and lifted for one week till follow up session. Follow up done every week; with taken photos and measurement of ulcers diameter. Fig. (2). 6

7 Fig. (2): A-PRP sparyed at edge of the ulcer B) PRP dressing at floor of the ulcer FOLLOW-UP: The patients were advised to avoid pressure on ulcer area. Special shoe with molded insole was used. Elevation of the feet was recommended during setting or lying down to decrease edema. The patients were seen twice weekly throughout the treatment course and clinical evaluation was performed once weekly. Clinical laboratory tests were performed every 4 weeks for all treatment groups. The patients are evaluated for the rate of healing of the ulcer in about 3 months and this evaluation was carried out by measuring the ulcer s dimensions (length and width) using metric tape at the initial visit and then every week. characteristics of wound : exudates, necrotic tissue, infection and granulation tissue were documented. use of antibiotics: were more in some cases of group A were infection was more and healing power took long time and cost benefit & patients satisfaction was evaluated of both groups. Statistical analysis: From the first visit of the patient all information were collected to an excel file Excel 2007 (Microsoft Office, Microsoft, Washington D.C, USA).According to normality assumption of wound changes (healing rate /week in cm2) we used the paired sample T-test throughout the duration of study at weeks two,four,eight and twelve. The p-value<0.05 was considered statistically significant. While Z test was used for testing the results of the results of the healed ulcer in each group. The p-value<0.05 was considered statistically significant. Data were analyzed using Statistical Package for Social Sciences version 20.0 (SPSS, Inc., Chicago, IL, USA). 7

8 Results: This study is prospective study done in Benha University including 60 diabetic patients having non healed feet ulcers were followed up for twelve months; patients were divided into two groups: Group A: including 30 patients underwent conventional ordinary dressing. Group underwent PRP dressing as their protocol of treatment. B: including 30 patients The age was ranged from 30 to 70 years with a mean of 48± 7.38 year as shown in Tab. (1). All patient presented by non-healed feet ulcers & none of them was presented with any other symptoms, the majority of patients were males (60%) as shown in Fig. (3), Forty-eight patients (80%) were on oral hypoglycemic drug while 12 patients (20%) were on insulin injections; Fig. (4). Eight patient ( 13.3%) had diabetic retinopathy, Twelve patient (20%) had diabetic nephropathy, Ischemic changes in 25 patients (41.6%) where transcutaneous oxygen more than 30% and 45 patients (60%) had controlled hypertension as shown in Fig. (5). Other co-morbidities encountered were bronchial asthma in one patient and mild mitral stenosis with rheumatic heart disease in one patient and the conditions were controlled medically; Tab. (2). Tab. (1): Age distribution of the studied group: Min-max Mean ± SD 48±7.38 Median 50 Tab. (2): Patients demographic data: No % Sex ( male :female %) 36 :24 60:40 Age of diabetes in years 11.2 ± 1.8 Hypertensive patients History of minor Amputations at the same foot or contralateral foot 8

9 Number of patients on 12 :48 20:80 insulin versus oral hypoglycemic Smoking Co-morbidities Retinopathy Nephropathy Fig. (3): Gender distribution of studied group 40% 60% Males females Fig. (4) Percentage of cases according to type of medication 20% 80% insulin injection oral hypoglycemic drugs 9

10 Fig. (5): Diabetic related co-morbidities in the studied group: No. of Pts in relation to comorbidity Nephropathy Retinopathy Angiopathy Hypertension No. of Pts in relation to comorbidity Tab. (3): The studied group according to some important clinical and lab parameter: No. % Positive knowledge of foot care Regular shoe wearing habit Presence of previous foot ulcer Spontaneous initiating factor Foot pain Intermitting claudication Fever Most of patients ulcers of the current study were healed within the estimated time for this study (12 weeks), the minimum time was 2 weeks and maximum was 12 weeks with average (7.11 weeks). Tab. (4). Tab. (4): Rate of healing in both groups: Duratio n parameter Conventional dressing PRP group P value No % No % 2 wks Ulcer healed 3 10% 9 30% <0.05 Healing cm²/week rate in 0.4± ±0.2 <

11 4 wks Ulcer healed 8 27% 14 47% <0.05 Healing rate in 0.5± ±0.1 <0.05 cm²/week 8 wks Ulcer healed 12 40% 5 16% <0.05 Healing rate in 0.3± ±0.1 >0.05 cm²/week 12 wks Ulcer healed 6 20% 2 7% >0.05 Healing cm²/week rate in 0.4± ±0.1 >0.05 The p value <0.05, statistically significant, The p value >0.05, statistically insignificant. Fig. (6): Rate of healing in both groups: The platelet rich plasma (PRP) have shown to be more effective than the conventional antiseptic dressing after the 2nd week (nine patients vs three patients respectively) with higher rate of healing per week(0.8±0.2 cm²/week VS 0.4±0.2 cm²/week respectively ) the same effect was shown at the 4th week as regard the number of the ulcer healed for the PRP group VS the conventional group (fourteen vs Eight respectively) with better healing rate for the PRP group (0.9±0.1 cm²/week VS 0.5±0.1 cm²/week respectively )after the 4the week the number of the whole ulcer healed was twenty three patients VS twelve patient's (77% of the patients VS 40% for the conventional group ).At the 12th week the normal antiseptic conventional dressing have shown higher rate of healing 0.4±0.1 11

12 cm²/week than the PRP dressing 0.2±0.1 cm²/week which affected the number of the ulcer healed to be Six VS two for the conventional dressing VS PRP dressing respectively the data was statistically insignificant p value >0.05. The ulcer shows the highest rate of healing at the 3 rd and 4 th weeks especially for the PRP group to be 0.9±0.1 cm²/week vs the conventional group 0.5±0.1 cm²/week )with the lowest rate of healing at the 11 th and 12 th weeks for the PRP group to be 0.2±0.1 cm²/week.while for the conventional group the lowest rate of healing was at 7 th and 8 th weeks 0.3±0.15 cm²/week. As regard complications occurred during the dressing period; there were infection, exudates and Pain which was observed more in group (A); 8 cases (26.6%), 12 cases (40%), 18 cases (60%) respectively vs 5 cases (16%), 3 cases (10%), 10 cases (33.3%) respectively in group (B); Tab. (4); Fig. (7). Tab. (4): Postoperative complications: Parameters Group A Group B No % No % Infection Exudates Pain Fig. (7): Postoperative complications: Complications during the dressing Percentage 20 Infection 10 Exudates Pain Group B Group A 0 12

13 Discussion: Diabetic foot ulceration is a common clinical problem. Due to population aging and the increase of risk factors and co morbidities such as tobacco, obesity, hypertension and atherosclerosis, there is a clear trend to the increase risk of chronic ulcers. The social and economic effects are inevitable. (16). One of the most common causes of ulcers is growth factor abnormality. Platelets are considered as a rich source of growth factors. PRP enhance wound healing by either barrier effect to prevent the bacterial invasion into the wound or the growth factors stimulate wound healing. PDGF is one of growth factors was used alone for enhancing of the wound healing, but the application of PRP (with balanced amounts of growth factors) gives better result. Platelet-rich plasma (PRP) is defined as a portion of the plasma fraction of autologous blood having a platelet concentration above baseline. PRP also has been referred to as platelet-enriched plasma, platelet-rich concentrate, and autologous platelet gel. PRP have been used to treat wounds since (17). This study was conducted to evaluate the effectiveness of PRP in promotion of healing of diabetic feet ulcers, besides its preventive action, which reduces amputation rates. On the basis of the last 10 years of research, the results of the systematic review with meta-analysis published by Carter et al. suggest that PRP therapy can positively impact wound healing and associated factors such as pain and infection in both chronic and acute cutaneous wounds. (18). In the current study conducted on 60 patients with chronic ulcers, the patients ages were ranged from 30 to 70 years with a mean of 48± 7.38 years, The majority of patients were males (60%) and we found that age and gender had no effect on rate of healing. According to study proposed by Hany Saad and his colleagues, they included 24 patients with chronic ulcers with ages years they concluded that sex and age are insignificant in correlation with rate of healing of their ulcers. (19). 13

14 In the current study; diabetic feet ulceration distributed as 20 at forefoot 33.3%, 15 at mid foot 25% and 25at hind foot 41.6%. it was observed that there was no correlation significance between site in correlation with rate of healing (p value= 0.795) this results was mentioned by (20) who studied the effect of PRP on healing of lower extremity chronic ulcers in which 21 patients with chronic ulcers are included in the study they concluded that, there no significance between type and site of ulcers in correlation with rate of healing. In this study, ulcers varied in size. The least diameter was 5cm and maximal was 10cm. For statistical reason we use single diameter. It was observed that the relation between original size of ulcers and rate of healing and was found that there was significant strong inverted correlation between rate of healing and size of ulcers. (Pearson Correlation , p value 0.001) and there was significant strong proportional correlation between size of ulcers and treatment time (p=0.002) and there was significant strong proportional correlation between size of ulcers and the number of injections( p=0.040). Many trials concluded that the larger the ulcer the longer the time for treatment and the greater number of injections. (20, 21) Most of patients ulcers (60%) healed within the estimated time for this study (12 weeks),the minimum time was 6 weeks and maximum was 11 weeks with average 8.11 weeks. Average decrease in ulcer diameter (rate of healing) was 0.2 cm/week as minimum average rate and 0.7cm/week as the maximal average rate with mean 0.48cm/week. Complications happened in this study; there were infection, exudates and Pain which was observed more in group (A); 8 cases (26.6%), 12 cases (40%), 18 cases (60%) respectively vs 5 cases (16%), 3 cases (10%), 10 cases (33.3%) respectively in group (B); (22) reported only one patient with super-infection of the ulcer developed in one patient of PRP group. Conclusions: PRP is a powerful weapon for treating chronic ulcers, providing healing, reducing infection rates, besides its preventive action, which reduces 14

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