EFFECTS OF PLATELET RICH FIBRIN and NORMAL SALINE DRESSING IN CHRONIC WOUNDS - A PROSPECTIVE RANDOMIZED CONTROL TRIAL

INTRODUCTION

Chronic ulcers or non-healing ulcers are defined as spontaneous ortraumatic lesions, that are unresponsive to initial therapy or that persistdespite appropriate care and do not proceed towards healing in a definedtime period with an underlying etiology that may be related to systemicdisease or local disorders There are many types of non-healing ulcers that may include venous,arterial, diabetic, pressure and traumatic ulcers[1]Nonhealing ulcers affect patient quality of life and productivity andrepresent a substantial financial burden on the health care system.More than 6 million persons in the United States are affected, and thisnumber is expected to increase as the population ages and more peopledevelop diabetes [2]In developing countries like India, low literacy rates, poor access toquality healthcare, inadequate health infrastructure, imported medicalequipment, affordability and lack of universal health insurance coverageand many other factors compound the burden of nonhealing ulcer.Health professionals and society in general are not fully aware of theindirect complications and socioeconomic burden of chronic wounds.We are only seeing the tip of iceberg while we access a non healing ulcerin regular outpatient set up.Only published major community based cross-sectional study in India forassessing burden of NHU in India was conducted in 2001–2003 by Guptaet al (2004). The study reported that the overall prevalence of NHU per1000 of the population was 15.03[3]

Standard treatment for ulcers include debridement of necrotic tissue,revascularization surgery, infection control, mechanical offloading,management of blood glucose, nutritional support, mechanical

compression, or limb elevation [4].Advanced wound care therapies has two main purposesTo get the wound healed earlier than standard treatmentTo heal the wound which is not healed by standard treatment.

Although a large and growing array of advanced wound care therapiesexists, their efficacy, comparative effectiveness, and harms are notwell-established.

Various wound care therapies are,

Negative pressure wound therapy

Biological dressings

Silver dressings

Hyperbaric oxygen therapy

Platelet rich plasma therapy

Platelet rich fibrin dressings

Placental extract dressings

Many more such therapies are described with various levels of evidenceplatelet rich plasma: a case series. Journal of biomedical science. 2017 Dec;24:1-0.

Ulcers can occur due to a variety of etiologies, and the treatment depends upon specific etiology such as venous stasis, arterial insufficiency,pressure and neuropathic ulcers.[1]

Chronic ulcer” is termed when the ulcer does not heal within a period of three months or more.[i]

Ulcers have a huge burden on the patient, by having high morbidity in terms of chronic pain, partial or complete loss of function, mental health issues, social isolation, and financial burden.[2]

Wound healing is a complex and dynamic process that includes organized cellular, molecular, and humoral mechanisms.[2] Disruption of any of these factors leads to impaired or delayed wound healing.

The general management of such ulcers includes debridement, infection management and serial dressings.However, several newer topical agents such as growth factors, colony-stimulating factors, platelet-derived products, and acellular dermal matrix have been tested for the treatment of chronic ulcers.[2]

The use of blood-derived products to seal wounds and stimulate healing started with the use of fibrin glues.  PRF (platelet-rich fibrin) is the latest development of these protocols and blood is collected without any anticoagulant and immediately centrifuged.[4]

A natural coagulation process then occurs and allows for the easy collection of a leucocyte and platelet-rich fibrin (-PRF) clot, without the need for any biochemical modification of the blood, that is, no anticoagulants, thrombin or calcium chloride are required.[4]

This is known as Open-access technique.It is the simplest& also the least expensive technique developed so far.This technique was described by Choukroun’s et al in 2001.[2]

Platelet-rich fibrin (PRF) is being used in the treatment of nonhealing ulcers of the limbs and surgical site wounds.It contains aggregates of a network of platelets and leukocytes that release various growth factors and cytokines, which aid in multiple ways to wound healing.[2]

RATIONALE OF THE STUDY

As previously explained, curing an ulcer in shorter span of time will give a good quality of life to the patient.The benefits of PRF are yet to be established in chronic wounds as there are not many studies regarding the same in this population. In this study the Efficacy & Potential of PRF in treating chronic wounds will be evaluated by comparing it with a control group where dressing will be done with normal saline as an already established method of dressing the treatment of chronic ulcers.

REVIEW OF LITERATURE

1.       Singampalli Z et al. (2022)[10] conducted a study. The Efficacy of Platelet-Rich Fibrin in the Management of Chronic Nonhealing Ulcers of the Lower Limb in Fifty patients divided into two groups with 25 patients in each group. Cases were treated with PRF dressings weekly for a period of six weeks. The mean percentage reduction in the wound size after six weeks of treatment was 89.3% among PRF group and is significantly higher than in the normal saline group.

2.       Suthar M., Gupta S et al.[3] did a case series on treatment of chronic non-healing ulcers using autologous platelet rich plasma. They evaluated the safety and efficacy of autologous platelet rich plasma for the treatment of chronic non-healing ulcers on the lower extremity. All the patients showed signs of wound healing with reduction in wound size, and the mean time duration to ulcer healing was 8.2 weeks. The study concluded the potential safety and efficacy of autologous platelet rich plasma for the treatment of chronic non-healing ulcers.

3.       Naik B. et.al (2013)[3] did a critical review with the aim to review and discuss the strategies available for use of platelet rich fibrin as healing aid in dentistry by pooling the extracted data from selected papers, the reviewed data was synthesized & found good promising results with use of the PRF, it has proved to have a good prospect for its use as healing aid in various aspects of the dentistry.

4.       Kumar VR et al (2013)[6] gave an article which clearly mentions about the benefits of platelet rich fibrin in various procedures done over different oral tissues. He collected data from different researches done with PRF, including soft tissue and bony as well. Along with the advantages and disadvantages of PRF and various types of platelet component that can be used, they concluded that PRF promotes early wound improvement.

5.       Ehrenfest DM et al[7] published his research in which he discussed about several techniques for platelet concentrates available; however, their applications have been confusing because each method leads to a different product with different biology and potential uses. They presented the classification of the different platelet concentrates into four categories, depending on their leucocyte and fibrin content such as Choukroun’s PRF to elucidate successes and failures that have occurred so far, as well as providing an objective approach for the further development of these techniques.

6.       Choukroun et all published their study in 2012 in which they documented the beneficial effect of PRF as promoters of wound healing, they described  L-PRP and L-PRF as powerful tools for soft tissue reconstruction in cosmetic, plastic and reconstructive surgery. They described its efficiency in heling of chronic wounds, even in the patients suffering from AIDS. The use of these materials results in a reduction in operating time and postoperative pain, enhances flap and graft survival, hastens epithelialization, decreases the necessity of drains and pressure dressings and the incidences of complications.

7.       Bilgen F et al aimed to present the beneficial effects of topical application of PRF on chronic ulcers that do not respond to standard wound care in cases of chronic ulcers that require a long treatment process and high costs. They included 16 patients and the mean number of PRF applications in the patients was 4.37 (range: 1-8), while the wounds of 10 patients were completely closed up to the mean number of applications, and at least 50% of the wounds of 4 patients were closed up to the mean number of applications. They found PRF is a safe, practical, easy to use adjuvant treatment method which has a potential for closing chronic wounds.

8.       Steenvoorden F et al enrolled 12 patients above 18years in their study from outpatient dept with non-infected hard to heal wounds. They used 120 ml of autologous blood to extract 6 ml of PRF and sprayed topically. The mean treatment period was 4.2 weeks. None of the healed wound reopened. they also found no side effects with high healing rates with this treatment.

AIMS:

This study aims to compare the efficacy of platelet-rich fibrin (PRF)andNormal Saline (NS) dressings in the treatment of chronic wounds.

OBJECTIVES:

1. To investigate difference between PEF Vs normal saline by comparing the weekly percentage reduction in the surface area of wounds after treatment in both groups.
2. To study the effects of PRF during the treatment of chronic wounds.

Material and Methods

Study site: The study will be conducted in Department of Physical Medicine and Rehabilitation, King George’s Medical University, Lucknow after getting approval of Institutional ethics committee, Research Cell, KGMU, Lucknow.

Study population: Patients attending the general OPD or admitted to the indoor facility of department of PMR, KGMU, Lucknow.

Study Duration: 18 Months

Study Type:  Randomized Control Trial

Randomization: Homogenised randomization by computer generated block method.

Sample size calculation:

Sample size is calculated on the basis of mean percentage reduction in the surface area of wound after 4 weeks of treatment in cases and controls.

Where,

•       p₁ = mean percentage reduction in the surface area of wound after 6 weeks of treatment in cases group.

•       p₂ = mean percentage reduction in the surface area of wound after 6 weeks of treatment in control group.

•       Type I error α=0.001%, for the significance level of 99.999%.

•       Type II error β=0.2 %, for detecting the results with 80% power of study,

•       The minimum sample size required comes out to be n = 14 each group with 10% attrition bias the sample size would be 30 (15 each group)

Calculated from the reference paper:

Singampalli Z, Rajan YR, Rathod RH, RajLaxmi Jr PL, RajLaxmi PL. The Efficacy of Platelet-Rich Fibrin in the Management of Chronic Nonhealing Ulcers of the Lower Limb. Cureus Journal of Medical Science. 2022 Jul 13;14(7)¹⁰

INCLUSION CRITERIA:

1.       Age above 2 years and below 60 years (Male,Female& Transgender).

2.        Non healing ulcers.

3.       Serum platelet count more than 150000/dl.

4.       Hb >9g/dl.

5.        INR <1.5

6.       Serum albumin >3.5g/dl.

7.       Patients compliant to appropriate offloading procedure recommended by investigator.

EXCLUSION CRITERIA:

1.       Wounds with signs of active local or systemic infection (Surrounding redness, local warmth, fever)

2.       Wound size > 50 cm2.

3.       Diabetic patients with HbA1C > 7% .

4.       Radiological evidence of osteomyelitis of the underlying bone.

5.       Immunocompromised states, uncontrolled systemic illnesses.

6.       Patients on antiplatelet drugs.

7.       Patients with mental illness or not able to give consent.

8.       Patient refused to participate in study

STUDY METHOD

METHOD OF MEASUREMENT OF WOUND SURFACE AREA

•       Customized transparent vinyl graph paper with 1mm small squares will be used for measuring the surface area of wound & measurement to be done by grid tracings.

•       For e.g. 12 small squares 12 mm²

•       Measurement will be done every 7^th day for 6 weeks using 6 new sheets and lastly by the end of 6 weeks summation of all 6 readings to be done and compared.

METHOD OF PREPARATION OF PRF

•       Autologous 10 ml blood is collected into a sterile test tube without anticoagulant, and the other test tube will be filled with same amount of normal saline to balance the metal rotor (the range depends on the size of the wound, more the surface area more will be the blood taken from patient)

•       These tubes are placed in the opposite holes of the metal rotor, and the lid is closed.

•       Centrifugation will be done at 3,000 rotations per minute (rpm) for 15 minutes.

•       The tube with the patient’s blood will be containing three layers; a top layer of plasma, a middle layer of PRF gel, and a bottom layer of RBC.

•       The supernatant plasma is discarded, and the PRF gel along with the RBC layer is removed with forceps.

•       The RBC layer is separated from the PRF gel with a sterile blade.

•       The PRF gel thus obtained is applied over the wound.

METHOD OF DRESSINGS

1. The wound is debrided with sharp dissection to remove any necrotic slough or fibrous layer followed by thorough saline wash to remove any debris / blood clots.
2. PRF gel is spread over the surface of the wound.
3. A secondary dressing with a sterile gauze pad is placed over this and secured with micropore tapes.
4. This dressing is left intact for 7 days and is removed on the 8th day & repeated the same
5. The patients will be asked to take precautions to avoid wetting of the dressing from external sources.
6. At the time of changing the dressing, the wound will be checked for any clinical evidence of infection & if yes then patient to be excluded.
7. This process is to be repeated for a total of 6 weeks or wound heals, which comes first.

STATISTICAL ANALYSIS

Collected data will be entered in Microsoft Excel Latest version and statistical analysis will be done using latest version of SPSS (Statistical package for the social sciences) software under the guidance of statistician posted at Clinical epidemiology unit, KGMU, Lucknow for statistical analysis.

ETHICAL APPROVAL

The protocol of the thesis will be submitted to the Institutional Ethics Committee (IEC) after clearance from Departmental Research Committee, King George’s Medical University, Lucknow for further processing and approval. The study will be conducted after the approval of the ethical committee.