Elsevier

Annals of Vascular Surgery

Volume 38, January 2017, Pages 206-211
Annals of Vascular Surgery

Clinical Research
Platelet-Rich Plasma for the Treatment of Clean Diabetic Foot Ulcers

https://doi.org/10.1016/j.avsg.2016.04.023Get rights and content

Background

Diabetic foot ulcer is considered as a major health problem that predisposes to limb amputation. Among the different methods to achieve ulcer healing, platelet-rich plasma (PRP) gel is gaining popularity. It is thought to stimulate wound closure by providing essential growth factors for healing. This study aims to evaluate the value of autologous PRP gel in the treatment of diabetic ulcers.

Methods

The study included 56 patients of both sex from 18 to 80 years, with clean chronic diabetic foot ulcers divided into 2 equal groups. The first group was treated by antiseptic ointment dressing, and the second group was treated by autologous platelet gel. PRP together with thrombin were prepared by centrifugation at each dressing session. Thrombin and calcium chloride were used to activate the PRP. The formed platelet gel was applied to the wound twice weekly.

Results

Statically significant increase in healing rate was found in the PRP-treated group, and complete healing was achieved in 86% of them in comparison to 68% of the control group. In the study group, rate of healing per week was greater during the first 8 weeks and starts to decline afterward. The use of platelet gel showed a lower rate of wound infection.

Conclusions

Autologous platelet gel is more effective than the local antiseptic dressing in terms of healing rate and prevention of infection in clean diabetic ulcers.

Introduction

Diabetes is a major health problem in different societies. Specifically, in Egypt, the published figures showed that the prevalence of diabetes in persons over 20 years is increasing from 9.9% in 1995 to 10.2% in 2000 and expected to reach 13.3% in 2025.1 It is estimated that diabetic patients will be 439 million worldwide by 2030.2

Unfortunately, up to 15%, of diabetics will have diabetic foot ulcer.3 This is secondary to multiple diabetes-related risk factors, such as; microangiopathy, neuropathy, and immunopathy.4 Nonhealing diabetic foot ulcer is a major complication, that, in an unacceptably high number of cases the final treatment result is lower-extremity amputation.5

The standard lines to treat diabetic foot ulcer includes revascularization, debridement, antibiotics, and offloading6 does not guarantee, in many patients, closure of the ulcer. These may be secondary to lack of essential factors for healing such as vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF). The deficiency of these substances in diabetic foot ulcer is well recognized in comparison to the wound of the nondiabetic patients.2

Therefore, other local physical methods to encourage wound healing were used. Examples includes vacuum-assisted closure,7 high-voltage pulsed current electrical stimulation,8 hyperbaric oxygen therapy,9 and others used single growth factors such as epidermal growth factor (EGF), VEGF, granulocyte-colony stimulating factors, and nerve growth factor. Although the previously mentioned methods improved the time of healing, none had significantly enhanced wound healing.2

Over the past 2 decades, extensive cellular and molecular details have been elucidated regarding the regulation of cutaneous wound healing. It is now clear that no single exogenous agent can effectively mediate all aspects of a wound healing response. Platelets are a rich source of the complex group of growth factors essential to natural wound healing.10 Autologous platelet-rich plasma (PRP) gel is increasingly used in almost all fields of surgery for the treatment of a variety of soft-tissue and hard-tissue defects, most notably in accelerating bone formation and in the management of chronic nonhealing wounds.11, 12, 13, 14, 15

PRP contains a high concentration of thrombocytes and the α-granules of platelets contain many platelet-released growth factors. Degranulation of platelets by proteins such as thrombin causes them to release these factors, which include PDGF, transforming growth factor (TGF)-β1, TGF-β2, platelet factor IV, interleukin-1, platelet-derived angiogenesis factor, VEGF, EGF, insulin-like growth factor, osteocalcin, osteonectin, fibrinogen, vitronectin, fibronectin, and thrombospondin-1, which stimulate cell proliferation and differentiation resulting in tissue formation.4, 16

Despite these solid biological bases, the outcomes of treatment of diabetic ulcers with platelet gel are varied, and there are relatively few controlled studies. This study aimed to evaluate the value of autologous PRP gel in the treatment of clean diabetic ulcers by comparing it to an antiseptic ointment dressing that is currently used in the surgical outpatient clinic.

Section snippets

Patients and Methods

This study is a prospective comparative study that took place in the surgical and clinical pathology departments, Suez Canal University Hospital, Ismailia, Egypt, in the period between 2012 and 2014.

We aimed at recruiting 56 diabetic patients with the following inclusion and exclusion criteria (Table I).

Eligible patients were allocated randomly into 2 groups. The first group included 28 patients and was considered as the control group. They were treated according to the best practice guidelines,

Results

Over a period of 2 years, we were able to recruit 28 patients in each group. The characteristic risk factors for each group are summarized in Table II. There was no significant statistical difference regarding age, gender, associated risk factors or other laboratory parameters, and ankle-brachial pressure index between both groups (Table II).

Wound characteristics were matched in both groups, as shown in Table III. The most common site was the metatarsal area 50% and 57%, followed by the heal in

Discussion

Unhealed diabetic foot ulcer in the absence of infection or significant ischemia is thought to be due to growth factor deficiency at the wound area.

The role of PRP as a local dressing is to provide the required growth factors locally at the wound area. This role is suggested to be beneficial because diabetic foot ulcers are deficient in growth factors.2 In contrast, when PRP was used in an operative wounds that are not known to be deficient in growth factors, it showed no beneficial effect.

Conclusions

The present study supports the conclusion that autologous PRP gel does effectively accelerate wound healing in clean diabetic foot ulcers when compared with the conventional antiseptic ointment dressing. It is safe and easily used and may have an antimicrobial effect.

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