Local Platelet-rich plasma (PRP) injection for the treatment of delayed union after internal fixation in fractures of long bones

  • Tanup Prasai KMCTH, Sinamangal
  • Sashmit Sharma
  • Kiran Prasad Rijal
  • Krishna Raj Khanal


Introduction: Long bone fractures are among the most common orthopaedic injuries encountered. A fracture that fails to progress to union despite appropriate fixation and absence of complications presents a treatment dilemma to the surgeon. The usual solution of re-fixation with or without bone graft constitutes repeat exposure to surgery and its risks, as well as added morbidity and cost. Recent advances in molecular biology suggest Platelet rich plasma (PRP) may have bone forming potential. This study was done to determine whether PRP has any beneficial role in patients with delayed healing of long bone fractures.
Methods: A prospective interventional study was done on patients arriving at the department of orthopaedic surgery of Kathmandu Medical College with delayed union of long bone fractures after internal fixation between January 2014 and January 2017.  Patients were treated with local injection of group-matched PRP directly into the fracture gap and were followed-up for six months to check for radiological signs of fracture union.
Results: A total of 10 fractures were included in 10 patients that involved four humeri, three tibiae, and three femora. Eight out of the 10 fractures united at a median time of three months after the injection. Two had non-union that required revision surgery.
Conclusion: Local Platelet rich plasma injection may constitute a ‘nothing to lose, everything to gain’ intermediate option before a decision for major reoperation on such patients is made.


1.Wilkins RM, Kelly CM: The effect of Allo- Matrix injectable putty on the outcome of long bone applications. Orthopaedics 2003;26: 567–570.

2.Simpson AHR, Mills L, Noble B: The role of growth factors and related agents in accelerating fracture healing. J Bone Joint Surg [Br] 2006; 88: 701–70

3.Lopez-Vidriero E, Goulding K A, Simon D A, Sanchez M, Johnson DH, The Use Of Platelet-Rich Plasma in Arthroscopy and Sports Medicine: Optimizing the Healing Environment. Arthroscopy, Vol 26, no.2, 2010: pp269-278

4.Broggini M, Hoffstetter W, Hunziker E, Bosshardt DD, Bornstein MM, Seto I, Weinbrich G, Buser D, The influence of PRP on early bone formation in membrane protected defects. A histological and histomorphometric study in the rabbit calvaria. Clin Implant Dent Relat Res.2011 Mar; 13(1):1-12

5.Bielecki T, Gazdzik TS, Szczepanski T. Benefit of percutaneous injection of autologous platelet-leukocyte rich gel in patients with delayed union and non union. Eur Surg Res 2008;40:289-96

6.Govender S et al, Recombinant human bone morphogenic protein-2 for treatment of open tibial fractures: a prospective , controlled, randomized study of four hundred and fifty patients. J Bone Joint Surg Am. 2002 Dec; 84-A(12): 2123-34

7.Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Mujika I. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med 2007;35:245-251

8.Arnoczky SP, Anderson L, Fanelli G, Ho S, Mishra A, Sgaglione N. The role of platelet-rich plasma in connective tissue repair. Orthopedics Today 2009;26:29

9.Gosen T, Sluimer J. Prospective randomized study on the effect of autologous platelets injection in lateral epicondylitis compared with corticosteroid injection. Poster P25-444. Presented at: 13th Congress of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), Porto, Portugal, May 21-24, 2008.

10.Gerard D, Carlson ER, Gotcher JF,Jacobs M. Effects of platelet-rich plasma on the healing of autologous bone grafted mandibular defects in dogs. J Oral Maxillofac Surg.2006 Mar;64(3):443-51

11.Y Sun, Y Feng, CQ Zhang, SB Chen, XG Cheng. The regenerative effect of platelet- rich plasma on healing in large osteochondral defects. International Orthopaedics (SICOT) (2010) 34: 589-597

12. Lowery GL, Kulkarni S, Pennisi AE: Use of autologous growth factors in lumbar spinal fusion. Bone 1999; 2: 47–502-21

13.Braly HL, O’Connor DP, Brinker MR. Percutaneous autologuos bone marrow injection in the treatment of distal meta-diaphyseal tibial ninunions and delayed unions. J Orthop Trauma.2013 Sep;27(9):527-33

14.Seijas R, Santana-Suarez RY, Garcia-Balletbo M, Cusco X, Ares O, Cugat R. Delayed union of clavicle treated with plasma rich in growth factors. Acta Orthop. Belg,2010,76,689-693

15.Kassolis JD, Reynolds MA. Evaluation of the adjunctive benefits of platelet-rich plasma in subantral sinus augmentation. J Craniofac Surg 2005; 16:280–287.

16.Aghaloo TL, Moy PK, Freymiller EG. Evaluation of plateletrich plasma in combination with anorganic bovine bone in the rabbit cranium: a pilot study. Int J Oral Maxillofac Implants 2004; 19:59–65

17.Ouyang XY, Qiao J. Effect of platelet-rich plasma in the treatment of periodontal intrabony defects in humans. Chin Med J 2006; 119:1511–1521

18.Suba Z, Takacs D, Gyulai-Gaal S, Kovacs K. Facilitation of beta-tricalcium phosphate-induced alveolar bone regeneration by platelet-rich plasma in beagle dogs: a histologic and histomorphometric study. Int J Oral Maxillofac Implants 2004; 19:832–838

19.Aghaloo TL, Moy PK, Freymiller EG. Investigation of platelet-rich plasma in rabbit cranial defects: a pilot study. J Oral Maxillofac Surg 2002; 60:1176–1181

20.Furst G, Gruber R, Tangl S, et al. Sinus grafting with autogenous platelet-rich plasma and bovine hydroxyapatite.A istomorphometric study in minipigs. Clin Oral Implants Res 2003; 14:500–508

21.Grageda E, Lozada JL, Boyne PJ, Caplanis N, McMillan PJ. Bone formation in the maxillary sinus by using platelet-rich plasma: an experimental study in sheep. J Oral Implantol 2005; 31:2–17

22.Choi BH, Im CJ, Huh JY, Suh JJ, Lee SH. Effect of plateletrich plasma on bone regeneration in autogenous bone graft. Int J Oral Maxillofac Surg 2004; 33:56–59

23.Graziani F, Ivanovski S, Cei S, Ducci F, Tonetti M, Gabriele M. The in vitro effect of different PRP concentrations on osteoblasts and fibroblasts. Clin. Oral. Impl. Res. 17,2006;212-219

24.Lucarelli F, Beccheroni A,Donati D, Sangiorgi L, Cenacchi A, Del Vento AM, Meotti C, Bertoja AZ, Giardino R, Fornasari PM, Mercuri M, Picci P. Biomaterials. 2003 Aug;24(18)3095-100.

25.Soffer, E., Ouhayoun, J.P., Dosquet, C., Meunier, A. & Anagnostou, F. (2004) Effects of platelet lysates on select bone cell functions. Clinical Oral Implants Research 15: 581–588

26.Kilian, O., Flesch, I., Wenisch, S., Taborski, B., Jork, A., Schnettler, R. & Jonuleit, T. (2004) Effects of platelet growth factors on human mesenchymal stem cells and human endothelial cells in vitro. European Journal of Medical Research 9:337–344

27.Okuda, K., Kawase, T., Momose, M., Murata, M., Saito, Y., Suzuki, H., Wolff, L.F. & Yoshie, H. (2003) Platelet-rich plasma contains high levels of platelet-derived growth factor and transforming growth factor-beta and modulates the proliferation of periodontally related cells in vitro. Journal of Periodontology 74:849–857

28.Marx, R.E., Carlson, E.R., Eichstaedt, R.M., Schimmele, S.R., Strauss, J.E. & Georgeff, K.R. (1998) Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 85:638–646.

29. Say F, Turkeli E, Bulbul M. Is platelet rich plasma injection an effective choice in cases of non union? Acta Chirurgiae Orthopaedicae et Traumatologiae Cechosl, 81, 2014,p 340-345

30.Guo Y, Qiu J, Zhang C. Follow up study on platelet rich plasma in repairing chornic wound non union of lower limbs in 47 cases. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2008 Nov;22(11):1301-5.

31.Calori GM, Tagliabue L, Gala L, D’Imporzano M, Peretti G, Albisetti W. Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone non unions: A prospective randomized clinical study on 120 patients. Injury, Int. J Care Injured (2008) 39,1391-1402

32.Rai B, Oest ME, Dupont KM, Ho KH et al. combination of platelet rich plasma with polycaprolactomne- tricalcium phosphate scaffolds for segmental bone defect repair. J Biomed Mater Res, 2007 ( 81A): 888–899

33.Kamoda H, Yamashita M, Ishikawa T, Miyagi M et al. Platelet rich plasma combined with hydroxyapatite for lumbar interbody fusion promoted bone formation and decreased an inflammatory pain neuropeptide in rats. Spine 2012;37(20):1727-33

34.Hernigou P, Poignard A, Beaujean F, et al. Percutaneous autologous bone-marrow grafting for nonunions. Influence of the number and concentration of progenitor cells. J Bone Joint Surg Am. 2005;87:1430–1437

35.Goel A, Sangwan SS, Siwach RC, et al. Percutaneous bone marrow grafting for the treatment of tibial non-union. Injury. 2005;36:203–206 8-10

36.Bhargava R, Sankhla S, Gupta A, et al. Percutaneous autologus bone marrow injection in the treatment of delayed or nonunion. Indian J Orthop. 2007;41:67–71

37.Liu, Y., Kalen, A., Risto, O. & Wahlstrom, O. (2002) Fibroblast proliferation due to exposure to a platelet concentrate in vitro is pH dependent. Wound Repair and Regeneration 10: 336–340
How to Cite
PRASAI, Tanup et al. Local Platelet-rich plasma (PRP) injection for the treatment of delayed union after internal fixation in fractures of long bones. J Soc Surg Nep, [S.l.], v. 23, n. 1, p. 30-36, dec. 2020. ISSN 2392-4772. Available at: <http://jssn.org.np/index.php?journal=jssn&page=article&op=view&path%5B%5D=378>. Date accessed: 19 jan. 2021.