الفهرس 
Platelet-rich PlasmaOnly 14 pages are availabe for public view
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Abstract
The present study provides evidence that the application of platelet-rich plasma (PRP) stimulates proliferation and improves the take and quality of the split thickness skin graft (STSG). PRP is a blood derivative that contains a high value of platelet concentration which acts as a delivery system of many growth factors (GFs). Through these release reactions of many GFs, PRP is believed to have a crucial role in the healing process.
Since the introduction of platelet concentrates as topical adjuvant therapy to treat chronic leg ulcers in the late 1980, the use of platelet products has been extended to many fields of medicine, with the aim of promoting the healing of various pathologies in numerous kinds of tissues. The attractive possibility of using patients’ own GFs to enhance reparative processes in tissues with low healing potential, the promising preliminary clinical findings and the safety of these methods, explain the wide use of this biological approach.
No standard method for PRP preparation is present, although many studies have discussed the PRP clinical applications in various specialties e.g. maxillofacial, orthopedics and plastic surgery. Most of these studies emphasized on the role of PRP in chronic wounds. The present study believes that researching the effect of autologus PRP use on the STSG improves its take and quality. This allows us to judge the PRP in wound healing fairly without bias caused by many factors that may alter the healing process.
Cutaneous wound healing is a complex biological process leading to re-establishment of the epidermal barrier. The clinical significance of timely wound closure is obvious in extensive wounds like burns, when delayed healing can lead to infection of the wound site and scarring. Topical treatments that accelerate wound healing are urgently needed to reduce these sequelae.
The benefit of applying SGs is that the wound can be taken care of in an outpatient setting. The wound can be debrided and the patient can be discharged on daily dressing changes with oral or intravenous antibiotic therapy until the wound is ready for skin grafting. Many adjunctive wound healing therapies can be added in the outpatient setting if there is inadequate formation of healthy granulation tissue.
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Summary and conclusion
PRP acts to secure the STSG to the wound bed. GFs released from the PRP promote wound healing and revascularization of the STSG. PRP is a product with a miniscule possibility of disease transmission to the patient and is easily and readily obtained at minimal cost.
The results of this study support the concept that the addition of PRP to STSG recipient sites may enhance primary healing and reduce the time to ≥90% healing in patients with well-controlled medical comorbidities. This is likely the combined result of shearing force reduction and enhancement of the wound environment with multiple GFs.
The present study finds that pain perception pre-dressing in the PRP group is less than the control group in the 7th day with significant difference between the median values pain the PRP group and control group P< 0.001 as shown in table(13), more over pain perception during dressing in PRP group is less too in the 7th and 13th day as shown in tables(14-15). The present study doesn’t find any association between the age of patients and rate of epithelization. The present study doesn’t encounter any complication for PRP injection in the wounds. The recipient site of STSG wounds that is injected with activated PRP, exhibits more epithelization surface area specially in the 7th day with statistically significance difference from the control group P value < 0.001 as shown in table(17).
In the present study, the activated PRP is injected to the PRP group and the other control group is managed without PRP and with the conventional method. All the present study patients are monitored clinically on day 7, 13 and 21 as regard epithelization surface area difference, soaking of the dressing, pain perception pre dressing and pain perception during dressing for two weeks as shown in tables (13-15). A 6 mm punch biopsy is taken from both PRP group and control group and histopathological examination is done comparing both specimen as regard the epidermal thickening, collagen bundles, neovascularization and inflammatory infiltrate as shown in tables (19-24).
The complex regulation of GFs in tissue balance and regeneration is still partial, and mechanisms of action of the GFs administrated with platelets are far from being fully understood. The difficulty in this field of research is further increased by the numerous products used, which makes it difficult to compare results obtained in different studies.
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Summary and conclusion
Histopathological examination represented an important method to evaluate the effect of autologus PRP use on the take and quality of STSG in the present study. Examination of PRP group reveals significant difference from control group increase epidermal thickness with differentiated epidermal keratinocytes, epidermal thickness with P value =0.001 as shown in table (19), melanin pigmentation with P value <0.001 (X100) as shown in table (20) and migration of keratinocytes, bridging cells, keratinization with P value <0.001 as shown in table (21). Differentiated polyhydral cells in stratum spongiousum. Cells in stratum granulosum are fully differentiated and display keratohyaline granules (X400), inflammatory cells with P value <0.001 (X200) as shown in table (22) with neovascularization with P value =0.016 as shown in table (23) and more numbers of early and mature collagen fibers and collagen fiber deposition collagen deposition are in the dermis with P value =0.001 as shown in table (24) in the PRP group.
The most important conclusion from this study is that the use of the PRP in treating problematic skin wounds results in complete healing of all cases, regardless of the etiology of the wound or the accompanying diseases of the patient. The standard therapy consisting of bandages and wound debridement can’t provide proper healing because it does not produce enough GFs to support the healing process.
It is far too early to draw conclusions about the efficacy of PRP as a treatment for all these conditions. Further high-quality research is needed to establish the clinical and cost-effectiveness of PRP and the optimal PRP protocol.
There are no studies reporting the negative effects of PRP. The assumption that autologous products are intrinsically safe should be critically evaluated. When cells are in their natural environment, they behave “naturally” meaning many of their activities, interactions and released bioactive factors can be predicted. However, when cells and cell fragments are exposed to unnatural environments, for instance, a high-speed centrifugation process, the resulting products and exerted effects may be less predictable. Furthermore, there is no guarantee that platelets (in the form of PRP) will remain localized at the site where they are injected. Dissemination may result in unexpected results in surrounding tissues or even systemically. As such, the safety of autologous blood products especially in the presence of cell, GF, and platelet activator adjuncts-proves yet another aspect of PRP therapy warranting research.
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Summary and conclusion
Conclusions:
Based on the present study data could conclude that:
• PRP actually improves the take and quality of STSG.
• In the study, PRP provides an important safe adjuvant therapy in management the recipient site of STSG based on absence of complications of PRP injection.
• Safety: derived from self-blood and not mixed with risky materials.
• Low infection: mixture with WBCs.
• In the study 40 patients, with raw area of different aetiologies need skin grafting, the belief that there are only five cases with complications in STSG. Two cases with hyperpigmentation, one case with hypopigmentation, one case with graft failure and one case with hypertrophic scar. All that cases are from control group only.
• Autologous STSGs are a safe and reliable alternative for the treatment of raw area of different aetiologies.
• Skin grafting is a well-established and fundamental technique in the area of wound management and healing.
• The PRP preparation method provides an effective, cheap and tested method for preparation with a short time from blood sample withdrawing till the activated PRP injection.
• PRP has an analgesic effect which is evident before and during dressing of the wounds.
• By accelerating the healing rate and its analgesic effect, PRP injection in the recipient site of STSG would shorten hospital stay in surgical patients and improve their quality of life.
• By shortening the time of healing, PRP injection in the recipient site of STSG would decrease the potentials of complications of healing.
• The pain scores are considerably low.
• Gender and age of the patient had no influence on the pain scores.
• Time to full re-epithelialization, is found to be associated with platelet count, which might be a confounding factor.
• More studies are needed for evaluation of the PRP use as an aid in management
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Summary and conclusion
of the recipient site of STSG with larger number of patients are needed to validate the present study’s initial results with more statistical strength level and wound clinicians must critically review research reports in order to maintain evidence-based practice.
Recommendations:
Strong scientific and clinical findings can then be used in conjunction to help develop clinical recommendations for:
The wide applications of PRP in:
• The management of recipient site of STSG with PRP injection.
• Skin wounds that do not heal in at least 6 weeks and are caused by high energy trauma are called problematic skin wounds.
Therapeutic treatment of such wounds is significantly challenging in the following cases: prominence of bones, ligaments or metal, in patients with another underlying disease or when reconstructive surgery is impossible.
• Acute wounds heal in a particular biological sequence that could be slowed down by the presence of skin defects, patient’s old age and underlying diseases.