Limb Saving with a Combination of Allogenic Platelets-Rich Plasma, Fibrin Glue, and Collagen Matrix in an Open Fracture of the Tibia: A Case Report

Abstract

Tibia open fractures and lower limb soft tissue injuries are undesired conditions for orthopedic and general surgeons, and there is no ideal procedure for treating recalcitrant ulcers or severe traumatic ulcers. Recently, several novel approaches have been proposed, such as bone marrow stem cells, platelets, fibrin glue, and collagen matrix. The current study was conducted to evaluate the effectiveness of combining platelets, fibrin glue, and a collagen matrix for treating a serious limb-threatening wound in a 33-year-old male with a right lower limb injury. After treatment, the wound was fully closed, tissue granulation was grown, skin grafting was done, and the right leg was saved. In conclusion, the combination of the mentioned components can be utilized to synergistically enhance wound healing and preserve the limb.

Introduction

Serious open fractures of the tibia are devastating and, in numerous cases, they ultimately lead to amputation.¹ Non-healing wounds are correlated with a high percentage of morbidity and mortality and have an adverse effect on the lives of patients.^2,3 The cost imposed on the health system for non-healing wounds has been calculated to be approximately $70,000.⁴ The tibia fractures are the most common type of lower extremity fractures^5,6 and are considered a challenge to orthopedic and plastic surgeons.⁶ High-grade open tibial fractures usually need complicated reconstruction with advanced soft tissue coverage methods to improve fracture and wound healing.⁷ The British Orthopaedic Association Standards for Trauma instructions suggest that open fractures of the lower extremity should be managed in a tertiary referral center, irrespective of any specific time frame.⁸

The management procedures for the limb injury as suggested by Xu YQ et al., include antibiotic administration, serial debridement, bone grafting if needed, and the application of various flaps (free thoraco-umbilical, gastrocnemius muscular flaps, sural neurocutaneous vascular, saphenous neurocutaneous vascular, and fasciocutaneous), and various external fixators (Hybrid fixators, half-ring, AO, unilateral axial dynamic, and Weifang).⁹

Open tibial fractures typically occur with high-velocity harm, and such cases can cause serious harm to other limbs and body parts.¹⁰ Court-Brown et al. reported that 21% of patients with an open long bone fracture had an Injury Severity Score of more than 15 and that 45% experienced other substantial musculoskeletal injuries .⁵

Offloading, debridement, and supplementary treatments are current therapies for non-healing wounds. However, the response to these treatments often yields poor outcomes and proves to be disappointing.

In platelets, there are biologically active granules known as α-granules and dense granules Alpha-granule has some cytokine and bioactive factors, such as insulin-like growth factor (IGF-I, IGF-II), fibroblast growth factor, transforming growth factor-β, platelet-derived growth factor, vascular endothelial growth factor, and epidermal growth factor.

These factors and cytokine have a significant impact on the steps of wound healing, including cell proliferation, cell differentiation, and neovascularization. ^{11, 12}

Here, we present a combined application of platelet growth factors, collagen matrix, and fibrin glue as a delivery vehicle for the sustainable release of platelet-fibrinogen rich plasma (PFRP)-derived bioactive factors. This approach aims to promote healing in refractory ulcers.

Case Presentation

A 33-year-old farmer, who sustained a serious limb-threatening wound and an open fracture of the tibia due to a collision with a Gleaner combine, was referred to the Shahid Kamyab Trauma Referral Center (Academic Hospital of Mashhad University of Medical Sciences), Mashhad, Iran. A Gustilo IIIB open tibia fracture was diagnosed during the first consultation with the general surgeon and orthopedic surgeon. The patient had no past medical history of chronic diseases, infections, or other diseases. Upon arrival at the care center, he exhibited good hemodynamic status. The medical consultation committee recommended amputating the right leg from the knee, but the patient disagreed and asked for alternative solutions. So external fixation, a treatment combining the use of a collagen matrix, allogeneic platelet-rich plasma, and fibrin glue, along with autologous skin grafting were suggested for the patient. The patient demonstrated understanding, was able to read, and expressed satisfaction with signing the informed consent form.

The fibrin glue and platelets were prepared using standard methods. A total of 350 cc of peripheral blood was collected from a blood group match donor into 400 cc triple blood donation bags. The platelets were separated through two rounds of centrifugation: the first at 1,800 × g for 5 minutes, followed by the second at 3,500 × g for 10 minutes. The supernatant plasma was then isolated, resulting in the obtainment of 25 cc of platelet-rich plasma.¹³ The fibrinogen concentrate can be obtained from the plasma using two different biochemical procedures (i.e., the cryoprecipitate procedure or the ethanol precipitation procedure).¹⁴ In the coprecipitation procedure, the plasma was subjected to a -75°C freeze followed by a 3°C thaw. Then, the plasma was centrifuged at 6,500 × g for 5 minutes. The supernatant plasma was removed to a final volume of 25cc. In the ethanol precipitation procedure, absolute ethanol at 0°C was added to 10% v/v plasma. Fibrinogen was collected by centrifugation at 6,000 × g for 20 minutes, and the supernatant plasma was eliminated to the final volume of 25 cc. Finally, a total of 25cc of concentrated fibrinogen mixed with platelets (final volume 50cc: PFRP) was obtained. One milliliter of thrombin was created by adding 10% calcium gluconate to the removed plasma. Viral inactivation of PFRP and thrombin was done by incubating them at 62°C for one hour. Afterward, it is stored in a -20°C freezer until use, with a maximum storage period of three months. Before the application of PFRP, the devitalized and necrotic area of the wound was surgically debrided until macroscopic bleeding was observed. This resulted in the PFRP coming into contact with living tissue of the wound. When using PFRP, a 50-cc volume of PFRP was mixed with calcium gluconate and 1 ml of thrombin. Subsequently, the collagen matrix (Surgicoll ®; MBP, Medical Biomaterial Products, GmbH, Tehran, Germany) was immediately impregnated with 51cc of the resulting mixture and placed on the wound.

Finally, a paraffin gauze was placed over the wound and secured with a rolled gauze bandage. After two days, the whole dressing was removed and the wound was irrigated with a solution of isotonic sodium chloride. The whole process mentioned above was repeated every two days for granulation tissue formation and wound closure. The patient was regularly observed for ulcer closure, the orthopedic condition of bone fracture, and any other possible complications. After a complete tissue granulation in the wound, plastic surgeons and orthopedic surgeons performed multiple surgeries for skin grafting. Figure 1 displays the sequential photographs of the patient. [Figure 1] After four months of orthopedic treatment, multiple surgeries, and grafting, a viable and functional leg was successfully achieved.

Figure 1.

Serial photography of the treatment of the patient. (A) Leg wound before the surgery, (B) Surgical intervention and necrotic tissue removal, (C) Tissue granulation following the application of allogeneic platelet-rich plasma, fibrin glue, and collagen matrix, (D) Skin grafting after tissue granulation, (E) Fully healed limb

Discussion

This study reports a patient with a recalcitrant and limb-threatening wound that was treated using a combination of fibrin glue, allogeneic platelets, and collagen matrix. Guidelines from the British Orthopaedic Association recommend amputation when the projected functional outcome following reconstruction is expected to be worse than that of a trans-tibial amputation.⁸ Reuss et al. demonstrated that while time (up to 48 hours) was not a main factor in predicting infection and nonunion, increased severity of the fracture and the frequency of debridement were important factors in predicting infection rate and the development of infection, respectively. In addition, they stated that the infection rate for fractures initially treated with external fixation and subsequently with intramedullary (IM) nailing was significantly higher compared to fractures treated solely with IM nailing.¹⁵

Traditionally, debridement, external fixation, and delayed soft-tissue closure had been used to manage open tibial fractures.^16-18 Today, due to the proven role of autologous and allogeneic platelet-rich plasma (PRP) in stimulating tissue growth and regeneration, it can be used alongside traditional methods to accelerate repair in non-healing wounds.^{19, 20}

Franchini et al. employed the platelet gel (autologous platelet concentrate and cryoprecipitate) in different operations, primarily oral and maxillofacial surgery, for 19 patients. Physiologic bone structure reconstruction and the improved osteoblastic reaction were observed in all patients, with no negative reactions.²¹

Some authors who are war surgeons have reported the functional results of transtibial amputees from the Vietnam War.²²

Crovetti et al. investigated the efficiency of the weekly application of allogenic for 21 patients and autologous for 3 patients platelet gel (PG) in healing cutaneous refractory wounds with different etiologies. In their study, 9 patients achieved complete healed, 9 patients showed partial response, 2 patients received cutaneous grafts, and 4 patients discontinued treatment. While pain reduction was reported with the application of PG, it is worth noting that neither clinicians nor patients were blinded to the treatment, potentially introducing bias to the self-reporting of pain.²³

Mandible defects were treated with PRP administration on the affected side.²⁴ the findings of a study by Kanthan et al. demonstrated the favorable use of PRP in non-uniting segmental tibial defects in an animal model.²⁵

The results of this study have demonstrated the feasibility of our method as a non-invasive approach in the treatment of limb-threatening wounds. The application of PFRP-collagen therapy, which involves a combination of continuous and immediate release of growth factors, significantly healed or reduced the size of recalcitrant ulcers. There was no evidence of systemic or local complications associated with the method. Based on our findings, we have been prompted to conduct a larger study to further assess the effectiveness of PFRP-collagen therapy in treating recalcitrant ulcers, wounds, and injuries. Additionally, considering the authors' experience in stem cell therapy,²⁶ the authors suggest that for patients who do not respond to the PFRP-collagen therapy, by considering the pathological factors related to the phenotypically changed and/or senescent mesenchymal cells in the ulcer, stem cell therapy could be pursued as an alternative method for curing recalcitrant ulcers.