Autologous platelet rich fibrin versus normal saline dressings in chronic venous leg ulcer patients in ulcer size reduction and quality of life : a randomized control trial

BACKGROUND AND RATIONALE

 â€¢         Venous Leg ulcers are breach in continuity of skin of the lower one third of leg which are caused by chronic venous insufficiency.

•         Venous ulcers are the most common type of chronic leg ulcers and are three to four times more prevalent than arterial ulcers.

•         Risk factors include old age, obesity, previous trauma history, immobility and genetic thrombophilic conditions such as factor V Leiden mutation [1]. Venous disease is more frequently observed in women  and pregnancy is known to increase the risk of developing a chronic venous ulcer .

•         The diagnosis of venous ulcers is clinically based on patient history and clinical presentation, augmented when necessary by diagnostic tests. While color-flow duplex ultrasound is currently the gold standard diagnostic procedure for chronic venous disease [2], other examinations can be performed in adjunct to duplex sonography like Photoplethysmography (also called light reflex rheography), also non-invasive, is a test which measures venous refill time.

•         The various modalities of treatment for venous leg ulcers include compression stockings , wound care and  surgical therapies.Dressings play a major role in healing of these ulcers . In order to improve the healing of chronic wounds, several kinds of functional dressings have also been used to treat chronic wounds in clinical treatment, such as hydrogel dressings and antimicrobial dressings. Hydrogel dressings can absorb the exudate of wounds and keep them moist, providing an appropriate environment for wound healing, but they are expensive for use in long-term treatment and lack abundant clinical evidence supporting their efficacy .

Iodine or silver-based dressings have proven antimicrobial ability in wound treatment, but some researchers are concerned that the high concentration of metallic ions can harm the human body, and long-term usage might delay healing [3].

•         Various studies have found that growth factors and cytokines play irreplaceable roles in modulating tissue repair and regeneration, especially in bone, skin, cartilage, and vascularized tissues . Platelet-rich plasma (PRP) has been extracted from the peripheral blood of patients and showed a concentration of various growth factors like transforming growth factor (TGF), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), platelet derived epidermal growth factor (PDEGF), insulin like growth factor (ILGF-1),Basic fibroblast GF and cytokines without known adverse effects.

•         PRP could release various biologically active factors and adhesion proteins into the microenvironment, which may contribute to initiating hemostatic cascade, vascularization, and tissue regeneration [4,5]. Many studies have confirmed that growth factors derived from PRP are able to shorten the wound healing process via the supraphysiological releasing of growth factors promoting cell proliferation, migration, and vascularization Neovascularization is an essential process to reconstruct blood supply and support the high metabolic activity of tissue regeneration.

•         In animal experiments, it has been found that senescent stem cells could recover proliferation and colony formation ability  after PRP treatment, confirming that PRP could resist cell senescence during tissue regeneration [6].. T]he platelet aggregation is activated, and they lead to a cascade reaction of cytokines, producing an amount of pain-modulating 5hydroxytryptamine sufficient to relieve local pain

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       â€¢         PRP is an advanced method because of its pleasant effect, simple procedure, low cost, and safety . PRP consists of large amounts of growth factors and cytokines, which are released onto the wound and can recruit stem cells and various kinds of growth factors via cascade reactions. These cells and factors can contribute to regulating epithelial cell proliferation and migration, regulating fibroblastic activity , promoting angiogenesis and vessel permeability , and increasing protein and extracellular matrix synthesis . In vivo, these growth factors could enhance the metabolic reprogramming of fibroblasts, especially promoting their glycolytic energy metabolism, to stimulate fibroblast proliferation and differentiation during tissue repairing .

•         Additionally, concentrated platelets could stimulate the proliferation and pro-angiogenic properties of mesenchymal stem cells even under oxidative stress to promote angiogenesis and metabolic support around the wound . Besides, platelet accumulation can be stimulated by endothelial injury and microbial pathogens in chronic wounds, which could regulate leukocyte oxidative bursting to stimulate the immune response via platelet–neutrophil interactions . The activated immune system could then quickly identify and eliminate the viruses and bacteria around chronic wounds, resulting in the anti-infection effect of PRP dressings.

•         The inflammation would be inhibited after eliminating infection, and the red granulation tissue formation would be shown at the wound site . Through these mechanisms, PRP presents a promotion in tissue regeneration and chronic wound healing.

              AIMS AND OBJECTIVES   AIM

•     To study the efficacy of  autologous platelet rich fibrin over normal saline dressing  in patients of venous leg ulcer

 OBJECTIVES

 Primary outcome measure

 â€¢     To measure reduction in ulcer size

 Secondary outcome measure

 â€¢     To measure quality of life

                              MATERIALS AND METHODS  â€¢      STUDY PLACE

This study will be conducted in the department of General Surgery in association with department of Transfusion medicine ,King George’s Medical University ,Lucknow.

•      DURATION OF STUDY – one year

•      SAMPLE SIZE – 68 Cases (34 in each group )

•      TYPE OF STUDY – Randomised control study

•      STUDY POPULATION

All patients with  chronic venous ulcer attending in  General Surgery OPD and fulfilling the inclusion criteria will be included in the study.

                  ï‚· Sample size On the basis of mentioned study(7), the mean changes in Size of Ulcer area reduction (Healing progress in between PRP group (0.78 cm2) and Conventional treatment group (2.15 cm2) at 6 month was 1.37 cmand the variance (σ2) was 2.01(Helmy et al., 2021). The sample size (n) = 2 (Zα/2 + Z [1-β])2 × σ2/( μ1−μ2)2,assuming 0.05 level significance (Zα/2 =1.96), and 80% power (Z [1-β])=0.84) was 33.75. In this study we will enroll 34 patients in each group of the study.

 2(Zα/2 + Z [1-β])2 × σ2

 n=

(μ1−μ2)2

  n= 2 (1.96 + 0.84)2 ×2.01

 (2.15-0.78)2

  n=33.75(34)

    .

      ï‚· INCLUSION CRITERIA

 1)      Chronic venous ulcer of  lower extremity having for more than 3 months duration

2)      Age more than 18 years

  ï‚· EXCLUSION CRITERIA

 1)      Less than 3 months duration

 2)      Other causes like arterial/neuropathic/diabetic/vasculitic

 3)      Patients with Infected ulcers, osteomyelitis affecting the area of the ulcer, ulcers with exposed tendons or bones

 4)      Patients receiving antiplatelet drugs,anticoagulants,bleeding diathesis.

 5)      Patients not giving consent for being included in the study

                         METHODOLOGY  â€¢      After obtaining institute ethics committee approval, consecutive patients will be recruited in this study .

•      A written and informed consent will be obtained from all the patients. Thereafter patients will be randomly allocated to one of the groups by computer generated random number table.

•         After taking consent from patient, 10 ml of blood will be withdrawn in to a vacutainer without any anticoagulant and immediately centrifuged at 3000rpm for 15 minutes.

•         After 15 minutes, a fibrin gel appears in the centre of the vacutainer between the Red blood cells (RBCs) below and acellular plasma above which will be removed with the help of sterile non-toothed  forceps and  placed over the ulcer after removing the adherent RBCs carefully.

•         Group A: The measurements of the ulcer will be taken. The PRF gel is then placed on the ulcer floor and covered with a sterile gauze piece (primary dressing), which is, in turn, covered with a sterile gauze pad (secondary dressing) held in place with a sterile roller bandage. And then 4 layered compression bandage will be applied.

•         The dressing will be removed after 1 week. The PRF remnants are removed with water and sterile gauze.

    â€¢         Group B: The measurement of the ulcer will be taken. The ulcer is covered with a sterile gauze soaked in saline (primary dressing), which is in turn covered with a sterile gauze pad (secondary dressing) and is covered with a sterile roller bandage and then 4 layered compression bandage will be applied. This dressing is left in place for 1 week

•         The greatest length and greatest breadth were measured using a thread and a scale.

•         The measurement of ulcer size will be taken before starting the treatment and before repeating the treatment each time at weekly intervals and after the treatment completion.

•         Digital photographs were taken before starting the treatment, before repeating the treatment each time at weekly intervals and after the treatment was completed.

             â€¢         The quality of life in general is assessed by EQ-5D-5L QUESTIONNAIRE and the ulcer specific assessment is done byThe Charing Cross Venous Ulcer Questionnaire.

•         The EQ-5D-5L is a brief, multiattribute, generic, health status measure composed of 5 questions with Likert response options (descriptive system) and a visual analog scale (EQ-VAS). The latter asks patients to rate their own health from 0 to 100 (the worst and best imaginable health, respectively). The descriptive system covers 5 dimensions of health (mobility, self-care, usual activities, pain or discomfort, and anxiety or depression) with 5 levels of severity in each dimension (no problems, slight problems, moderate problems, severe problems, and unable to perform or extreme problems)

                        • The Charing Cross Venous Ulcer Questionnaire                               23 4  This questionnaire is composed of 21 items distributed  in to 4 domains

1)   Social interaction

2)   Domestic activities

3)   Emotional state

4)   aesthetics

                                                                   Statistical Analysis  Statistical analysis will be carried out by exporting the data into Excel (Microsoft Corporation, Seattle, WA) and SPSS-22nd version. The measurement data are presented as the mean ±standard error of the mean. t-test and Chi square test done and the results are compared.

   REVIEW OF LITERATURE.

 â€¢         Yasser helmy et al (7) enrolled 80 patients with chronic venous leg ulcers and treated with autologous platelet rich plasma(PRP) and conventional treatment by compression and dressing and PRP therapy showed better results and high p value significance when compared to conventional herapy

•         Somani A, et al (2017) (8) conducted a study of autologous RF with saline dressing in 15 patients with chronic venous leg ulcer and compared the mean reduction in ulcer area at the end of 4 weeks. The mean reduction in the area of the ulcer size in PRF group was 85.51%, and the mean reduction in the area of the ulcer size in Saline group was 42.74% which was statistically significant with a P< 0.001  concluding that PRF dressing can be used as it is effective, inexpensive, safe and an outpatient procedure.

•         Goda ,et al (09) conducted a study with 36 patients with venous ulcers and treated with autologous L-PRF dressing  and dressing change was done once weekly and the other group was treated with conventional dressing of VU, but dressing change was done once in 2 days. There was a statistically significant difference between the PRF group and control group regarding the rate of completely healed ulcer at the fourth week for ulcer size less than 10 cm2 and at the seventh week for ulcer size more than 10 cm2.

•         Moneib et al (2017)(10) studied  40 patients with chronic venous leg ulcers who were treated with autologous PRP and conventional treatment

(compression and dressing)  weekly for 6 weeks.  Compared to conventional therapy, a highly significant improvement in the ulcer size was observed postPRP therapy (P-value = .0001). The mean change in the area of the ulcer postPRP and conventional therapy was 4.92 ± 11.94 cm and 0.13 ± 0.27 cm, respectively, while the mean percentage improvement in the area of the ulcer post-PRP and conventional therapy was 67.6% ± 36.6% and 13.67% ± 28.06%.

•         Elsaid et al. [11] reported a complete healing rate at 20 weeks; the PRP dressing group was significantly higher than the normal saline dressing group (3/25 vs. 0/25, p = 0.03), and they showed that the time of wound to maximum healing was significantly shorter in the PRP dressing group than in the normal saline dressing group (6.3 ± 2.1 vs. 10.4 ± 1.7 weeks, p < 0.0001). Elsaid et al. [40] also found the inefficient rate was significantly lower in the PRP group; only 8% of wounds presented no response to PRP dressings, while more than

66% of wounds had no response to saline dressings

•         Manuel et al. [12] reported the percentage of the healed area after 24 weeks of treatment, and found that the PRP dressing group was significantly quicker than the normal saline dressing group (67.7% ± 41.54 vs. 11.17% ± 24.4, p = 0.001), and the PRP group had significant pain reduction (p = 0.001).

•         Elgarhy et al. [13] evaluated the inflammation and regeneration of chronic wounds via histologic staining. They found that local tissues presented less inflammatory cell infiltration and well-formed granulation tissues after six weeks of PRP dressing treatment, while moderate vascular proliferation and marked chronic inflammatory cells after six weeks of saline dressing treatment.

   REFERENCES 1.    Santler B, Goerge T. Chronic venous insufficiency: a review of pathophysiology, diagnosis, and treatment. J Dtsch Dermatol Ges 2017;15:538-56.

2.    Cavezzi A, Labropoulos N, Partsch H, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs: UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 2006;31:288-99.

3.Jones, R.E.; Foster, D.S.; Longaker, M.T. Management of Chronic Wounds— 2018. JAMA 2018, 320, 1481–1482.

4..Everts, P.; Onishi, K.; Jayaram, P.; Lana, J.; Mautner, K. Platelet-Rich Plasma: New Performance Understandings and Therapeutic Considerations in 2020. Int. J. Mol. Sci. 2020, 21, 7794.

5..Xing, F.; Xiang, Z.; Rommens, P.M.; Ritz, U. 3D Bioprinting for Vascularized TissueEngineered Bone Fabrication. Materials 2020, 13, 32429135.

 6.Liu, H.-Y.; Huang, C.-F.; Lin, T.-C.; Tsai, C.-Y.; Chen, S.-Y.T.; Liu, A.; Chen, W.-H.; Wei, H.J.; Wang, M.-F.; Williams, D.F.; et al. Delayed animal aging through the recovery of stem cell senescence by platelet rich plasma. Biomaterials 2014, 35, 9767–9776.

 7.Helmy, Y.; Farouk, N.; Dahy, A.A.; Abu-Elsoud, A.; Khattab, R.F.; Mohammed, S.E.; Gad, L.A.; Altramsy, A.; Hussein, E.; Farahat,(7)A. Objective assessment of platelet-rich plasma (prp) potentiality in the treatment of chronic leg ulcer: Rct on 80 patients with venous ulcer. J. Cosmet. Dermatol. 2021, 20, 3257–3263

 8.Somani A, Rai R. Comparison of Efficacy of Autologous Platelet-rich Fibrin versus Saline Dressing in Chronic Venous Leg Ulcers: A Randomised Controlled Trial. J Cutan Aesthet Surg. 2017 Jan-Mar;10(1):8-12. doi: 10.4103/JCAS.JCAS_137_16. PMID: 28529414; PMCID: PMC5418991

 9.Autogenous leucocyte-rich and platelet-rich fibrin for the treatment of leg venous ulcer ,a randomized control study ,Goda, Asser A. MD,The Egyptian Journal of Surgery 37(3):p 316-321, Jul–Sep 2018. | DOI: 10.4103/1110-1121.239205

     â€¢  10..Moneib HA, Youssef SS, Aly DG, Rizk MA, Abdelhakeem YI. Autologous platelet-rich plasma versus conventional therapy for the treatment of chronic venous leg ulcers: A comparative study. J Cosmet Dermatol. 2018 Jun;17(3):495-501.

 â€¢  11.Elsaid, A.; El-Said, M.; Emile, S.; Youssef, M.; Khafagy, W.; Elshobaky, A. Randomized Controlled Trial on Autologous Platelet-Rich Plasma Versus Saline Dressing in Treatment of Non-healing Diabetic Foot Ulcers. World J. Surg. 2020, 44, 1294–1301.

 â€¢  12 Cardeñosa, M.E.; Domínguez-Maldonado, G.; Córdoba-Fernández, A. Efficacy and safety of the use of platelet-rich plasma to manage venous ulcers. J. Tissue Viability 2017, 26, 138– 143.

 â€¢  13 Elgarhy, L.H.; El-Ashmawy, A.A.; Bedeer, A.E.; Al-Bahnasy, A.M. Evaluation of safety and efficacy of autologous topical platelet gel vs platelet rich plasma injection in the treatment of venous leg ulcers: A randomized case control study. Dermatol. Ther. 2020, 33, e13897.

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