|Year : 2018 | Volume
| Issue : 3 | Page : 316-321
Autogenous leucocyte-rich and platelet-rich fibrin for the treatment of leg venous ulcer: a randomized control study
Asser A Goda
Department of Vascular Surgery, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
|Date of Submission||13-Jan-2018|
|Date of Acceptance||27-Jan-2018|
|Date of Web Publication||17-Aug-2018|
Asser A Goda
Department of Vascular Surgery, Sohag Faculty of Medicine, Sohag University, 82511 Sohag
Source of Support: None, Conflict of Interest: None
Background Venous ulcer (VU) is a serious health problem that has no satisfactory treatment. Platelet-rich fibrin (PRF) is one of regenerative medicines that promote wound healing by sustained release of growth factor (GF) and protein matrix for more than 7 days.
Aim This study aims to evaluate the efficacy and safety of autologous leukocyte-platelet-rich fibrin (L-PRF) with venous leg ulcer.
Patients and methods A randomized controlled study was conducted that included 36 patients with VUs. The eligible patients were enrolled in one of two groups (PRF and control groups) according to randomization schedule. Each group included 18 patients. The PRF group was treated with autologous L-PRF dressing, and dressing change was done once weekly. The control group was treated with conventional dressing of VU, but dressing change was done once in 2 days.
Results The mean percentage of wound reduction of PRF group was found significantly higher than that of control group. 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.
Conclusion Autologous L-PRF is effective and safe for treatment of venous leg ulcer.
Keywords: platelet-rich fibrin, regenerative medicine, venous ulcer
|How to cite this article:|
Goda AA. Autogenous leucocyte-rich and platelet-rich fibrin for the treatment of leg venous ulcer: a randomized control study. Egypt J Surg 2018;37:316-21
|How to cite this URL:|
Goda AA. Autogenous leucocyte-rich and platelet-rich fibrin for the treatment of leg venous ulcer: a randomized control study. Egypt J Surg [serial online] 2018 [cited 2019 Aug 20];37:316-21. Available from: http://www.ejs.eg.net/text.asp?2018/37/3/316/239205
| Introduction|| |
Venous ulcers (VUs) constitute a serious public health problem. They interfere with the quality of life owing to their complications, which may result in significant morbidity . VUs represent 70% of lower limb ulcers . The treatment is often difficult and is generally associated with high recurrence rate ,,. Platelet concentrates have been widely used in regenerative medicine to promote wound healing as they contain growth factors . Platelet-rich fibrin (PRF) is a second-generation platelet concentrate . Leukocyte-platelet-rich fibrin (L-PRF) requires simplified processing without use of bovine thrombin and anticoagulants . It helps in efficient cell migration and proliferation. It has supportive effect on immune system and also aids in hemostasis .
The aim of this study was to evaluate the efficacy and safety of autogenous L-PRF for treatment of VUs in randomized control multicenter double-blind design.
| Patients and methods|| |
This prospective, randomized, and controlled study conducted at Vascular Surgery of Sohag Faculty of Medicine included patients with VU between September 2016 and October 2017 after approval of the Scientific Ethics Committee.
Inclusion criteria included patients with venous leg ulcers (VLUs).
Exclusion criteria were as follows:
- Patients with peripheral arterial disease, characterized by ankle brachial index (ABI) less than 1.
- Osteomyelitis of leg bone.
- Wound infection.
This study was performed on 36 patients. The patient provides a written informed consent before enrollment in the study. All eligible patients were randomized into two groups according to randomization schedule.
The randomization schedule was generated using SPSS program (SPSS Inc., Chicago, Illinois, USA). Each eligible study participant was assigned to one of two treatment groups, PRF group or control group, by receiving the next available consecutive randomization number, and type of dressing according to randomization schedule.
- PRF group (18 patients): The wounds in this group were covered with PRF as their dressing protocol.
- Control group (18 patients): The wounds in this group were covered with conventional dressing.
- NB: General rules regarding compression using elastic stocking or elastic bandage were followed.
- A blood sample is taken without anticoagulant in 10-ml tubes, which are immediately centrifuged at 3000 rpm for 10 min.
- Coagulation starts during the centrifugation, and three parts quickly appear in the tube: a red blood cell base at the bottom, a cellular plasma as a supernatant (platelet-poor plasma), and the L-PRF clot in between. The latter is rich in fibrin, platelets (±95% of initial blood), and leukocytes (±50% of initial blood).
- A fibrin clot is then obtained from the middle of the tube, and is further transformed into a membrane, circa 1 mm in thickness, by careful compression between two gauzes.
PRF group (18 patients)
- The fibrin clot membrane was applied to the ulcer followed by paraffin gauze and secondary sterile dry dressing. Lastly, elastic bandage was applied.
- The frequency of change of dressing was once weekly. The dressing protocol was performed for up to 8 weeks or stopped whenever healing occurred.
Control group (18 patients)
Conventional dressing was applied to the ulcer using paraffin gauze that was applied to the ulcer followed by secondary sterile dry dressing. Finally, elastic bandage was applied.
The frequency of change of dressing was once in 2 days. The dressing protocol was performed for up to 8 weeks or stopped whenever healing occurred.
- The ulcer area was calculated at the initial visit by measuring the ulcer’s dimensions (length and width) using metric tapes.
- The ulcer area was measured every week for all patients in each group, and the ulcer area reduction is calculated each week.
- The number of complete ulcer healing is detected in each group.
- Laboratory tests were performed for all patients in two groups at the initial visit and every 4 weeks until the patients reach the end point.
The end points of the current analysis were ulcer healing or end-of-study occurred at completion of the week 8.
Data were analyzed by STATA, version 12.1 (Stata Statistical Software: Release 12; StataCorp LP, College Station, Texas, USA). Quantitative data were represented as mean and SD. Data were analyzed using student t-test to compare means of two groups. Qualitative data were presented as number and percentage and compared using either χ2-test or fisher exact test. P value was considered significant if it was less than 0.05.
| Results|| |
During the study period, 36 patients with VUs met the inclusion criteria and were enrolled in the current series in one of the two groups according to randomization schedule, with 18 patients in each.
The baseline criteria of the study patients are shown in [Table 1]. There was no statistically significant difference regarding demographic data, risk factors, and laboratory parameters at the baseline for each group.
The mean ulcer area reductions in two groups are shown in [Table 2] and [Figure 1]. The mean ulcer area reduction in PRF group with initial size less than 10 cm was 25.3, 53.4, 80.2, and 100% after 1, 2, 3, and 4 weeks, respectively. The mean ulcer area reduction in control group with initial size less than 10 cm was 12.3, 23.5, 47.2, 62.2, 78.3, and 100% after 1, 2, 3, 4, 5, and 6 weeks, respectively.
|Table 2 The mean ulcer size reduction in platelet-rich fibrin group and control group|
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|Figure 1 The mean ulcer size reduction in platelet-rich fibrin group and control group.|
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The mean ulcer area reduction in PRF group with initial size more than 10 cm was 16.3, 31.1, 49.4, 64.3, 79.5, 96.3, and 100% after 1, 2, 3, 4, 5, 6, and 7 weeks, respectively. The mean ulcer area reduction in control group with initial size more than 10 cm was 6.9, 14.4, 29.1, 43.3, 58.3, 71.6, 86.8, and 97.3% after 1, 2, 3, 4, 5, 6, 7, and 8 weeks, respectively.
There were no adverse effects detected from L-PRF dressing. There was a statistically significant difference between PRF group and control group regarding the mean ulcer area reduction either with initial length less than or more than 10 cm2. The mean ulcer area reduction is significantly higher in PRF group than control group.
The rate of complete healing of the ulcers in PRF group and control group is present in [Table 3]. The rate of complete closure in PRF group with initial size less than 10 cm2 was 30% at the third week, and 100% at the fourth week, whereas in the control group with the same initial ulcer size (<10 cm2), it was 0% at the third week and 9.1% at the fourth week.
|Table 3 The rate of complete healing of the ulcers in platelet-rich fibrin group and control group|
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The rate of complete closure in PRF group with initial size of more than 10 cm2 was 50% at the sixth week and 100% at the seventh week, whereas in the control group with the same initial ulcer size (>10 cm2), it was 14.3% at the sixth week and 42.6% at the seventh week.
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.
There were no statistically significant differences in the PRF group and control group from the baseline to the end-point laboratory shift in blood picture (hemoglobin and platelet count) and blood chemistry (albumin) ([Table 4]).
|Table 4 Comparison of the laboratory investigation between platelet-rich fibrin group and control group from the baseline to the end point|
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| Discussion|| |
The hypothesis for this study is a consequence of the increasing interest in the use of regenerative medicine for treatment of VLU in modern medicine, where the conventional therapy cannot provide satisfactory healing results.
PRF is an autologous platelet and L-PRF material and is an important advancement in regenerative medicine . PRF is a second-generation platelet concentrate ,,. L-PRF is rich in fibrin, platelets, and leukocytes . L-PRF release significantly large amounts of growth factors and matrix proteins  for a long period (>7 days)  owing to a specific polymerization and architecture of the fibrin matrix .
The use of PRF for treatment of VU is supported in many literatures. Anitue et al.  reported in a review of the use PRF on VLU that the PRF is ‘promising’. Moreover, O’Connell et al.  proved that PRF was very efficacious in the treatment of VUs, and its efficacy in healing of VU was more than that of non-VU.
In this study, we used L-PRF for treatment of VLUs to evaluate its efficacy and safety, in prospective randomized controlled study. The baseline characteristics regarding demographic data, risk factors, laboratory parameters, ankle brachial index, and wound variables of both PRF group and control group are almost similar, with no statistically significant difference.
In this study, the mean ulcer area reduction is significantly higher in PRF group than control group. There was a statistically significant difference between PRF group and control group regarding the mean ulcer area reduction with either initial length of less than or more than 10 cm2. The result in this study is similar to the results reported in many literature studies ,,.
In a randomized controlled study done by Somani and Rai , 15 patients with chronic VLU who were not responding to available treatment modalities for more than 6-month duration were included. The ulcer size area was at least 1 cm2 and less than or equal to 5 cm2. The patients were randomly divided into two groups: PRF dressing group and saline dressing group. That study reported that 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 the saline group was 42.74%, which was statistically significant, with a P<0.001.
Moreover, Pravin et al.  included in a randomized, open-labeled comparative study 30 patients with nonhealing ulcers of various etiologies, and 22 of them were VUs. Fifteen patients were treated with PRP and 15 patients with L-PRF at weekly intervals for a maximum of 6 treatments. The study concluded that L-PRF is more efficacious and has a quicker healing rate than PRP.
Another, autocontrolled prospective cohort study was done by Pinto et al.  on the use of L-PRF therapy for chronic wounds refractory to standard treatment for at least 3 months. The study included 49 chronic wounds, where 32 of them were VLUs (17 of them were >10 cm2 and 15 were <10 cm2). After the L-PRF therapy, all 49 wounds showed significant improvements in the healing process and symptomatic relief.
Moreover, Jorgensen, et al.  included in a prospective, uncontrolled pilot study 16 lower extremity chronic wounds that had not responded to previous treatments. The wounds were of varying etiologies; six of them were VUs. The wound size ranged from 0.4 to 15.7 cm2 (median: 2.3 cm2). The ulcers were treated weekly with Leucopatch (Reapplix, Birkerod, Denmark). That study found the mean wound area decreased significantly by 65%, resulting in a median wound size of 0.9 cm2 (range=0–9.6 cm2) with Leucopatch.
In this study, 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. The result in this study is similar to the results reported by Somani and Rai , Pravin et al. , and Pinto et al. .
Somani and Rai  reported that the complete closure of the ulcers in the PRF group was five (55.55%) patients and in the saline group was no case.Pravin et al.  reported that ∼100% healing of the ulcer was seen in 11 of the 15 ulcers in L-PRF and eight of the 15 ulcers in PRP at the end of the sixth treatment (73.3 vs. 53.3%).
Pinto et al.  reported that following the use of L-PRF therapy, all VLUs of less than or equal to 10 cm2 showed full closure within a 3-month period. All wounds of patients with VLUs more than 10 cm2 who continued therapy (10 wounds) could be closed, whereas in the five patients who discontinued therapy, improvement of wound size was observed.
In this study, there were no adverse effects detected from L-PRF dressing. There were no statistically significant differences in each group (PRF group and control group) from the baseline to the end-point laboratory shift in blood picture (hemoglobin and platelet count) and blood chemistry (albumin). Moreover, Jorgensen et al.  reported that there were no serious adverse events detected with the use of L-PRF for the treatment of recalcitrant chronic wounds.
| Conclusion|| |
Autologous L-PRF represents an effective and safe treatment modality that shows significant higher potential for healing of VLUs than conventional therapy. Autologous L-PRF should be added to our armamentarium for treatment of VLUs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dias TYAF, Costa IKF, Melo MDM, Torres SMSGSO, Maia EMC, Torres GV. Avaliação da qualidade de vida de pacientes come sem úlcera venosa. Rev Latino-Am Enferm 2014; 22:576–581.
O’Donnell TF Jr, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL et al.
Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2014; 60:3s–59s.
Bergqvist D, Lindholm C, Nelzén O. Chronic leg ulcers: the impact of venous disease. J Vasc Surg 1999; 29:752–755.
Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health 1999; 53:149–153.
Mayer W, Jochmann W, Partsch H. Varicose ulcer: healing in conservative therapy. A prospective study. Wien Med Wochenschr 1994; 144:250–252.
Somani A, Rai R. Comparison of efficacy of autologous platelet-rich fibrin versus saline dressing in chronic venous leg ulcers: a randomized controlled trial. J Cutan Aesthet Surg 2017; 10:8–12.
Pravin A, Sridhar V, Srinivasan B. Autologous platelet rich plasma (PRP) versus leucocyte-platelet rich fibrin (L-PRF) in chronic non-healing leg ulcers − a randomized, open labeled, comparative study. J Evolution Med Dent Sci 2016; 5:7460–7462.
Ehrenfest D, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol 2009; 27:158–167.
Ehrenfest D., Andia I, Zumstein MA, Zhang CQ, Pinto NR, Bielecki T. Classification of platelet concentrates (platelet-rich plasma-PRP, platelet-rich fibrin-PRF) for topical and infiltrative use in orthopedic and sports medicine: current consensus, clinical implications and perspectives. Muscles Ligaments Tendons J 2014; 4:3–9.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101:e37–e44.
Ehrenfest D, Del Corso M, Diss A, Mouhyi J, Charrier JB. Three-dimensional architecture and cell composition of a Choukroun’s platelet-rich fibrin clot and membrane. J Periodontol 2010; 81:546–555.
Ehrenfest D, De Peppo GM, Doglioli P, Sammartino G. Slow release of growth factors and thrombospondin-1 in Choukroun’s platelet-rich fibrin (PRF): a gold standard to achieve for all surgical platelet concentrates technologies. Growth Factors 2009; 27:63–69.
Ehrenfest D, Diss A, Odin G, Doglioli P, Hippolyte MP, Charrier JB. In vitro effects of Choukroun’s PRF (platelet-rich fibrin) on human gingival fibroblasts, dermal prekeratinocytes, preadipocytes, and maxillofacial osteoblasts in primary cultures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108:341–352.
Ehrenfest D, Bielecki T, Jimbo R, Barbe G, Del Corso M, Inchingolo F, Sammartino G. Do the fibrin architecture and leukocyte content influence the growth factor release of platelet concentrates? An evidence-based answer comparing a pure platelet-rich plasma (P-PRP) gel and a leukocyte- and platelet-rich fibrin (L-PRF). Curr Pharm Biotechnol 2012; 13:1145–1152.
Anitua E, Sanchez M, Nurden AT, Zalduendo M, de la Fuente M, Orive G et al.
Autologous fibrin matrices: a potential source of biological mediators that modulate tendon cell activities. J Biomed Mater Res A 2006; 77:285–293.
O’Connell S, Impeduglia T, Hessler K, Wang X, Carroll R, Dardik H. Autologous platelet-rich fibrin matrix as cell therapy in the healing of chronic lower-extremity ulcers. Wound Rep Reg 2008; 16:749–756.
Pinto N, Ubilla M, Zamora Y, Del Rio V, David M, Ehrenfest D, Quirynen M. Leucocyte- and platelet-rich fibrin (L-PRF) as a regenerative medicine strategy for the treatment of refractory leg ulcers: a prospective cohort study. Platelets 2017; 20:1–8.
Jørgensen B, Karlsmark T, Vogensen H, Haase L, Lundquist R. A pilot study to evaluate the safety and clinical performance of leucopatch, an autologous, additive-free, platelet-rich fibrin for the treatment of recalcitrant chronic wounds. Int J Lower Extrem Wounds 2011; 10:218–223.
[Table 1], [Table 2], [Table 3], [Table 4]