Advancing Wound Management: A Comparative Study of Mechanical Fixation and Platelet-Rich Plasma in Split Skin Grafting

Introduction

An autologous product called ‘platelet-rich plasma’ (PRP) concentrates a lot of platelets into a minimal amount of plasma.

Acting as a fibrin adhesive, PRP possesses hemostatic and tissue-sealing attributes, uniquely fostering wound recovery.¹ This agent promptly ensures surgical hemostasis, ensuring biocompatibility, safety, and efficacy. PRP expedites endothelial, epithelial, and epidermal renewal, fosters angiogenesis, boosts collagen synthesis, supports soft tissue mending, reduces dermal scarring, and augments the injury's hemostatic response.¹ Platelets, the minute disc-shaped blood components, facilitate these processes.

The mean platelet count ranges from 1.5 to 3.0 × 10-5/ mL of circulating blood, with platelets having an in vivo half-life of approximately seven days.² Split thickness skin grafting (STSG) is a widely used technique for soft-tissue coverage due to its versatility, ease of procurement, and standard equipment. STSG healing progresses through three stages, Stage 1: Anchorage, Stage 2: Inosculation, and Stage 3: Maturation, with the success of the initial two stages crucial for the overall success.

It has been suggested recently to apply autologous Platelet-Rich Plasma (PRP) to STSG sites to speed up the skin graft's initial anchoring and the inosculation process with nutrient-rich blood media.³ PRP administration at STSG recipient sites seems to enhance primary healing and reduce healing time, most likely through lowering shear stresses and improving the growth factor-filled wound environment.

Chronic wounds may experience a deficiency in growth factors due to reduced production and release, entrapment, excessive degradation, or a combination of these mechanisms, leading to delayed healing. PRP can overcome this deficiency. This study aimed to compare two patient groups: one receiving topical autologous PRP application on wound beds before split skin grafting and another without any such application.

Materials and Methods

In order to compare autologous platelet-rich plasma (PRP) to more traditional techniques like glue, staplers, or sutures for skin graft resurfacing, this prospective randomized controlled trial sought to determine how effective PRP is in wound beds. This study was conducted at General Surgery Department at a Tertiary Care Centre, over one-year period from January 2023 to January 2024. The local ethical committee approved the study, and all the participants provided informed written consent.

A total of sixty patients were divided into two groups of thirty each. One group received autologous PRP, while the others were managed with conventional methods for anchorage of skin grafts. Detailed medical history was obtained from all the patients, including information on duration, onset, progression, and associated symptoms of their wounds. Factors contributing to chronicity were also investigated. Wound examinations were performed on all cases, including traumatic, infective, and post-burn ulcers. In this study, patients with co-morbidities such as hypertension, diabetes mellitus and those consuming aspirin analogs were included.

Exclusion criteria comprised ulcers showing evidence of malignancy, active infection with pus discharge or slough, immunocompromised status, ulcers exposing tendons, ligaments, or bone, gangrene, recent radiation or chemotherapy, active cancer, decompensated liver disease, renal dialysis, or steroid therapy. Under aseptic conditions, 12 mL of blood was drawn from the antecubital region and processed to obtain PRP. Approximately 5 mL of PRP was applied as a thin film over the wound area before graft application in the study group. Grafts were secured with sutures or staples and covered with compressive dressing in the control group.

Graft success was assessed based on parameters including discharge from graft, instant adhesion, graft edema, hematoma, graft loss, day when graft was first time inspected, frequency of dressing changes, and duration of hospital stay. First inspection was done usually by one week and based on the wetness present over the site, dressing was done in both the groups. Statistical analysis was performed using unpaired student's "t" test and Chi-square test, with P <0.05 considered significant.

Results

Comparison of mean age, gender distribution, etiology of wounds, wound location, presence of comorbidities, and use of aspirin analogues was conducted between the two groups (Table 1). Additionally, objective assessment parameters were compared between the subjects in both the groups. Notably, all of the grafts in the PRP group attached well within a few seconds of administration, while the control group’s grafts exhibited zero adhesion. In the PRP group, graft edema was seen in 2% of patients, while it was detected in 18% of patients in the control group. While 20% of patients in control group experienced discharge from STSG sites, it had no effect on the PRP group (0%).

Table 2 shows that the PRP group had a much lower incidence of hematomas (3.3%) than the control group (23.3%), demonstrating the effectiveness of PRP in establishing and preserving hemostasis during STSG procedures.

Secondary grafting was required in only 2% of PRP patients compared to 33.3% in control group due to graft loss. Most PRP group patients (90%) required their first graft inspection after one week, similar to 86.7% in control group (Table 3). The control group required dressing change 3-5 times in 90% of cases, while only 4% of PRP patients required the same frequency of dressing change during their hospital stay. Discharge within 10 days post-graft was noted in 90% of control group patients and 83.3% of PRP group patients.

Diabetes, hypertension, and aspirin use were identified as significant factors negatively impacting graft intake. Because of its hemostatic qualities, PRP has been shown to be beneficial for individuals with hypertension and those consuming aspirin analogs. PRP treatment was beneficial for foot ulcers, which are frequently linked to diabetes. In more severe situations, it led to earlier healing and better graft intake than standard techniques without PRP.

PRP administration was found to be an effective therapeutic strategy for graft recovery overall, minimizing post-surgical hematoma and promoting faster healing and improved integration in the recipient bed. A statistical study showed that there were significant differences (P value <0.05) between the PRP and control groups in every objective evaluation parameter.

Discussion

Platelet-Rich Plasma (PRP), is a biological derivative made from patient's own plasma fraction, and has more platelets than normal. Before centrifugation, blood must be drawn from the patient.⁴ There are a number of names for platelet-rich plasma, including growth factor, platelet concentrate, and Platelet-Rich Fibrin (PRF) matrix. PRP was first used in hematology in the 1970s referring to plasma with an increased platelet count that was given to thrombocytopenia patients as transfusion.⁴ PRP has been widely used in the field of medicine for a number of years, mostly in sports medicine and musculoskeletal injuries. It has also been embraced in a number of medical specialties, including ophthalmology, dermatology, cardiac surgery, gynecology, urology, pediatric surgery and plastic surgery.

The main objective of using PRP before skin graft resurfacing is to help the graft adhere to the wound bed instantly and stably without the need for mechanical fixation. PRP promotes faster soft-tissue wound healing and enhances vascularization of healing tissues by delivering growth factors. Additional benefits include promoting hemostasis, reducing operating time, and minimizing the need for post operative dressings. PRP exerts its beneficial effects by releasing growth factors stored in alpha granules within platelets. These growth factors initiate wound repair by accelerating processes such as cellular proliferation, matrix formation, connective tissue healing, angiogenesis, and collagen synthesis.

PRP releases growth factors by the degranulation of alpha granules in platelets, acting as a tissue sealant and drug delivery system to start the healing process of wounds. Among these, the secretory proteins include, Transforming Growth Factor-β (TGF-β), Platelet-Derived Growth Factor (PDGF-AA, BB, and AB isomers), Interleukin-1 (IL-1), Platelet-Derived Angiogenesis Factor (PDAF), Platelet Factor 4 (PF4),Vascular Endothelial Growth Factor (VEGF), Epidermal Growth Factor (EGF), Epithelial Cell Growth Factor (ECGF), Insulin-like Growth Factor (IGF), Platelet-Derived Endothelial Growth Factor (PDEGF), Fibrinogen (Ff), Vitronectin (Vn), Fibronectin (Fn), and Thrombospondin-1 (TSP-1).

The growth factors released by PRP play a crucial role in healing by attracting undifferentiated cells to matrix that is newly formed, and by stimulating cell division. PRP may also suppress cytokine release, reduce inflammation, and interact with macrophages to enhance healing of tissues and regeneration, promote growth of new capillaries, and helps in epithelialization of chronic wounds.⁵

While previous studies focused on specific etiological groups, our study utilized PRP across all types of wounds, yielding favorable outcomes.^6-10 Autologous PRP applied to split-thickness skin grafting (STSG) sites has been proposed to facilitate nutrient rich blood media which helps in immediate anchorage of skin graft, along with inosculation.³

In our study, all the 30 patients in the PRP test group exhibited instant skin graft adhesion to the wound bed, unlike the control group where this did not occur. Studies have shown similar instant adherence following the application of fibrin sealant on burn wounds.¹¹ According to Gibran et al., PRP is safe and effective for skin graft fixation, surpassing outcomes achieved by glue, sutures or staples.¹² This not only saves operative time but also reduces post-operative efforts.

In the PRP-treated group, only 2% experienced graft edema in comparison to control group which was 18% within a week. PRP's angiogenic capacity, attributed to its fibrin matrix, growth factor, leukocytes and cytokine accelerates capillary inosculation and circulation, reducing graft edema earlier.^13-14 In our study, patients categorized in the PRP group required fewer dressing changes, including diabetic patients, indicating improved healing and reduced infection rates.¹⁵

Autologous PRP proved effective in managing chronic non-healing ulcers, leading to reduced hospital stays.¹⁶ In our study, 90% of PRP group patients were discharged within 10 days post-graft, compared to 16 days for the control group. Encompassing sixty patients of 18 to 70 years age group, the study demonstrated statistically significant results (P<0.005) across all objective parameters.

The application of autologous PRP offers significant potential and practical benefits, improving graft outcomes across various wound etiologies. No adverse effects or reactions were observed when applying autologous PRP to wounds.

Conclusion

The utilization of PRP is deemed safe and effective in managing acute wounds. This approach not only proves to be cost-effective but also facilitates early skin grafting and subsequently reduces hospital stays. Our findings highlight the myriad benefits of PRP, both for patients and surgeons alike. Based on our results, we advocate using autologous PRP routinely across all age groups and wound types before resurfacing procedures to ensure enhanced and expedited healing.

Funding

No external funding sources were utilized for this study.

Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

The study received approval from the Institutional Ethics Committee.