Introduction

Right from the days of Sushruta in Ancient India, due to frequent battles and wars, healing of wounds was a matter of concern [1] Sushruta Samhita has two separate chapters dealing with healing of these wounds, and describes more than 100 plants for treatment of wounds both singly and in combination [2] Sushruta has mentioned not only procedures and drugs to obtain a clean wound (VranaShodan) followed by healing (VranaRopan) but also medicines to help treatment of keloids [3].

Chronic wounds can be classified into vascular ulcers (eg, venous and arterial ulcers), diabetic ulcers, and pressure ulcers. Some common features shared by each of these include a prolonged or excessive inflammatory phase [4,5].

Persistent infections, formation of drug-resistant microbial biofilms, and the inability of dermal and/or epidermal cells to respond to reparative stimuli [6].

Pressure ulcers develop as a result of prolonged unrelieved pressure and shearing force applied to skin and the underlying muscle tissue leading to a decrease in oxygen tension, ischemic injury, and tissue necrosis. Pressure ulcers are common in patients with compromised mobility and decreased sensory perception (neuropathies) [7,8].

The phenotypic abnormalities of epidermis- and dermis-derived cells residing in chronic wounds include lower density of growth factor receptors and lower mitogenic potential preventing them from responding properly to environmental cues.

For instance, fibroblasts, isolated from patients with chronic diabetic, chronic nondiabetic wounds, or patients with venous insufficiency, have lower mitogenic response to PDGF-AB, IGF, bFGF, and epidermal growth factor applied separately or in combination. These findings are likely due to a decrease in receptor density [9, 10, 11].

Successful treatment of a particular chronic wound requires a detailed understanding of the molecular and cellular components present within each wound bed. Currently, chronic (and acute) wounds of different etiologies are treated using a multistep approach based on contemporary knowledge of wound healing and known by the acronym TIME.

Method: These patients were thoroughly evaluated. The study group patients were subjected to wound infiltration of autologous inactivated PRP prepared by double spin technique as per the standard protocol, using 20-40 ml of patient’s blood as per the size of the wound, using a 22 gauge needle under strict asepsis.

This will be done on the day of recruitment and subsequently every 4th day till the wound has reached the size of less than 100 sq. mm. These patients were dressed with moist saline dressing only. No antibiotics were used as far as possible. Similarly, analgesics were avoided. No surgical intervention was done once the patient was enrolled.

Method of preparing PRP

It was done with a double spin method, using 20ml of venous autologous blood, freshly drawn from the patient. 5ml blood was then transferred to 4 EDTA test tubes each and centrifuged at 2000 RPM for 15 minutes. RBCs got settled in lower portion of test tube and plasma in the upper part. Plasma was extracted and collected in a separate test tube and re-centrifuged at 1200 RPM for 10 minutes. The plasma further separated into upper buffy coat with platelet poor plasma and lower 3-4 ml layer containing platelet rich plasma.

STARS THERAPY PROTOCOL [22]

The autologous PRP thus obtained is transferred to a 10 ml syringe and locally infiltrated into wound margins through a 22 gauge needle at a distance of approximately 1cm. The process is repeated every 4th day. Local moist saline dressing is performed on alternate days. Diluted cetrimide and chlorhexidine gluconate solution are used for cleaning dirty wounds. No further surgical interventions were undertaken.  

Inclusion Criteria

1. All age and genders
2. Wound of the size at least 100 square mm.
3. All chronic wounds (more than 90 days) including trophic ulcers, decubitus ulcers, diabetic and venous ulcers.

Exclusion criteria

1. Wound size less than 100 square mm in area.
2. Wounds less than 90 days duration.
3. Patient on I/V antibiotics.
4. patient with serious systemic illness and moribund patients

Shrivastava et al in their protocol STAR therapy have advocated direct injection of platelet rich plasma into the wound instead of making gel preparation with good results. The STAR protocol in our study was found tobe simple, rapid, early reproducible, with use of minimal equipment and inexpensive [22].

We had used autologous blood for PRP preparation, and therefore none of our patient had any adverse reaction.

There are large number of studies in the published literature are on chronic non healing wounds like trophic ulcers of leprosy, diabetic foot ulcers, chronic lower limb ulcers etc. but with mix results.

In the present study, we have studied chronic wounds sustained because of variety of reasons being treated with PRP alone without use of analgesics and antibiotics, no debridement and moist saline dressings only. Chronic wounds were classified as per center for medical services definition [23].

Graph paper tracing was used to record the size of the wound. More than 71.43% of patients showed 50% + 5% reduction in the size of the wound with in 5 infiltration and 90% wounds reached 50% + 5% size with in 10 infiltrations i.e. in 40 days. However complete healing took much long time. The larger was the surface area of the wound, the longer it took to heal. More than 90% of cases healed with in 40 days (20 infiltrations).

One of the patient had a non healing ulcer over the sole of the foot which was of about 7 years duration. Using the present protocol with only 10 infiltrations the patient showed complete healing. Not only the STARS protocol of PRP therapy brought about the complete healing but this healing left behind minimal scar which was of good quality and unlikely to breakdown in near future.

Further, as the amount of scaring was minimal there were no secondary deformities because of scar contraction. Similarly a patients with non healing ulcers over both ankles of over 10 year duration showed complete healing.

One of the most remarkable things was the quality of wound healing in these cases. The healed area shows much less scarring. Whatever scar was left behind was of good quality and unlikely to breakdown in future.

In none of the patient, oral or systemic antibiotic were given. However, most of these patients were on antibiotics before the start of protocol, which were stopped. At the start of study, 34.29% of patients had positive culture of wound, which decrease to 11.43% by 3rd infiltration and complete eradication of infection by 5th infiltration.

None of the patient showed increased clinical signs of infection and there were no complication related to infection. The wound cultures showed a growth of variety of bacteria including MRSA, pseudomonas and E. coli. Usually, these were present as individual infecting organisms.

Marrisa J Cartier et al in their meta-analysis found that superficial and deep infections and postoperative complications were significantly lower in PRP treated subjects than in control group. Further, infection was significantly increase in control group than in PRP group [26].

In this series during the whole course of study, there was no significant complication. Some patients experienced pain of injection which was not severe and subsided immediately after the procedure.

One patient had severe pain to start with (VAS score 8). This patient had long standing ulcers over both ankles. The pain increased after infiltration and persisted throughout the course of treatment.

Overall, it was found that PRP infiltrations not only helped in wound healing but also significantly promoted skin regeneration leading to minimization of scar formation and its resulting problems.

Conclusion

Autologous PRP could be easily prepared and used, utilizing minimal instrumentation even at centers with limited resources. The STARS protocol of preparing and infiltrating PRP in the wound margin was easy and effective irrespective of their etiology with minimal complications.

References