Platet Rich Plasma or Hyperbaric Oxygen Therapy as callus accellerator in aseptic tibial non union. Evaluate of outcomes.

Main Article Content

Giuseppe Rollo
Enrico Maria Bonura
Gabriele Falzarano
Michele Bisaccia
Julio Ribes Iborra
Predrag Grubor
Marco Filipponi
Paolo Pichierri
Philip Hitov
Danilo Leonetti
Valentina Russi
Walter Daghino
Luigi Meccariello


Tibial Nonunion; Ilizarov; Paltlet Rich Plasma; Hyperbaric Oxigen Therapy; Outcomes; ASAMI; Limb Reconstruction; Limb Savage.


Background and aim of the work: The incidence of long bone non-unions has been estimated to range between 5-10%. Nonunion of fracture is a delayed complication of fracture. A large bone resection, associated with Ilizarov's osteo-distraction technique, is commonly used in these cases. The war experience was very important for dealing with these injuries. The purpose of this study is to report whether the use of Platelet Rich of Plasma(PRP) or Hyperbric Oxygen Therapy(HOT) as an adjuvant to the osteogenic distraction of Ilizarov with respect to the classical method has advantages.

Methods: From 183 tibial non union, we enrolled 50 patients suffering by Type B according ASAMI non union classification.  We divided the patients into two groups. The first group was a retrospective group of patient treated by Ilizarov Tecnique plus PRP. Instead the second group, patients were treated by Ilizarov Tecnique associated with  HOT. The chosen criteria to evaluate the two groups during the clinical and radiological follow-up were: the complication after the surgery in the two groups; the duration of surgery; the objective quality Bone results and functional results were evaluated according to ASAMI classification while the subjective quality of  life correlated with Ilizarov frame function by the Short Form 12 Health Survey (SF-12); The correlation between bone regenerate/bone healing and X-rays. The evaluation endpoint was set at 12 months from the remotion of Ilizarov’s frame for both groups.

Results: In comparing the complications  of the two populations, there were a significant statistically difference(p<0.05) in the local skin inflammation and Dockin Point Skin retraction  for HOT group while  in refracture  p<0.05 was for group PRP. From the SF-12 we discovered not statistically differences p<0.05. The average correlation between Bone Regenerate-Bone Healing/ X-rays is absolutely in the PRP as in the HOT, p>0.05. The average Time for remove Ilizarov’s Frame in months was 15.37(±7.34; range 9–32) in PRP while in HOT was15.22(± 7.83; range 9–31), p>0.05.

Conclusions: From our study we can conclude that the association of HOT and PRP with the Ilizarov technique does not improve the functional outcomes but allows a more rapid healing of the regenerated bone and therefore an early removal of the device and a corresponding improvement in the quality of life.


Download data is not yet available.


Metrics Loading ...
Abstract 2 | PDF Downloads 0


1. Larsen P, Elsoe R, Hansen SH, Graven-Nielsen T, Laessoe U, Rasmussen S (2015) Incidence and epidemiology of tibial shaft fractures. Injury 46(4):746-50. doi: 10.1016/j.injury.2014.12.027.
2. Al Shahrani AA, Tedla JS, Ahmad I (2015) Effectiveness of Ilizarov frame fixation on functional outcome in aseptic tibial non-union cases at Abha, Kingdom of Saudi Arabia: An experimental study. Journal of Taibah University Medical Sciences 10(2):216-221. Doi:
3. Calori GM, Colombo M, Mazza EL, Mazzola S, Malagoli E, Marelli N, Corradi A (2014) Validation of the Non-Union Scoring System in 300 long bone non-unions. Injury 45 Suppl 6:S93-7. doi: 10.1016/j.injury.2014.10.030.
4. Zura R, Xiong Z, Einhorn T, Watson JT, Ostrum RF, Prayson MJ, Della Rocca GJ, Mehta S, McKinley T, Wang Z, Steen RG (2016) Epidemiology of Fracture Nonunion in 18 Human Bones. JAMA Surg 151(11):e162775. doi: 10.1001/jamasurg.2016.2775.
5. Hak DJ (2017) Editorial on "Epidemiology of fracture nonunion in 18 human bones". Ann Transl Med 5(Suppl 1):S19. doi: 10.21037/atm.2017.03.86.
6. Calori GM, Giannoudis PV(2011) Enhancement of fracture healing with the diamond concept: the role of the biological chamber. Injury 42(11):1191-3. doi: 10.1016/j.injury.2011.04.016.
7. Rodriguez-Collazo ER, Urso ML (2015) Combined use of the Ilizarov method, concentrated bone marrow aspirate (cBMA), and platelet-rich plasma (PRP) to expedite healing of bimalleolar fractures. Strategies Trauma Limb Reconstr 10(3):161-6. doi: 10.1007/s11751-015-0239-x.
8. Martel' II, Dolganova TI, Nikolaĭchuk, Sazonova NV, Dolganov DV (2003) Hyperbaric oxygenation in the treatment regimen using Ilizarov technique in patients with open fractures. Vestn Khir Im I I Grek 162(6):35-9.
9. Yin P, Zhang L, Li T, Zhang L, Wang G, Li J, Liu, Zhou J, Zhang Q, Tang P (2015) Infected nonunion of tibia and femur treated by bone transport. J Orthop Surg Res 10:49. doi: 10.1186/s13018-015-0189-5.
10. Kindwall E, Whelan H. Hyperbaric Medicine Practice. 2nd ed. Flagstaff, AZ: Best Publishing Company; 2004. chap 1, 18, 19, 20, 25, 29, 30.
11. Yin P, Zhang Q, Mao Z, Li T, Zhang L, Tang P (2014) The treatment of infected tibial nonunion by bone transport using the Ilizarov external fixator and a systematic review of infected tibial nonunion treated by Ilizarov methods. Acta Orthop Belg 80(3):426-35
12. Iliopoulos E, Morrissey N, Cho S, Khaleel A (2017) Outcomes of the Ilizarov frame use in elderly patients. J Orthop Sci 22(4):783-786. doi: 10.1016/j.jos.2017.03.002.
13. Demirtaş A, Azboy I, Bulut M, Uçar BY, Alemdar C, Alabalık U, Akpolat V, Yıldız I, Ilgezdi S (2014) The effect of hyperbaric oxygen therapy on fracture healing in nicotinized rats. Ulus Travma Acil Cerrahi Derg 20(3):161-6. doi: 10.5505/tjtes.2014.52323.
14. Grubor P, Grubor M, Meccariello L (2013) Use of external fixation and bone graft vs ao plates and bone graft in fractures of tibial shaft during the war in bosnia. Med&CH Orto (4):60-68.
15. Grubor P, Falzarano G, Grubor M, Piscopo A, Franzese R, Meccariello L (2014) Treatment of the chronic war tibial osteomyelitis, Gustilo type IIIB and Cierny-Mader IIIB, using various methods. A Retrospective study. EMBJ 9(2):7-18. Doi: 10.3269/1970.5492.2014.9.2
16. Grubor P, Milicevic S, Grubor M, Meccariello L (2015) Treatment of Bone Defects in War Wounds: Retrospective Study. Med Arh. 69(4): 260-264. doi: 10.5455/medarh.2015.69.260-264
17. Wu D, Malda J, Crawford R, Xiao Y (2007) Effects of hyperbaric oxygen on proliferation and differentiation of osteoblasts from human alveolar bone. Connect Tissue Res 48:206-13. DOI: 10.1080/03008200701458749
18. Milovanova TN, Bhopale VM, Sorokina EM, Moore JS, Hunt TK, Hauer-Jensen M, Velazquez OC, Thom SR (2009) Hyperbaric oxygen stimulates vasculogenic stem cell growth and differentiation in vivo. J Appl Physiol 106:711-28. DOI:10.1152/japplphysiol.91054.2008.
19. Bennett MH, Stanford RE, Turner R (2012) WITHDRAWN: Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union. Cochrane Database Syst Rev 14;(3):CD004712. doi: 10.1002/14651858.CD004712.pub3.
20. Bennett MH, Stanford RE, Turner R (2012) Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union. Cochrane Database Syst Rev 11:CD004712. doi: 10.1002/14651858.CD004712.pub4.
21. Karamitros AE, Kalentzos VN, Soucacos PN (2006) Electric stimulation and hyperbaric oxygen therapy in the treatment of nonunions. Injury 37 Suppl 1:S63–73. DOI: 10.1016/j.injury.2006.02.042
22. Barilaro G, Francesco Masala I, Parracchini R, Iesu C, Caddia G, Sarzi-Puttini P, Atzeni F (2017) The Role of Hyperbaric Oxygen Therapy in Orthopedics and Rheumatological Diseases. Isr Med Assoc J 19(7):429-434.
23. Millar IL, McGinnes RA, Williamson O, Lind F, Jansson KÅ, Hajek M, Smart D, Fernandes T, Miller R, Myles P, Cameron P (2015) Hyperbaric Oxygen in Lower Limb Trauma (HOLLT); protocol for a randomised controlled trial. BMJ Open (6):e008381. doi: 10.1136/bmjopen-2015-008381.
24. Mathieu D, Marroni A, Kot J (2017) Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving Hyperb Med 47(1):24-32.
25. Wroblewski AP, Mejia HA, Wright VJ (2010) Application of platelet-rich plasma to enhance tissue repair. Oper Tech Orthop 20(2):98–105.
26. Jiang ZQ, Liu HY, Zhang LP, Wu ZQ, Shang DZ (2012) Repair of calvarial defects in rabbits with platelet-rich plasma as the scaffold for carrying bone marrow stromal cells. Oral Surg Oral Med Oral Pathol Oral Radiol 113(3):327–333. DOI: 10.1016/j.tripleo.2011.03.026
27. Hernandez-Fernandez A, Velez R, Soldado F, Carlos Saenz-Ríos J, Barber I, Aguirre-Canyadell M (2013) Effect of administration of platelet-rich plasma in early phases of distraction osteogenesis: an experimental study in an ovine femur model. Injury 44(7):901–907. DOI: 10.1016/j.injury.2012.10.018
28. Latalski M, Elbatrawy YA, Thabet AM, Gregosiewicz A, Raganowicz T, Fatyga M (2011) Enhancing bone healing during distraction osteogenesis with platelet-rich plasma. Injury 42(8):821–824. DOI:
29. Hwang YJ, Choie JY (2010) Addition of mesenchymal stem cells to the scaffold of platelet-rich plasma is beneficial for the reduction of the consolidation period in mandibular distraction osteogenesis. J Oral Maxillofac Surg 68(5):1112–1124. doi: 10.1016/j.joms.2008.08.038.
30. Dehghan MM, Baghaban Eslaminejad M, Motallebizadeh N, Ashrafi Halan J, Tagiyar L, Soroori S, Nikmahzar A, Pedram M, Shahverdi A, Kazemi Mehrjerdi H, Izadi S (2015) Transplantation of Autologous Bone Marrow Mesenchymal Stem Cells with Platelet-Rich Plasma Accelerate Distraction Osteogenesis in A Canine Model. Cell J 17(2):243-52.
31. Rodriguez-Collazo ER, Urso ML (2015) Combined use of the Ilizarov method, concentrated bone marrow aspirate (cBMA), and platelet-rich plasma (PRP) to expedite healing of bimalleolar fractures. Strategies Trauma Limb Reconstr 10(3):161-6. doi: 10.1007/s11751-015-0239-x.
32. Papakostidis C, Bhandari M, Giannoudis PV (2013) Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis.Bone Joint J 95-B(12):1673-80. doi: 10.1302/0301-620X.95B12.32385.
33. Yin P, Ji Q, Li T, Li J, Li Z, Liu J, Wang G, Wang S, Zhang L, Mao Z, Tang P (2015) A Systematic Review and Meta-Analysis of Ilizarov Methods in the Treatment of Infected Nonunion of Tibia and Femur. PLoS One 10(11):e0141973. doi: 10.1371/journal.pone.0141973.