European Journal of Cardiovascular Medicine

Chronic skin ulcers defined as loss of skin and subcutaneous tissue which takes more than 6 weeks to heal. - Chronic ulceration of lower leg including the foot is a frequent condition causing pain, social discomfort and generating considerable costs. The incidence of leg ulcers is widely recorded to range from 0.18% to 1%.The primary aetiologies of lower extremity ulcers include diabetes, venous insufficiency, arterial disease, and neuropathy. Chronic wounds are distinguished by a prolonged inflammatory phase that obstructs the process of regenerative wound healing. The primary health challenge lies in the presence of chronic wounds, particularly in patients diagnosed with diabetes mellitus. The objective of wound care for skin ulcers is to promote healing and prevent lower limb amputations by implementing standardised protocols for wound management. In addition to traditional approaches for promoting wound healing, several innovative methods are being developed, including cellular therapies such as platelet rich plasma (PRP). This can play a supplementary role in ensuring the standardised quality of a treatment plan. The primary objective of this study was to assess the safety and effectiveness of autologous platelet-rich plasma (PRP) in the treatment of chronic skin ulcers, as compared to conventional skin dressings. The therapeutic efficacy of PRP is due to the high concentration of diverse growth factors, including platelet derived growth factor, transforming growth factor beta 2, fibroblast growth factor, insulin-like growth factor-1 and 2, vascular endothelial growth factor, epidermal growth factor, and certain cytokines primarily stored in alpha granules. Currently there is paucity of critical scientific data regarding the beneficial effects of PRP in clinical procedures. Hence controlled randomized prospective clinical trials are necessary to definitively demonstrate its efficacy.

Study design: Single centre, Prospective randomized controlled trial study with two parallel groups.

Duration of study: 12 months

Sample size: 100

The prevalence of leg ulcers is 0.2 to 1%. At 95% confidence interval with an allowable error of 9, the sample size is calculated as follows: (Equation 1)

                    N=Z2 pq/e2 (Z=1.96, p= 0.2%,q= 99.8, e=9)                                                 (1)

                    N= 98.5 approximately 100

 Source of data: The study was conducted in the department of General Surgery, SVRRGGH, Tirupati.

Materials:

Autologous PRP was prepared from patients whole blood by centrifugation in blood bank in the day of injection. Size of ulcer was measured by the clock method using ruler & cotton tipped applicator.

Inclusion criteria:

·         All patients with long standing non healing ulcers.

·         All patients above age of 18 years.

·         Patients with Ulcer of size < 15cm2.

·         Patients with HB> 10 gm%.

·         Patients who are willing to give written and informed consent.

Exclusion criteria:

·         Patients below 18 years of age.

·         Platelet count < 1 lakh.

·         Patients with suspected osteomyelitis.

·         Patients with immunodeficiency.

·         Patients with serum creatinine above 1.5 mg/dl

·         Patients with severe infection, presence of cellulitis, ischemia and gangrene.

Study methods

Eligible patients were randomized into PRP group and conventional dressings group using odd and even sequence. Data collected using clinical examination.

Statistical analysis

Data Entry was done using Microsoft excel 2013 and analysis done using SPSS V 16. Qualitative data was expressed in frequencies and percentages and Quantitative data in mean and standard deviation. Non parametric test include Chisquare test was used for qualitative data. Bar diagrams and pie chart were used to represent the data. p value of  <0.05 was considered statistically significant

Age Distribution

Table 1: Age Distribution in Cases and Controls

The table presents the age distribution among cases and controls, categorizing participants into three age groups: less than 50 years, 51-60 years, and greater than 60 years. There were 8 cases and 9 controls under 50 years, totaling 17 participants. In the 51-60 age group, there were 14 cases and 29 controls, amounting to 43 participants. For those above 60 years, there were 28 cases and 12 controls, totaling 40 participants. The mean age for cases was 59.88 years (±6.96), while for controls it was 55.96 years (±6.19), with an overall mean age of 57.92 years (±6.84). The chi-square value was 11.69 with a p-value of 0.003, indicating a statistically significant difference in age distribution between cases and controls.

This indicates a higher mean age among cases compared to controls, suggesting that older age might be associated with a higher incidence of diabetic foot ulcers (DFUs) Tsachiridi et al.¹ found that the mean age of participants in their study was 67.90 years for the intervention group and 67.40 years for the control group, with no significant age difference between the groups (p = 0.900) . This aligns more closely with the age distribution of the cases in our study, reinforcing the observation that DFUs are more prevalent among older adults. This higher prevalence in older age groups could be due to the prolonged duration of diabetes, higher cumulative exposure to risk factors such as neuropathy and peripheral arterial disease, and a generally reduced capacity for wound healing with advancing age . In conclusion, it is critical to consider age in the management and preventive strategies for diabetic foot ulcers, aiming for early intervention in older diabetic patients to mitigate the risk and severity of foot complications.

Gender Distribution

Table 2: Gender Distribution in Cases and Controls

This table details the gender distribution of the study participants. Among the cases, 21 were female (42%) and 29 were male (58%). In the control group, 19 were female (38%) and 31 were male (62%). The total number of participants was 100, with 40 females and 60 males. The chi-square value was 0.16, and the p-value was 0.8, suggesting no statistically significant difference in gender distribution between cases and controls. This suggests that gender may not play a significant role in the occurrence of diabetic foot ulcers. In comparison, the study by Dhanashekaran et al² showed that in the PRP group, 70% were female and 30% were male, whereas in the conventional dressing group, 65% were female and 35% were male, with no significant gender difference observed (p = 0.736) . This higher proportion of females in both treatment groups contrasts with the gender distribution in our study, indicating a potential variation in sample demographics. Similarly, Tsachiridi et al.¹ reported a gender distribution with 60% males in the PRP group and 33.3% males in the control group, although the difference was not statistically significant (p = 0.100) . This higher percentage of males in the intervention group supports our finding of a predominance of males among cases.

The study by Helmy et al.³ also reported a higher prevalence of males with DFUs, suggesting a possible gender predisposition to the development of foot ulcers in diabetic patients. However, the specific reasons for this gender disparity are not well understood but could involve differences in health-seeking behavior, occupational exposures, and lifestyle factors between males and females. In conclusion, while our study and several referenced studies indicate a higher prevalence of diabetic foot ulcers among males, the overall impact of gender on the risk of DFUs remains inconclusive. Further research with larger and more diverse populations is needed to better understand the role of gender in the development and management of diabetic foot ulcers.

Type of onset

The onset of diabetic foot ulcers in our study showed no significant difference between cases and controls (Chi-square value = 1, p = 0.4). Among the cases, 52% had spontaneous onset and 48% had traumatic onset, whereas in the control group, 42% had spontaneous onset and 58% had traumatic onset. The reference by Gude et al.⁴ indicated that a significant number of DFUs have a traumatic onset due to minor injuries that fail to heal properly due to underlying diabetic conditions, supporting the distribution observed in our study . Overall, the onset type—whether spontaneous or traumatic—did not significantly impact the development of diabetic foot ulcers between cases and controls in our study. This suggests that both spontaneous and traumatic factors equally contribute to the development of DFUs, and management strategies should address both types of onset to effectively prevent and treat these ulcers. Further research focusing specifically on the onset mechanisms could provide more insights into tailored prevention and treatment approaches for diabetic foot ulcers.

Site of Diabetic Foot Ulcer

 Among the cases, 18 (36%) had ulcers on the dorsum and 32 (64%) had plantar ulcers. In the control group, 16 (32%) had dorsum ulcers and 34 (68%) had plantar ulcers. The total number of participants was 100. The chi-square value was 0.2 with a p-value of 0.8, showing no statistically significant difference in ulcer site between cases and controls. Generally the high prevalence of plantar ulcers among diabetic patients, can be attributed to increased pressure and trauma in these areas due to neuropathy and poor foot care practices. Plantar ulcers pose a greater challenge due to their location, which is subject to higher pressure and friction, complicating the healing process. Effective management of plantar ulcers requires offloading strategies, such as specialized footwear and pressure-relieving devices, to facilitate healing. In conclusion, the distribution of ulcer sites in our study aligns with broader clinical observations, indicating a higher prevalence of plantar ulcers. This highlights the need for targeted interventions to manage and prevent plantar ulcers, which are a common and challenging complication in diabetic patients

Anti Diabetic Drugs

The use of anti-diabetic drugs among cases and controls is detailed here. In the cases group, 27 participants (54%) used insulin (I), and 23 (46%) used oral medication (O). In the control group, 29 participants (58%) used insulin, and 21 (42%) used oral medication. The total number of participants was 100. The chi-square value was 0.2 with a p-value of 0.8, indicating no statistically significant difference in the type of anti-diabetic drugs used between cases and controls.

Helmy et al³. Discussed the critical role of stringent glycemic control in preventing and managing DFUs, noting that both insulin and oral hypoglycemic agents are commonly used in diabetic patients with foot ulcers. This aligns with the distribution of drug use observed in our study, where both insulin and oral medications are used by a substantial proportion of patients. The similarity in the use of anti-diabetic drugs between our study and the referenced studies underscores the importance of maintaining effective glycemic control in diabetic patients. Both insulin and oral medications play vital roles in managing blood glucose levels, which is crucial for wound healing and preventing complications. In conclusion, effective glycemic control through these medications is fundamental in managing diabetic foot ulcers and should be a key component of comprehensive diabetic care plans.

The mean FBS for cases was 113.06 mg/dL (±11.25) and for controls, it was 113.52 mg/dL (±10.32). The t-value was -0.2 with a p-value of 0.8, indicating no statistically significant difference in FBS levels between cases and controls.

The mean Hb for cases was 11.16 g/dL (±0.94) and for controls, it was 11.68 g/dL (±1.33). The t-value was -2.25 with a p-value of 0.02, indicating a statistically significant difference in Hb levels between cases and controls.

Wound Culture Sensitivity

The wound culture sensitivity in our study showed no significant difference between cases and controls (Fisher’s Exact value = 1.96, p = 0.7). Among the cases, 6% had Escherichia coli (EC), 58% had no organism growth cultures (NOGC), 6% had Pseudomonas aeruginosa (PA), 8% had Proteus mirabilis (PM), 51 and 22% had Staphylococcus aureus (SA). In the control group, the respective percentages were 4%, 68%, 4%, 10%, and 14%.

The study by Gude et al⁴. emphasized the high prevalence of bacterial infections in diabetic foot ulcers, particularly with organisms like Staphylococcus aureus and Pseudomonas aeruginosa. Their findings support the importance of regular wound cultures to guide appropriate antibiotic therapy. The consistent findings across studies indicate that bacterial infections are common in diabetic foot ulcers and need to be addressed promptly to facilitate healing. The high rate of NOGC in our study suggests that many ulcers might not have active infections at the time of sampling, possibly due to prior antibiotic use or effective wound care practices. In conclusion, the wound culture sensitivity results highlight the critical role of infection management in diabetic foot ulcer care. Regular wound cultures and appropriate antibiotic therapy are essential components of comprehensive DFU management, as supported by our study and referenced literature.

Wound Contraction

Table 3: Wound Contraction

The extent of wound contraction is presented in this table. Among the cases, no participants had less than 5% contraction, 10 (20%) had 5.1-15% contraction, 37 (74%) had 15.1-25% contraction, and 3 (6%) had more than 25% contraction. In the control group, 3 (6%) had less than 5% contraction, 47 (94%) had 5.1-15% contraction, and none had more than 15% contraction. The total number of participants was 100. The mean wound contraction was 18.91% (±4.03) for cases and 7.04% (±0.91) for controls, with an overall mean of 12.98% (±6.64). Fisher’s Exact value was 77.98 with a p-value of less than 0.001, indicating a statistically significant difference in wound contraction between cases and controls.

Dhanashekaran et al² reported significant wound contraction with PRP treatment, with a substantial proportion of patients showing complete healing or significant reduction in wound size. Their findings align with our observation of greater wound contraction in cases, suggesting the efficacy of targeted interventions in promoting wound healing. Tsachiridi et al¹. Also noted improved wound contraction with PRP application, with a stable and positive healing rate throughout the treatment period. This supports the beneficial effects of PRP in enhancing wound healing and reducing ulcer size.

The study by Gude et al⁴. Further confirmed the positive impact of advanced wound care modalities on wound contraction, highlighting the importance of comprehensive treatment approaches in managing DFUs. The significant difference in wound contraction between our study and other references highlights the effectiveness of advanced treatment strategies, such as PRP, in promoting wound healing. The higher contraction rates observed in cases suggest that targeted interventions can significantly improve wound outcomes in diabetic patients.

In conclusion, the findings on wound contraction reinforce the importance of advanced wound care interventions, such as PRP, in managing diabetic foot ulcers. These interventions can significantly enhance wound healing, reduce ulcer size, and improve overall patient outcomes.

Percentage of Area of Reduction

Table 4: Percentage of Area of Reduction

This table examines the percentage of area reduction in wounds. In the cases group, no participants had less than 16% reduction, 4 (8%) had 16.1-26% reduction, and 46 (92%) had more than 26% reduction. In the control group, 48 (96%) had less than 16% reduction, 2 (4%) had 16.1-26% reduction, and none had more than 26% reduction. The total number of participants was 100. The mean area reduction was 33.82% (±3.86) for cases and 12.84% (±1.89) for controls, with an overall mean of 23.33% (±10.97). Fisher’s Exact value was 122.36 with a p-value of less than 0.001, indicating a statistically significant difference in the percentage of area reduction between cases and controls.

Duration of Wound Contraction

Table 5: Duration of Wound Contraction

The duration of wound contraction is outlined here. Among the cases, 47 (94%) had wound contraction within 4 to 5 weeks, and 3 (6%) had contraction within 5 to 6 weeks. In the control group, 2 (4%) had contraction within 4 to 5 weeks, 12 (24%) within 5 to 6 weeks, and 36 (72%) within 6 to 7 weeks. The total number of participants was 100. The mean duration was 4.5 weeks (±0.46) for cases and 6.19 weeks (±0.39) for controls, with an overall mean of 5.35 weeks (±0.95). Fisher’s Exact value was 100.71 with a p-value of less than 0.001, indicating a statistically significant difference in the duration of wound contraction between cases and controls.

In our study, the duration of wound contraction was significantly shorter in the cases compared to the controls (Fisher’s Exact value = 100.71, p < 0.001). Among the cases, 94% had wound contraction within 4 to 5 weeks, and 6% had contraction within 5 to 6 weeks. In contrast, in the control group, only 4% had contraction within 4 to 5 weeks, 24% within 5 to 6 weeks, and 72% within 6 to 7 weeks. The mean duration for cases was 4.5 weeks (±0.46) compared to 6.19 weeks (±0.39) for controls, indicating a faster healing process in the intervention group. In Dhanashekaran et al2 study, the mean duration of hospital stay, which can be an indirect indicator of wound healing time, was significantly shorter for the PRP group at 18 days compared to 39 days for the conventional dressing group. This significant difference (p = 0.002) reflects the faster healing associated with PRP treatment.

Tsachiridi et al1 reported that the healing rate (HR) in the PRP group was stable and positive throughout the treatment period, whereas the control group initially had a negative HR that only became positive after the third week of  treatment. The mean duration of treatment was 5 weeks for both groups, but the PRP group showed a significant reduction in ulcer depth much earlier (mean reduction of more than 1 mm in depth, p = 0.0006) . In the study by Gude et al4 the mean healing time for PRP-treated ulcers was significantly shorter than for those treated conventionally. The study highlighted a mean healing time of 6.8 weeks for the PRP group compared to 12 weeks for the control group, demonstrating the efficacy of PRP in accelerating the healing process. Overall, the referenced studies consistently show that PRP treatment significantly reduces the duration of wound contraction compared to conventional methods. This aligns with our findings, where the intervention group experienced significantly faster wound contraction. The faster healing observed in PRP-treated wounds can be attributed to the growth factors and cytokines in PRP that enhance tissue regeneration and repair. In conclusion, the comparison of the duration of wound contraction in our study with the referenced studies reinforces the effectiveness of PRP in accelerating the healing process. The significantly shorter healing times and faster wound contraction in PRP-treated cases underscore the potential of PRP as a superior treatment modality for chronic non-healing ulcers. This emphasizes the need for incorporating PRP into standard care protocols for diabetic foot ulcers to improve patient outcomes and reduce the overall treatment duration.

The study provides valuable insights into the demographic and clinical characteristics of patients with diabetic foot ulcers. The significant differences observed in age distribution, wound contraction, percentage of area reduction, and duration of wound contraction between cases and controls highlight the critical role of advanced treatment strategies like platelet-rich plasma (PRP) in managing DFUs. Older age was identified as a significant risk factor for the development of DFUs, reinforcing the need for targeted preventive measures in older diabetic patients. The similar gender distribution and onset mechanisms indicate that both males and females, regardless of the onset type, are at risk for DFUs, necessitating comprehensive diabetic foot care for all patients. The high prevalence of plantar ulcers and the common occurrence of bacterial infections emphasize the importance of regular monitoring, appropriate antibiotic therapy, and effective offloading strategies to manage and prevent DFUs. The significantly better outcomes in wound contraction and area reduction in the intervention group underscore the potential of PRP in accelerating wound healing and improving patient outcomes. Overall, the study supports the integration of advanced wound care modalities, such as PRP, standard diabetic foot care protocols to enhance healing rates, reduce treatment duration, and improve the quality of life for patients with diabetic foot ulcers. Further research with larger sample sizes and longer followup periods is recommended to confirm these findings and optimize treatment strategies for DFUs.

1.       Tsachiridi M, Galyfos G, Andreou A, Sianou A, Sigala F, Zografos G, Filis K. Autologous platelet-rich plasma for nonhealing ulcers: a comparative study. Vascular specialist international.;35(1):22, Mar 2019.

2.       Dhanasekaran U, Arumugam R, Jayasubramaniyar L. Comparative study on management of diabetic ulcer with platelet-rich plasma and conventional dressing. International Surgery Journal.;7(12):4148-52, 27 Nov 2020.

3.       Helmy M, Patel S, Agrawal A. Evaluation of the effectiveness of platelet-rich plasma (PRP) in the treatment of chronic diabetic foot ulcers: a prospective study. J Clin Med.;6(6):75-80, 2017.

4.       Gude W, Hagan W, Pham T, et al. The impact of advanced treatment modalities on wound contraction and healing in diabetic foot ulcers. J Wound Care.;27(4):224-230, 2018.