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Percutaneous Injection Of Autogenous Growth Factors In Patient With Nonunion Of The Humerus. A Case Report.

*Tomasz Mariusz Bielecki, Tadeusz Szymon Gazdzik

*Department and Clinic of Orthopaedics, Medical University of Silesia, Sosnowiec, Poland

Address for Correspondence
Tomasz Mariusz Bielecki
Department and Clinic of Orthopaedics
Medical University of Silesia, Pl. Medyków 1
41-200 Sosnowiec
, Poland
Phone: +48501129739


We describe a fifty-year old woman with nonunion of humerus who had undergone two unsuccessful operations. Union was obtained by the use of autologous platelet-rich gel (PRG). Platelet concentration rich in growth factors is a novel osteoinductive therapy that could achieve this goal in the treatment of disturbances of bone healing processes. This article reports the efficiency of percutaneous autogenic PRG injection into the humeral diaphyseal nonunion gap as a minimally invasive treatment method offering the advantage of decreased morbidity associated with the classic grafting techniques. According to our knowledge, this is the first report where PRG was used in nonunion treatment.

J.Orthopaedics 2006;3(3)e15


Most diaphyseal fractures of the humerus heal without secondary surgical intervention. The two most common methods for fixation of a humeral diaphyseal fracture are plate osteosynthesis and intramedullary nail fixation [1]. Recently, rigid humeral intramedullary nails are the most commonly used, they can be with or without interlocking. When nonunion does occur, it is likely to be related to the severity of the initial injury, the transverse pattern of the fracture, distraction of the fracture, soft tissue interposition or inadequate immobilization. Despite continued advances in the treatment of long bone fractures, disturbances of healing processes remain a difficult challenge [2]. Surgical methods are various and include open reduction and internal fixation with plates and screws, reamed intramedullary nailing and external fixation [1]. Supplementing fixation bone graft reliably achieves union. Autogenous cancellous bone harvested from the iliac crest has been reported as the most successful material for bone grafting and alternative substances must be equally successful in achieving union, as well as providing some increase in benefit, to justify their use [3].

Platelet concentration rich in growth factors is a novel osteoinductive therapy that could achieve this goal in the treatment of disturbances of bone healing processes [4]. Platelet a-granules contain over 30 growth factors. The most important are platelet derived growth factor (PDGF), transforming growth factor-b (TGF-b), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF) and epithelial growth factor (EGF) [5]. By concentrating platelets a higher level of growth factors might be reached which could stimulate the halted healing processes in bone. The activator for platelet-rich plasma (PRP) is a mixture of thrombin and calcium chloride. After connecting these substances platelet-rich gel (PRG) is formed [6].

This article reports the efficiency of percutaneous autogenic PRG injection into the humeral diaphyseal nonunion gap as a minimally invasive treatment method offering the advantage of decreased morbidity associated with the classic grafting techniques.

Case Report

A fifty-year old woman after a fall experienced humeral fracture in the beginning of 2002. The fracture had been treated using a rigid humeral intramedullary nail without interlocking and probably with cause an inadequate immobilization nonunion occurred (fig. 1). The patient started to attend our ambulatory outpatient clinic in February 2003 and was qualified to operation. In March the nail was removed and fixation performed using a rigid intramedullary nail with interlocking. Unfortunately the nail without interlocking had been in position to long and was displaced and leaned at the clavicle inducing a considerable reduction of the range of motion. Despite this treatment the union did not occur. In February 11 months after the last operation there was no radiological evidence about bone healing processes occurring in the fracture site (fig. 2.) and on 22.02.2004 percutaneous autologous platelet-rich gel (PRG) grafting into the nonunion site was performed. 

PRG preparation procedure

108 ml of whole blood with 12 ml of anticoagulant (sodium citrate) was drawn into sterile tubes and centrifuged. Whole blood was drawn at a rate of 12 minutes, with a centrifuged speed of 3200 RPM (GPS system, Biomet). The blood was centrifuged into its three basic components: red blood cells, platelet-rich plasma (PRP) sometimes referred to as “buffy coat”, and platelet-poor plasma (PPP). Because of differential densities, the red blood cell layer forms at the lowest level, the PRP layer in the middle and the PPP layer at the top. The cell separator separates each layer from the less dense to the more dense; therefore it separates PPP first and PRP second, leaving the residual red blood cells. Then the top yellow serum component PPP was removed into a 30 ml syringe. Next the tubes were shaken vigorously for 30 seconds to suspend platelets and then two 10 ml syringes were connected to the tubes to extract 12 ml PRP. The PRP application requires initiating the coagulation process with a mixture of 3 ml 10% calcium chloride mixed with 4800 units of bovine thrombin. The PRP was stored at room temperature. After connecting these substances platelet-rich gel (PRG) was formed.

Surgical procedure

In general anaesthesia an 18-gauge needle was introduced immediately into the gap of nonunion under fluoroscopic guidance. By injecting PRG the area was literally peppered. The second injection into the gap or operation using bone grafts was not performed.

Following the outpatient procedure, the participant was followed up on a regular basis with clinical examinations, roentgenograms, dual-energy x-ray absorptiometry (DEXA) examinations and functional evaluations. All examinations were taken at 3 days and 3, 5, 8, 12, 18 and 24 weeks after percutaneous injection. X-ray films were taken in two views: anteroposterior and lateral. DEXA examination was performed at LUNAR DPX once per one visit. The University Ethic Committee refused its performance more than once in one visit in the patient. Union was determined on strict roentgenographic criteria: the patient was considered healed when 75% of the circumference of the bone at the defect site had resolved. 

During the first visit at the 3rd week and subsequent periods the healing process was noted on roentgenograms. At the 8th week over 75% of the circumference of the bone at the defect site had resolved and during later visits remodeling of the union was observed on X-ray films (fig. 3). The patient also exhibited an increase in bone mineral density in DEXA examinations (table 1). A maximum value in all cases was reached at the 18th week. 12 months after PRG injection the intramedullary nail was removed. Despite carry on active rehabilitation the range of motion is lower than normal.


The use of growth factors in combination with tissue engineering seems to be the most promising method in the future for the treatment of bone and cartilage defect [7]. Growth factors are cytokines with regulatory functions for healing in tissues of the musculoskeletal system. These small peptides are synthesised by resident cells at the site of injury such as mesenchymal stem cells and chondrocytes, or by the infiltrating inflammatory process. During clotting, platelets aggregate and release numerous regulatory molecules to the fracture site such as PDGF, TGF-b, VEGF, IGF and EGF. They play an important role in the initial phase of the healing process [8]. It is generally accepted that once cells enter the wound, their proliferation and differentiation are most likely to be determined by the type and level of growth factor presented in the site of the fracture [7,8].

Table 1. Bone mineral density (BMD) increasing.




BMD increasing 3th  week


BMD increasing 5th  week


BMD increasing 8th  week


BMD increasing 12th  week


BMD increasing 18th  week


BMD increasing 24th  week



Autologous bone graft potentially contributes three vital local components: osteoconduction, osteoinduction and osteogenic cells. According to some authors to reach successful in the treatment of disturbances of bone healing process, an alternative technique must also provide these osteogenic components. However, surgical procedures requiring harvesting of the iliac crest bone graft introduce a variety of potential risks to the patient, including increased surgical time and stay in hospital, increased blood loss and postoperative pain, infection, scar, etc [3]. For this reason many surgeons perform a secondary operation of nonunion with using bone marrow as a low-invasive method. Connolly [9] and Haley et al. [10] have demonstrated that percutaneous injections of autologous bone marrow can successfully treat between 78% and 95% of nonunions. In more bone defects or persistent nonunions to increase the possibility of the rate of success many authors connect osteoconductive biomaterials, such as demineralized bone matrix (DBM) which possesses also osteoinductive properties, with bone marrow which dominates osteoinductive and osteogenic properties. This mix can substitute autograft with success [3]. However, the level of the osteoprogenitor cells in aspirated bone marrow is totally different. It ranges between 12 and 1224 progenitors/cm2 [11]. That is why nowadays, application of the concentration of active substances begin to be in common use. Hernigou et al. injected bone marrow concentration into a gap of noninfectious atrophic nonunion. They achieved union in all cases where obtained concentrate with high density of osteoprogenitors cells were >1500/cm3. They mentioned that the fibrous tissue interposed between the bone ends ossified after the injection of bone marrow. However, they could not explain the exact mechanism that allows the transformation of fibrous tissue into callus [11].

The autogenous percutaneous bone marrow injection offers the advantage of decreased morbidity associated with the classic open grafting techniques. Additional advantages are decreased cost and hospitalization. Although autologous bone marrow harvesting is thought to be a relatively simple procedure, it has not been without complications. Donor site problems include bleeding, hematoma, chronic pain and infections [9]. The time of operation including harvesting and application is too long to use general short-term intravenous anaesthesia.

The use of platelet-rich gel (PRG) to enhance bone regeneration and soft tissue maturation has increased in the fields of maxillofacial surgery over the last decade [12,13,14]. Autologous platelets as a source of healing factors have been shown to promote tissue repair in several clinical situations in orthopaedic surgery. Lowery et al. used PRG with allogenic grafts in lumbar spinal fusion with good results. They observed no radiological or clinical evidence of pseudoarthrosis in all patients [15]. Kitoh reviewed clinical results of distraction osteogenesis with transplantation of marrow-derived mesenchymal stem cells (MSCs) and PRG in 3 patients. A mixture of PRP and osteoblast-like cells were injected into the callus. In one case they had to increase the distraction to 1,5 mm/day between 34th and 47th because callus formation was likely to consolidate prematurely. Enhanced callus formation was observed radiographically after the first transplantation of MSCs and PRG in all three cases. However, they connected 2 osteoinductive biomaterials and we do not know exactly the influences of PRP on bone formation in vivo [16].

To estimate bone healing processes we used X-ray and DEXA examination. During the first visit at the 3rd week and subsequent periods healing processes were noted on roentgenograms. At the 8th week over 75% of the circumference of the bone at the defect site had resolved and during later visits on X-ray films remodeling of the union was observed. Many authors have reported that DEXA is an accurate, reproducible and non-invasive technique for measuring mineral density [17,18]. The patient also exhibited an increase in bone mineral density in DEXA examinations. At the 18th and 24th week the BMD in union site was higher than above and below its. Unfortunately we did not receive agreement from the University Ethic Committee for performing more than one DEXA examination during one visit, so we can not estimate a precision error and repeatability of examination.

Platelet-rich gel dominates only osteoinductive properties [19,20], but our investigation showed that percutaneous injection in this case is a sufficient method to obtain union, which is less invasive procedure than bone marrow injection. By using special dual-caniule applicator PRP and thrombin with calcium ions are injected into the delayed union site. PRG comes into being by connecting PRP and thrombin during 5-25 seconds and the liquid can reach even a small gap before gelatinous mass will be formed [6].

Our results confirm that percutaneous autologous platelet-rich gel grafting could be an effective and safe method for the treatment of nonunion. In contrast to PRG, recombinant growth factor such as BMP-7 is expensive and cartilage-derived morphogenetic protein is not available for clinical use [21]. We believe that it will be in common use in orthopedics in persistent bone disorders [22]. According to our knowledge, this is the first report where PRG was used in nonunion treatment and further trials are needed to determine whether platelet gel will be able to induce healing processes in nonunion.

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This is a peer reviewed paper 

Please cite as : Tomasz Mariusz Bielecki:Percutaneous Injection Of Autogenous Growth Factors In Patient With Nonunion Of The Humerus. A Case Report.

J.Orthopaedics 2006;3(3)e15





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