Emerging Options for Biologic Enhancement of Stress Fracture Healing in Athletes

Timothy L. Miller, MD; Christopher C. Kaeding, MD; Scott A. Rodeo, MD


J Am Acad Orthop Surg. 2020;28(1):1-9. 

In This Article

Autologous Platelet-rich Technologies

Autologous platelet-rich technologies including platelet-rich plasma (PRP) and autologous conditioned plasma are referred to as osteopromotive materials when used in bone healing applications. The efficacy of these options for enhancing bone healing has been demonstrated in both animal and human models.[19–23] Guzel et al[19] compared 30 female rats that received PRP after undergoing mid-diaphyseal transverse femur fractures with 30 rats that did not receive PRP at the fracture site. Earlier weight bearing and accelerated fracture healing were observed in the PRP-treated animals. In addition, the PRP-treated femurs were able to withstand a greater maximal load compared with rats that did not receive PRP. A systematic review of 29 articles comparing PRP-treated fractures with non-PRP control groups demonstrated multiple beneficial effects on animal long-bone fractures. Eighty percent of studies reported increased bone area with 89% reporting earlier bone healing on histologic/histomorphometric assessment. All authors reported greater torsional stiffness and increased bone formation on radiographs in the PRP-treated groups.[20]

Despite the positive results of platelet-rich technologies seen in preclinical (animal) studies, less conclusive results have been reported in human clinical studies. There are few well-designed human studies.[22–24] Studies by Gandhi et al[23] have suggested a role for PRP in enhancing fracture healing among diabetic patients and other high-risk fractures. Their results among diabetic rat femur fractures indicated that percutaneous administration of PRP improved cellular proliferation in the early stages of fracture healing and mechanical strength in the late stages.[23] Studies with standardized protocols for preparation and administration of platelet-rich materials employing randomization and control groups are required to confirm efficacy in human stress fractures.