What are the recommendations for using Platelet-Derived Growth Factor (PDGF) and Platelet-Rich Plasma (PRP) as adjunctive therapies on surgical wound beds?

Adjunctive Therapies: PDGF and Platelet Rich Plasma for Surgical Wound Beds

PDGF therapy is not recommended as an adjunctive therapy for surgical wound beds, while platelet-rich plasma may be considered only in specific cases where standard care has failed. 1

Current Recommendations for PDGF

The 2024 International Working Group on the Diabetic Foot (IWGDF) guidelines provide the most recent and definitive recommendations regarding PDGF use:

• PDGF is not recommended as an adjunctive therapy to standard care for wound healing 1
• This recommendation is based on seven studies investigating PDGF, with only one considered at low risk of bias, which showed no difference in healing between PDGF and control groups 1
• Earlier studies that showed positive outcomes were at moderate to high risk of bias, reducing confidence in their results 1

Evidence Quality Issues with PDGF

• None of the PDGF studies reported on critical outcomes such as:
  • Sustained healing
  • Amputation prevention
  • Resource utilization
  • Maintenance of function
  • Mortality 1

Platelet-Rich Plasma (PRP) Applications

PRP contains a supraphysiological concentration of platelets that provide growth factors and cytokines important in wound healing 1. However, its clinical application remains controversial:

• PRP is not standardized in terms of preparation methods, content, and quality 1
• There are few properly controlled randomized clinical trials evaluating PRP efficacy 1
• The IWGDF does not specifically recommend PRP for surgical wound beds 1

Mechanism of Action

PRP and PDGF work by:

• Promoting chemotactic recruitment of cells involved in wound repair 2, 3
• Enhancing formation of granulation tissue 2
• Stimulating proliferation of cells essential for tissue repair 3

Clinical Decision Algorithm for Adjunctive Therapies

1. First-line approach: Implement standard wound care practices

   • Surgical debridement of necrotic tissue 4
   • Appropriate dressing selection based on exudate level 4
   • Pressure offloading and redistribution 4

2. For post-surgical wounds specifically:

   • Consider negative pressure wound therapy (NPWT) as it may be beneficial in post-operative wounds, though evidence remains limited 1, 4
   • NPWT has shown some benefit in both time to healing and proportion of wounds healed in post-surgical settings 1

3. If standard care fails:

   • Consider placental-derived products before PRP (conditional recommendation with low-quality evidence) 1
   • PRP may be considered as a last resort, but with awareness of limited evidence 1

4. Do not use PDGF as an adjunctive therapy for wound healing 1

Special Considerations

High-Risk Patients

For patients with multiple risk factors for wound complications, particularly in spinal oncology:

• Primary flap closure may be more beneficial than PRP or PDGF 5
• Individualized risk stratification should guide preventative interventions 5

Cost and Accessibility Concerns

• PRP preparation requires specialized equipment and training 1
• PDGF products like becaplermin (Regranex) are expensive, with limited evidence of cost-effectiveness 1
• Resource limitations may decrease equity and feasibility, particularly in low-income healthcare systems 1

Common Pitfalls to Avoid

1. Overreliance on growth factors: Do not use biologically active products (including growth factors) routinely for wound management, as evidence doesn't support this practice 4

2. Inadequate standard care: Ensure proper debridement, infection control, and pressure redistribution before considering adjunctive therapies 4

3. Inappropriate patient selection: Not all wounds benefit from the same approach; surgical wounds have different requirements than chronic wounds 1

4. Lack of standardization: PRP preparation methods vary widely, affecting clinical outcomes 1

5. Delayed intervention for infected wounds: Don't delay treatment of infected wounds as this increases amputation risk 4

In conclusion, while PDGF is not recommended for surgical wound beds, NPWT may be considered for post-surgical wounds, and PRP might be an option in cases where standard care has failed, though evidence for its efficacy remains limited.