BACKGROUND: Fracture nonunion remains a challenging clinical problem associated with prolonged disability and repeated surgical interventions. Platelet-rich plasma (PRP) has been proposed as a biological adjunct to enhance bone healing; however, clinical evidence remains inconsistent. This study aimed to evaluate the effectiveness of PRP in the management of fracture nonunion.
METHODS: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines (PROSPERO Registration: CRD420261366849). PubMed, Embase, and Scopus were searched from inception to March 2026. Studies evaluating PRP in fracture nonunion and reporting union rate or time to union were included. Random-effects meta-analyses were performed to compare PRP with control interventions. Risk ratios (RR) were calculated for union rates and standardized mean differences (SMD) for time to union. Additional single-arm analyses were performed to estimate pooled outcomes in PRP-treated cohorts.
RESULTS: Twenty-one studies comprising 877 patients were included. Two comparative studies (n = 119) demonstrated a higher likelihood of union with PRP (RR 1.17, 95% confidence interval [CI] 1.01-1.36, p < 0.05) without significant heterogeneity. Six studies (n = 250) showed no significant difference in time to union between PRP and control groups (SMD -0.72, 95% CI -1.48-0.05), with substantial heterogeneity (I² = 85%). In PRP-only analyses, the pooled union rate was 0.86 (95% CI 0.76-0.94; I² = 61%) across seven studies (n = 150), and the pooled mean time to union was 6.08 months (95% CI 4.26-7.90; I² = 100%) across eight studies (n = 187).
CONCLUSION: PRP was associated with higher union rates in the limited comparative evidence, although no statistically significant difference in time to union was demonstrated. Heterogeneity in PRP protocols, methodological limitations, and the small comparative evidence base limit the certainty of these findings. PRP may have a potential role as a biological adjunct in fracture nonunion management, but further well-designed randomized controlled trials are required before definitive clinical recommendations can be made.
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