Abstract
OBJECTIVES:
Treatments for injured articular cartilage have not advanced to the point that efficient regeneration is possible. However, there has been an increase in the use of platelet-rich plasma for the treatment of several orthopedic disorders, including chondral injuries. Our hypothesis is that the treatment of chondral injuries with platelet gel results in higher-quality repair tissue after 180 days compared with chondral injuries not treated with gel.
METHODS:
A controlled experimental laboratory study was performed on 30 male rabbits to evaluate osteochondral injury repair after treatment with or without platelet gel. Osteochondral injuries were surgically induced in both knees of each rabbit at the medial femoral condyle. The left knee injury was filled with the platelet gel, and the right knee was not treated. Microscopic analysis of both knee samples was performed after 180 days using a histological grading scale.
RESULTS:
The only histological evaluation criterion that was not significantly different between treatments was metachromasia. The group that was treated with platelet gel exhibited superior results in all other criteria (cell morphology, surface regularity, chondral thickness and repair tissue integration) and in the total score.
CONCLUSION:
The repair tissue was histologically superior after 180 days in the study group treated with platelet gel compared with the group of untreated injuries.
Platelet-Rich Plasma; Articular Cartilage; Injuries; Regenerative Medicine
INTRODUCTION
Treatments for injured articular cartilage have not advanced to the point that
efficient regeneration is possible because chondral tissue consists of few cells and
a rich, complex extracellular matrix. Chondral tissue also has no nerves, lymphatic
drainage or blood vessels, which are essential to the processes of clot formation
and repair (11. Bhosale AM, Richardson JB. Articular cartilage: structure,
injuries and review of management. Br Med Bull. 2008;87(1):77-95,
http://dx.doi.org/10.1093/bmb/ldn025.
http://dx.doi.org/10.1093/bmb/ldn025...
2. Buckwalter JA. Articular cartilage injuries. Clin Orthop Relat
Res. 2002;402:21-37,
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3. Ribeiro JL, Camanho GL, Takita LC. Estudo macroscópico e
histológico de reparos osteocondrais biologicamente aceitáveis. Acta
Ortop Bras. 2004;12(1):16-21,
http://dx.doi.org/10.1590/S1413-78522004000100003.
http://dx.doi.org/10.1590/S1413-78522004...
-44. Souza TD, Del Carlo RJ, Viloria MIV. Avaliação
histológica do processo de reparação da superfície articular
de coelhos. Cienc Rural. 2000;30(3):439-44,
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). Moreover, scar tissue from cartilage injury does not support loads
in the same manner as normal tissue and a long-term evolution to osteoarthritis
often results (44. Souza TD, Del Carlo RJ, Viloria MIV. Avaliação
histológica do processo de reparação da superfície articular
de coelhos. Cienc Rural. 2000;30(3):439-44,
http://dx.doi.org/10.1590/S0103-84782000000300011.
http://dx.doi.org/10.1590/S0103-84782000...
). Osteoarthritis is an
incurable, disabling disease. The 50 million cases of the disease in the USA (55. Bittencourt RAC. Cultura de condrócitos para uso
terapêutico: reconstituição de cartilagem [Tese].
Botucatu: Faculdade de Medicina, Universidade Estadual Paulista; 2008. 129f.
Available online:
http://www.athena.biblioteca.unesp.br/exlibris/bd/bbo/33004064006P8/2008/bittencourt_rac_dr_botfm.pdf.
http://www.athena.biblioteca.unesp.br/ex...
) are associated with estimated treatment
costs of approximately 65 billion dollars per year (66. D'Lima DC, Colwell Jr CW. Clinical objectives for cartilage
repair. Clin Orthop Relat R. 2001;391:S402-5,
http://dx.doi.org/10.1097/00003086-200110001-00037.
http://dx.doi.org/10.1097/00003086-20011...
). Surgical options may be considered in the treatment of chondral
injuries to prevent or slow the onset of osteoarthritis. Most of the surgical
techniques are based on the stimulation of mesenchymal cell migration, which leads
to the formation of scar tissue (55. Bittencourt RAC. Cultura de condrócitos para uso
terapêutico: reconstituição de cartilagem [Tese].
Botucatu: Faculdade de Medicina, Universidade Estadual Paulista; 2008. 129f.
Available online:
http://www.athena.biblioteca.unesp.br/exlibris/bd/bbo/33004064006P8/2008/bittencourt_rac_dr_botfm.pdf.
http://www.athena.biblioteca.unesp.br/ex...
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outcomes, and future directions. Am J Sports Med.
2005;33(3):443-60.). More recently, the use of autologous
chondrocyte transplantation has increased, but the cost of this technique remains
high and the reported results are variable and not guaranteed to prevent the onset
of symptomatic degenerative joint disease (22. Buckwalter JA. Articular cartilage injuries. Clin Orthop Relat
Res. 2002;402:21-37,
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et al. The Clinical Use of human culture-expanded autologous bone marrow
mesenchymal stem cells transplanted on platelet-rich fibrin glue in the
treatment of articular cartilage defects: a pilot study and preliminary results.
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10. Costa AJF, Oliveira CRGCM, Leopizzi N, Amatuzzi MM. O uso da
matriz óssea desmineralizada na reparação de lesões
osteocondrais. Estudo experimental em coelhos. Acta Ortop Bras.
2001;9(4):27-38.-1111. Wasiak J, Clar C, Villanueva E. Autologous cartilage
implantation for full thickness articular cartilage defects of the knee.
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Art N°CD003323.DOI:10.1002/14651858.CD003323.pub4.
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).
The use of platelet-rich plasma (PRP) for the treatment of several types of
orthopedic disorders, including chondral injuries, has increased recently (1212. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo AS.
Platelet-rich plasma - from basic science to clinical applications.
Am J Sports Med. 2009;37(11):2259-72,
http://dx.doi.org/10.1177/0363546509349921.
http://dx.doi.org/10.1177/03635465093499...
).
PRP is a plasma fraction that contains a high concentration of platelets and is rich
in many growth factors. These growth factors are part of the natural process of
tissue healing and homeostasis and they have the capacity to stimulate cell
proliferation, mesenchymal stem cell chemotaxis and cell differentiation. PRP also
has the capacity to stimulate debris scavenging, angiogenesis, extracellular matrix
synthesis (1313. Mehta S, Watson JT. Platelet rich concentrate: Basic science and
current clinical applications. J Orthop Trauma.
2008;22(6):433-8.), bone synthesis and the
production of intra-articular hyaluronic acid (1212. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo AS.
Platelet-rich plasma - from basic science to clinical applications.
Am J Sports Med. 2009;37(11):2259-72,
http://dx.doi.org/10.1177/0363546509349921.
http://dx.doi.org/10.1177/03635465093499...
,1414. Lopez-Vidriero E, Goulding KA, Simon DA, Sanchez M, Johnson DH.
The use of platelet-rich plasma in arthroscopy and sports medicine: optimizing
the healing environment. Arthroscopy. 2010;26(2):269-78,
http://dx.doi.org/10.1016/j.arthro.2009.11.015.
http://dx.doi.org/10.1016/j.arthro.2009....
,1515. Sanchez M, Anitua E, Orive G, Mujika I, Andia I. Platelet-rich
therapies in the treatment of orthopaedic sport injuries. Sports Med.
2009;39(5):345-54,
http://dx.doi.org/10.2165/00007256-200939050-00002.
http://dx.doi.org/10.2165/00007256-20093...
) and to reduce pain (1414. Lopez-Vidriero E, Goulding KA, Simon DA, Sanchez M, Johnson DH.
The use of platelet-rich plasma in arthroscopy and sports medicine: optimizing
the healing environment. Arthroscopy. 2010;26(2):269-78,
http://dx.doi.org/10.1016/j.arthro.2009.11.015.
http://dx.doi.org/10.1016/j.arthro.2009....
,1515. Sanchez M, Anitua E, Orive G, Mujika I, Andia I. Platelet-rich
therapies in the treatment of orthopaedic sport injuries. Sports Med.
2009;39(5):345-54,
http://dx.doi.org/10.2165/00007256-200939050-00002.
http://dx.doi.org/10.2165/00007256-20093...
). A literature review by
Kon et al. (1616. Kon E, Filardo G, Di Martino A, Marcacci M. Platelet-rich plasma
(PRP) to treat sports injuries: evidence to support its use. Knee Surg Sports
Traumatol Arthrosc. 2011;19(4):516-27,
http://dx.doi.org/10.1007/s00167-010-1306-y.
http://dx.doi.org/10.1007/s00167-010-130...
) also cites the potential of
PRPs to decrease hemorrhage, cartilage fibrillation and hypertrophy of synovial
tissue. PRP is obtained from the patient using a minimally invasive technique that
is relatively easy and inexpensive (55. Bittencourt RAC. Cultura de condrócitos para uso
terapêutico: reconstituição de cartilagem [Tese].
Botucatu: Faculdade de Medicina, Universidade Estadual Paulista; 2008. 129f.
Available online:
http://www.athena.biblioteca.unesp.br/exlibris/bd/bbo/33004064006P8/2008/bittencourt_rac_dr_botfm.pdf.
http://www.athena.biblioteca.unesp.br/ex...
,1212. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo AS.
Platelet-rich plasma - from basic science to clinical applications.
Am J Sports Med. 2009;37(11):2259-72,
http://dx.doi.org/10.1177/0363546509349921.
http://dx.doi.org/10.1177/03635465093499...
).
However, the literature has few well-designed studies on the use of PRP in chondral
injuries, with only controversial pre-clinical and clinical results (1616. Kon E, Filardo G, Di Martino A, Marcacci M. Platelet-rich plasma
(PRP) to treat sports injuries: evidence to support its use. Knee Surg Sports
Traumatol Arthrosc. 2011;19(4):516-27,
http://dx.doi.org/10.1007/s00167-010-1306-y.
http://dx.doi.org/10.1007/s00167-010-130...
).
Therefore, this study treated osteochondral injuries of the articular cartilage of the knee with PRP gel, using rabbits as experimental models. The hypothesis was that treated injuries would have higher-quality repair tissue than non-treated injuries.
MATERIALS AND METHODS
The Ethics Committee for Animal Research of the associated institution approved this study under protocol 717.
Thirty New Zealand rabbits, minimum age of 3 months (average: 4.6 m) and weighing over 2 kg (average: 3.1 kg) were obtained from the Orthopedics and Experimental Surgery Laboratory. The animals were confined to individual metal cages before and after the surgical procedure and fed standardized rations and water ad libitum.
The sample size was based on previous studies performed using the same animal model
and methodology (55. Bittencourt RAC. Cultura de condrócitos para uso
terapêutico: reconstituição de cartilagem [Tese].
Botucatu: Faculdade de Medicina, Universidade Estadual Paulista; 2008. 129f.
Available online:
http://www.athena.biblioteca.unesp.br/exlibris/bd/bbo/33004064006P8/2008/bittencourt_rac_dr_botfm.pdf.
http://www.athena.biblioteca.unesp.br/ex...
,1717. Qi YY, Chen X, Jiang YZ, Cai HX, Wang LL, Song XH, et al. Local
delivery of autologous platelet in collagen matrix simulated in situ articular
repair. Cell Transplant. 2009;18(10):1161-9,
http://dx.doi.org/10.3727/096368909X12483162197169.
http://dx.doi.org/10.3727/096368909X1248...
18. Sun Y, Feng Y, Zhang CQ, Chen SB, Cheng XG. The regenerative
effect of platelet-rich plasma on healing in large osteochondral defects. Int
Orthop. 2010;34(4):589-97,
http://dx.doi.org/10.1007/s00264-009-0793-2.
http://dx.doi.org/10.1007/s00264-009-079...
-1919. Yan H, Yu C. Repair of full-thickness cartilage defects with
cells of different origin in a rabbit model. Arthroscopy. 2007;23(2):178-87,
http://dx.doi.org/10.1016/j.arthro.2006.09.005.
http://dx.doi.org/10.1016/j.arthro.2006....
).
First, the blood of several rabbits was collected to prepare the PRP with the
addition of 3.8% sodium citrate to avoid coagulation. This procedure was performed
in the blood bank of our hospital. The blood was centrifuged at 1000 RPM for 10
minutes, which resulted in a separation into three layers: a lower layer of
concentrated red blood cells, a middle layer of white blood cells and an upper layer
of plasma. The upper layer was separated and centrifuged for another 10 minutes at
3000 RPM, which yielded two fractions: platelet-poor plasma (the upper fraction) and
PRP (the lower fraction). This method was validated at the blood bank to produce a
PRP of at least 1 million platelets per microliter of plasma (55. Bittencourt RAC. Cultura de condrócitos para uso
terapêutico: reconstituição de cartilagem [Tese].
Botucatu: Faculdade de Medicina, Universidade Estadual Paulista; 2008. 129f.
Available online:
http://www.athena.biblioteca.unesp.br/exlibris/bd/bbo/33004064006P8/2008/bittencourt_rac_dr_botfm.pdf.
http://www.athena.biblioteca.unesp.br/ex...
). The PRP was activated 1 day before surgery via the addition
of calcium and human thrombin.
Our PRP was P3-x-Bβ according to the classification proposed by Delong et al.
(2020. Delong JM, Russel RP, Mazzoca AD. Platelet-rich plasma: the PAW
classification system. Arthroscopy. 2012;28(7):998-1009,
http://dx.doi.org/10.1016/j.arthro.2012.04.148.
http://dx.doi.org/10.1016/j.arthro.2012....
).
Surgical Technique
Animals were anesthetized intramuscularly with tiletamine and zolazepam in combination with 2% xylazine hydrochloride at doses of 15.0-30.0 mg/kg and 4 mg/kg of body weight, respectively. Local anesthesia was applied (Xylocaine 2%) at the point of incision. A medial parapatellar incision was made and the patella was dislocated to the side. The medial femoral condyles were exposed and perforated with a trephine with the knees bent to cause lesions 3.5 mm in diameter and 4.0 mm deep on both knees. The lesions were washed with sterile saline solution (0.9% NaCl) and the injury to the left knee was filled with PRP gel (Figures 1 and 2). The right knee was left untreated. The injuries were sutured in layers using 4-0 nylon monofilament.
Animals received 0.1 ml/kg of Enrofloxacin (antibiotic) subcutaneously for 5 days after surgery and 0.2 mg/kg of Meloxicam 0.2% (anti-inflammatory) subcutaneously for 2 days after surgery.
The animals were euthanized 180 days post-surgery with an overdose of sodium pentobarbital. The medial femoral condyles were removed, preserved in a 10% formalin solution and sent to the university's Department of Morphology for histological analyses. Samples were decalcified, cut and stained with toluidine blue. A blinded morphologist evaluated and classified each sample according to the histological grading scale described by Wakitani et al. (2121. Wakitani S, Goto T, Pineda SJ, Young RG, Mansour JM, Caplan AI, et al. Mesenchymal cell-based repair of large, full-thickness defects of articular cartilage. J Bone joint Surg Am. 1994;76(4):579-92.) (Table 1).
A Leica Qwin Colour¯ (RGB) image analyzer coupled to a Leica¯ DM 2500 microscope was used for microscopic analyses.
Mann-Whitney and Wilcoxon's non-parametric tests were used for statistical analyses in SPSS Inc. Version 15.0 (Chicago, IL, USA), with significance set at p<0.05.
RESULTS
Between May 2009 and January 2010, 30 rabbits underwent surgery. There were 15 deaths: 13 from respiratory infection and 2 during the surgical procedure. These 15 animals were excluded from statistical analyses. A microscopic evaluation could not be performed on the right knee sample of rabbit number 10 due to decalcification problems. No surgical site infection was encountered in any case. Synovitis and arthrofibrosis were not evaluated.
Histological analyses, with separate consideration given to each criterion score, revealed significant differences in cell morphology (p = 0.002), surface regularity (p<0.001), chondral thickness (p<0.02) and lateral integration (p<0.02), with the best results observed in the treated group. There was no difference in metachromasia (p = 0.063). The difference in final scores was statistically significant (p<0.001), with superior results obtained in the treated group (Table 2).
Examples of microscopic findings are shown in Figures 3 and 4.
Histological view of rabbit 8 samples, stained with toluidine blue. A) Right knee (4× zoom): note the fibrocartilaginous tissue with an irregular surface; B) Left knee (4× zoom): more cartilaginous tissue, better organized and smoother surface; C) Right knee (20× zoom): the presence of more elongated cells (fibroblasts); D) Left knee (20× zoom): the presence of organized chondrocytes and a smooth surface (source: personal file).
Histological view of rabbit 21 microscopic samples, stained with toluidine blue (4× zoom). A) Right side; B) Left side. Note the deep repair tissue, with a lush matrix and numerous chondrocytes on both sides, but better organized on the left side (B) (source: personal file).
A large amount of scar tissue was present bilaterally for the injuries of rabbit 21, but the scar was much better organized on the treated side (Figure 4).
DISCUSSION
Rabbits were chosen for this study due to their widespread use as a model for
chondral injury repair. The use of very young rabbits was avoided due to their
greater repair potential (11. Bhosale AM, Richardson JB. Articular cartilage: structure,
injuries and review of management. Br Med Bull. 2008;87(1):77-95,
http://dx.doi.org/10.1093/bmb/ldn025.
http://dx.doi.org/10.1093/bmb/ldn025...
,2222. Wei X, Messner K. Maturation-dependent durability of spontaneous
cartilage repair in rabbit knee joint. J Biomed Mater Res.
1999;46(4):539-48,
http://dx.doi.org/10.1002/(SICI)1097-4636(19990915)46:4<539::AID-JBM12>3.0.CO;2-S.
http://dx.doi.org/10.1002/(SICI)1097-463...
,2323. Fuller JA, Ghadially FN. Ultrastructural observations on
surgically produced partial-thickness defects in articular cartilage. Clin
Orthop Relat R. 1972; 86:193-205,
http://dx.doi.org/10.1097/00003086-197207000-00031.
http://dx.doi.org/10.1097/00003086-19720...
).
Euthanasia was delayed until the 180th day after injury to evaluate
injury repair over a longer time period. Buckwalter (22. Buckwalter JA. Articular cartilage injuries. Clin Orthop Relat
Res. 2002;402:21-37,
http://dx.doi.org/10.1097/00003086-200209000-00004.
http://dx.doi.org/10.1097/00003086-20020...
) reported that chondral and osteochondral repair is fully completed
within 6 weeks, but remodeling continues for months or even years. The minimum time
until analysis of repair should range from 4 to 6 weeks, but even the most promising
methods require evaluation after 6 months. Bittencourt (55. Bittencourt RAC. Cultura de condrócitos para uso
terapêutico: reconstituição de cartilagem [Tese].
Botucatu: Faculdade de Medicina, Universidade Estadual Paulista; 2008. 129f.
Available online:
http://www.athena.biblioteca.unesp.br/exlibris/bd/bbo/33004064006P8/2008/bittencourt_rac_dr_botfm.pdf.
http://www.athena.biblioteca.unesp.br/ex...
) observed good evolution of chondral repair with platelet gel
at 90 days. Therefore, we selected the same treatment method, but we employed a
larger injury and a single 180-day evaluation to assess the durability of the
tissue.
A 3.5-mm-diameter injury was chosen because of its repair difficulty and to
demonstrate the heightened potential of PRP gel. Lesions larger than 3.0 mm in
diameter rarely heal in rabbits without some form of treatment (1717. Qi YY, Chen X, Jiang YZ, Cai HX, Wang LL, Song XH, et al. Local
delivery of autologous platelet in collagen matrix simulated in situ articular
repair. Cell Transplant. 2009;18(10):1161-9,
http://dx.doi.org/10.3727/096368909X12483162197169.
http://dx.doi.org/10.3727/096368909X1248...
). A depth of 4 mm was chosen because this
depth reaches the subchondral bone without causing bone marrow destruction (33. Ribeiro JL, Camanho GL, Takita LC. Estudo macroscópico e
histológico de reparos osteocondrais biologicamente aceitáveis. Acta
Ortop Bras. 2004;12(1):16-21,
http://dx.doi.org/10.1590/S1413-78522004000100003.
http://dx.doi.org/10.1590/S1413-78522004...
,2424. Martin-Hernandes C, Cebamanos-Celma J, Molina-Ros A,
Ballester-Jimenez J, Ballester-Soleda J. Regenerated cartilage produced by
autogenous periosteal grafts: a histologic and mechanical study in rabbits under
the influence of continuous passive motion. Arthroscopy. 2010;26(1):76-83,
http://dx.doi.org/10.1016/j.arthro.2009.07.005.
http://dx.doi.org/10.1016/j.arthro.2009....
).
Several other studies using similar models of injury in rabbits obtained superior
results in treated specimens, but the treatment methods were different and different
materials were used (33. Ribeiro JL, Camanho GL, Takita LC. Estudo macroscópico e
histológico de reparos osteocondrais biologicamente aceitáveis. Acta
Ortop Bras. 2004;12(1):16-21,
http://dx.doi.org/10.1590/S1413-78522004000100003.
http://dx.doi.org/10.1590/S1413-78522004...
,1010. Costa AJF, Oliveira CRGCM, Leopizzi N, Amatuzzi MM. O uso da
matriz óssea desmineralizada na reparação de lesões
osteocondrais. Estudo experimental em coelhos. Acta Ortop Bras.
2001;9(4):27-38.,1919. Yan H, Yu C. Repair of full-thickness cartilage defects with
cells of different origin in a rabbit model. Arthroscopy. 2007;23(2):178-87,
http://dx.doi.org/10.1016/j.arthro.2006.09.005.
http://dx.doi.org/10.1016/j.arthro.2006....
,2525. Ozsoy MH, Aydogdu S, Taskiran D, Sezak M, Hayran M, Oztop F, et
al. The effects of early or late treatment of osteochondral defects on joint
homoeostasis: an experimental study in rabbits. Knee Surg Sports Traumatol
Arthrosc. 2009;17(6):578-89,
http://dx.doi.org/10.1007/s00167-008-0675-y.
http://dx.doi.org/10.1007/s00167-008-067...
). Nonetheless, hyaline cartilage in its
classic form did not appear in the repair tissues, which is consistent with our
results.
Wei & Messner (2222. Wei X, Messner K. Maturation-dependent durability of spontaneous
cartilage repair in rabbit knee joint. J Biomed Mater Res.
1999;46(4):539-48,
http://dx.doi.org/10.1002/(SICI)1097-4636(19990915)46:4<539::AID-JBM12>3.0.CO;2-S.
http://dx.doi.org/10.1002/(SICI)1097-463...
) demonstrated that the
biomechanical behavior of repair tissue, even with 80% hyaline-like cartilage, is
inferior to normal cartilage and it tends to deteriorate more slowly over time.
Ozsoy et al. (2525. Ozsoy MH, Aydogdu S, Taskiran D, Sezak M, Hayran M, Oztop F, et
al. The effects of early or late treatment of osteochondral defects on joint
homoeostasis: an experimental study in rabbits. Knee Surg Sports Traumatol
Arthrosc. 2009;17(6):578-89,
http://dx.doi.org/10.1007/s00167-008-0675-y.
http://dx.doi.org/10.1007/s00167-008-067...
) made an interesting
comment: even untreated control injuries present macroscopically adequate repair,
but with a catabolic activity that is higher than the treated group. Therefore,
treatment of chondral injuries could potentially increase the duration and function
of the repair tissue, despite the fibrocartilaginous of the tissue. PRP is capable
of reducing chondral catabolism (2626. Kon E, Buda R, Filardo G, Di Martino A, Timoncini A, Cenacchi A,
et al. Platelet-rich plasma: intra-articular knee injections produced favorable
results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc.
2010;18(4):472-9, http://dx.doi.org/10.1007/s00167-009-0940-8.
http://dx.doi.org/10.1007/s00167-009-094...
) and
inhibiting the apoptosis of chondrocytes subjected to trauma (2727. Rezende MU, Silva RBB, Bassit ACF, Tatsui NH, Sadigursky D, Neto
RB. Efeito do plasma rico em plaquetas na apoptose pós-traumática de
condrócitos. Acta Ortop Bras. 2011;19(2):102-5.), which also plays an important role in the longevity of
repair tissue. This result was also confirmed by Milano et al. (2828. Milano G, Passino ES, Deriu L, Careddu G, Manunta L, Manunta A,
et al. The effect of platelet rich plasma combined with microfractures on the
treatment of chondral defects: an experimental study in a sheep model.
Osteoarthritis Cartilage. 2010;18(7):971-80,
http://dx.doi.org/10.1016/j.joca.2010.03.013.
http://dx.doi.org/10.1016/j.joca.2010.03...
), who showed that PRP gel associated with
microfractures in chondral injuries in sheep yielded the best macroscopic,
histological and biomechanical results.
The poor metachromasia results may demonstrate a more deficient matrix with a lower
concentration of glycosaminoglycans, although this deficiency could improve over
time with matrix production by chondrocytes. Drengk et al. (2929. Drengk A, Zapf A, Sturmer EK, Sturmer KM, Frosch KH. Influence
of platelet-rich plasma on chondrogenic differentiation and proliferation of
chondrocytes and mesenchymal stem cells. Cells Tissues Organs.
2009;189(5):317-26, http://dx.doi.org/10.1159/000151290.
http://dx.doi.org/10.1159/000151290...
) observed that cell proliferation of sheep chondrocytes and
mesenchymal stem cells cultivated in vitro with the addition of PRP
was up to 67% greater compared with cells cultivated without PRP, although type-II
collagen mRNA expression was reduced. The suggested explanation was that increased
proliferation negatively influenced cell differentiation, but this phenotype might
be altered in an in vivo environment after cell proliferation
reached its limit.
Several articles commonly used scaffolds, such as collagen matrix (1717. Qi YY, Chen X, Jiang YZ, Cai HX, Wang LL, Song XH, et al. Local
delivery of autologous platelet in collagen matrix simulated in situ articular
repair. Cell Transplant. 2009;18(10):1161-9,
http://dx.doi.org/10.3727/096368909X12483162197169.
http://dx.doi.org/10.3727/096368909X1248...
), polylactic-glycolic acid matrix (1818. Sun Y, Feng Y, Zhang CQ, Chen SB, Cheng XG. The regenerative
effect of platelet-rich plasma on healing in large osteochondral defects. Int
Orthop. 2010;34(4):589-97,
http://dx.doi.org/10.1007/s00264-009-0793-2.
http://dx.doi.org/10.1007/s00264-009-079...
) and polylactic acid matrix (1919. Yan H, Yu C. Repair of full-thickness cartilage defects with
cells of different origin in a rabbit model. Arthroscopy. 2007;23(2):178-87,
http://dx.doi.org/10.1016/j.arthro.2006.09.005.
http://dx.doi.org/10.1016/j.arthro.2006....
). However, scaffolding might not be
necessary when using PRP in a gel form because we did not use any scaffolding and
our results were similar to the literature.
This study has several limitations that should be considered. The multiple deaths may have modified results, but we chose not to recruit more animals because our results demonstrated statistically significant differences. Nevertheless, the standard deviation may be considered high, even with the significant intergroup differences. Perhaps a larger sample of cases might address or compensate for this finding. Histological scoring may be subject to bias because it is examiner-dependent. We attempted to reduce this bias by having an experienced, blinded morphologist perform the microscopic analyses. The absence of clinical assessment parameters was also a limitation in our study. Synovitis or arthrofibrosis could have occurred more in one group and changed our results. We could have also performed immunohistochemistry for type II collagen data, but this technique was not in the original study project. We did not pursue this option because the results were already significantly different.
From these data, we concluded that chondral injuries in rabbit knees treated with platelet gel presented histologically superior repair results following a 180-day period compared with identical untreated injuries.
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No potential conflict of interest was reported.
Publication Dates
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Publication in this collection
Oct 2014
History
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Received
6 Apr 2014 -
Reviewed
15 May 2014 -
Accepted
9 June 2014