Growth Factor Delivery to a Cartilage-Cartilage Interface Using Platelet-Rich Concentrates on a Hyaluronic Acid Scaffold

doi:10.1016/j.arthro.2019.12.004

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 36, Issue 5, May 2020, Pages 1431-1440

https://doi.org/10.1016/j.arthro.2019.12.004 Get rights and content

Purpose

To determine whether (1) human leukocyte-platelet-rich plasma (L-PRP) or (2) leukocyte-platelet-rich fibrin (L-PRF) delivered on a hyaluronic acid (HA) scaffold at a bovine chondral defect, a simulated cartilage tear interface, in vitro would improve tissue formation based on biomechanical, histologic, and biochemical measures.

Methods

L-PRF and L-PRP were prepared from 3 healthy volunteer donors and delivered in conjunction with HA scaffolds to defects created in full-thickness bovine cartilage plugs harvested from bovine femoral condyle and trochlea. Specimens were cultured in vitro for up to 42 days. Treatment groups included an HA scaffold alone and scaffolds containing L-PRF or L-PRP. Cartilage repair was assessed using biomechanical testing, histology, DNA quantification, and measurement of sulfated glycosaminoglycan and collagen content at 28 and 42 days.

Results

L-PRF elicited the greatest degree of defect filling and improvement in other histologic measures. L-PRF–treated specimens also had the greatest cellularity when compared with L-PRP and control at day 28 (560.4 μg vs 191.4 μg vs 124.2 μg, P = .15); at day 48, there remained a difference, although not significant, between L-PRF versus L-PRP (761.1 μg vs 589.3 μg, P = .219) . L-PRF had greater collagen deposition when compared with L-PRP at day 42 (40.1 μg vs 16.3 μg, P < .0001). L-PRF had significantly greater maximum interfacial strength compared with the control at day 42 (10.92 N vs 0.66 N, P = .015) but had no significant difference compared with L-PRP (10.92 N vs 6.58 N, P = .536). L-PRP facilitated a greater amount of sulfated glycosaminoglycan production at day 42 when compared with L-PRF (15.9 μg vs 4.3 μg, P = .009).

Conclusions

Delivery of leukocyte-rich platelet concentrates in conjunction with a HA scaffold may allow for improvements in cartilage healing through different pathways. L-PRF was not superior to L-PRP in its biomechanical strength, suggesting that both treatments may be effective in improving biomechanical strength of healing cartilage through different pathways.

Clinical Relevance

The delivery of platelet-rich concentrates in conjunction HA scaffolds may augment healing cartilaginous injuries.

Section snippets

Preparation of the Cartilage Plugs

The explant model used in this study has been used previously to evaluate cartilage repair, scaffold integration, and cartilage interface development in vitro.³¹ Three operators performed the specimen preparations. In total, 24 full-thickness osteochondral plugs were harvested from a bovine femoral condyle and trochlea in a sterile manner using a 7-mm diameter osteochondral graft harvester (single-use OATS set 7 mm; Arthrex, Naples, FL). The diameter of these plugs was 7 mm and thickness was

Blood Collection

The number of platelets within the L-PRP was 188.4 × 10⁴cells/μL, representing a 10-fold increase from the original blood specimens collected. The average number of white blood cells was 15.5 × 10³cells/ μL, which was a 3.2-fold increase from the original blood specimens collected. The hematocrit value was 36, which was a 0.12-fold decrease from the original blood specimen collected. We did not evaluate changes in cellular concentrations in L-PRF, given its gelatinous form.

Mechanical Strength of the Interface

Following 42 days in

Discussion

The 2 principal findings of our study are that L-PRF elicited the greatest degree of cellularity, collagen production, whereas L-PRP facilitated the greatest amount of sGAG production. There was no superiority observed in biomechanical strength between the platelet concentrates used in this study.

An important finding was that L-PRF had the greatest number of cells. The significant increase in the L-PRF group may be artificially elevated because of the presence of leukocytes in the preparation

Conclusions

Acknowledgments

We thank Lilly Ying, B.S., for the immunohistochemical preparations. This study was supported by the Russell Warren Chair in Tissue Engineering.

References (44)

S. Nehrer et al.
Three-year clinical outcome after chondrocyte transplantation using a hyaluronan matrix for cartilage repair
Eur J Radiol
(2006)
C. Sermer et al.
The addition of platelet-rich plasma to scaffolds used for cartilage repair: A review of human and animal studies
Arthroscopy
(2015)
N.P. Rhodes
Inflammatory signals in the development of tissue-engineered soft tissue
Biomaterials
(2007)
A. Matsiko et al.
Addition of hyaluronic acid improves cellular infiltration and promotes early-stage chondrogenesis in a collagen-based scaffold for cartilage tissue engineering
J Mech Behav Biomed Mater
(2012)
E. Kon et al.
Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: From early degeneration to osteoarthritis
Arthroscopy
(2011)
X. Xie et al.
Comparative evaluation of MSCs from bone marrow and adipose tissue seeded in PRP-derived scaffold for cartilage regeneration
Biomaterials
(2012)
C.J. Meheux et al.
Efficacy of intra-articular platelet-rich plasma injections in knee osteoarthritis: A systematic review
Arthroscopy
(2016)
H. Stegemann et al.
Determination of hydroxyproline
Clin Chim Acta
(1967)
C. Bassleer et al.
Stimulation of proteoglycan production by glucosamine sulfate in chondrocytes isolated from human osteoarthritic articular cartilage in vitro
Osteoarthritis Cartilage
(1998)
D.M. Dohan et al.
Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2006)

L.A. Solchaga et al.

Repair of osteochondral defects with hyaluronan- and polyester-based scaffolds

Osteoarthritis Cartilage

(2005)

I.S. Park et al.

Sizable scaffold-free tissue-engineered articular cartilage construct for cartilage defect repair

Artif Organs

(2019)

E.V. Medvedeva et al.

Repair of damaged articular cartilage: Current approaches and future directions

Int J Mol Sci

(2018)

Y. Ogata et al.

Purified human synovium mesenchymal stem cells as a good resource for cartilage regeneration

PLoS One

(2015)

A. Gobbi et al.

Long-term results after microfracture treatment for full-thickness knee chondral lesions in athletes

Knee Surg Sports Traumatol Arthrosc

(2014)

S.H. Park et al.

Tissue-engineered cartilage using fibrin/hyaluronan composite gel and its in vivo implantation

Artif Organs

(2005)

E. Tognana et al.

hyaluronan-based scaffolds in tissue-engineered cartilage

Cells Tissues Organs

(2007)

A. Facchini et al.

Human chondrocytes and mesenchymal stem cells grown onto engineered scaffold

Biorheology

(2006)

A.M. Haleem 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

Cartilage

(2010)

J. Chahla et al.

A call for standardization in platelet-rich plasma preparation protocols and composition reporting: A systematic review of the clinical orthopaedic literature

J Bone Joint Surg Am

(2017)

A.F. Grecu et al.

Platelet-rich fibrin and its emerging therapeutic benefits for musculoskeletal injury treatment

Medicina (Kaunas)

(2019)

B.W. Oudelaar et al.

Concentrations of blood components in commercial platelet-rich plasma separation systems: A review of the literature

Am J Sports Med

(2019)

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: Ashley Titan and Michael Schär contributed equally to this work.

: The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

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Original ArticleGrowth Factor Delivery to a Cartilage-Cartilage Interface Using Platelet-Rich Concentrates on a Hyaluronic Acid Scaffold

Purpose

Methods

Results

Conclusions

Clinical Relevance

Section snippets

Preparation of the Cartilage Plugs

Blood Collection

Mechanical Strength of the Interface

Discussion

Conclusions

Acknowledgments

Eur J Radiol

Arthroscopy

Biomaterials

J Mech Behav Biomed Mater

Arthroscopy

Biomaterials

Arthroscopy

Clin Chim Acta

Osteoarthritis Cartilage

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Osteoarthritis Cartilage

Sizable scaffold-free tissue-engineered articular cartilage construct for cartilage defect repair

Artif Organs

Repair of damaged articular cartilage: Current approaches and future directions

Int J Mol Sci

Purified human synovium mesenchymal stem cells as a good resource for cartilage regeneration

PLoS One

Long-term results after microfracture treatment for full-thickness knee chondral lesions in athletes

Knee Surg Sports Traumatol Arthrosc

Tissue-engineered cartilage using fibrin/hyaluronan composite gel and its in vivo implantation

Artif Organs

hyaluronan-based scaffolds in tissue-engineered cartilage

Cells Tissues Organs

Human chondrocytes and mesenchymal stem cells grown onto engineered scaffold

Biorheology

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

Cartilage

A call for standardization in platelet-rich plasma preparation protocols and composition reporting: A systematic review of the clinical orthopaedic literature

J Bone Joint Surg Am

Platelet-rich fibrin and its emerging therapeutic benefits for musculoskeletal injury treatment

Medicina (Kaunas)

Concentrations of blood components in commercial platelet-rich plasma separation systems: A review of the literature

Am J Sports Med

Original Article
Growth Factor Delivery to a Cartilage-Cartilage Interface Using Platelet-Rich Concentrates on a Hyaluronic Acid Scaffold