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The Effect of Platelet-Rich Plasma on Autologous Osteochondral Transplantation An in Vivo Rabbit Model Niall A. Smyth, MD, Amgad M. Haleem, MD, Christopher D. Murawski, BS, Huong T. Do, MA, Jonathan T. Deland, MD, and John G. Kennedy, MD, FRCS Investigation performed at the Hospital for Special Surgery, New York, NY

Background: Autologous osteochondral transplantation restores a cartilage defect with a cylindrical unit of bone and articular cartilage. Previous studies have described poor graft integration at the chondral interface and degeneration of the cartilage. This has prompted the investigation of adjuncts to address these concerns, including platelet-rich plasma (PRP), which has the potential to improve chondral interface integration and decrease cartilage degeneration. The purpose of this study was to evaluate the effect of PRP on autologous osteochondral transplantation in a rabbit model. Methods: Bilateral osteochondral defects (2.7 mm in diameter and 5 mm in depth) were created on the femoral condyles of twelve New Zealand White rabbits. Osteochondral grafts were harvested from the ipsilateral femoral condyle and, after randomization, were treated with either PRP or saline solution before implantation into the defect site. The rabbits were killed at three, six, or twelve weeks postoperatively. The osteochondral graft was assessed using the International Cartilage Repair Society (ICRS) macroscopic and modified ICRS histological scoring systems. Results: Macroscopic assessment revealed no significant difference between the two groups (mean and standard deviation, 11.2 ± 0.9 for the PRP-treated group versus 10.3 ± 0.9 for the control group; p = 0.09). The mean modified ICRS histological score was significantly higher overall and at each time point for the PRP-treated osteochondral transplants compared with the controls (overall mean, 18.2 ± 2.7 versus 13.5 ± 3.3; p = 0.002). Assessing graft integration specifically, the mean score for the PRP-treated group was significantly higher than that for the control group (2.5 ± 0.9 versus 1.6 ± 0.7; p = 0.004). No adverse events occurred as a result of the surgical procedure or PRP. Conclusions: PRP may improve the integration of an osteochondral graft at the cartilage interface and decrease graft degeneration in an in vivo animal model. Clinical Relevance: The use of PRP as a biological adjunct to autologous osteochondral transplantation has the clinical potential to enhance graft integration, decrease cartilage degeneration, and improve clinical outcomes of autologous osteochondral transplantation.

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rticular cartilage is well known to have a poor capacity for self-repair because of its avascular and hypocellular properties1,2. Small cartilaginous lesions may spontaneously heal; however, larger defects may lead to progressive joint destruction and osteoarthritis3. Surgical strategies for addressing cartilage lesions may be divided into two broad categories: reparative and replacement techniques. Reparative techniques, including arthroscopic bone-marrow stimulation

(e.g., microfracture), have been used for treating small cartilage defects, while replacement strategies have been used to treat large or cystic lesions4,5. Autologous osteochondral transplantation is one such replacement modality, in which a cylindrical osteochondral autograft is used to replace a full-thickness osteochondral lesion. Traditionally, autologous osteochondral transplantation has been used for osteochondral lesions that are large or cystic in

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2013;95:2185-93

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nature, or as a secondary procedure for previously failed index procedures6-8. There are numerous clinical studies in the literature outlining the efficacy of this mode of treatment, with a success rate of up to 90% reported6-12. There are few high-level studies regarding autologous osteochondral transplantation; however, a randomized controlled trial comparing autologous osteochondral transplantation and microfracture for osteochondral lesions of the knee concluded that autologous osteochondral transplantation allowed for a higher rate of return to athletic activities12. Despite promising clinical outcomes, certain concerns have arisen. Following autologous osteochondral transplantation of the knee, cartilage degeneration of the graft, poor integration at the chondral graft interface, and subchondral cyst formation have been described13,14. Similar findings have been demonstrated following autologous osteochondral transplantation for osteochondral lesions of the talus, with up to 75% of cases demonstrating postoperative cyst formation on magnetic resonance imaging (MRI)10,15. These findings, and the potential detriment to the long-term health of the joint, have led to investigation of various biological adjuncts that may improve chondral repair following autologous osteochondral transplantation16-18. Recombinant growth factors, including fibroblast growth factor16, hepatocyte growth factor17, and bone morphogenetic protein-218, have been investigated in animal models in an attempt to decrease cartilage degeneration and improve interface integration of the osteochondral graft. The studies drew similar conclusions on the effect of recombinant growth factors, with the results showing less cartilage degeneration of the graft, but no improvement in integration at the chondral interface. As a result of these potential concerns, it has been proposed that a combination of growth factors may be beneficial in improving the results of surgical treatment for osteochondral lesions, allowing for improved cartilage repair and integration of an osteochondral graft19. One such source of growth factors is platelet-rich plasma (PRP), which can be defined as an autologous blood product derived by the centrifugation of whole blood, yielding a concentration of platelets that is increased above baseline value20. In vitro, PRP promotes chondrocyte proliferation, as well as increases proteoglycan and type-II collagen deposition21-24. These findings have been translated to the in vivo setting, with studies demonstrating improved cartilage repair when PRP is used as an adjunct to microfracture for full-thickness osteochondral lesions in goat knees25,26. However, the effect of PRP on grafts following autologous osteochondral transplantation has yet to be investigated. The objective of this study was to evaluate the effects of PRP when used as a biological adjunct to autologous osteochondral transplantation in a rabbit model. We hypothesized that PRP would improve integration at the chondral interface and decrease cartilage degeneration of the osteochondral graft in comparison with a control. Materials and Methods Experimental Design

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pproval from the Institutional Animal Care and Use Committee of our institution was received prior to the commencement of this study. Twelve

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New Zealand White rabbits, with a mean weight of 4 kg (range, 3.7 to 4.2 kg) and a mean age of twenty-three weeks (range, twenty-two to twenty-four weeks), were used. Randomized, computer-generated assignments were used to determine for each animal whether the left or right knee received PRP with autologous osteochondral transplantation or autologous osteochondral transplantation alone. A rabbit model was chosen for this study as the rabbit knee is large enough to accommodate the procedure, and it is a well-established model that has been used previously for autologous osteochondral transplanta17,27-29 tion . The rabbits were held in individual cages and allowed unrestricted cage activity for seven days preoperatively.

Surgical Procedure Anesthesia was induced using subcutaneous administration of ketamine (40 mg/kg) and acetylpromazine (0.5 mg/kg) and was maintained with isoflurane inhalation. Antibiotic prophylaxis (25 mg/kg of ampicillin) was given thirty minutes prior to surgery. With the rabbits under anesthesia, 27 mL of blood was drawn from the great aural artery of each animal and was mixed with 4 mL of anticoagulant citrate dextrose solution A (ACD-A). One milliliter of blood was then dispensed into a separate syringe for cytological analysis. The remaining blood was centrifuged using a standard, commercially available platelet concentration system (Magellan Autologous Platelet Separator; Arteriocyte, Cleveland, Ohio) to yield 3 mL of PRP according to the manufacturer’s protocol (centrifuge force, 1200 g ; centrifuge time, seventeen minutes). Of this, 1 mL was retained for cytological analysis and the remainder was reserved for surgical use. No attempt was made to reduce the concentration of leukocytes in the PRP preparation. Following shaving and sterile preparation of both lower extremities, a 4-cm medial parapatellar arthrotomy was created in each knee, exposing the medial and lateral femoral condyles. At this point, the joint was inspected to rule out any preexisting cartilage pathology. With use of a drill, an osteochondral lesion, measuring 2.7 mm in diameter and 5 mm in depth, was created on a weight-bearing portion of the lateral femoral condyle of the left knee. The defect was then carefully debrided of any remaining cartilaginous or osseous fragments. Next, an osteochondral graft, measuring 2.9 mm in diameter and 5 mm in depth, was harvested using a mosaicplasty harvester (Smith & Nephew, Memphis, Tennessee) from the lateral femoral condyle of the right knee. The osteochondral graft was then press-fit into the lesion created on the lateral femoral condyle of the left knee. After that, the same procedure was conducted on the medial femoral condyles, with an osteochondral lesion created in the right knee and implanted with a graft harvested from the left knee (Fig. 1).

Fig. 1

Photograph of autologous osteochondral transplant at the time of implantation.

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Prior to osteochondral graft implantation, the grafts were randomized to be allowed to soak in either 1 mL of PRP or saline solution (control) for ten minutes before placement into the osteochondral lesion. Therefore, either the right or the left knee received a PRP-treated graft and the corresponding contralateral knee received a saline solution-treated graft, so that each rabbit served as its own control. During graft implantation, great care was taken to ensure that the graft was level and congruent with the surrounding articular surface. The osteochondral graft donor sites were not backfilled. The surgeon was blinded as to graft treatment at the time of graft harvest; however, blinding was not possible once the grafts had been treated prior to implantation. The wound was closed in layers using simple interrupted sutures (4-0 Vicryl; polyglactin; Ethicon, Johnson & Johnson), with final skin closure achieved using a running subcutaneous stitch (4-0 Vicryl). Following wound closure, 0.5 mL of PRP or saline solution was administered as an intra-articular injection. Finally, the knee was moved through a full range of motion to ensure normal patellar tracking. Postoperatively, the animals were given fentanyl skin patches (12 mg/hr) for pain relief and allowed unrestricted cage activity. The rabbits were killed using pentobarbital (100 to 150 mg/kg, intravenously) at three, six, or twelve weeks after the initial surgery, with four rabbits killed at each time point.

Cytological Analysis Both the whole blood and PRP aliquots underwent cytological analysis to determine platelet, red blood-cell, and white blood-cell counts.

Gross and Histological Processing and Scoring Two reviewers, who were blinded to the treatment groups, performed all scoring independently. The ICRS (International Cartilage Repair Society) macroscopic scoring system (a scale from 0 to 12, with 12 being normal cartilage and 0 indicating severely abnormal) was used to assess the gross speci30 mens (see Appendix). Both knee joints were removed en bloc and fixed in 10% formalin for seven days. The specimens were then decalcified in a sodium citrate-formic acid solution for an additional seven days prior to being embedded in paraffin. This is an established method of preparing osteochondral specimens in our 31 laboratory . The specimens were cut into 8-mm sections at the posterior, middle, and anterior aspect of the graft in order to provide a representative view of overall graft-healing. Sections were stained with hematoxylin and eosin for modified ICRS histological scoring, were stained with alcian blue to assess glycosaminoglycan content, and were processed for type-II collagen immunohistochemistry. The modified ICRS histological score was graded on a scale of 0 to 21, with a modification to assess cartilage integration between 32 the graft and the native tissue (see Appendix). Both macroscopic scoring and histological scoring were performed by two blinded, independent observers.

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Statistical Analysis A pre hoc power analysis was performed on the basis that the primary outcome was the modified ICRS histological score. Given a 2-point difference and a standard deviation of 2 points in a paired t test regardless of time point, twelve rabbits provided 88% power to detect this difference. The Shapiro-Wilk statistic was calculated to determine normality of all analysis variables prior to analysis. This test indicated that the results were not normally distributed, and therefore the variables were evaluated using the Wilcoxon signed-rank test. Using a nonparametric statistical test allowed for a more conservative and appropriate estimate of the significance of the results, given the small sample size. The Kruskal-Wallis test was used to test for differences in macroscopic and histological scores at each time point. Intraclass correlation coefficients were calculated to assess interobserver reliability. All analyses were performed using SAS software (version 9.2; SAS Institute, Cary, North Carolina).

Source of Funding This study was funded through educational grants from Arteriocyte Inc., the Ohnell Family Foundation, and Mr. and Mrs. Michael J. Levitt, given directly to Hospital for Special Surgery. This funding was used for supplies and animal costs. No author received any financial benefit from this study.

Results ll surgical procedures were performed without difficulty or perioperative complication. No rabbit exhibited any signs of lameness or developed an infection postoperatively at any time point.

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Cytological Analysis The PRP group had a 5.1-fold increased platelet count compared with whole blood (mean and standard deviation, 817.6 ± 155.0 · 103/mL versus 161.5 ± 42.6 · 103/mL; p < 0.001). The white blood-cell count was 1.9 times higher in the PRP group compared with whole blood (10.0 ± 3.2 · 103/mL versus 5.1 ± 1.0 · 103/mL; p < 0.001). In contrast, the red blood-cell count in the PRP group was only 28% that of the whole blood group (10.1 ± 1.8 · 103/mL versus 35.6 ± 2.4 · 103/mL; p < 0.001). Macroscopic and Histological Appearance of the Osteochondral Graft At three, six, or twelve weeks after surgery, the rabbits were killed and the knee joints were removed. Macroscopic assessment

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Figs. 2-A and 2-B Photographs of femoral condyles at twelve weeks after surgery. Fig. 2-A Osteochondral graft (A) and osteochondral graft donor site (B) in an animal from the PRP-treated group. Fig. 2-B Osteochondral graft donor site (C) and graft donor site (D) from an animal in the control group.

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Fig. 3

Figs. 3-A through 3-D Sagittal sections of osteochondral grafts at twelve weeks following surgery, showing one of the best results (hematoxylin and eosin). Hematoxylin and eosin was used to stain the sections for assessment with the modified ICRS scoring system. The left column (Figs. 3-A and 3-B) shows the PRP-treated specimen, and the right column (Figs. 3-C and 3-D) shows the control specimen. The top row images are magnified 200·, and the bottom row images are magnified 20·.

showed an improved mean ICRS macroscopic score in the PRP-treated group compared with the control group (11.2 ± 0.9 versus 10.3 ± 0.9), although the difference was not significant (p = 0.09). The PRP-treated grafts showed blurring of the demarcation between the graft and surrounding native tissue, potentially indicating improved integration. Additionally, the surface of the PRP-treated grafts showed less evidence of fibrillation and fissuring compared with the control group (Figs. 2-A and 2-B). The synovium, on gross inspection, appeared to be hypertrophied in the PRP-treated group. The mean modified ICRS histological score was significantly higher overall and at each time point for the PRP-

treated osteochondral transplants compared with the control group (overall mean, 18.2 ± 2.7 versus 13.5 ± 3.3; p = 0.002). In the assessment of graft integration specifically, the mean score was significantly higher for the PRP-treated group than for the control group (2.5 ± 0.9 versus 1.6 ± 0.7; p = 0.004). The PRP-treated grafts showed greater evidence of integration through cartilage-like tissue, while the control group demonstrated prominent fissures or fissures partially filled with fibrous tissue (Figs. 3, 4, and 5). The mean ICRS histological scores for the PRP-treated grafts at three, six, and twelve weeks postoperatively were 19 ± 1.4, 15.8 ± 3.2, and 19.8 ± 1.3, respectively. These were all

Fig. 4

Figs. 4-A through 4-D Sagittal sections of osteochondral grafts at twelve weeks following surgery, showing one of the average results (hematoxylin and eosin). Hematoxylin and eosin was used to stain the sections for assessment with the modified ICRS scoring system. The left column (Figs. 4-A and 4-B) shows the PRP-treated specimen, and the right column (Figs. 4-C and 4-D) shows the control specimen. The top row images are magnified 200·, and the bottom row images are magnified 20·.

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Figs. 5-A through 5-D Sagittal sections of osteochondral grafts at twelve weeks following surgery, showing one of the worst results (hematoxylin and eosin). Hematoxylin and eosin was used to stain the sections for assessment with the modified ICRS scoring system. The left column (Figs. 5-A and 5-B) shows the PRP-treated specimen, and the right column (Figs. 5-C and 5-D) shows the control specimen. The top row images are magnified 200·, and the bottom row images are magnified 20·.

higher than the mean ICRS histological scores for the control grafts, which were 13.8 ± 2.2, 13.3 ± 1.0, and 13.5 ± 6.0 at the same time points. The mean difference in the histological score for the PRP-treated grafts compared with the control

grafts was 5.25 (95% confidence interval [CI], 1.27, 9.23) at three weeks, 2.5 (95% CI, 21.29, 6.29) at six weeks, and 6.25 (95% CI, 23.68, 16.18) at twelve weeks. The intraclass correlation coefficients for the ICRS macroscopic score and

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Sagittal sections of osteochondral grafts at twelve weeks following surgery, showing one of the best results. Glycosaminoglycan content was assessed using alcian blue staining (top row), and type-II collagen (Col II) content was assessed using type-II collagen immunohistochemistry (bottom row). The left column shows the PRP-treated specimen, and the right column shows the control specimen; the images are magnified 20·.

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Fig. 7

Sagittal sections of osteochondral grafts at twelve weeks following surgery, showing one of the average results. Glycosaminoglycan content was assessed using alcian blue staining (top row), and type-II collagen (Col II) content was assessed using type-II collagen immunohistochemistry (bottom row). The left column shows the PRP-treated specimen, and the right column shows the control specimen; the images are magnified 20·.

modified ICRS histological score were 0.84 and 0.81, respectively. There was greater alcian blue staining at the borders of the osteochondral graft as well as at the interface of the PRP-treated group compared with the control, indicating increased glycos-

aminoglycan content (Figs. 6, 7, and 8). The PRP-treated group also demonstrated greater type-II collagen immunoreaction compared with the control group. The difference between the two groups was particularly prevalent at the border of the osteochondral graft and at the chondral interface (Figs. 6, 7, and 8).

Fig. 8

Sagittal sections of osteochondral grafts at twelve weeks following surgery, showing one of the worst results. Glycosaminoglycan content was assessed using alcian blue staining (top row), and type-II collagen (Col II) content was assessed using type-II collagen immunohistochemistry (bottom row). The left column shows the PRP-treated specimen, and the right column shows the control specimen; the images are magnified 20·.

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Discussion steochondral lesions occur in frequently injured articulating joints, such as the knee and ankle33,34. Autologous osteochondral transplantation is a surgical treatment with promising clinical outcomes in the treatment of large or cystic osteochondral lesions at the short and medium-term followup7,35-37. However, histological and MRI assessment of the osteochondral grafts show reason for concern. Evans et al.14, in a case report of two patients who underwent autologous osteochondral transplantation for osteochondral lesions of the knee, reported that histological evaluation at twelve months revealed cartilage degeneration with loss of proteoglycan content in the osteochondral graft. In a case series of twenty-four patients who underwent autologous osteochondral transplantation for an osteochondral lesion of the knee, Marcacci et al.38 reported that MRI at seven years postoperatively revealed that 25% of the patients did not have full cartilage integration of the graft and three patients had evidence of cyst formation. Valderrabano et al.15, in a small case series of twelve patients with autologous osteochondral transplantation for osteochondral lesions of the talus and follow-up of seventy-two months, demonstrated that 75% of the patients had evidence of subchondral cyst development on MRI. The authors hypothesized that chondral damage and poor cartilage integration promotes synovial fluid inflow, leading to cystic change. The basic-science literature further highlights the issues associated with autologous osteochondral transplantation that may be countered with the use of PRP as a biological adjunct. Studies have shown that an impaction load to articular cartilage may lead to matrix degradation and cell death39-41. As an autologous osteochondral transplantation involves press-fitting the osteochondral graft with use of a series of tamps, the overlying cartilage of the graft is inevitably subjected to a mechanical insult. This mechanical insult to the articular cartilage leads to matrix degradation as well as necrosis and apoptosis of the chondrocytes42,43. Gulotta et al.31 further confirmed that this degradative process continues following implantation of the graft. Longer-term follow-up of histological changes following autologous osteochondral transplantation has demonstrated similar results. Tibesku et al.44, using an ovine autologous osteochondral transplantation model, showed that grafts exhibited severe signs of degeneration at three months postoperatively. This was further confirmed by Kleemann et al.45 who reported evidence of graft cartilage degeneration, including hypercellularity and chondrocyte clustering, at three months following autologous osteochondral transplantation in an ovine model. Continued degeneration of the graft may be further promoted by the presence of a catabolic joint environment, as mechanical stress on chondrocytes is known to cause release of matrix metalloproteinases (MMPs)31,46. In addition to cartilage degeneration of the graft, integration of the cartilage interface has been highlighted in the in vivo basic-science literature. Lane et al.47,48, in a goat model of autologous osteochondral transplantation, demonstrated that there was a persistent cleft between the graft and surrounding tissue at the chondral level at the three-month and six-month

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postoperative time periods. Tibesku et al.44 reported similar results in a sheep model of autologous osteochondral transplantation, concluding that, at three months postoperatively, there was no evidence of cartilage integration. Graft chondral degeneration and poor integration may cause the postoperative subchondral cyst formation seen in clinical studies15. The improvement in the appearance of the PRP-treated grafts was shown on histological assessment as the modified ICRS histological score was significantly improved in the PRPtreated group. This improvement in histological appearance may counteract processes such as postoperative cyst formation and potentially improve patient outcomes. The improved histological appearance of the graft may be explained by the in vitro and in vivo basic-science literature demonstrating that PRP may mediate the degenerative effect of the catabolic cytokines present in the intra-articular environment following graft implantation. Intra-articular levels of catabolic cytokines, such as interleukin-1 (IL-1) and tumor necrosis factor-alpha, are elevated following an insult to the joint, such as the surgical trauma induced by autologous osteochondral transplantation, causing upregulation of MMPs and consequent degradation of cartilage31,46,49. In vitro evidence has indicated that PRP may partially inhibit the IL-1-mediated upregulation of MMPs50. Furthermore, van Buul et al.51 and Wu et al.50 demonstrated that PRP has the potential to inhibit the degradative effects of the catabolic cytokines, lessening the IL-1-mediated decrease in type-II collagen and aggrecan gene expression. Integration of the graft at the chondral surface also improved in the PRP-treated group. On gross assessment, the PRP-treated graft borders were less demarcated compared with the control grafts, and there was a significant improvement in scoring of the integration at the cartilage interface on histological assessment. Chondrocyte viability and proliferation are increased in the presence of PRP50,52,53. Additionally, chondrocytes cultured with PRP may increase their proteoglycan deposition and type-II collagen content22,24,53, potentially increasing the quality and quantity of repair tissue at the chondral interface. The autologous osteochondral transplantation procedure may also recruit subchondral-derived mesenchymal stem cells to the lesion following curettage of the site of the osteochondral lesion, leading to bleeding of the subchondral bone. PRP may increase cartilage repair at the graft interface through recruitment of mesenchymal stem cells, as it has been shown to have a positive effect on migration of mesenchymal stem cells21. Furthermore, in vitro evidence has indicated that PRP may promote chondrogenic differentiation of mesenchymal stem cells21,23,54, and consequent deposition of proteoglycan and type-II collagen21. It is likely that a culmination of these effects, including the inhibition of intra-articular catabolic activity, leads to improved graft chondral integration and decreased cartilage degeneration. The reason for apparent swelling of the synovium after PRP injection remains unknown, and the literature regarding the effect of PRP on synovium is sparse and somewhat conflicting. Anitua et al.55 reported that PRP enhanced the secretion of hyaluronic acid by synovial fibroblasts harvested from

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arthritic patients. Additionally, PRP did not affect the release of MMPs (MMP-1, 3, and 13) to a significant level. This contrasts with the findings of Browning et al.56, who reported that PRPtreated synoviocytes showed significantly increased levels of MMP-1 and MMP-3. The differing results of the studies may be attributed to varying preparations of PRP and the pathological state of the synovium, as the former study assessed the effect of PRP on synovium harvested from arthritic joints. The effect of PRP on synovium warrants further investigation. A potential limitation of this study is the lack of blinding of the surgeon with regard to the treatment group at the time of graft implantation. This may lead to possible bias in the pressfit process of graft implantation. The height of an osteochondral graft relative to the surrounding articular cartilage is known to influence the contact pressures sustained by the graft, potentially causing undue degradation of the cartilage and affecting histological results57,58. A second potential confounder is the use of saline solution as a control. Saline solution was chosen as it is the solution of choice used in clinical practice to irrigate the surgical site prior to closure. However, in vitro evidence has indicated that cartilage metabolism may be inhibited by exposure to normal saline solution59.

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In conclusion, the results of this study show that PRP may improve the integration of an osteochondral graft at the cartilage interface and decrease graft degeneration in an in vivo animal model. Appendix Tables showing the ICRS macroscopic score and the modified ICRS histological score are available with the online version of this article as a data supplement at jbjs.org. n

Niall A. Smyth, MD Amgad M. Haleem, MD Christopher D. Murawski, BS Huong T. Do, MA Jonathan T. Deland, MD John G. Kennedy, MD, FRCS Hospital for Special Surgery, 523 East 72nd Street, Suite 507, New York, NY 10021. E-mail address for N.A. Smyth: [email protected]

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The effect of platelet-rich plasma on autologous osteochondral transplantation: an in vivo rabbit model.

Autologous osteochondral transplantation restores a cartilage defect with a cylindrical unit of bone and articular cartilage. Previous studies have de...
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