Intraoperative platelet-rich plasma does not improve outcomes of total knee arthroplasty Masayuki Morishita MD, Kazunari Ishida MD, Tomoyuki Matsumoto MD, Ryosuke Kuroda MD, Masahiro Kurosaka MD, Nobuhiro Tsumura MD PII: DOI: Reference:

S0883-5403(14)00238-1 doi: 10.1016/j.arth.2014.04.007 YARTH 53932

To appear in:

Journal of Arthroplasty

Received date: Revised date: Accepted date:

10 November 2013 3 April 2014 6 April 2014

Please cite this article as: Morishita Masayuki, Ishida Kazunari, Matsumoto Tomoyuki, Kuroda Ryosuke, Kurosaka Masahiro, Tsumura Nobuhiro, Intraoperative platelet-rich plasma does not improve outcomes of total knee arthroplasty, Journal of Arthroplasty (2014), doi: 10.1016/j.arth.2014.04.007

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ACCEPTED MANUSCRIPT INTRAOPERATIVE PLATELET-RICH PLASMA DOES NOT IMPROVE OUTCOMES OF TOTAL KNEE ARTHROPLASTY

Kazunari Ishida, MD1, 3, Ryosuke Kuroda, MD2, Masahiro Kurosaka, MD2,

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Nobuhiro Tsumura, MD1

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Tomoyuki Matsumoto, MD2

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Masayuki Morishita, MD1,

1070 Akebono, Nishi, Kobe 651-2181, Japan

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1. Department of Orthopaedic Surgery, Hyogo Rehabilitation Center Hospital

2. Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine

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7-5-1 Kusunoki, Chuo, Kobe 650-0017, Japan

3. Department of Orthopaedic Surgery, Kobe Kaisei Hospital

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3-11-15, Shinohara-Kita, Nada, Kobe, 657-0068, Japan

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Please address all correspondence to: Kazunari Ishida, M.D. Department of Orthopaedic Surgery Kobe Kaisei Hospital 3-11-15, Shinohara-Kita, Nada, Kobe, 657-0068, Japan Tel: 81-78-871-5201 / Fax: 81-78-871-5206 email: [email protected]

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ACCEPTED MANUSCRIPT Abstract This randomized controlled study was conducted to assess the effects of platelet-rich plasma (PRP) on outcomes of total knee arthroplasty (TKA). Forty patients who underwent unilateral TKA were evaluated

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prospectively; 20 received intraoperative PRP and 20 served as control subjects. The results showed no

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significant differences in reduction of bleeding, range of motion, swelling around the knee joint, muscle power recovery, pain, Knee Society Scores, and Knee Injury and Osteoarthritis Outcome Score between

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the 2 groups. Additionally, no distinct clinical characteristics were found in patients who received

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intraoperative PRP. Therefore, we conclude that intraoperative PRP does not improve outcomes of TKA.

Keywords: platelet-rich plasma, total knee arthroplasty, bleeding, postoperative recovery, functional

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score

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Running head: Platelet-rich plasma and outcomes after TKA

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ACCEPTED MANUSCRIPT Introduction With regard to orthopedic surgery, an increasing number of total knee arthroplasties (TKAs) are performed because of aging of the population [1]. TKA is a well-established surgical procedure associated

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with a high rate of success [1]; however, several factors remain to improve the quality of TKA. Among the

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complications of TKA, one of the most critical is bleeding; thus, blood conservation is essential [2] and researchers are continuously attempting to reduce blood loss after TKA [3, 4].

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As a relatively new autologous source, platelet-rich plasma (PRP) came into the spotlight in nonorthopedic surgical fields for increasing bone, healing wounds, and reducing blood loss [5]. PRP, a so-

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called buffy coat product prepared from freshly drawn autologous blood, is a mixture of platelet- and leukocyte-rich plasma (activated with thrombin to produce a viscous gel cloth). PRP contains high

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concentrations of platelets with at least 6 abundant platelet growth factors such as platelet-derived growth factor and transforming growth factor, inside α-granules, each with a specific function during wound repair

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[6-8]. Activated PRP releases growth factors from the α-granules, which has been suggested to accelerate wound healing after surgery [8]. In this manner, PRP was originally considered a source of regenerative

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medicine mainly in oral and maxillofacial surgery [9, 10]. Unlike other agents such as allogeneic blood products, PRP is autologous and not homologous, which does not impart an overt immune reaction.

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Additionally, PRP is expected to be effective in hemostasis, including wound and bone healing, pain relief, and infection control, by local administration in a variety of surgical fields [7, 8, 11, 12]. In the orthopedic surgical field, PRP has been adopted in a number of surgeries, including those for tendon injury and spinal fusion, and is expected to improve bone and soft tissue healing, hemostasis, and pain relief [11, 13]. Recently, several studies have suggested that application of PRP to the incision during TKA may substantially decrease postoperative bleeding [14-16]. Compared with favorable results, few peer-reviewed reports have demonstrated substantial clinical effectiveness. In addition, whether PRP is related to pain relief or functional outcome remains controversial [17, 18]. This randomized prospective study aimed to assess the role of PRP as a hemostatic surgical tool during TKA and in the improvement of clinical outcomes such as pain relief and range of motion (ROM), up to 1 month after surgery. The primary outcome is blood loss, and the next outcome is improvement of clinical outcomes.

Materials and Methods

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ACCEPTED MANUSCRIPT This study was approved by the institutional review board at our facility, and informed consent was obtained from all patients. From November 2010 to January 2012, 40 patients (40 knees) who were scheduled to undergo primary unilateral TKA were included in this observational study. They were

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randomly divided into 2 groups: 20 patients were treated with PRP (PRP group) and the remaining 20 were

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treated without PRP and served as untreated controls (control group). We used table of random numbers for randomization. We approached 40 patients and all the patients agreed to participate in this randomized

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study. The total number of patients enrolled in this study was chosen based on a previous study in our department on the minimum number of patients required to examine clinical differences, and further

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backed up by the power analysis for the study (alpha = 0.05; power level =80 %, typical standard deviation = 20 %; difference detection = 20 %; JMP Statistical Software Version 8.0.1). In all patients, the indication

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for TKA was osteoarthritis of the knee. Patients who were treated with anticoagulants and antiplatelets or who had bleeding diatheses were excluded from this study. Table 1 shows the demographic data of each

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group.

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Platelet Gel Preparation

In this study, the autologous platelet gel used was prepared from PRP and, according to the

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manufacturer’s protocol, was produced using the Accelerate Concentrating System (Exactech, Gainesville, FL). Briefly, a 60-mL container was filled with 57 mL of fresh whole blood, withdrawn via venous puncture just prior to surgery, and 3 mL citrate to avoid clotting. The 60-mL container was centrifuged at 3,500 rpm for 15 min (Tabletop Centrifuge 2420; KUBOTA Corporation, Osaka, Japan) to separate PRPcontaining buffy coat layers. The contents were kept until application. After finishing the components implantation, we sprayed the platelet gel (5 mL of PRP combined with 5 mL of 5,000 units of thrombin in 2% calcium chloride solution) on all accessible surfaces of the deep wound in each patient in the PRP group (Fig. 1). In the control group, no application was performed, although fresh whole blood was similarly withdrawn from each patient’s vein. All patients were blinded to this treatment.

Surgical Procedure Under spinal anesthesia with an air tourniquet, a medial parapatellar approach was used to expose the knee joint. After intramedullary femoral and extramedullary tibial alignments, rods were employed for a

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ACCEPTED MANUSCRIPT measured resection technique, and a cruciate-sacrificing prosthesis (Advance [5 cases/10 controls], Wright Medical Technology, Arlington, TN; GenesisⅡ[2 cases/0 controls], Smith & Nephew, Mississauga, ON; Low Friction Anatomical [1 case/1 control], Kyocera, Kyoto, Japan; Optetrak [10 cases/9 controls],

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Exactech; Vanguard [2 cases/0 controls], Biomet, Warsaw, IN) was implanted in all subjects. Both components were fixed with cement, and the patella was not resurfaced. After platelet gel treatment, the joint was closed layer by layer. No surgical suction drains were used in this study. In addition to

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mechanical prophylaxis with an intermittent pneumatic compression device until postoperative day 1, patients received 10,000 IU of heparin sodium (Ajinomoto, Tokyo, Japan) intravenously to protect against

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venous thromboembolism. The knee rested in bulky dressings for 1 day after the surgery, and a continuous

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passive motion device was used to encourage knee motion.

Patient Evaluations

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Hemoglobin (Hb) and hematocrit (Ht) levels were documented preoperatively and on postoperative days 1, 7, 14, and 28. Estimated blood loss was computed according to the formula of Gross and Sehat [19, 20],

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and each patient’s blood volume (PBV) was calculated using the formula of Nadler et al., as follows:

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VL= PBV × {(HO－HF) / HAV}

VL (mL) = estimated blood loss, HO = preoperative Ht, HF = postoperative Ht, HAV = (HO + HF) / 2 PBV (mL) = kl × height (m)3 + k2 × weight (kg) + k3 kl = 0.3669, k2 = 0.3308, k3 = 0.6041 for men; kl = 0.3561, k2 = 0.3308, k3 = 0.1833 for women [21]

C-reactive protein level also was recorded to evaluate inflammation preoperatively and on postoperative days 1, 7, 14, and 28. The affected knee’s passive ROM was noted preoperatively and 1 month after surgery. A numeric rating scale was used to measure pain 3 times daily from the day before surgery to postoperative day 7. The highest score on each day was recorded. Muscle strength of knee extension was measured using a handheld dynamometer (Commander Muscle Tester Powertrack II; JTECH Medical, Salt Lake City, UT) preoperatively and on postoperative days 7, 14, 21, and 28. On each day, patients sat on a chair while physical therapists measured open kinetic isometric muscle strength of knee extension with 90° of knee flexion. The hand-held dynamometer (HHD) was fixed at the distal third of the patient’s lower limb. Measurements were performed 5 times daily, and the mean was used for analysis. For evaluating

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ACCEPTED MANUSCRIPT swelling around the knee joint, knee circumference at the upper pole of the patella and 5 cm and 10 cm above the upper pole of the patella were recorded preoperatively and 1 week after surgery. Differences in the circumferences between the day before surgery and postoperative day 7 were used for analysis. Knee

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Society Knee Score, Knee Society Functional Score [22], and Knee Injury and Osteoarthritis Outcome

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Score (KOOS) [19, 23] were assessed preoperatively and on postoperative day 28. Additionally, perioperative complication and transfusion rates were recorded. Measurement, collection, and evaluation

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of all these data were performed by authors who were independent of the treatment.

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Statistical analyses were performed using R version 2.8.1 (The R Foundation for Statistical Computing, Vienna, Austria). The nonpaired Student’s t test was used to examine differences between groups, whereas

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Pearson’s χ2 test was used to assess frequency tabulations, comparing outcomes between treatments. Differences were considered significant at P ≤ 0.05. Power analysis was performed using G Power 3.1

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software. Results

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Demographic data were comparable between the 2 groups (Table 1). Operation time was significantly longer in the PRP group than in the control group (P = 0.03).

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Hb level reduction after TKA was not significantly different between the 2 groups. Likewise, there were no significant differences in C-reactive protein level or estimated blood loss between the 2 groups (Fig. 2a). The intraoperative use of PRP gel had no effect on patients’ postoperative passive ROM, Knee Society Knee Score, Knee Society Functional Score (Fig. 2b), or KOOS (Fig. 2c). The PRP gel also did not significantly improve pain immediately after surgery, compared with the control group (Fig. 3a). Differences in muscle strength of knee extension between the 2 groups on each day were not significant (Fig. 3b). Differences in all circumferences also were not significant between the 2 groups (Fig. 3 c). Homologous blood transfusions were not administered to any patient. However, 3 out of 20 patients needed secondary skin suture for incomplete wound healing in the control group, whereas 1 out of 20 patients required secondary suture in the PRP group. The patients who required secondary suture had no delay in their rehabilitation protocol and showed no sign of superficial wound infection. Additionally, deep infection was not seen in any patient, and no patient reported problems with functional recovery.

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ACCEPTED MANUSCRIPT Discussion The most important finding of this study is that PRP gel applied to the wound site in TKA showed almost no obvious benefit. There were no differences in blood loss, early range of motion, or pain relief.

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Furthermore, there were no significant differences in muscle power recovery, postoperative swelling, or

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early functional outcome between groups. The strength of this study is the variety of evaluations performed.

early subjective clinical outcomes of TKA using PRP gel.

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To our knowledge, this is the first prospective randomized study to evaluate muscle power recovery and

The effect of PRP gel in TKA is controversial. Everts et al. prospectively reported improved

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postoperative Hb values with the use of PRP during TKA. However, their study had many variables, including the use of suction drains in the control group but not in PRP patients [15]. This may have

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increased perioperative blood loss in the control group [24]. In addition, they used fibrin sealant as well as PRP gel. Although fibrin sealant itself is well known to reduce blood loss after TKA, the true contribution

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of PRP gel is unknown [15, 25, 26]. In a retrospective study, Gardner et al. also reported that patients treated with an autologous platelet gel had lower postoperative Hb loss and narcotic requirements than

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those not treated with an autologous platelet gel [16]. Conversely, Peerbooms et al. and DiIorio et al. reported no differences in wound healing, pain, blood loss, ROM, or functional outcomes after PRP

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application [18, 27]. The results of this prospective randomized study also support that there are no clinical benefits of PRP gel in TKA.

The results of this study confirmed that there was no significant difference in blood loss after TKA between the control and PRP groups. PRP is known to be active only when α-granules are released from the exploded platelets. PRP gel is already active by adding thrombin and calcium; thus, we consider that the reduction in blood loss is not caused by the primary aggregation of concentrated platelets, but is mainly dependent on fibrinogen or other coagulation factors contained in α-granules. There are some possible explanations why we did not achieve the expected results. One speculation is that PRP was washed out with bleeding; thus, adequate local concentrations could not achieve the effect. Another possibility is the quality of PRP gel used in this study. This study lacks the evaluation of PRP gel quality. The optimal concentration and method for preparing PRP are controversial. Marx et al. suggested that the concentration of PRP should be up to 1 million/μL and 6 mL [28]; therefore, he applied a double-spin technique to obtain the required PRP concentration [8]. On the other hand, Eby reported that they developed a technique to

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ACCEPTED MANUSCRIPT obtain a consistent PRP platelet concentration of approximately 300% above whole blood levels using a single-spin centrifuge [29]. In this study, we determined the optimal condition of centrifuge by measuring platelet concentrations under various conditions (data not shown). We concluded that the concentration of

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PRP was sufficient to use, but, for this study, we considered it was better to evaluate the amount of growth

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factors contained in the PRP gel to evaluate the quality of PRP gel. The evaluation has not been performed in this study. Furthermore, we also supposed that the amount of autologous blood, from which the PRP gel

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was made, might be one of the most important factors for PRP gel quality. Previous reports revealed that PRP made from 450 mL of blood showed positive results [16], whereas, PRP made from only 128 mL of

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blood showed no effect [30] on blood loss reduction. Since the quality of PRP gel depends on the number of platelets, PRP gel made from larger amounts of blood might have improved the results in this study.

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The results also indicated that the number of patients requiring secondary suture for wound closure was higher in the control group; however, neither superficial nor deep wound infections were found in this

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study. In addition, there was no significant difference in postoperative C-reactive protein level between the 2 groups. These results might indicate that wound healing was promoted by PRP gel, and that PRP gel

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would not affect the infection rate in TKA, although the rate of secondary suture was relatively high in this study. The application of PRP gel for preventing infection in TKA is also controversial. PRP gel contains a

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buffy coat containing concentrated leukocytes, which can inhibit infection at the wound site [30]. The wound-healing properties of PRP gel contribute to the antibacterial properties via reduction of wound leakage [27]. One demerit of PRP gel use is that its preparation requires several steps in nonsurgical fields. PRP preparation significantly prolonged operation time in this study and should be noted to prevent infection in TKA surgery. We did not discover any benefit of applying PRP gel for preventing infection in TKA. Contrary to expectations, PRP gel application did not affect postoperative pain, recovery of ROM, early objective clinical scores, early patient-relevant treatment effects, muscle power recovery, or swelling in this study. The results indicated that PRP gel did not improve functional recovery after TKA. However, the knee joints in the control group had a greater tendency to swell at the upper pole of the patella and 5 cm above the patella than those in the PRP group. The results suggested that PRP might reduce knee swelling after TKA. Furthermore, sports and quality of life scores in the KOOS were higher in the PRP group compared with the control group; the differences showed no statistical significance, however. Horstsmann

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ACCEPTED MANUSCRIPT suggested that PRP seals the tissue resulting in less extravasation of blood into the soft tissue, thereby preventing the formation of hematoma [30]. We supposed that PRP might reduce knee swelling via wound healing promotion; however, whether PRP truly affects knee swelling remains unknown in this study

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because of the multiple factors for leg swelling. A larger number of cases might demonstrate the

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significance of PRP gel application in these evaluations. If PRP reduces postoperative swelling, it might also reduce postoperative pain and improve muscle power recovery after surgery, resulting in higher sports

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and quality of life scores in the KOOS.

The main limitation in this study is the limited number of patients. Some of the results are

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underpowered, but the primary outcome in this study is blood loss. Power analysis for estimated blood loss after 7 days was found to be sufficient at 0.96. However, the other outcome measures were

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underpowered. The comparison between PRPs made from different volumes requires further investigation, and the measurement of calf girth might provide detailed features of leg swelling.

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In conclusion, we found no evident effect of PRP in TKA. PRP gel made from larger volumes of whole blood might improve the effect; however, we could not recommend the application of PRP gel as a

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bioactive autologous material to improve the clinical outcomes in TKA.

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ACCEPTED MANUSCRIPT References 1. Gidwani S, Fairbank A. The orthopaedic approach to managing osteoarthritis of the knee. BMJ (Clinical research ed) 329(7476): 1220, 2004

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2. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood

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management in patients having a total hip or knee arthroplasty. The Journal of bone and joint surgery American volume 81(1): 2, 1999

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3. Tsumara N, Yoshiya S, Chin T, Shiba R, Kohso K, Doita M. A prospective comparison of clamping the drain or post-operative salvage of blood in reducing blood loss after total knee arthroplasty. The Journal of

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bone and joint surgery British volume 88(1): 49, 2006

4. Ishida K, Tsumura N, Kitagawa A, Hamamura S, Fukuda K, Dogaki Y, Kubo S, Matsumoto T,

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Matsushita T, Chin T, Iguchi T, Kurosaka M, Kuroda R. Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty. International orthopaedics

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35(11): 1639, 2011

5. Waters JH, Roberts KC. Database review of possible factors influencing point-of-care platelet gel

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manufacture. The Journal of extra-corporeal technology 36(3): 250, 2004 6. Alsousou J, Thompson M, Hulley P, Noble A, Willett K. The biology of platelet-rich plasma and its

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application in trauma and orthopaedic surgery: a review of the literature. The Journal of bone and joint surgery British volume 91(8): 987, 2009 7. Pietrzak WS, Eppley BL. Platelet rich plasma: biology and new technology. The Journal of craniofacial surgery 16(6): 1043, 2005

8. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics 85(6): 638, 1998 9. Del Corso M, Vervelle A, Simonpieri A, Jimbo R, Inchingolo F, Sammartino G, Dohan Ehrenfest DM. Current knowledge and perspectives for the use of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in oral and maxillofacial surgery part 1: Periodontal and dentoalveolar surgery. Current pharmaceutical biotechnology 13(7): 1207, 2012 10. Simonpieri A, Del Corso M, Vervelle A, Jimbo R, Inchingolo F, Sammartino G, Dohan Ehrenfest DM. Current knowledge and perspectives for the use of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF)

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ACCEPTED MANUSCRIPT in oral and maxillofacial surgery part 2: Bone graft, implant and reconstructive surgery. Current pharmaceutical biotechnology 13(7): 1231, 2012 11. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. The

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American journal of sports medicine 34(11): 1774, 2006

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12. DelRossi AJ, Cernaianu AC, Vertrees RA, Wacker CJ, Fuller SJ, Cilley JH, Jr., Baldino WA. Plateletrich plasma reduces postoperative blood loss after cardiopulmonary bypass. The Journal of thoracic and

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cardiovascular surgery 100(2): 281, 1990

13. Hee HT, Majd ME, Holt RT, Myers L. Do autologous growth factors enhance transforaminal lumbar

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interbody fusion? European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society

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12(4): 400, 2003

14. Berghoff WJ, Pietrzak WS, Rhodes RD. Platelet-rich plasma application during closure following total

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knee arthroplasty. Orthopedics 29(7): 590, 2006

15. Everts PA, Devilee RJ, Brown Mahoney C, Eeftinck-Schattenkerk M, Box HA, Knape JT, van Zundert

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A. Platelet gel and fibrin sealant reduce allogeneic blood transfusions in total knee arthroplasty. Acta anaesthesiologica Scandinavica 50(5): 593, 2006

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16. Gardner MJ, Demetrakopoulos D, Klepchick PR, Mooar PA. The efficacy of autologous platelet gel in pain control and blood loss in total knee arthroplasty. An analysis of the haemoglobin, narcotic requirement and range of motion. International orthopaedics 31(3): 309, 2007 17. Bloomfield MR, Klika AK, Molloy RM, Froimson MI, Krebs VE, Barsoum WK. Prospective randomized evaluation of a collagen/thrombin and autologous platelet hemostatic agent during total knee arthroplasty. The Journal of arthroplasty 27(5): 695, 2012 18. Peerbooms JC, de Wolf GS, Colaris JW, Bruijn DJ, Verhaar JA. No positive effect of autologous platelet gel after total knee arthroplasty. Acta orthopaedica 80(5): 557, 2009 19. Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology 58(3): 277, 1983 20. Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. The Journal of bone and joint surgery British volume 86(4): 561, 2004 21. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery 51(2):

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ACCEPTED MANUSCRIPT 224, 1962 22. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clinical orthopaedics and related research (248): 13, 1989

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23. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome

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Score (KOOS)--development of a self-administered outcome measure. The Journal of orthopaedic and sports physical therapy 28(2): 88, 1998

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24. Esler CN, Blakeway C, Fiddian NJ. The use of a closed-suction drain in total knee arthroplasty. A prospective, randomised study. The Journal of bone and joint surgery British volume 85(2): 215, 2003

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25. Levy O, Martinowitz U, Oran A, Tauber C, Horoszowski H. The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty. A prospective, randomized,

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multicenter study. The Journal of bone and joint surgery American volume 81(11): 1580, 1999 26. Wang GJ, Hungerford DS, Savory CG, Rosenberg AG, Mont MA, Burks SG, Mayers SL, Spotnitz WD.

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Use of fibrin sealant to reduce bloody drainage and hemoglobin loss after total knee arthroplasty: a brief note on a randomized prospective trial. The Journal of bone and joint surgery American volume 83-A(10):

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1503, 2001

27. Diiorio TM, Burkholder JD, Good RP, Parvizi J, Sharkey PF. Platelet-rich plasma does not reduce

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blood loss or pain or improve range of motion after TKA. Clinical orthopaedics and related research 470(1): 138, 2012

28. Marx RE. Platelet-rich plasma: evidence to support its use. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 62(4): 489, 2004 29. Eby BW. Platelet-rich plasma: harvesting with a single-spin centrifuge. The Journal of oral implantology 28(6): 297, 2002 30. Horstmann WG, Slappendel R, van Hellemondt GG, Wymenga AW, Jack N, Everts PA. Autologous platelet gel in total knee arthroplasty: a prospective randomized study. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 19(1): 115, 2011

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ACCEPTED MANUSCRIPT Figure legends Fig.1 Injection of PRP After finishing the components implantation, we sprayed the platelet gel (5ml of PRP, combined with the

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5ml of 5000 units of thrombin in 2% calcium chloride solution) to all accessible surfaces of the deep

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wound in PRP group. Fig.2 Drop in Hb level, laboratory and clinically data

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(a) Drop in Hb level. Mean post-operative reduction in the Hb level for the two groups. Reduction differences in Hb levels between two groups were not significant on each day. (solid line; control group,

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broken line; PRP group) (b) Laboratory data, estimated blood loss, range of motion and knee society scores. (c) KOOS.

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Fig.3 Numeric Rating Scale, muscle strength and differences of circumferences of knee (a) Numeric Rating Scale. The mean post-operative Numeric Rating Scale for the two groups. Differences

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between the two groups were not significant on each day. (solid line; control group, broken line; PRP group) (b) Muscle Strength. The mean muscle strength using HHD for the two groups. Differences

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between two groups were not significant on each week.(solid line; control group, broken line; PRP group)

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(c) The differences of circumferences of knee.

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Figure 1

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Figure 2

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Figure 3

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ACCEPTED MANUSCRIPT Table 1 SD

P value

power

5.7

0.09 0.15

0.50 0.74

148.8 58.5 26.5 12/8

6.1 6.3 3.5

150 57 25.4 10/10

4.6 9.5 4.4

113

13.4

102.5

12.7 38.4 23.4

1.2 3.2 5.2

12.6 38 23.1

0.17

0.32

0.13

0.48 0.55 0.36 0.53

0.58 0.62 0.53 0.77

15.5

0.03

0.51

1.0 2.6 4.4

0.66 0.71 0.82

0.69 0.73 0.83

0.12

0.69

0.72

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4.1

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72 2/18

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control group (n=20) 74.7 0/20

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SD

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age gender (male/female) Height (cm) Weight (kg) BMI Operated side (R/L) Operation time (min) Hb (g/dl) Ht (%) Platelets (× 104 µl) CRP (mg/dl)

PRP group (n=20)

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ACCEPTED MANUSCRIPT Acknowledgement

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We thank Ms. Ashleen Kishore for English rewriting.

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