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BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Background: The use of plasma rich in growth factors (PRGF) has been proposed to improve the healing of Achilles
tendon injuries, but there is debate about the effectiveness of this therapy. The objective of the present study was to
evaluate the histological effects of PRGF, which is a type of leukocyte-poor platelet-rich plasma, on tendon healing.
Methods: The Achilles tendons of twenty-eight sheep were divided surgically. The animals were randomly divided into
four groups of seven animals each. The repaired tendons in two groups received an infiltration of PRGF intraoperatively and
every week for the following three weeks under ultrasound guidance. The tendons in the other two groups received
injections with saline solution. The animals in one PRGF group and one saline solution group were killed at four weeks, and
the animals in the remaining two groups were killed at eight weeks. The Achilles tendons were examined histologically,
and the morphometry of fibroblast nuclei was calculated.
Results: The fibroblast nuclei of the PRGF-treated tendons were more elongated and more parallel to the tendon axis
than the fibroblast nuclei of the tendons in the saline solution group at eight weeks. PRGF-treated tendons showed more
packed and better oriented collagen bundles at both four and eight weeks. In addition to increased maturation of the
collagen structure, fibroblast density was significantly lower in PRGF-infiltrated tendons. PRGF-treated tendons exhibited
faster vascular regression than tendons in the control groups, as demonstrated by a lower vascular density at eight weeks.
Conclusions: PRGF was associated with histological changes consistent with an accelerated early healing process in
repaired Achilles tendons in sheep after experimental surgical disruption. PRGF-treated tendons showed improvements in
the morphometric features of fibroblast nuclei, suggesting a more advanced stage of healing. At eight weeks, histological
examination revealed more mature organization of collagen bundles, lower vascular densities, and decreased fibroblast
densities in PRGF-treated tendons than in tendons infiltrated with saline solution. These findings were consistent with a
more advanced stage of the healing process.
Clinical Implications: Based on the findings in this animal model, PRGF infiltration may improve the early healing
process of surgically repaired Achilles tendons.
Disclosure: None 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 any
aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with
any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, 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.
http://dx.doi.org/10.2106/JBJS.K.01659
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The surgical approach of the Achilles tendon through a lateral skin incision
allowed precise and reproducible measurements of the tenotomy area
(Fig. 1-A). The tenotomy point was 5 cm proximal to the calcaneal tuberosity. This point was measured with use of a ruler (Fig. 1-B). A three-loop
pulley pattern was used to repair the tenotomy (Fig. 1-C). The tarsal
transarticular external skeletal fixation system protected the repaired
tendon while the animal was bearing weight on the operatively treated limb.
The bars on the tibia and metatarsus were joined together with two connecting bars, forming a triangular configuration (Fig. 1-D).
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was collected just prior to surgery and was processed intraoperatively. The upper
layer of the centrifuged plasma was removed with use of a pipette and was
discarded. The remaining 0.5 mL of plasma fraction that lies just above but
not including the interphase zone (buffy coat) was retrieved with use of a sterile
pipette and was placed in a fractioning tube. This plasmatic fraction is the PRGF
according to the manufacturers instructions. The plasma separation procedure
was done in a laminar flow cabinet in accordance with the PRGF-Endoret system
manufacturer instructions. The 0.5 mL of PRGF from each of the four tubes were
combined to obtain a total volume of 2 mL of PRGF per animal. The platelets were
activated by adding 0.1 mL of 10% calcium chloride just prior to the injection of
PRGF in the injured tendon. The time delay between blood collection and PRGF
application was less than one hour.
The sheep were randomly divided into four groups of seven animals
each. In the sheep in the two experimental groups, 2 mL of PRGF were infiltrated
intratendinously into the divided tendon stumps with use of a 23-gauge needle
just before suturing of the peritenons. The injections were repeated every week
for the following three weeks. The repaired tendons in the other two groups
(controls) were injected with 2 mL of saline solution plus 0.1 mL of 10% calcium
chloride as described above. The infiltrations during the postoperative period
were carried out in properly sedated animals with use of sterile technique under
ultrasonographic guidance. The animals in one PRGF-treated group and one
saline solution-treated group were killed at four weeks, and the remaining animals
were killed at eight weeks.
Histological Procedure
After each animal was killed, both Achilles tendons were harvested and were
fixed in 10% neutral buffered formalin. Contralateral (non-operatively treated)
tendons were studied as normal controls. Each operatively treated tendon was
cut lengthwise on the dorsal midline with use of a scalpel blade. A 1-mm-thick
slab of tissue that included the entire repaired area was excised. This slab of
tissue also contained intact tendon fibers on either side of the repaired area. The
margin adjacent to the intact tendon fibers was yellow-inked for histological
identification. Two paraffin blocks were obtained from each operatively treated
tendon. From each block, six 4-mm-thick consecutive paraffin sections were
cut. Sections were mounted in slides, and three were stained with hematoxylin
and eosin and three were stained with Masson trichrome.
The stained sections were digitalized with use of a photomicroscope
(Axiophot; Carl-Zeiss, Oberkochen, Germany) with an attached digital camera
(DS-5M camera head; Nikon, Tokyo, Japan) coupled with a digital imaging
controller (DS-L1 camera control unit, Nikon) that allowed us to observe, focus,
and capture histological images. Slides were sampled in a systematic randomized
manner by superimposing a dotted transparent template onto each slide. Several
dots spanning the whole tissue section were marked over the glass of the slide
with use of a permanent marker. The regions of interest were chosen during
the histological examination beside a previously marked dot. In Masson
trichrome-stained sections, nine histological images per slide were captured with
a magnification of 200. In hematoxylin and eosin-stained sections, nine
histological images per slide were captured with a magnification of 200 and
nine histological images per slide were captured with a magnification of 630.
These histological images were transferred to a computer equipped with imageanalysis software (Image Pro Plus, version 6.0; MediaCybernetics, Rockville,
Maryland) to perform quantitative measurements. In order to blind the evaluation
of the histological images, all of the captures were encoded with use of an
identification number and were randomly evaluated by three independent
pathologists.
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major axis) was also calculated, with values approaching zero suggesting a
23
spindle shape and with the value of 1.00 representing a perfect circle . The
nuclear orientation angle was defined as the angle between the major axis of
the nucleus and the longitudinal tendon axis, with values of 0 representing a
nucleus that is perfectly aligned toward the longitudinal axis. When this value
increases, the nucleus becomes more angled until it approaches 90, where it
23
lies perpendicular to the long axis of the tendon .
Fibroblast Density
The fibroblast density was determined with use of a counting frame that
was superimposed onto each histological image; these images were captured at a
magnification of 630 and were stained with hematoxylin and eosin (Fig. 2-B).
The number of fibroblasts per area was calculated according to the formula:
fibroblasts/mm2 = N/AF , where N was the number of fibroblasts counted
within the counting frame, and AF was the area of the counting frames (in our
study, AF = 0.004 mm2).
Vascular Density
Vascular density was quantified with use of histological images that were captured at a magnification of 200 and stained with hematoxylin and eosin. The
number of blood vessels in each image area was divided by the area of the
histological image captured at a magnification of 200 (in our study, 0.142 mm2).
Statistical Analysis
Descriptive statistics for each study group (including the mean, standard deviation, and frequencies for categorical data) were calculated. The nonparametric
Kruskal-Wallis test and the Mann-Whitney U test were used to analyze the significance between groups for quantitative parameters (morphology of fibroblast
nuclei, fibroblast density, and vascular density). Categorical data (packing of
collagen fibers, orientation of collagen fibers, and inflammatory cell infiltration)
were analyzed with use of the chi-square test to determine if the infiltration with
PRGF or saline solution yielded significant differences in the frequency distribution between study groups. Values were presented as mean and the standard
deviation (SD). The level of significance was set at p < 0.05.
Source of Funding
This study was supported by the Garca-Cugat Foundation for Biomedical
Research and the Ministry of Health of the Spanish Government. One of the
authors (J.A.F.-S.) was the recipient of a grant from the Ministry of Education
and Science of Spanish Government (AP2006-00150). The authors do not have
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Fig. 2
Representative images demonstrating computer analysis of the histopathological captures. The nuclear profiles of the fibroblasts were traced manually with
use of the cursor of the image software that had been loaded onto a digital tablet, and morphometric parameters of the fibroblast nuclei were calculated
(Fig. 2-A). To determine the fibroblast density, a four-squares frame was superimposed onto each image, and the nuclei (asterisks) that were included
inside each square without touching the exclusion borders (red borders) were counted. The number of fibroblast nuclei was divided between the total area
of the four squares to obtain the fibroblast density (Fig. 2-B).
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Fig. 3
The main morphometric parameters of fibroblast nuclei (the nuclear aspect ratio [Fig. 3-A] and the nuclear orientation angle [Fig. 3-B]) were
significantly different between the PRGF group and the saline solution group at eight weeks. Fibroblast density was significantly different between
the PRGF and saline solution groups at both four and eight weeks (Fig. 3-C). There was a significant decrease in vascularization in the PRGF-treated
tendons at eight weeks (Fig. 3-D). Asterisks indicate a significant difference between the PRGF and saline solution groups (p < 0.05). In all experimental
groups, n = 7.
any financial interest or other relationship with any commercial company related to this study.
Results
ll animals reached the end of the study without incident.
Morphometric data on fibroblast nuclei are shown in
Table I. Fibrocyte nuclei in normal Achilles tendons had a
spindle shape, as demonstrated by a low value for the nuclear
aspect ratio (0.07 0.01) (see Appendix). The PRGF-treated
tendons showed lower values of the nuclear aspect ratio than
did the saline solution-treated tendons at both four and eight
weeks. Nuclei were significantly more elongated in PRGFtreated tendons than in saline solution-treated tendons at
eight weeks (p = 0.008) (Fig. 3-A). Fibrocyte nuclei in normal
tendons were highly aligned with respect to the longitudinal
tendon axis (mean nuclear orientation angle, 2.7 0.9). Fibroblast nuclei tended to be more parallel to the longitudinal
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TABLE I Quantitative Parameters (Morphometric Data on Fibroblast Nuclei, Fibroblast Density, and Vascular Density) in Normal,
Saline Solution, and PRGF Groups*
4 Weeks
Normal
Saline Solution
(N = 7)
PRGF
(N = 7)
0.07 0.01
2.7 0.9
0.39 0.02
16.0 2.8
0.36 0.02
12.3 1.1
31.11 4.16
1.93 0.28
7.44 0.84
44.80 11.92
62.35 7.64
11.53 0.98
4.06 0.33
1.71 0.05
36.53 6.05
27.32 2.22
Fibroblast density
(fibroblasts/mm2)
228 98
Vascular density
(vessels/mm2)
0.47 0.66
Morphometric data
Nuclear aspect ratio
Nuclear orientation
angle (deg)
Major axis (mm)
Minor axis (mm)
Roundness
Area (mm2)
Perimeter (mm)
8 Weeks
P
Value
Saline Solution
(N = 7)
PRGF
(N = 7)
P
Value
0.056
0.095
0.32 0.02
12.2 1.7
0.26 0.01
9.2 0.9
0.008
0.016
12.37 0.41
4.05 0.16
1.76 0.06
38.95 2.55
28.79 0.90
0.222
1.000
0.222
0.548
0.421
13.00 0.33
3.69 0.22
2.02 0.11
36.55 2.54
29.79 0.76
14.55 0.56
3.40 0.07
2.34 0.07
37.55 2.01
32.41 1.05
0.008
0.056
0.008
0.690
0.016
2699 156
2153 247
0.008
2612 130
1905 110
0.008
13.95 5.26
10.88 3.92
0.421
11.62 1.37
6.39 1.50
0.008
*The values are presented as the mean and the standard deviation. Significant difference between the saline solution and PRGF groups.
Fig. 4
Photomicrographs showing the histopathological appearance of the collagen structure. Collagen fibers were more packed in PRGF-treated tendons at both
four and eight weeks. Similarly, collagen fibers showed a better orientation in the PRGF group than in the saline solution group. The arrows indicate the
longitudinal tendon axis orientation (200, Masson trichrome; bar = 100 mm).
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TABLE II Packing of Collagen Fibers, Orientation of Collagen Fibers, and Inflammatory Cell Infiltration in Saline Solution
and PRGF-Treated Groups
4 Weeks
Normal
Saline
Solution
PRGF
100%
40
31.9%
62.2%
5.9%
3.26 0.56
5.6%
70.7%
23.7%
3.82 0.51
100%
40
0.4%
34.1%
51.5%
13.0%
1.1%
3.20 0.70
3.7%
60.7%
31.1%
4.4%
3.64 0.63
100%
00
4.4%
13.7%
36.3%
35.9%
9.6%
1.67 0.98
3.0%
7.8%
24.1%
34.8%
30.4%
1.18 1.04
8 Weeks
P Value
Saline
Solution
PRGF
P Value
<0.001
4.4%
61.1%
34.1%
0.4%
3.70 0.55
21.1%
73.7%
5.2%
4.16 0.49
<0.001
<0.001
2.6%
63.3%
28.9%
5.2%
3.63 0.62
25.9%
69.3%
4.8%
4.21 0.51
<0.001
<0.001
2.2%
11.1%
32.2%
46.7%
7.8%
1.53 0.87
0.4%
2.2%
13.7%
37.0%
46.7%
0.73 0.81
<0.001
*The values are given as the mean and the standard deviation.
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Fig. 5
Discussion
latelet-rich plasma is being used with increasing frequency
in sports medicine to try to accelerate healing and to allow
an earlier return to sports18,19. Despite this interest, there have
been only two clinical studies that have evaluated the effectiveness
of PRP in the treatment of ruptures of the Achilles tendon in
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Rafael J. Gomez-Villamandos,
DVM, PhD
DVM
Pilar Munoz-Rascon,
Department of Animal Medicine and Surgery,
University of Cordoba,
Campus de Rabanales,
University of Cordoba,
Campus de Rabanales,
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