Does the Application of Platelet-Rich Fibrin in Anterior Cruciate Ligament Reconstruction Enhance Graft Healing and Maturation? A Comparative MRI Study of 44 Cases

Abstract

Background: Anterior cruciate ligament (ACL) reconstruction performed with growth factors and activated platelets has been suggested to accelerate tendon ligamentization, leading to earlier return to daily activities and sports. Hypotheses: Platelet-rich fibrin (PRF) will result in improved graft maturation and healing as evaluated by magnetic resonance imaging (MRI) in patients undergoing hamstring ACL reconstruction. Hemostatic and analgesic properties of PRF will lead to less postoperative blood loss and pain. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 44 patients with isolated ACL injuries who underwent arthroscopic all-inside anatomic single-bundle ACL reconstruction with semitendinosus tendon graft were enrolled. Group 1 included 23 patients who had PRF sprayed to the surface of the graft; group 2 included 21 patients for whom no PRF was used. Patients were discharged after 24 hours and examined for hemarthrosis that needed to be aspirated. MRI was performed at the fifth postoperative month. A blinded radiologist evaluated graft maturation according to its signal intensity and the presence of synovial fluid at the tunnel-graft interface. Results: PRF-treated grafts demonstrated lower MRI signal intensity and less fluid in the graft-tunnel interface as compared with controls for the entire length of the graft. The mean full-length MRI signal intensities were 9.19 versus 16.59 ( P = .047) for groups 1 and 2, respectively. Subgroup analysis of the semitendinosus grafts demonstrated a signal intensity of 11.57 versus 23.98 ( P = .044) for the proximal third, 9.53 versus 13.83 ( P = .237) for the midbody, and 6.48 versus 11.98 ( P = .087) for the distal third. Synovial fluid at the graft-tunnel interface was detected in 1 patient in group 1 (4.3%) and 3 patients in group 2 (14.3%; P < .001). Patients in group 1 had significantly less hemarthrosis that needed to be aspirated ( P = .003), while postoperative analgesia requirements were similar in both groups ( P = .08). No clinical benefit of PRF could be demonstrated in clinical outcomes. Conclusion: Application of PRF led to superior graft integration and maturation in the proximal third of the ACL graft. There was no significant difference in MRI signal intensity in the midbody or distal tibial graft. Application of PRF also resulted in significantly lower rates of postoperative hemarthrosis that needed to be aspirated.

Graft tunnel integration occurs early in the tibial tunnel compared with the femoral tunnel after anterior cruciate ligament reconstruction with preserved insertion hamstring tendon graft

“…Many factors can affect the graft tunnel integration such as type of graft [autograft versus allograft; bone–patellar tendon–bone (BPTB) versus hamstring graft], size of the graft, fixation method, preservation of muscle fiber, BMPs, etc. [ 19 , 20 ]. Hamstring tendon grafts have gained more popularity due to less donor site morbidity as compared with BPTB grafts.…”

Biologic agents to optimize outcomes following ACL repair and reconstruction: A systematic review of clinical evidence

“…Sixteen articles did not fulfill the inclusion criteria and were further excluded, leading to a total of 31 studies included in the final analysis (Figure 1). Three papers dealt with the application of stem cells for ACL healing, [14][15][16] 2 papers investigated the concurrent action of PRP and stem cells, 17,18 2 papers the application of Platelet-Rich Fibrin 19,20 whereas 24 papers focused on PRP application solely, of which three in partial rupture [21][22][23] and 21 in ACL reconstruction. Based on the ACL injury pattern, 6 papers investigated biologic agents in ACL partial tears [16][17][18][21][22][23] whereas 25 papers in ACL reconstruction.…”

Fibrin‐based biomaterial systems to enhance anterior cruciate ligament healing

“…As a result of these limitations, several studies have attempted to bolster fibrin-based approaches and largely focus on loading of growth factors into the fibrin glues to promote enhanced healing of the ACL. In one example, connective tissue growth factor (CTGF), known for stimulating ECM and vascular endothelial growth factor (VEGF) production, was introduced via dissolution in fibrin glue into the bone tunnels used for suture repair of a partially torn ACL in the rabbit model (Sun et al, 2017(Sun et al, , 2018 bolster pro-healing properties for therapeutic effect (Beyzadeoglu et al, 2020;Silva & Sampaio, 2009). PRP and PRF originate from both autologous and donor blood sources and their manufacturing processes require the concentration of platelets in whole blood samples via erythrocyte removal (Mohan et al, 2019).…”

“…While fibrin glues are comprised of only the protein component of clots (fibrin), PRP and PRF products also incorporate platelets to bolster pro‐healing properties for therapeutic effect (Beyzadeoglu et al, 2020; Silva & Sampaio, 2009). PRP and PRF originate from both autologous and donor blood sources and their manufacturing processes require the concentration of platelets in whole blood samples via erythrocyte removal (Mohan et al, 2019).…”

“…While PRF has not been used for ACL healing in the context of repair, recent studies focus on the application of PRF to bone tunnel healing and graft integration in ACL reconstruction. Although PRP and PRF have been shown to promote fibroblast proliferation and collagen production in vitro and improve ACL graft ligamentization and mechanics in vivo, the myriad production platelet concentrations and techniques used, the various application methods and sites (intra‐articular, intra‐ACL or intra‐graft injection; bone tunnel or scaffold application), and mixed experimental results have led to much controversy, particularly in clinical outcomes (Andriolo et al, 2015; Beyzadeoglu et al, 2020). A recent editorial commentary explains this controversy succinctly and debates the value of pursuing platelet‐rich products as surgical adjuvants for ACL reconstruction (Figueroa, 2020).…”