Abstract
Tendons are subjected to tendinopathies caused by inflammation, degeneration, and weakening of the tendon, due to overuse and trauma, which may eventually lead to tendon rupture. Recently, there has been increasing interest in biological approaches to augment tissue healing. Tendon healing occurs through a dynamic process with inflammation, cellular proliferation, and tissue remodeling. In this review article, we discuss the more frequently proposed biological therapies for tendon injuries as platelet-rich plasma, mesenchymal stem cells, extracorporeal shockwave, and scaffolds.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Landesberg R, Roy M, Glickman RS. Quantification of growth factor levels using a simplified method of platelet-rich plasma gel preparation. J Oral Maxillofac Surg. 2000;58:297–300. discussion 300–291.
Anitua E, Andia I, Sanchez M, et al. Autologous preparations rich in growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in culture. J Orthop Res. 2005;23:281–6.
Eppley BL, Woodell JE, Higgins J. Platelet quantification and growth factor analysis from platelet-rich plasma: implications for wound healing. Plast Reconstr Surg. 2004;114:1502–8.
Whitman DH, Berry RL, Green DM. Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofac Surg. 1997;55:1294–9.
Efeoglu C, Akcay YD, Erturk S. A modified method for preparing platelet-rich plasma: an experimental study. J Oral Maxillofac Surg. 2004;62:1403–7.
Weibrich G, Kleis WK, Hafner G, Hitzler WE, Wagner W. Comparison of platelet, leukocyte, and growth factor levels in point-of-care platelet-enriched plasma, prepared using a modified Curasan kit, with preparations received from a local blood bank. Clin Oral Implants Res. 2003;14:357–62.
de Almeida AM, Demange MK, Sobrado MF, Rodrigues MB, Pedrinelli A, Hernandez AJ. Patellar tendon healing with platelet-rich plasma: a prospective randomized controlled trial. Am J Sports Med. 2012;40:1282–8. This article is a randomized trial evaluating the use of leukocyte free PRP obtained with apheresis technique in patellar tendon healing.
Pifer MA, Maerz T, Baker KC, Anderson K. Matrix metalloproteinase content and activity in low-platelet, low-leukocyte and high-platelet, high-leukocyte Platelet Rich Plasma (PRP) and the biologic response to PRP by human ligament fibroblasts. Am J Sports Med. 2014.
Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol. 2009;27:158–67.
McCarrel TM, Minas T, Fortier LA. Optimization of leukocyte concentration in platelet-rich plasma for the treatment of tendinopathy. J Bone Joint Surg Am. 2012;94(141–8):e143.
Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part V: histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:299–303.
Dohan Ehrenfest DM, Bielecki T, Mishra A, et al. In search of a consensus terminology in the field of platelet concentrates for surgical use: platelet-rich plasma (PRP), platelet-rich fibrin (PRF), fibrin gel polymerization and leukocytes. Curr Pharm Biotechnol. 2012;13:1131–7. This article helps to have a better understanding of differences between various PRP preparations.
Weibrich G, Kleis WK, Hafner G. Growth factor levels in the platelet-rich plasma produced by 2 different methods: curasan-type PRP kit vs PCCS PRP system. Int J Oral Maxillofac Surg. 2002;17:184–90.
Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med. 2009;37:2259–72.
Boswell SG, Cole BJ, Sundman EA, Karas V, Fortier LA. Platelet-rich plasma: a milieu of bioactive factors. Arthroscopy. 2012;28:429–39.
Molloy T, Wang Y, Murrell G. The roles of growth factors in tendon and ligament healing. Sports Med. 2003;33:381–94.
Kurtz CA, Loebig TG, Anderson DD, DeMeo PJ, Campbell PG. Insulin-like growth factor I accelerates functional recovery from Achilles tendon injury in a rat model. Am J Sports Med. 1999;27:363–9.
Chan BP, Fu S, Qin L, Lee K, Rolf CG, Chan K. Effects of basic fibroblast growth factor (bFGF) on early stages of tendon healing: a rat patellar tendon model. Acta Orthop Scand. 2000;71:513–8.
Anaguchi Y, Yasuda K, Majima T, Tohyama H, Minami A, Hayashi K. The effect of transforming growth factor-beta on mechanical properties of the fibrous tissue regenerated in the patellar tendon after resecting the central portion. Clin Biomech. 2005;20:959–65.
Lyras D, Kazakos K, Verettas D, et al. Immunohistochemical study of angiogenesis after local administration of platelet-rich plasma in a patellar tendon defect. Int Orthop. 2010;34:143–8.
Lyras DN, Kazakos K, Verettas D, et al. The effect of platelet-rich plasma gel in the early phase of patellar tendon healing. Arch Orthop Trauma Surg. 2009;129:1577–82.
Kajikawa Y, Morihara T, Sakamoto H, et al. Platelet-rich plasma enhances the initial mobilization of circulation-derived cells for tendon healing. J Cell Physiol. 2008;215:837–45.
Boswell SG, Schnabel LV, Mohammed HO, Sundman EA, Minas T, Fortier LA. Increasing platelet concentrations in leukocyte-reduced platelet-rich plasma decrease collagen gene synthesis in tendons. Am J Sports Med. 2014;42:42–9.
Kovacevic D, Rodeo SA. Biological augmentation of rotator cuff tendon repair. Clin Orthop Relat Res. 2008;466:622–33.
Matthews JS, Jones RL. Potentiation of aggregation and inhibition of adenylate cyclase in human platelets by prostaglandin E analogues. Br J Pharmacol. 1993;108:363–9.
Rodeo SA. Biologic augmentation of rotator cuff tendon repair. J Shoulder Elbow Surg. 2007;16(5 Suppl):S191–7.
Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper’s knee. Injury. 2009;40:598–603.
Filardo G, Kon E, Della Villa S, Vincentelli F, Fornasari PM, Marcacci M. Use of platelet-rich plasma for the treatment of refractory jumper's knee. Int Orthop. 2010;34:909–15.
Gosens T, Den Oudsten BL, Fievez E, van’t Spijker P. Fievez A Pain and activity levels before and after platelet-rich plasma injection treatment of patellar tendinopathy: a prospective cohort study and the influence of previous treatments. Int Orthop. 2012;36:1941–6.
Bowman Jr KF, Muller B, Middleton K, Fink C, Harner CD, Fu FH. Progression of patellar tendinitis following treatment with platelet-rich plasma: case reports. Knee Surg Sports Traumatol Arthrosc. 2013;21:2035–9.
Dragoo JL, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med. 2014;42:610–8. This is a randomized controlled trial regarding the use of PRP for patellar tendinopathy.
Gulotta LV, Rodeo SA. Biology of autograft and allograft healing in anterior cruciate ligament reconstruction. Clin Sports Med. 2007;26:509–24.
Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993;75:1795–803.
Da Silva M, Lucena S, Aguilar I, et al. Anti-platelet effect of cumanastatin 1, a disintegrin isolated from venom of South American Crotalus rattlesnake. Thromb Res. 2009;123:731–9.
Nin JR, Gasque GM, Azcarate AV, Beola JD, Gonzalez MH. Has platelet-rich plasma any role in anterior cruciate ligament allograft healing? Arthroscopy. 2009;25:1206–13.
Sanchez M, Anitua E, Azofra J, Prado R, Muruzabal F, Andia I. Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology. Arthroscopy. 2010;26:470–80.
Murray MM, Spindler KP, Ballard P, Welch TP, Zurakowski D, Nanney LB. Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagen-platelet-rich plasma scaffold. J Orthop Res. 2007;25:1007–17.
Radice F, Yanez R, Gutierrez V, Rosales J, Pinedo M, Coda S. Comparison of magnetic resonance imaging findings in anterior cruciate ligament grafts with and without autologous platelet-derived growth factors. Arthroscopy. 2010;26:50–7.
Krampera M, Pizzolo G, Aprili G, Franchini M. Mesenchymal stem cells for bone, cartilage, tendon and skeletal muscle repair. Bone. 2006;39:678–83.
Caplan AI. Adult mesenchymal stem cells for tissue engineering vs regenerative medicine. J Cell Physiol. 2007;213:341–7.
Caplan AI, Dennis JE. Mesenchymal stem cells as trophic mediators. J Cell Biochem. 2006;98:1076–84.
Young M. Stem cell applications in tendon disorders: a clinical perspective. Stem Cells Int. 2012;2012:637836.
Nixon AJ, Dahlgren LA, Haupt JL, Yeager AE, Ward DL. Effect of adipose-derived nucleated cell fractions on tendon repair in horses with collagenase-induced tendinitis. Am J Vet Res. 2008;69:928–37.
Pascual-Garrido C, Rolon A, Makino A. Treatment of chronic patellar tendinopathy with autologous bone marrow stem cells: a 5-year-followup. Stem Cells Int. 2012;2012:953510.
Li F, Jia H, Yu C. ACL reconstruction in a rabbit model using irradiated Achilles allograft seeded with mesenchymal stem cells or PDGF-B gene-transfected mesenchymal stem cells. Knee Surg Sports Traumatol Arthrosc. 2007;15:1219–27.
Soon MY, Hassan A, Hui JH, Goh JC, Lee EH. An analysis of soft tissue allograft anterior cruciate ligament reconstruction in a rabbit model: a short-term study of the use of mesenchymal stem cells to enhance tendon osteointegration. Am J Sports Med. 2007;35:962–71.
Okuizumi T, Tohyama H, Kondo E, Yasuda K. The effect of cell-based therapy with autologous synovial fibroblasts activated by exogenous TGF-beta1 on the in situ frozen-thawed anterior cruciate ligament. J Orthop Sci. 2004;9:488–94.
Silva A, Sampaio R, Fernandes R, Pinto E. Is there a role for adult non-cultivated bone marrow stem cells in ACL reconstruction? Knee Surg Sports Traumatol Arthrosc. 2014;22:66–71.
Notarnicola A, Moretti B. The biological effects of extracorporeal shock wave therapy (ESWT) on tendon tissue. Muscles Ligam Tendons J. 2012;2:33–7.
Hausdorf J, Schmitz C, Averbeck B, Maier M. Molecular basis for pain mediating properties of extracorporeal shock waves. Schmerz. 2004;18:492–7.
Chen YJ, Wang CJ, Yang KD, et al. Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression. J Orthop Res. 2004;22:854–61.
Vulpiani MC, Vetrano M, Savoia V, Di Pangrazio E, Trischitta D, Ferretti A. Jumper's knee treatment with extracorporeal shock wave therapy: a long-term follow-up observational study. J Sports Med Phys Fitness. 2007;47:323–8.
Vetrano M, Castorina A, Vulpiani MC, Baldini R, Pavan A, Ferretti A. Platelet-rich plasma vs focused shock waves in the treatment of jumper's knee in athletes. Am J Sports Med. 2013;41(4):795–803. This article demonstrate the outcomes of PRP and shock waves in the treatment of patellar tendinopathy.
Gigante A, Busilacchi A, Lonzi B, Cecconi S, Manzotti S, Renghini C, et al. Purified collagen I oriented membrane for tendon repair: an ex vivo morphological study. J Orthop Res. 2013;31:738–45.
Longo UG, Lamberti A, Maffulli N, Denaro V. Tendon augmentation grafts: a systematic review. Br Med Bull. 2010;94:165–88.
Meimandi-Parizi A, Oryan A, Moshiri A. Tendon tissue engineering and its role on healing of the experimentally induced large tendon defect model in rabbits: a comprehensive in vivo study. PLoS One. 2013;8:e73016.
Compliance with Ethics Guidelines
Conflict of Interest
Marco Kawamura Demange and Adriano Marques de Almeida declare that they have no conflict of interest. Scott A. Rodeo is a consultant for Rotation Medical and has stock with Cayenne Medical.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Demange, M.K., de Almeida, A.M. & Rodeo, S.A. Updates in biological therapies for knee injuries: tendons. Curr Rev Musculoskelet Med 7, 239–246 (2014). https://doi.org/10.1007/s12178-014-9230-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12178-014-9230-2