P-ISSN: 2808-5957

E-ISSN: 2808-6724

ijoms.internationaljournallabs.com

2453

PLATELET RICH PLASMA'S USE ON RECOVERING ACHILLES

TENDON RUPTURES OF WISTAR STRAIN WHITE MOUSE

Seprianto

, Rizki Rahmadian

, Benni Raymond

, Tofrizal

Faculty of Medicine, Universitas Andalas, Padang, West Sumatera, Indonesia

M.Djamil General Hospital, Padang, West Sumatera, Indonesia

dr.sepriantoruslan@gmail.com

rizki_md@yahoo.com

benni_raymond@yahoo.com

ARTICLE INFO

ABSTRACT

Published: February 25

, 2023

Achilles tendon is the most common site of lower extremity tendon rupture.

Current treatment has not been able to restore the biological and

mechanical properties of the tendon to pre-injure condition. One of the

treatments used to improve Achilles tendon healing is the application of

PRP. The research would like to determine the effect of using Platelet Rich

Plasma (PRP) on the recovery of tendon rupture in animals model (wistar

strain white rats). This is an experimental study with a post-test only control

group design using animals model (white rats). This study was conducted at

the INA Lab Laboratory, Padang in November 2022. The samples were

divided into two groups, the control group and the treatment group where

both of these groups were injured and sutured to the tendons. The control

group was not given PRP, while the treatment group was given 0.1 cc of

PRP. The PRP used was heterologous from healthy human blood.

Observations were made after 1 week both groups were maintained and

treated. There were 12 white rats which were divided into the PRP group

and the control group. The PRP group had a lower histopathological score

(5.83) than the control group (10.50). In this study, there was a significant

difference between the recovery of tendon ruptures in animal model (white

rats) that were given Human Platelet Rich Plasma (PRP) and experimental

animals (rats) that were not given PRP (p value 0.007). PRP improves

healing in Achilles tendon rupture.

Keywords: tendon rupture,

achilles tendon, PRP,

histopathological score of tendon

This work is licensed under CC

BY-SA 4.0

INTRODUCTION

Tendons are connective tissue components of the musculoskeletal system that connect

muscles to bones. This tissues that are sensitive to movement have special mechanical properties

that allow it to respond and adapt to the load transmitted by the muscles. Pathology of the tendons

can be chronic to acute with partial or complete tendon tears. Tendon tearing will interfere with

the continuity of the tendon causing a decrease or loss of transmitted force and potentially causing

impaired mobility (Nourissat et al., 2015).

Tendon injuries occur generally as a result of lacerations with the highest incidence being at

the age of 20-29 years and more common in men (Thomopoulos et al., 2015). Achilles tendon tears

are one of the most common tendon injuries in the adult population, with incidence ranging from

7-40 per 100,000 people/year (Lemme et al., 2018). From 2012 to 2016, there was a significant

increase in these cases, from 1.8 per 100,000 people/year in 2012 to 2.5 per 100,000 people/year

in 2016 in the United States (Lemme et al., 2018). At the age of over 50 years, rotator cuff injuries

are also quite common in around 13% of the population (Thomopoulos et al., 2015).

During sports and recreational activities, the tendons undergo large forces that are

transmitted to the skeletal system. Excessive activation of eccentric muscles largely leads to tendon

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2454 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

tearing. The risk of tendon tears has been shown to increase during plyometric activities such as

jumping, when a large eccentric force is followed by large concentric contractions (Lemme et al.,

2018).

Tendon healing is divided into several stages. After a tendon tear, blood will collect and

coagulate at the site of injury which is the hemorrhagic phase in the healing of the tendon.

Typically, platelets degranulate and release large amounts of cytokines and growth factors

including interleukin, TNF, vascular endothelial growth factor (VEGF), platelet-derived growth

factor (PDGF), FGF, TGF¬β, connective tissue growth factor (CTGF), epidermal growth factor

(EGF) and insulin-like growth factor (IGF)¬1, and others (Müller et al., 2015; Nourissat et al.,

2015).

Subsequently the tendon undergoes an inflammatory stage, during which neutrophils and

macrophages invade the hematoma and begin with the process of phagocytosis of necrotic material

and pieces of the extracellular matrix. This stage can last between 3 and 7 days after a tendon

injury. Extrinsic cells of peritendinous soft tissues such as tendon sheaths, fascia, periosteum, and

subcutaneous tissue. Intrinsic cells composed of epitenones and endotenons migrate and proliferate

in the area of tendon injury. Extrinsic and intrinsic cells will together form granulation tissue and

enter the proliferation stage. This immature tissue synthesizes type III collagen from the fifth day

of tendon healing onwards. Early collagen fibers were not yet parallel-oriented but already

contributed to biomechanical strength. Until the fifth week, the amount of collagen continues to

increase and the improvement of callus reaches its greatest size. In the fourth week, intrinsic

fibroblasts mainly from endotenons begin to proliferate. After about 40 days, these intrinsic

fibroblasts play the most active role in tendon healing, actively absorbing collagen, and producing

new collagen at the same time. Tendon tissues mature and the fibers are oriented more lengthwise

according to the tension force. This formative phase lasts for approximately 2 months (Müller et

al., 2015; Nourissat et al., 2015).

Finally, the maximum biomechanical strength is achieved in the remodeling phase, when the

physiological load is carried back to the tendon. Collagen fibers become more regular in the

longitudinal axis and more crosslinked. In addition, type III collagen produced during the

formative phase is replaced by more mechanically resistant type I collagen. As the mechanical

properties of the tissue increase, the transverse area of the callus gradually decreases. However,

tendons that have been renovated over the next few months remain hypercellular, higher amounts

of type III collagen with less potential to cross-bind fibers such as type I, and collagen fibrils are

thinner, leading to lower biomechanical quality than healthy tendons (Müller et al., 2015).

Achilles tendon tears are the most frequent tears of the lower extremities tendons (Shamrock

& Varacallo, 2022). Sudden pain in the back of the legs with a sudden "cracking" sound. On

physical examination, it was found that there were swelling and bruises, tenderness, and unable to

perform plantar pedis movements. The test that is often carried out is called the Simmond-

Thomson test by pinching the calf and assessing the presence or absence of flexion movements in

the plantar pedis. In acute conditions imaging is usually not required. Radiographic imaging is

performed to exclude the possibility of fractures. Ultrasound and MRI can be used to confirm the

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2455 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

diagnosis after the presence of suspicions based on anamnesis and physical examination (Boyd et

al., 2015; Shamrock & Varacallo, 2022).

The current treatment strategy is the technique of sewing or immobilization with a cast or

boot (tearing of the achilles tendon). The results of this treatment judged by the mechanical and

biological properties of the healed tendon appear to have never been the same as the original intact

tendon, leading to a high risk of further injury (5%-15%) or decreased function (Alsousou et al.,

2017). In addition, the tearing of the Achilles tendon is still associated with short-term and long-

term functional deficits (Lemme et al., 2018). The most common complications in achilles tendon

tears include tear area injuries, venous thromboembolic events, and sural nerve injuries

(Stavenuiter et al., 2019).

The application of growth factors from the outside, namely with platelet-rich plasma (PRP)

in previous studies is hypothesized to improve the process of improving tendons (Müller et al.,

2015; Nourissat et al., 2015). Platelet-rich plasma (PRP) is a blood derivative that contains platelet

concentrations above physiological levels. Platelets contribute to the healing of injuries by

releasing growth factors, cytokines, and various bioactive proteins in dissolved and membrane-

bound form during the life span of platelets. This includes the factors needed in the hemorrhagic

phase of tendon healing that have been discussed previously namely TGF-β1 and TGF-β2, PDGF-

AA, PDGF-AB and PDGF-BB, VEGF-A and VEGF-C, IGF-1 and EGF (Alsousou et al., 2017).

PRP improves the processes of angiogenesis, stem cell creation, migration, cell proliferation

and differentiation coupled with the deposition of proteins such as collagen that play a key role in

the restoration of normal tissue structures and the proliferation of tenocytes (Alsousou et al., 2017).

However, despite this, studies on the effects of PRP on tendon tears still vary. Zou et al conducted

a prospective study in 2016 and found in 24 months the PRP group had a better ankle ROM (range

of motion) than the control group. The results of his research suggest that PRP can serve as a

biological augmentation for the repair of acute Achilles tendon tears and improve short- and

medium-term functional outcomes (Zou et al., 2016). Different results were found by Boesen et

al. Boesen et al in 2020 conducted a randomized controlled trial on 40 men aged 18-60 years with

achilles tendon tears undergoing non-surgical therapy plus PRP and found no difference between

PRP-injected patients and not in non-surgical treated patients (Boesen et al., 2020).

The autografting technique is still the gold standard in the application of PRP but in the field

of research, because the model used is an animal model and what is tested is the effectiveness of

human PRP, the xenograft technique is evaluated in several studies. Xenograft is a tissue grafting

that is transplanted on animals of different species. Sadegh et al. (2019) conducted research on the

effects of allograft and xenographt PRP on bone defect healing by dividing the intervention group

into four in the rabbit model. In this study, the injection of cow PRP in the PRP xenograft group

was carried out and it was found that the use of cow PRP (xenograft) in rabbits was more

representative than the use of allograft PRP.

Based on the above review, the author is interested in conducting research on the effect of

the use of platelet rich plasma (PRP) on healing the achilles tendon tears of wistar white rats in

order to assess whether this therapy is effective for use in healing achilles tendon tears. This study

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2456 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

aims to determine the effect of using Platelet Rich Plasma (PRP) on healing the tendon tears of

experimental animals (Wistar strain white rats).

METHOD

This type of study is an experimental study to assess the effect of platelet rich plasma

administration in healing tendon tears in experimental animals (white mice). The research design

used in this study was a simple experiment (Post Test Only Control Group Design). This research

was conducted at the INA Lab Padang Laboratory which was carried out in November 2022.

The population used is wistar strain white rats. The sample used was a white rat (Rattus

norvegicus) of an 8-week-old male wistar strain weighing 250-300 grams. The determination of

sample size based on World Health Organization (WHO) criteria, which determined the minimum

number of samples per group for experimental studies of experimental animals was five mice

(Nourissat et al., 2015; Thomopoulos et al., 2015). To prevent a drop out in the middle of the

study because the rat died or became ill, a large sample correction was carried out using the

following formula:

𝑛

′

𝑛

(1 − 𝑓)

Information:

n': Minimum sample size

n: Calculated sample size

f : Approximate proportion of drop out

The proportion of sample drop out is about 10% (f = 0.1), so it is obtained:

𝑛

′

(1 − 0,1)

𝑛

′

(0,9)

= 5,5 ≈ 6

Based on the corrections above, the sample size of each treatment group was at least six mice.

To avoid the possibility of a drop out in the implementation of the study, the researcher took a total

of 10 heads for each group. This study consisted of 2 groups, namely the control group (without

the administration of platelet rich plasma) and the treatment group (with platelet rich plasma) so

that the total number of samples needed in this study was 12 mice.

The inclusion criteria for sampling were white rats (Rattus norvegicus) of healthy male wistar

strains, rat body weight was 250-300 grams, mice aged 8 minggu at the time of sample selection,

and mice that had no anatomical defects. As for the exclusion criteria, it is a dead mouse. Then

data analysis is carried out by data processing (editing, coding, processing, and cleaning), and data

analysis with univariate and bivariate analysis.

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2457 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

RESULT AND DISCUSSION

Characteristics of experimental animals

Table 11. Overview of Histology Assessment of Tendon Repair of Experimental Animals

Group

Chen Tendon Repair Histology Score

Fiber

Structure

Fiber

Arrangement

Nucleus

Shape

Inflam-

matory

Neo-

vascularization

Cell

Density

Total

Control

Treatment

Table 22. Average Description of Histology Characteristics of Tendon Repair of Experimental

Animals

Group

Chen Tendon Repair Histology Score (Mean)

Fiber

structure

Fiber

Arrangement

Nucleus

Shape

Inflam-

matory

Neo-

vascularization

Cell

Density

Total

Control

2,17

2,00

1,83

1,67

1,83

1,00

10,50

Treatment

0,67

0,83

1,17

1,50

1,00

5,83

In Tables 1 and 2 it appears that the scores were obtained lower in the treatment group than

in the control group which showed faster healing occurred in the treatment group with a dominant

uninterrupted fiber structure, a denser and parallel arrangement, tubular and long dominant cells,

inflammation occurred only about 10-20%, already fewer vascularization areas (10-20%) with

slightly increased cell density. Meanwhile, in the control group, judging from the scores obtained,

in the post-tear-tearful area of the tendon, edematous parts appeared, increased vascularity,

distribution of inflammatory cells, and partially fragmented tendon fibroblast cells. This gives the

impression of an ongoing healing process accompanied by inflammation. However, it appears that

in the cell density, control and treatment sections do not have a difference in average score.

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2458 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

Differences between Tendon Tear Healing in Experimental Animals (White Mice) Given

Human Platelet Rich Plasma (PRP) and Experimental Animals (White Mice) Not Given PRP

Table 33. Normality Test

Group

Shapiro-Wilk

Sig.

Control

,221

Treatment

,324

*Shapiro-Wilk

In table 3, you can see the significance value of the Shapiro-Wilk test >0.05 in both groups,

it can be concluded that the distributed data is normal. So the bivariate analysis in this study is

feasible using the T-independent Test.

Table 4. 4 Differences between Tendon Tear Healing in Experimental Animals (White Mice)

Given Human Platelet Rich Plasma (PRP) and Experimental Animals (White Mice) Not Given

PRP

Group

Score

P-value

Mean

Median

Min

Max

Control

10,50

11,00

0,007

Treatment

5,83

6,50

*T-independent test

In table 4, it can be seen that there is a statistically meaningful difference in the healing of

tendon tears given by Human Platelet Rich Plasma (PRP ) with those not given PRP with a p-value

of <0.05, which is 0.007.

Tendon Healing Characteristics

In this study, a larger tendon healing score was obtained in the control group with an average

of 10.50 while in the treatment group a smaller score of 5.83 was obtained. The Chen score known

for assessing tissue healing has a maximum score of 18 with a score of 0 indicating the best form

and a score of 3 indicating the condition of the tissue that is in the early stages of healing. In the

group given PRP, the dominant fiber structure is uninterrupted, the arrangement is more dense and

parallel, the dominant cells are tubular and long, inflammation occurs only about 10-20%, the area

of vascularization is already less (10-20%) with a slightly increased cell density while in the

control group more irregular cells are found, high levels of neovascularization and still high

inflammation. Li et al in 2021 stated that tendons that have not recovered tend to have irregular

collagen fibers, increased content of proteoglycans and glycosaminoglycans, increased non-

collagen ECM, cell proliferation and neovascularization (Li et al., 2021).

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2459 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

In this study, a need was carried out on the Achilles tendon of experimental mice. Acute

injury to the tendon followed by the rapid initiation of the healing process. This process is generally

divided into three chronological stages: inflammation, proliferation, and remodeling. Although

these stages overlap, each phase has different cytokines and cellular processes. The cytokines

expressed in tendon healing vary with generally pro-inflammatory cytokines predominating at the

beginning, and anti-inflammatory and restorative cytokines predominating at the end of the healing

process (Leong et al., 2020).

The inflammatory stage of tendon healing begins immediately after an acute injury with the

formation of clots in the damaged tissues. In this phase, clots form in the damaged blood vessels,

inflammatory cells are activated, and finally fibroblasts are recruited to continue the healing

process. Platelets and cells inside the blood clot release TGFβ, IGF-I, and PDGF, causing local

inflammation. The clot serves as the initial scaffolding for recruited extrinsic inflammatory cells.

This elaboration of growth factors recruits neutrophils, which in turn activate macrophages to

phagocytize necrotic debris. Approximately two days after the injury, these cytokines released

from macrophages and intrinsic cells of endotenons and epithenons begin the proliferation stage

by recruiting fibroblasts. TGFβ is responsible for regulating proteinase activity, stimulating

collagen production, and then recruiting fibroblasts. Similarly, IGF-I serves to stimulate the

production of the extracellular matrix and recruit fibroblasts to the area, PDGF increases DNA and

protein synthesis, and hence the expression of other growth factors. These factors work

synergistically to start the healing process (Leong et al., 2020).

Chisari et al. (2021) state the inflammatory phase lasts three to seven days from injury, and

this is indicated by the appearance of inflammatory cells such as monocytes and macrophages. A

balanced pro-inflammatory cytokine is needed for the continuation of a rapid healing process

where the inflammation that occurs is expected to be not too low and also not too high. In a study

by Ameer et al. (2018) stated that PRP has an anti-inflammatory effect that can balance the

inflammatory process so that healing occurs faster due to the shorter duration of the inflammatory

phase. Similar results were also shown by Sundman et al. (2014) who stated a decrease in the

number of pro-inflammatory cytokines such as TNF-alpha and IL-1β. The theory states that PRP

causes faster TNF-alpha secretion for PMN cell recruitment but PRP also regulates the amount of

these cytokines secreted so that inflammation is not too intense.

The proliferative phase is characterized by the expansion of the extracellular matrix, an

increase in cellularity, and the deposition of fibrovascular scars by fibroblasts. At the site of injury,

fibroblasts migrate and multiply themselves. Intrinsic cells of endotenone and epitenone also begin

to develop. Expression of IGF-I and TGFβ remains high, continuing to pull fibroblasts to the site

and increasing the production of the extracellular matrix. At this time, the expression of bFGF

from tenocytes, fibroblasts, and inflammatory cells reaches its peak, encouraging angiogenesis and

cell proliferation. VEGF expression is also high, stimulating angiogenesis to provide extrinsic

cells, nutrients, and additional growth factors to the injury area. Collagen synthesis is a process

that relies heavily on oxygen, which underlies the importance of the synergistic angiogenic action

of bFGF and VEGF in this healing stage (Leong et al., 2020).

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2460 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

Jo et al. (2012) examined the effects of PRP on cell proliferation on rotator cuff tendon tears

on days 7 and 14 and obtained PRP inducing the expression of type I collagen genes on days 7 and

but not on day 14, but PRP was known to increase collagen type III on days 7 and 14. Because

platelets contain a variety of growth factors in their granules, PRP can potentially release these

growth factors higher than physiological levels such as platelet-derived growth factor (PDGF),

epidermal growth factor (EGF), transforming growth factor-beta 1 (TGF-b1), insulin-like growth

factor (IGF-I), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF),

and hepatocyte growth factor (HGF) that are known to be involved during healing tendon.

Remodeling the injury area begins with a new collagen reorganization. Because in this study

both groups had collagen fiber arrangement scores between 1-2, it is likely that the mice were

between the proliferation phase and the remodeling phase. The PRP group had a more regular fiber

arrangement that reflected collagen deposition more quickly occurring in the group with PRP. The

reorganization of collagen overlaps with the proliferative phase, leading to a gradual decrease in

cellular and an increase in the fibrous matrix. Tenocytes and collagen fibers become aligned, with

a decrease in type III collagen, vascularity, cellularity, and corresponding water content in scar

formation. In the control group, the vascularity score was higher than the PRP group which showed

a rudimentary remodeling process because vascularity at the end of healing was expected to

decrease. The increase in collagenase in the resorption of type III collagen and its replacement

with type I collagen ends with the formation of tissues that have more crosslinking and tensile

strength. This process continues for months and years after the injury. However, the newly formed

tissue does not have the original biomechanical, biochemical and ultrastructural properties of the

tendons (Leong et al., 2020).

Differences in Tendon Tear Healing in Experimental Animals (White Mice) Given Platelet

Rich Plasma (PRP) and Experimental Animals (White Mice) Not Given PRP

In the study, there was a significant difference between the healing of tendons given by PRP

and those that were not given by PRP. These results are similar to a study by Xiong in China in

2012 on a mouse model weighing 190-240 grams. In this study, there were 36 mice divided into 3

groups, namely the control group, the PPP group and the PRP group. In the PPP and PRP groups,

100 mcL of PPP/PRP was injected weekly and tendon tissue was taken at week 1,2,3,4 after

surgery for morphological, histological and immunohistochemical observations. Furthermore,

specimens in each group were carried out biomechanical tests at week 4. By the end of the study,

all animals survived. Infiltration of inflammatory cells, angiogenesis, and collagen fibers was more

in the PRP group than in the PPP group and control group at 1 week. Over time, inflammatory cell

infiltration and angiogenesis gradually decrease. The modulus of elasticity and tensile strength of

the PRP group was significantly higher than that of the control group and the PPP group at week

4. In this study, it was concluded that PRP can improve the healing of achilles tendons in the early

repair of rat achilles tendon tears (Xiong et al., 2012).

Nazhvani et al. (2019) also examined the effect of PRP on tendons using 24 pig models

observed over 42 days. At the end of the study (42

day), all animals in euthanasia and tendon

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2461 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

samples were taken for further research. Histopathological observations showed that the group

given PRP had less inflammation and a more mature and organized histological picture of collagen

fibers as found in this study.

Another study was conducted by Takamura et al. (2017) in 2017 on 50 models of male albino

rabbits with heavy achilles tendon tears. In the study, the sample was divided into two groups,

namely the group given PRP and the group without PRP. The application of PRP is carried out by

placing 0.3 grams of PRP on the anteron side of the tendon directly after the tendon is cut, after

which the paratenon and skin are sutured. The tendons are immobilized in a 60° plantarflection

position with 1.8-mm Kirschner wire from the calcaneus bone through the talocrural joint to the

tibia and then a short leg cast is applied. Tendon tissue was taken at weeks 1, 2, 3, 4, and 6 after

therapy and the cut parts were stained with hematooxylin-eosin and monoclonal antibody against

CD31 and type 1 collagen. As a result, collagen fibers proliferated denser earlier after tendon

breakage, and subsequent remodeling of collagen fibers and estimates of normal tendinous tissue

occurred earlier in the PRP group than in the control group. The number of fibroblasts was

significantly higher in the PRP group than in the control group at 1 and 2 weeks. Similarly, the

CD31-positive cell area ratio was significantly higher in the PRP group than in the control group

at 1 and 2 weeks. Positive staining for type I collagen was more intense in the PRP group than in

the control group after 3 weeks indicating tendon maturation.

The long-term effects of PRP on human achilles tendons were assessed by Wang et al. (2021)

in 2021 in a systematic review. Wang et al. (2021) obtained positive results where PRP injection

for tendon tear therapy achiles increased the dorsoflection angle and dorsoextension strength of

the ankle and calf circle after 12 months compared to control.

Tendons are fibrous connective tissues containing 65–80% type I collagen, and elastin,

proteoglycans, glycoproteins, and water in smaller amounts inside tendon cells. Since the tendons

connect the bones with the muscles, the tendons are designed to withstand mechanical loads, that

is, muscle loads. However, excessive or repeated loads have padding on the tendons and cause

tendon injuries. When exposed to these abnormal loading conditions, cellular activity on the

tendons is modified resulting in structural changes that eventually interfere with the functioning

of the tendons. After a tendon injury, natural healing occurs. However, tendon healing is a slow

and inefficient process, which does not restore the normal biological and biomechanical properties

of the injured tendon. As a result, patients are more often unable to return to their normal activities

before the injury. More importantly, areas that are repaired especially in athletes have a higher risk

for re-injury. As a promising healing agent, PRP is widely used in orthopedic surgery and sports

medicine to promote the healing of injured musculoskeletal tissue, including tendons and

ligaments due to the faster healing process mediated by the content of growth factors in it

(J. H. C.

Wang & Nirmala, 2016).

In clinical applications, PRP treatment by injection improved pain intensity and functional

ability scores in patients with Achilles tendinopathy, elbow tendinopathy, and patellar

tendinopathy. In addition to PRP injection, PRP treatment can also be performed by implantation

of PRP gel, which may be better than injection and provide better treatment results because PRP

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2462 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

gel can remain in place without the potential for diffusion of the treated area. It has been reported

that implanting a PRP gel, called Platelet-Rich Fibrin Matrices (PRFM), into an Achilles tendon

tear in athletes improves range of motion and function faster than those who receive open suture

repair

(J. H. C. Wang & Nirmala, 2016).

Different results were found by Yuksel et al in 2015 who conducted a longer-period study in

20 mouse models. In this study, mice weighing 500-550 grams were carried out on the achilles

tendon and were divided into groups given PRP and control groups. Observations were made on

the 15

and 30

days to assess the histopathology and biomechanics of rat tendon samples. The

study used Movin and Bonar histopathology scores and obtained significantly lower scores in the

PRP group similar to this study which obtained lower Chen scores in PRP mice. However, on

biomechanical examination, no significant differences were found between the group of PRP mice

and control on days 15 and 30, so it was concluded that PRP was beneficial in tendon recovery in

the initial phase and only slightly increased tendon strength. In this study, immobilization in rats

was not carried out so that this could have an effect on the healing of tendons (Yuksel et al., 2015).

In human research, Keene et al. (2019) also found different results that mentioned no

evidence that PRP injection could improve achilles tendon function compared to controls. In this

study, the study sample was humans with an average age of 46 years. This discrepancy is thought

to be due to two main factors; PRP-related and patient-related. PRP-related factors include: 1) the

composition of PRP: the presence or absence of white blood cells (leukocytes) in PRP

preparations; 2) Platelet concentration: low or high platelet concentration relative to complete

blood levels; 3) PRP status: enabled or not activated; 5) Method of administration: injection or

implantation; and 6) Number of PRP administrations: one-time injection or multiple injections.

Patient-related factors include: 1) Age: young or old; 2) Types of tendon injuries: acute or chronic;

3) The patient's activity level: active or passive; 4) Treatment history: previous treatment, surgery,

etc.; and 5) Post-recovery plan: rehabilitation or without physiotherapy. In the literature study,

patients were not homogeneous with various factors so it was difficult to assess the factors that

caused the use of PRP to be unhelpful. However, in general the relatively older age of the patient

can contribute to a less beneficial modification of the PRP (Keene et al., 2019; J. H. C. Wang &

Nirmala, 2016).

Boksh et al. (2022) conducted a literature review that included 510 patients with 256 people

getting PRP injections and the remaining 254 not. In this study, the average age of respondents

was 41.6 years with the average distance between PRP administration and the need was 5.9 days.

Follow-up is carried out up to 61 weeks. In the study, biomechanical tests were tested including

heel endurance, isokinetic strength, calf circumference and range of motion of each group. At the

end of the study, it was found that PRP injection in achilles tendon tears did not improve medium-

and long-term clinical and biomechanical outcomes. The factor of ineffectiveness of PRP

compared to the control of contributing age and also treatment to patients. Since it is a metaanalysis

study, the sample can not be uniformed which can lead to the risk of bias.

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2463 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

CONCLUSION

In this study, it was found that the achilles tendon given by PRP had a better histological

picture with a dominant uninterrupted fiber structure, a denser and more aligned arrangement,

tubular and long dominant cells, less inflammation and fewer vascularization areas. Meanwhile,

in the control group, in the post-tear area, there was still an increase in vascularity, the distribution

of inflammatory cells, and partially fragmented tendon fibroblast cells. There was a significant

difference between tendon tear healing in experimental animals (white mice) given Human Platelet

Rich Plasma (PRP) and experimental animals (white mice) who were not given PRP.

This study was conducted on animal models so it takes research conducted in humans to

assess the effect of PRP on the comprehensive healing of Achilles tendon tears. Research with a

longer duration is needed to assess the effects of PRP on long-term healing of Achilles tendon

tears such as the biomechanical properties of tendons and the likelihood of re-injury after therapy.

More research is needed at the molecular level to look at the growth factors that play a role during

the healing phase of the tendons that PRP provides.

REFERENCE

Alsousou, J., Keene, D. J., Hulley, P. A., Harrison, P., Wagland, S., Byrne, C., Schlüssel, M. M.,

Dutton, S. J., Lamb, S. E., & Willett, K. (2017). Platelet rich plasma in Achilles tendon

healing 2 (PATH-2) trial: Protocol for a multicentre, participant and assessor-blinded,

parallel-group randomised clinical trial comparing platelet-rich plasma (PRP) injection

versus placebo injection for Achilles tendon rupture. BMJ Open, 7(11).

https://doi.org/10.1136/bmjopen-2017-018135

Ameer, L. A. A., Raheem, Z. J., Abdulrazaq, S. S., Ali, B. G., Nasser, M. M., & Khairi, A. W. A.

(2018). The anti-inflammatory effect of the platelet-rich plasma in the periodontal pocket.

European Journal of Dentistry, 12(4), 528–531. https://doi.org/10.4103/ejd.ejd_49_18

Boesen, A. P., Boesen, M. I., Hansen, R., Barfod, K. W., Lenskjold, A., Malliaras, P., & Langberg,

H. (2020). Effect of platelet-rich plasma on nonsurgically treated acute Achilles tendon

ruptures: A randomized, double-blinded prospective study. American Journal of Sports

Medicine, 48(9), 2268–2276. https://doi.org/10.1177/0363546520922541

Boksh, K., Elbashir, M., Thomas, O., Divall, P., & Mangwani, J. (2022). Platelet-rich plasma in

acute Achilles tendon ruptures: A systematic review and meta-analysis. The Foot, 53,

101923. https://doi.org/10.1016/j.foot.2022.101923

Boyd, R. P., Dimock, R., Solan, M. C., & Porter, E. (2015). Achilles tendon rupture: How to avoid

missing the diagnosis. British Journal of General Practice, 65(641), 668–669.

https://doi.org/10.3399/bjgp15X688069

Chisari, E., Rehak, L., Khan, W. S., & Maffulli, N. (2021). Tendon healing is adversely affected

by low-grade inflammation. Journal of Orthopaedic Surgery and Research, 16(1).

https://doi.org/10.1186/s13018-021-02811-w

Jo, C. H., Kim, J. E., Yoon, K. S., & Shin, S. (2012). Platelet-rich plasma stimulates cell

proliferation and enhances matrix gene expression and synthesis in tenocytes from human

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2464 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

rotator cuff tendons with degenerative tears. American Journal of Sports Medicine, 40(5),

1035–1045. https://doi.org/10.1177/0363546512437525

Keene, D. J., Alsousou, J., Harrison, P., Hulley, P., Wagland, S., Parsons, S. R., Thompson, J. Y.,

O’Connor, H. M., Schlüssel, M. M., Dutton, S. J., Lamb, S. E., & Willett, K. (2019). Platelet

rich plasma injection for acute Achilles tendon rupture: PATH-2 randomised, placebo

controlled, superiority trial. The BMJ, 367. https://doi.org/10.1136/bmj.l6132

Lemme, N. J., Li, N. Y., DeFroda, S. F., Kleiner, J., & Owens, B. D. (2018). Epidemiology of

Achilles tendon ruptures in the United States: Athletic and Nonathletic Injuries From 2012

to 2016. Orthopaedic Journal of Sports Medicine, 6(11).

https://doi.org/10.1177/2325967118808238

Leong, N. L., Kator, J. L., Clemens, T. L., James, A., Enamoto-Iwamoto, M., & Jiang, J. (2020).

Tendon and ligament healing and current approaches to tendon and ligament regeneration.

Journal of Orthopaedic Research, 38(1). https://doi.org/10.1002/jor.24475

Li, Z. J., Yang, Q. Q., & Zhou, Y. L. (2021). Basic research on tendon repair: Strategies,

evaluation, and development. Frontiers in Medicine, 8.

https://doi.org/10.3389/fmed.2021.664909

Müller, S. A., Todorov, A., Heisterbach, P. E., Martin, I., & Majewski, M. (2015). Tendon healing:

An overview of physiology, biology, and pathology of tendon healing and systematic review

of state of the art in tendon bioengineering. Knee Surgery, Sports Traumatology,

Arthroscopy, 23(7). https://doi.org/10.1007/s00167-013-2680-z

Nazhvani, F. D., Naeini, A. T., Nazhvani, S. D., Nazhvani, A. D., & Koohpeyma, F. (2019). Does

platelet-rich plasma improve the tendon gap healing? Shiraz E Medical Journal, 20(5).

https://doi.org/10.5812/semj.82620

Nourissat, G., Berenbaum, F., & Duprez, D. (2015). Tendon injury: From biology to tendon repair.

Nature Reviews Rheumatology, 11(4). https://doi.org/10.1038/nrrheum.2015.26

Sadegh, B. A., & Balajadeh, M. S. (2019). The effect of allograft PRP and xenograft PRP on bone

defect healing in rabbit model. Iranian Journal of Veterinary Clinical Sciences, 13(2).

Shamrock, A. G., & Varacallo, M. (2022). Achilles tendon rupture. StatPearls Publishing.

https://pubmed.ncbi.nlm.nih.gov/28613594/

Stavenuiter, X. J. R., Lubberts, B., Prince, R. M., Johnson, A. H., DiGiovanni, C. W., & Guss, D.

(2019). Postoperative complications following repair of acute Achilles tendon rupture. Foot

and Ankle International, 40(6), 679–686. https://doi.org/10.1177/1071100719831371

Sundman, E. A., Cole, B. J., Karas, V., della Valle, C., Tetreault, M. W., Mohammed, H. O., &

Fortier, L. A. (2014). The anti-inflammatory and matrix restorative mechanisms of platelet-

rich plasma in osteoarthritis. American Journal of Sports Medicine, 42(1), 35–41.

https://doi.org/10.1177/0363546513507766

Takamura, M., Yasuda, T., Nakano, A., Shima, H., & Neo, M. (2017). The effect of platelet-rich

plasma on Achilles tendon healing in a rabbit model. Acta Orthopaedica et Traumatologica

Turcica, 51(1), 65–72. https://doi.org/10.1016/j.aott.2016.12.001

Platelet Rich Plasma's Use on Recovering Achilles Tendon Ruptures of Wistar Strain White Mouse

2465 | I n d o n e s i a n J o u r n a l o f M u l t i d i s c i p l i n a r y S c i e n c e , 2 ( 5 ) , F e b ,

2023

Thomopoulos, S., Parks, W. C., Rifkin, D. B., & Derwin, K. A. (2015). Mechanisms of tendon

injury and repair. Journal of Orthopaedic Research, 33(6), 832–839.

https://doi.org/10.1002/jor.22806

Wang, C., Fan, H., Li, Y., Yun, Z., Zhang, Z., & Zhu, Q. (2021). Effectiveness of platelet-rich

plasma injections for the treatment of acute Achilles tendon rupture: A systematic review

and meta-analysis. Medicine, 100(41), e27526.

https://doi.org/10.1097/MD.0000000000027526

Wang, J. H. C., & Nirmala, X. (2016). Application of tendon stem/progenitor cells and platelet-

rich plasma to treat tendon injuries. Operative Techniques in Orthopaedics, 26(2), 68–72.

https://doi.org/10.1053/j.oto.2015.12.008

Xiong, X., Wu, L., Xiang, D., Ni, G., Zhao, P., & Yu, B. (2012). Effect of platelet-rich plasma

injection on early healing of Achilles tendon rupture in rats. Zhongguo Xiu Fu Chong Jian

Wai Ke Za Zhi = Zhongguo Xiufu Chongjian Waike Zazhi = Chinese Journal of Reparative

and Reconstructive Surgery, 26(4), 466–471.

Yuksel, S., Adanir O, Gultekin MZ, Caglar A, Kucukyildirim BO, Gulec MA, & et al. (2015). The

examination of the effect of platelet rich plasma for curing achilles tendons of free moving

rats after surgical ıncision and treatment. Acta Orthop Traumatol Turc.

https://doi.org/10.3944/AOTT.2015.15.0028

Zou, J., Mo, X., Shi, Z., Li, T., Xue, J., Mei, G., & Li, X. (2016). A Prospective Study of Platelet-

Rich Plasma as Biological Augmentation for Acute Achilles Tendon Rupture Repair.

BioMed Research International, 2016. https://doi.org/10.1155/2016/9364170