Open Access

EFFECTIVENESS OF ARTHROSCOPIC MICROFRACTURE COMBINED WITH PLATELET-RICH PLASMA COMPLEX IN THE TREATMENT OF KNEE CARTILAGE INJURY

JIN HE

https://orcid.org/0009-0002-7954-2744

Department of Orthopedics, People’s Hospital of Zhongjiang County, Zhongjiang 6181001, P. R. China

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JIHUI CHANG

https://orcid.org/0009-0001-6693-1428

Department of Orthopedics, People’s Hospital of Zhongjiang County, Zhongjiang 6181001, P. R. China

E-mail Address: 442644280@qq.com

Corresponding author.

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KAI LI

https://orcid.org/0009-0000-0697-8366

Department of Orthopedics, People’s Hospital of Zhongjiang County, Zhongjiang 6181001, P. R. China

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XUZHONG QIU

https://orcid.org/0009-0002-5421-2028

Department of Orthopedics, People’s Hospital of Zhongjiang County, Zhongjiang 6181001, P. R. China

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LINYING ZENG

https://orcid.org/0009-0005-9658-9220

Department of Orthopedics, People’s Hospital of Zhongjiang County, Zhongjiang 6181001, P. R. China

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DONGMEI TANG

https://orcid.org/0009-0003-7312-7045

Department of Orthopedics, People’s Hospital of Zhongjiang County, Zhongjiang 6181001, P. R. China

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JIAN LUO

https://orcid.org/0009-0009-4713-8756

Department of Orthopedics, People’s Hospital of Zhongjiang County, Zhongjiang 6181001, P. R. China

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, and

SHUANG ZHANG

https://orcid.org/0000-0002-7134-0454

Department of Orthopedics, People’s Hospital of Zhongjiang County, Zhongjiang 6181001, P. R. China

Data Recovery Key Laboratory of Sichuan Province, School of Artificial Intelligence, Neijiang Normal University, Neijiang 641100, P. R. China

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https://doi.org/10.1142/S0219519424400700Cited by:0 (Source: Crossref)

This article is part of the issue:

Special Issue: Application and Progress of Biomechanics in Medicine — Part III
Guest Editors: Esteban Peña Pitarch and Eddie Y. K. Ng

Abstract

Background: Combining arthroscopic microfractures (MF) with platelet-rich plasma (PRP) complexes is a potential approach for treating knee cartilage injuries. However, effective treatment of cartilage injuries in the knee joint remains a challenge. Objective: To evaluate the clinical effects of a platelet-rich complex based on MF surgery for treating knee cartilage injuries. Methods: We selected 120 patients with knee cartilage injury and divided them into observation and experimental groups according to the use of a platelet-rich complex. Preoperative and postoperative follow-up visit data were retrospectively collected and analyzed. Results: Preoperative visual acuity scores between the two groups were comparable ( $P > 0.05$ $P > 0.05$ ). At 3 and 6 months postoperatively, the scores were lower in the experimental group than in the control group ( $P < 0.05$ $P < 0.05$ ). The preoperative Lysholm knee scores and Tegner activity were similar ( $P > 0.05$ $P > 0.05$ ) but greater in the experimental group at 3 and 6 months postoperatively ( $P < 0.05$ $P < 0.05$ ). Postoperative complications were similar between the two groups according to Fisher’s exact test ( $P = 1.00$ $P = 1.00$ ). Conclusion: The platelet-rich complex based on MF surgery treatment of knee cartilage injuries exhibited a better clinical effect and is an easy-to-operate and effective method worthy of clinical consideration.

Keywords:

1. Introduction

The knee is a vital joint in the human body that connects the upper and lower extremities and is susceptible to damage from external forces. Its articular surface is covered with smooth cartilage composed of hyaline chondrocytes, which facilitate smooth flexion and extension.¹ However, because the knee lacks lymphatic or vascular tissues, damaged cartilage cannot heal independently, leading to degenerative arthritis, which can cause chronic pain in later stages. Typical clinical treatments include nonsteroidal anti-inflammatory drugs, rehabilitation exercise therapy, and intra-articular hyaluronic acid injections, which are not very effective. Minimally invasive arthroscopic techniques can improve cartilage healing by managing the lesion intra-articularly; however, these techniques have a high failure rate. Platelet-rich plasma (PRP) contains over 1400 growth factors that inhibit catabolic cytokine production, promote chondrogenesis, and enhance cartilage repair.² With advancements in cartilage repair techniques, academics and hospitals have combined arthroscopic microfractures (MF) with other methods to address knee cartilage injury. Knee cartilage injuries are common, and their diagnosis and incidence rates have been increasing annually owing to improved living standards, national fitness campaigns, and a desire for a better quality of life. Arøen et al.³ found that cartilage injuries occurred in 66% of patients with knee diseases who underwent arthroscopic cartilage injury treatment, with 11% having a full-layered cartilage defect. Effective treatment of knee cartilage injuries is a significant challenge in orthopedic research.^4,5

There are various methods for treating knee cartilage injuries, including glucocorticoid treatment, which involves the administration of glucocorticosteroids to reduce inflammation and relieve pain.⁶ Nonsteroidal anti-inflammatory drugs can also provide analgesic effects; however, their long-term use is not recommended because of their adverse effects on the digestive and renal systems. Cartilage and periosteum implantation techniques are considered more effective, as they involve the differentiation of bone and cartilage from undifferentiated mesodermal cells, which has been confirmed through animal experiments and clinical trials.⁷ In one study by Astur et al.,⁸ cartilage implantation using autogenous bone was performed in 33 patients with patellar cartilage injuries, with an average follow-up of 30.2 months. After 6 months, 83% of the transplants achieved complete fusion, and this rate reached 100% after 1 year. Magnetic resonance imaging (MRI) revealed no uneven articular surfaces.

Tissue engineering and gene therapy research focused on the use of various seed cells for cartilage defect repair, including mesenchymal stem cells (MSCs), adipose-derived stem cells, and embryonic stem cells.⁹ Wang et al.¹⁰ used MSCs as seed cells, combined them with fibrin glue planting technology and a double-layer chitosan/hydroxyapatite composite scaffold to treat bone cartilage injury in rabbits, and observed satisfactory cartilage defect repair through microscopic observations.

Green¹¹ was the first to use chondrocyte implantation with a decalcified bone scaffold material to initiate cartilage tissue engineering. Xu et al.¹² co-cultured human adipose stem cells with a collagen scaffold and confirmed the chondrogenic differentiation of adipose-derived stem cells and MSCs after four weeks.

Wang et al.¹³ constructed a gene vector with recombinant adenovirus 5 (rAd5) and transfected bone marrow mesenchymal stem cells (BMSCs) of Austroyunnanese small-eared pigs with the TGF- $β$ $β$ 3 gene. The results of flow cytometry, immunofluorescence staining, western blotting, and post-transfection in vitro culture demonstrated that the recombinant adenovirus rAd5-TGF- $β$ $β$ 3 could transfect BMSCs and promote the differentiation of BMSCs into chondrocytes through stable expression of the TGF- $β$ $β$ 3 protein.

The arthroscopic MF technique was first introduced by Kraeutler et al.¹⁴ in the 1980s to treat cartilage injuries using a specialized MF bradawl. This method involves the use of bone marrow blood fibrous clots to fill cartilage defects and promote the differentiation of blood BMSCs to repair the defects. The efficacy of MF surgery may be affected by factors such as poor blood exudation, spillage of cancellous bone stem cells, and growth factors. Autologous bone marrow aspirate concentrates (BMACs) have been found to be a safe and abundant source of stem cells and other progenitor cells, and their clinical use in orthopedics and related fields can improve the quality and quantity of new bone generation and reduce patient suffering.^15,16 PRP contains over 1400 synergistically active growth factors, which have been shown to inhibit catabolic cytokines, promote cartilage formation, and enhance cartilage tissue repair in vitro.¹⁷ The academic world and hospitals are combining MF with other techniques to address knee cartilage injuries, as cartilage repair techniques continue to develop.

The safety of combined treatment methods has been confirmed through animal experiments and clinical trials, resulting in improved outcomes. In a study by Huh et al.,¹⁸ MF surgery was combined with PRP to repair cartilage injuries in rabbit knee joints, showing that the regenerated tissues covered a larger area of the defect and promoted cartilage regeneration. Similarly, Xing et al.¹⁹ used a combination of MF surgery and cartilage paste transplantation to repair full-thickness cartilage injuries in rabbit knee joints, resulting in an improved quality of the regenerated cartilage. Martin-Hernandez et al.²⁰ combined MF surgery with a BST–CarGel scaffold to repair full-thickness cartilage defects, leading to more cartilage regeneration compared to MF surgery alone. Frappier et al.²¹ found that combining MF surgery with the BST–CarGel scaffold technique is a cost-effective surgical procedure that produces similar results to MF surgery alone. Gigante et al.²² used a combination of MF surgery, concentrated bone marrow cells, and protective scaffolds to repair full-thickness cartilage defects and regenerate hyaline cartilage. Enea et al.²³ combined MF surgery with concentrated bone marrow cells and a polyglycolic acid/hyaluronic acid matrix to repair full-thickness cartilage defects, demonstrating that this method is safe and can regenerate hyaline cartilage. These studies showed that combining MF surgery with other techniques is a promising approach for repairing cartilage injuries in the knee joint, resulting in effective and safe outcomes.

Orthopedic research has aimed to identify a convenient, economical, and efficient method for treating knee cartilage injuries. However, the effective treatment of cartilage injuries in the knee joint remains a challenge, making it a critical issue in clinical treatment research.²⁴ This study specifically focused on exploring the clinical effects of arthroscopic MF combined with PRP complex in treating knee cartilage injuries.

2. Materials and Methods

2.1. General materials

This study was approved by the Ethics Committee of the Zhongjiang County People’s Hospital (No. JY20196321). All the patients voluntarily participated in the study and signed an informed consent form.

We selected 120 patients with knee cartilage injuries treated in the hospital’s Orthopedics Department between May 2019 and March 2024. Patients were divided into experimental and control groups according to the treatment method ( $n = 60$ $n = 60$ each). The experimental group comprised 28 males and 32 females, aged 27–60 years (mean $47.57 \pm 9.552$ $47.57 \pm 9.552$ ), with disease durations of 3–18 months (mean $10.91 \pm 5.21$ $10.91 \pm 5.21$ ), including 31 injury sites in the left knees and 29 in the right knees. The degree of cartilage injury was classified using the Reht method and included 29 Class III and 31 Class IV cases. In the experiment, patients used an arthroscopic hand cone to drill holes in the cartilage injury area, with each hole having a diameter of approximately 1.8–2.3mm, a depth of 2.5–4.1mm, and a spacing of 2–2.5mm between adjacent holes. There were no more than 5holes/cm², and the group received $MF + PRP$ $MF + PRP$ treatment. The control group comprised 25 males and 35 females, aged 23–58 years (mean: $48.02 \pm 9.024$ $48.02 \pm 9.024$ ), with disease durations of 4–17 months (mean: $11.01 \pm 6.15$ $11.01 \pm 6.15$ ), including 32 injury sites in the left knees and 28 in the right knees. Cartilage injuries included 28 Class III and 31 Class IV cases. The general characteristics of the groups were not significantly different ( $P > 0.05$ $P > 0.05$ ). This group received conventional MF treatment.

2.2. Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) age between 18 and 60 years; (2) location of the focal articular cartilage injury in the femoral condyle and tibial plateau, the longest diameter of the defect was $< 3$ $< 3$ cm, and an MRI examination indicated a Reht classification Class IV/V injury; (3) normal mechanical axes of the lower limbs; (4) a body mass index (BMI) of 18–30; (5) mature epiphyseal development; and (6) the participant signed informed consent forms and understood and was willing to cooperate actively with the postoperative rehabilitation treatment.

Reht classification has five classes: Class I, the articular cartilage is complete but thinner, and the surface is smooth; Class II, the cartilage layering disappears, a local low signal appears, and the cartilage surface remains smooth; Class III, the cartilage surface is mildly or moderately irregular; the articular cartilage shows defects but is less than half the normal thickness; Class IV, the cartilage surface shows a severe defect; the articular cartilage defect is more than half the normal thickness but not completely peeled off; and Class V, the cartilage is completely peeled off, with severe defects, exposed subchondral bone, and possible subchondral bone signal change.

The exclusion criteria were: (1) combined subchondral bone defect; (2) open knee injury or combined fracture around the knee; (3) severe joint ankylosis or arthrofibrosis; (4) exclusion of cartilage injury due to senile osteoarthritis or autoimmune response; and (5) severe liver or kidney insufficiency due to underlying diseases or inability to tolerate anesthesia or surgery because of heart, brain, lung, or other related diseases.

2.3. Treatment method

All surgeries were performed by the same group of surgeons. In the control group, arthroscopic MF was performed under subarachnoid block anesthesia (Fig. 1); arthroscopic probing was performed through the anterior medial and lateral approaches to the knee. First, the residual cartilage fragments were cleared with a plane cutter and curved curette to make the cartilage edges around the defect healthy and vibrant, forming a sunken structure. A spatula was used to gently scrape off the residual cartilage in the defect area to completely expose the bone bed. The exposed subchondral plate was perforated using a specially designed arthroscopic hand cone to create MF. Numerous MF perforations were performed, starting near the edge of the intact cartilage and extending to the center of the cartilage defect.

Fig. 1. Intraoperative arthroscopy, debridement of the cartilage injury area, radiofrequency formation, MF surgery, and PRP complex injection treatment are provided simultaneously.

The interval between perforations was approximately 3–4mm (3–4holes/cm²). When adequate bone marrow release was observed, the instruments were removed from the knee joint, fluid was drained, and the operation was concluded. In the experimental group, 20mL of venous blood was drawn from the patient’s elbow before the MF operation; a centrifugation technique was routinely used. The samples were centrifuged at 215g/10min, the lower layer of red blood cells was discarded, and the upper layer was centrifuged again at 863g/10min. Approximately 3/4 of the supernatant was collected, and the remainder was discarded, yielding approximately 3mL of PRP.

A sheet was laid in the ipsilateral iliac region. Approximately 2mL of bone marrow fluid was drawn by puncturing the anterior superior spine using a sterile medullo-puncture needle and mixed with PRP fluid. After MF surgery, the prepared PRP compound was injected into the articular cartilage defect via an injection needle, the puncture needle was withdrawn, and a sterile dressing was applied. After the surgery, the knee joint was moved to promote uniform distribution, the patient was helped to elevate the affected limb, and the affected knee was iced for 24h. The PRP complex was injected again 14 days after surgery for two injections total.

2.4. Postoperative rehabilitation

Within one week after the operation, routine swelling treatment was performed, and the patients were forbidden to walk. Within 2–4 weeks after the operation, the patients were allowed to use a brace to get out of bed and walk with double crutches; however, bearing weight was not allowed. Flexion and extension of the knee joints were allowed in bed. Straight leg raising and sitting on a chair with a drooping knee were also allowed. Within 5–8 weeks after the operation, the patients were allowed to walk on the ground under the protection of a knee joint brace; however, relevant protection was required. The knee joint was suitable for normal walking within 9–12 weeks postoperatively.

2.5. Observation indicators and determination criteria

Pain indicators were assessed using the visual acuity score (VAS) pain assessment scale at 3 and 6 months before and after surgery. A scale plate ranging from 0cm to 10cm was used. A score of 0 indicated no pain; a higher score indicated a patient had ached more. The Lysholm Scale^25,26,27 was used to assess knee function recovery and evaluate a patient’s ability to complete activities of daily living 3 and 6 months before and after surgery. The scores ranged from 0 to 100, with higher scores indicating better knee function. The patients’ activity functions were assessed using the Tegner Activity Score.^26,27 This score has been widely used to assess the activity of patients with knee lesions. The assessment was performed 3 and 6 months before and after surgery. This scoring method is used to classify the patient’s activity level on a scale of 0–10, with a score of 0 indicating sick/disabled and 10 indicating that the person could participate in top-level national or international competitive sports; by analyzing the imaging data of preoperative and postoperative MRI examinations of patients at 6 months, observing the imaging manifestations and grading of joint cartilage injuries, referring to the Recht grading standard (0–IV level) for joint cartilage injury imaging, understanding the recovery and grading of cartilage injuries, and evaluating the recovery status of cartilage defects in each group. Higher scores indicated better recovery of athletic ability. After 6 months of medical follow-up, the postoperative occurrence of wound infection, thrombosis, hematoma, and other complications was assessed to compare the post-treatment effects between the two groups.

2.6. Statistical methods

SPSS 17.0 statistical software was used to perform statistical analysis. Normal data are expressed as the $mean \pm standard$ $mean \pm standard$ deviation, skewed data as the median (M), and count data as percentages or constituent ratios. When comparing the two groups, the t-test was applied to normal data, the rank sum test to skewed data, the Chi-squared test to count data, and Fisher’s exact test if the expected frequency was $< 5$ $< 5$ . Statistical significance was set at $P < 0.05$ $P < 0.05$ .

3. Results

No significant differences were found in the preoperative general data (sex, age, BMI, and disease duration) between the two groups (Table 1). At 3 and 6 months after surgery, VAS scores were significantly lower in the experimental group than in the control group ( $P < 0.05$ $P < 0.05$ ; Table 2). No significant difference was found in the VAS scores before surgery ( $P > 0.05$ $P > 0.05$ ). At 1 and 6 months after surgery, the Lysholm knee scores were significantly higher in the experimental group than in the control group ( $P < 0.05$ $P < 0.05$ ; Table 3). No significant difference between the two groups was found in the Lysholm knee scores compared with the preoperative period ( $P > 0.05$ $P > 0.05$ ). Comparison of the Tegner activity scores between the two groups with those before surgery revealed no significant difference ( $P > 0.05$ $P > 0.05$ ). However, at 1 and 6 months after surgery, the activity function scores were higher in the experimental group than in the control group ( $P < 0.05$ $P < 0.05$ ; Table 4). After 6 months of treatment, MRI assessment was conducted, The Reht grading was 24/36 (I/II) cases in the experimental group and 12/48 (I/II) cases in the control group, respectively. The magnetic resonance evaluation showed that the experimental group performed significantly better than the control group (Fig. 2).

Fig. 2. Preoperative and postoperative MRI examinations of the same part of the knee joint. The injured intercondylar cartilage area healed significantly compared to the preoperative period; the edema zone was relieved, and new cartilage grew in the defect area.

**Table 1. Comparison of preoperative general data between experimental and control groups.**
Indicators	Experimental group ( $n = 60$ $n = 60$ )	Control group ( $n = 60$ $n = 60$ )	Statistical value	P
Age ( $mean \pm SD$ $mean \pm SD$ )	$47.57 \pm 9.552$ $47.57 \pm 9.552$	$48.02 \pm 9.024$ $48.02 \pm 9.024$	$- 0.265$ $- 0.265$	0.556
Sex (male/female)	28/32	25/35	0.304	0.581
BMI (kg/m²)	$27.53 \pm 3.18$ $27.53 \pm 3.18$	$27.92 \pm 2.46$ $27.92 \pm 2.46$	0.431	0.668
Reht level (III/IV)	29/31	28/32	0.256	0.563
Duration of illness	10.91 (3–18 months)	11 (4–17 months)	2.233	0.024

Notes: Statistical significance was set at $P < 0.05$ $P < 0.05$ . BMI: body mass index; SD: standard deviation.

**Table 2. Comparison of VAS pain scores before and after treatment between two groups.**
Group	n	N before surgery	$B$ $B$ 3 months after surgery	G 6 months after surgery
Experimental	60	2.80	11.42	0.23
Control	60	2.45	1.88	0.68
$t / Z$ $t / Z$		$- 1.853$ $- 1.853$	$- 4.663$ $- 4.663$	$- 4.926$ $- 4.926$
P		0.064	0.000	0.000

Notes: Significance was set at $P < 0.05$ $P < 0.05$ ; values are presented as medians (points). VAS: visual acuity score; $t / Z$ $t / Z$ : t-value or Z-value; P: P-value.

**Table 3. Comparison of knee Lysholm scores before and after treatment between two groups.**
Group	n	N before surgery	$β$ $β$ 3 months after surgery	G 6 months after surgery
Experimental	60	56.93	$75.95 \pm 4.131$ $75.95 \pm 4.131$	91.63
Control	60	54.63	$65.00 \pm 6.314$ $65.00 \pm 6.314$	85.07
$t / Z$ $t / Z$		$- 1.513$ $- 1.513$	11.241	$- 6.860$ $- 6.860$
P		0.130	0.005	0.000

Notes: Significance was set at $P < 0.05$ $P < 0.05$ ; values are presented as the $mean \pm standard$ $mean \pm standard$ deviation or median (points); $t / Z$ $t / Z$ : t-value or Z-value; P: P-value.

**Table 4. Comparison of Tegner activity scores before and after treatment between two groups.**
Group	n	N before surgery	$β$ $β$ 3 months after surgery	G 6 months after surgery
Experimental	60	0.9933	2.0583	5.2033
Control	60	0.9417	1.8083	4.8483
$t / Z$ $t / Z$		$- 0.378$ $- 0.378$	$- 3.336$ $- 3.336$	$- 3.477$ $- 3.477$
P		0.706	0.001	0.001

Notes: $P < 0.05$ $P < 0.05$ compared with the control group; values are presented as medians (points); $t / Z$ $t / Z$ : t-value or Z-value; P: P-value.

Preoperative complications in the two groups included one case of postoperative infection and one case of hematoma formation in the experimental group, with a complication rate of 3.33%. The observation group included one case of postoperative hematoma and one case of thrombus, with a complication rate of 3.33%. The difference in postoperative complications between the two groups was not significant according to Fisher’s exact test ( $P = 1.00$ $P = 1.00$ ).

4. Discussion

In this study, VAS pain scores at 3 and 6 months after surgery were significantly lower in the experimental group than in the control group, suggesting that MF therapy based on the PRP complex had a significant clinical effect, and its therapeutic effect was better than that of the control group without biologic co-adjuvants. The PRP complex may indirectly relieve pain in patients through bioremediation of local tissues, and with the gradual restoration of cartilage growth, the inflammatory response subsided, and the degree of pain decreased.

In this study, Lysholm and Tegner activity scores of the knee joint were significantly higher in the experimental group than in the control group. This finding suggests that combining PRP therapy with MF surgery improves knee joint function and articular balance in patients by promoting the division of chondrocytes and subchondral osteoblasts and proliferating and repairing the articular cartilage. PRP and BMACs may combine to form a complex for treating knee cartilage injuries, and BMAC contains MSCs absent in PRP. Thus, they complement each other to provide growth factors and pluripotent stem cells, thereby improving cartilage recovery.

Arthroscopic MF promotes the recovery and regeneration of damaged cartilage. The rough surface of MF holes in the cartilage defect area produced by the MF technique artificially creates nutrient pathways for cell growth, which are conducive to better growth and cartilage recovery.

When exploring the clinical effectiveness of PRP therapy based on MF surgery for the treatment of knee articular cartilage damage,^28,29,30 it is indeed observed that some patients are reluctant to undergo MRI and knee arthroscopy follow-up examinations due to postoperative symptom relief. This reluctance potentially impacts the conclusions drawn in this paper, specifically in the following two aspects: Data Integrity, MRI and knee arthroscopy are crucial tools for evaluating cartilage repair. If some patients refuse these examinations, it will result in incomplete postoperative data collection, potentially affecting the accuracy and reliability of the overall conclusions. Result Bias, patients who do not undergo follow-up examinations tend to be those who are satisfied with the treatment effects or believe they have fully recovered. This could skew the evaluation results toward optimism, failing to fully reflect the true recovery situation of all treated patients.

Differences in postoperative complications after 6 months and in treatment costs were insignificant, indicating that using autologous PRP and BMAC reduced the risk of disease transmission and immune rejection. Furthermore, they are easy to obtain and economical to use. The Tegner activity scores were not high, possibly because the region is mountainous and economically underdeveloped, and the patients were mostly local farmers who seldom participated in competitive sports, including skiing, baseball, or even soccer leagues. These findings suggest that the activity level was slightly lower than that in developed areas. However, we believe that this evaluation indicator is useful.

5. Conclusions

This study analyzed and evaluated the clinical effects of PRP complexes based on MF surgery for the treatment of knee cartilage injuries. Patients treated postoperatively with a PRP complex exhibited significantly greater VAS pain, Lysholm, and Tegner activity scores than patients in the control group. These results suggest that treating knee joint cartilage injuries using a combination of arthroscopic MF surgery and PRP showed a better therapeutic effect, decreased pain, and improved athletic ability. The convenience, low cost, and high efficacy of this method are worth promoting for clinical applications.

Acknowledgments

The work presented in this paper was supported by the Foundation of the Deyang City Major Science and Technology Projects under Grant 2022SCZ107, and the Sichuan Medical Association Funded Projects under Grant 2021SAT10, 2021TG23, 2021TG29, 2021HR46, and the Sichuan Applied Psychology Research Center of Chengdu Medical College Funded Projects under Grant CSXL-23305.

ORCID

Jin He https://orcid.org/0009-0002-7954-2744

Jihui Chang https://orcid.org/0009-0001-6693-1428

Kai Li https://orcid.org/0009-0000-0697-8366

Xuzhong Qiu https://orcid.org/0009-0002-5421-2028

Linying Zeng https://orcid.org/0009-0005-9658-9220

Dongmei Tang https://orcid.org/0009-0003-7312-7045

Jian Luo https://orcid.org/0009-0009-4713-8756

Shuang Zhang https://orcid.org/0000-0002-7134-0454

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Vol. 24, No. 09

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Received 26 March 2024

Accepted 14 August 2024

Published: 19 November 2024

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This is an Open Access article published by World Scientific Publishing Company. It is distributed under the terms of the Creative Commons Attribution 4.0 (CC BY) License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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