Effect of Carboxymethylcellulose Hyaluronan (SEPRAFİLM®) on an Arthrofibrosis Model Created in Rabbit Knees

Effect of Carboxymethylcellulose Hyaluronan (SEPRAFİLM®) on an Arthrofibrosis Model Created in Rabbit Knees | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Carboxymethylcellulose Hyaluronan (SEPRAFİLM®) on an Arthrofibrosis Model Created in Rabbit Knees Ismail Tugay Yagci, Ovunc Akdemir, Atilla Eyuboglu, Murat Sezak, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7047607/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Sep, 2025 Read the published version in Life → Version 1 posted You are reading this latest preprint version Abstract Purpose: This study aimed to evaluate the efficacy of carboxymethylcellulose (Seprafilm®) for preventing and treating arthrofibrosis in rabbit knees. Additionally, we aimed to assess the underlying mechanisms of action of Seprafilm® against fibrosis and adhesions. Methods: Sixteen male New Zealand white rabbits were randomly assigned to two groups: a control group and a treatment group receiving Seprafilm® after arthrofibrosis in the knee joint was induced. Macroscopic and histological evaluations were also conducted to assess various parameters, including adhesion, fibrosis, inflammation, and edema. Results: Macroscopic adhesion scoring revealed significant adhesion in 5 rabbits (62.5%) in the control group (MAS: 3), moderate adhesion in 2 rabbits (25%) (MAS: 2), and minimal adhesion in 1 rabbit (12.5%) (MAS: 1). No macroscopic adhesion was observed in the Seprafilm® group (MAS: 0). The mean macroscopic adhesion score was 2.5 ± 0.75 in the control group, while there was no adhesion in the Seprafilm® group (p < 0.001). Significant fibrosis was observed in 5 rabbits (62.5%),and moderate fibrosis was observed in 3 rabbits (37.5%) in the control group; however, all the Seprafilm® group rabbits exhibited minimal fibrosis, indicating a significant difference (p < 0.001). Conclusion: Seprafilm® demonstrated efficacy in reducing adhesion and fibrosis in arthrofibrosis models in rabbit knees. These results highlight the potential of Seprafilm® as a preventive and therapeutic measure for arthrofibrosis and related conditions. Orthopedic Surgery Adhesion reduction Arthrofibrosis Fibrosis prevention rabbit knee model Seprafilm® Figures Figure 1 Figure 2 INTRODUCTION The term "arthrofibrosis" was first coined by J. Vernon Luck and is defined as a loss of range of motion secondary to intra-articular scar tissue formation. The incidence of arthrofibrosis ranges from 2–35%. 1,2 The frequency of arthrofibrosis is increasing among older patients and those with degenerative arthritis. 3 Arthrofibrosis disrupts normal knee kinematics and may lead to progressive degenerative changes in the knee. 4 The etiology of arthrofibrosis includes surgical technique, surgical timing, immobilization, additional ligament surgery, infection, and reflex sympathetic dystrophy. Arthrofibrosis can develop not only following nonsurgical joint injuries but also after surgical intervention. 5 Motion-limiting arthrofibrosis has been described in numerous joints, including the knee, shoulder, ankle, elbow, and hand. 6 – 8 Arthrofibrosis occurs when there is an excessive fibrotic response during the healing process, resulting in the deposition of fibrous tissue within or around the joint. This buildup ultimately leads to a progressive loss of joint motion. 9 Certain fibrotic disorders share histological similarities with arthrofibrosis but fall outside the scope of this joint-specific model. 10 Arthrofibrosis is driven by an excessive inflammatory response in the synovium, leading to the activation and proliferation of fibroblasts and a significant increase in extracellular matrix protein deposition. The pathophysiology initially encompasses synovial inflammation, followed by subsynovial fibrosis, culminating in capsular thickening and eventual contracture of the affected joint. 11 However, the exact cause of arthrofibrosis is unclear. One possible explanation is that tissue damage triggers immune cell activation, leading to oxidative stress and the release of proinflammatory cytokines, including platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-beta), and interleukin (IL)-1. 12 , 13 Approaches to the treatment of ankle fibrosis include manipulation under anesthesia, debridement, and physical therapy, but the ideal measure is to prevent the development of arthrofibrosis. Several agents, including hydrogel microspheres, temperature-sensitive antiadhesive poloxamer (TAP) hydrogels, hyaluronic acid, carboxymethylcellulose, decorin, chitosan, lovastatin, rapamycin, and hydroxycaptotensin, have shown antiadhesive effects. Chitosan and TAP hydrogels have shown efficacy in clinical trials. 14 – 21 Nevertheless, these agents have not been commercialized, and no surgical methods for preventing adhesions following ankle surgery have been established. When used on its own, hyaluronic acid has a short local retention time, limiting its effectiveness in preventing adhesions. To extend its retention, it is chemically bonded with carboxymethylcellulose to form a protective film. This film, known as Seprafilm® (Genzyme Corp., Cambridge, Massachusetts, USA), is already used clinically by gynecologists and general surgeons to prevent adhesions in the intestinal tract and uterine appendages. According to Burns et al., the carboxymethylcellulose placed within the abdominal cavity transforms into a gel within 24–48 hours after application and remains at the site of application for approximately 7 days. During this period, carboxymethylcellulose acts as an effective barrier, preventing adhesions by physically isolating damaged tissue from surrounding tissues. After local absorption, the carboxymethylcellulose primarily decomposes in the liver and is excreted in the urine within 28 days. Its ability for accessing organs outside the abdominal cavity has not been conclusively confirmed. Hayashi and colleagues have indicated that Seprafilm® reduces adhesion in the rabbit joint. However, their study explained the mechanism of action through the relationship between fibroblasts and fibrosis. 17 In this study, we aimed to evaluate the effect of carboxymethylcellulose (Seprafilm®) on arthrofibrosis occurring in joints and its underlying mechanisms in greater detail. Furthermore, we evaluated the effectiveness of Seprafilm® application against fibrosis and adhesions. MATERIALS AND METHODS This study was conducted at the Experimental Animal Production and Research Laboratory and approved by the authors' affiliated institutions. The experimental protocol adhered to the guidelines outlined by the National Research Council for the Care and Use of Laboratory Animals. The present study adhered to the guidelines for humane animal treatment. All procedures performed on animals were in accordance with ethical standards and guidelines established for the care and use of laboratory animals. The study protocol was reviewed and approved by the institutional animal care and use committee (IACUC). Efforts were made to minimize animal suffering and to reduce the number of animals used in the study. Sample Size and Animal Allocation A preliminary power analysis was performed to determine the appropriate sample size, considering the expected effect size, variability of outcome measures, and a statistical power of 80%. Sixteen skeletally mature male New Zealand White rabbits (3500–4000 g, ≥ 6 months) were randomly assigned into two equal groups (n = 8). Male rabbits were chosen to avoid hormonal variability, which could influence fibrosis and adhesion outcomes. Randomization was performed using a computer-generated sequence (Randomizer®, Austria) by an independent researcher to minimize allocation bias. Animals were housed in numbered cages without any other selection criteria. Group 1 (control) (n = 8) : No additional procedures were performed on the rabbit knee joint after the arthrofibrosis procedure. Group 2 (treatment) (n = 8) : After inducing arthrofibrosis in the rabbit knee joint similar to that in the control group, Seprafilm® was placed in the knee joint. Animal Husbandry and Environmental Control All procedures were conducted in an IACUC-approved facility under controlled temperature (20–22°C), humidity (50–60%), and a 12-hour light/dark cycle. Rabbits were housed individually (5.43 ft² floor area) and provided ad libitum access to water and a standardized high-fiber rabbit diet (Invigo 2031). Environmental enrichment, including chew toys and hiding spaces, was provided to reduce stress-related variables. Standardization and Bias Control To reduce interindividual variability, surgical and postoperative procedures were standardized and performed by a single surgeon. Animal health and behavior were monitored daily, with deviations recorded and assessed. Histopathological evaluations were performed by a single pathologist blinded to the treatment groups to prevent assessment bias. While the operating surgeon was aware of group allocation, all subsequent evaluations were conducted under blinding protocols to minimize subjective influence. This study was reported in accordance with the ARRIVE guidelines for in vivo experimental research. Surgical methods A standardized surgical procedure was employed for both groups. Anesthesia was induced via intramuscular injection of a mixture of ketamine (Alfamine® 10% injectable - ALFASAN) at 35 mg/kg and xylazine hydrochloride (Xylazol® - PROVET) at 8 mg/kg. To ensure consistency, the same surgeon performed all surgeries. The rabbits were placed in a supine position, and a longitudinal skin incision was made on the anterior aspect of the right knee, which was flexed at 90°. The quadriceps muscle was exposed, and the knee joint was accessed using a medial parapatellar approach with a parallel incision following the muscle fibers. The lateral and medial femoral condyles were exposed. Abrasion was performed using a No. 11 blade on the patellar joint surface and the anterior region of the supracondylar femur. 17 In Group 1, after the surgical procedure described above, capsulorrhaphy was performed with Vicryl 3 − 0, followed by skin closure with Nylon 4 − 0 sutures. 22 In Group 2, a sterile Seprafilm® patch measuring 2.5x1.5 cm, intended to prevent adhesion formation, was placed in the supracondylar anterior femur region where abrasion was performed. Subsequently, capsulorrhaphy was performed with Vicryl 3 − 0, and skin closure was completed with Nylon 4 − 0 sutures. Following closure, the immobilization of the knee joint of rabbits in both groups was achieved with No. 5 wire sutures. Six weeks after the procedure, all rabbits were euthanized with a high dose of intravenous barbiturate. Wire sutures were removed. For macroscopic and histopathological evaluation, soft tissues were dissected up to the medial condyle of the femur without damaging the extensor mechanism using a No. 11 blade (Fig. 1 ). During the 6-week period following trauma induction, the animals were monitored daily. No mortalities were observed among the rabbits’ post procedure. MACROSCOPIC EVALUATION A modified adhesion scoring system (MAS) was used to macroscopically assess adhesions in the suprapatellar region between the quadriceps and the anterior cortex of the femur. 23 This system categorizes adhesions into four grades based on their severity: Grade 0 indicates no adhesion present; Grade 1 denotes a weak, soft film-like adhesion that can be easily eliminated with minimal manual traction; Grade 2 represents a moderate adhesion that can be removed with manual traction; and Grade 3 signifies intense adhesion requiring surgical intervention for removal (Table 1). HISTOPATHOLOGICAL EVALUATION After fixation in 10% neutral buffered formalin for approximately 24 hours, all connective tissues containing fibrotic adhesive scars were preserved, and the knee joints were decalcified in 20% formic acid for 48 hours at room temperature. Four 5 mm-thick sections were obtained from each sample, starting 2 cm proximally to the femoral joint surface and extending into the suprapatellar pouch. Following routine tissue processing with a Leica ASP 3005, the samples were embedded in paraffin blocks. Eight 4 µm sections were cut from the paraffin blocks using a Leica RM 2145 microtome. Hematoxylin-eosin staining was applied to the sections. A single pathologist performed the evaluation in a blind manner. We employed a semiquantitative scoring system to assess the parameters. The presence of adhesions in rabbit knees, along with the intensity of fibrosis (fibroblast proliferation), inflammatory cell types (lymphocytes, neutrophils (PMNL), macrophages), edema, vascular proliferation, the giant cell response, and the formation and intensity of synovial chondrometaplasia, were semiquantitatively scored. These parameters (neutrophils, lymphocytes, macrophages, fibrosis, edema, vascular proliferation, giant cell response, and synovial chondrometaplasia) were semi quantitatively scored in 10 randomly selected fields at ×20 and ×100 magnification by a pathologist. The criteria for each score level were rigorously defined and applied uniformly. 1. Distinguishing and scoring of cell types : Neutrophils, lymphocytes, and macrophages Neutrophils Identified by their characteristic multilobed nuclei and pale-staining cytoplasm in hematoxylin-eosin (H&E)-stained sections. Lymphocytes Recognizable by their small, round nuclei and scant cytoplasm. The H&E sections generally exhibited a darker staining pattern. Macrophages These cells were identified by their larger, more irregular nuclei and abundant cytoplasm, which may also contain phagocytosed material. The cells of each type were counted and scored semi quantitatively in 10 fields at x20 and x100 magnification. The scoring system ranged from 0 to 3, where 0 = absent, 1 = minimal, 2 = moderate, and 3 = abundant. 2. Fibrosis : Fibroblast Proliferation Evaluated based on the density of fibrous tissue and the extent of fibroblast proliferation. Areas with a high density of collagen and fibroblasts were scored as 3, while areas with minimal fibrosis were scored as 1. The scoring was performed semiquantitatively in the same 10 fields. Identification Fibrosis is characterized by the accumulation of dense fibrous connective tissue, predominantly collagen fibers. In H&E-stained sections, fibrosis appears as thickening or scarring of the tissue, often accompanied by an increase in fibroblast proliferation. Evaluation technique Areas with extensive collagen deposition and fibroblast proliferation was identified by their eosinophilic staining and dense appearance compared to those of the surrounding tissue. The degree of fibrosis was evaluated semi-quantitatively, considering the density and distribution of the fibrous tissue. 3. Edema : Edema was assessed based on the amount of interstitial fluid and tissue swelling observed. The severity of the disease was scored as 0 = none, 1 = mild, 2 = moderate, or 3 = severe. Identification Edema is characterized by an accumulation of interstitial fluid leading to swelling of the tissue. It can be observed as an increase in the space between cells and clear spaces or vacuoles can be observed in the tissue sections. Evaluation technique Edema is identified by the presence of these spaces or vacuoles in the tissue. The severity of edema was scored based on the extent of swelling observed in the tissue sections. 4. Vascular Proliferation : The extent of vascularization was evaluated by counting the number of newly formed blood vessels. Vascular proliferation was scored as 0 = absent, 1 = few, 2 = moderate, or 3 = numerous. Identification Vascular proliferation involves the formation of new blood vessels within the tissue. This is typically observed as an increased number of capillaries or small blood vessels in the tissue. Evaluation technique Vascular proliferation was assessed by counting the number of new blood vessels in the tissue sections. The presence of newly formed vessels was noted, and the extent of vascularization was scored based on the number of vessels and their distribution. 5. Giant Cell Response : The presence of multinucleated giant cells was noted, and the extent of their formation was scored similarly to other parameters: 0 = absent, 1 = few, 2 = moderate, and 3 = many. Identification Giant cells are multinucleated cells formed by the fusion of macrophages in response to chronic inflammation. They are identified by their large size and multiple nuclei. Evaluation technique The presence of giant cells was noted by their distinctive morphology. The extent of giant cell formation was assessed semi quantitatively based on the number and size of the giant cells present in the tissue. 6. Formation and Intensity of Synovial Chondrometaplasia : Synovial Chondrometaplasia: The formation and intensity of this morphology were assessed based on the presence and distribution of cartilaginous metaplasia within the synovial tissue. The scores ranged from 0 = none to 1 = focal, 2 = moderate, and 3 = extensive. Identification Synovial chondrometaplasia involves the formation of cartilage-like tissue within the synovial membrane. It is identified by the presence of cartilage nodules or islands within the synovial lining. Evaluation technique The formation and intensity of chondrometaplasia were assessed based on the number and size of these cartilage formations within the synovial membrane. The presence and extent of chondrometaplasia were scored according to the distribution and intensity of the cartilage-like tissue. Quality Control To ensure accuracy and consistency in histopathological scoring, the pathologist was trained and calibrated in the scoring system before the evaluations. Interobserver variability was minimized by standardizing the evaluation procedures. Regular quality checks were incorporated to maintain adherence to the defined scoring criteria. STATISTICAL ANALYSIS: All the statistical analyses were performed using SPSS 16.0 (Windows®) software. The data are expressed as the mean ± standard deviation (SD) where applicable. The means and standard deviations were calculated for the data from the Seprafilm® application group and the control group. Histopathological findings for both groups {adhesion, fibrosis (fibroblast proliferation), vascular proliferation, synovial chondrometaplasia, giant cell response, edema, lymphocyte, neutrophil (PMNL), and macrophage} and macroscopic adhesion scores 23 were evaluated using the Mann‒Whitney U test, and a p value < 0.05 was considered to indicate statistical significance. RESULTS Macroscopic adhesion scores : Macroscopic adhesion scoring was performed according to the modified adhesion scoring system for the control group rabbits, revealing significant adhesion in 5 rabbits (62.5%) at a high level (MAS: 3), moderate adhesion in 2 rabbits (25%) (MAS: 2), and minimal adhesion in 1 rabbit (12.5%) (MAS: 1). No macroscopic adhesion was observed in rabbits from the Seprafilm® group (MAS: 0). The mean macroscopic adhesion score in the control group was 2.5 ± 0.75, while no macroscopic adhesion was observed in the Seprafilm® group. The Mann‒Whitney U test was used to compare the groups based on the presence of macroscopic adhesions, revealing a significantly greater incidence of adhesions in the control group (p < 0.001). (Table 2) According to these results, adhesion formation was observed in 100% of the patients (8/8) in the control group, whereas no instances of adhesion formation were observed in the Seprafilm-treated group. Histopathological Findings Histopathologically, microscopic adhesion was observed in all rabbits in the control group, while no microscopic adhesion was detected in rabbits from the Seprafilm® group. This histological difference resulted in a significantly greater amount of adhesion in the control group than in the Seprafilm® group (p < 0.001). In the control group, significant fibrosis (fibroblast proliferation) was observed in 5 rabbits (62.5%), and moderate fibrosis was observed in 3 rabbits (37.5%), while all rabbits in the Seprafilm® group exhibited minimal fibrosis (fibroblast proliferation). Fibrosis (Fibroblast Proliferation) After comparing the fibrosis levels between the control and Seprafilm® groups based on histopathological assessment of minimal, moderate, or significant fibrosis (fibroblast proliferation), a significantly greater degree of fibrosis was observed in the control group (p < 0.001). Vascular Proliferation Regarding vascular proliferation, 2 rabbits (25%) in the control group exhibited moderate vascular proliferation, 3 (37.5%) had minimal vascular proliferation, and 4 (50%) had no vascular proliferation in the Seprafilm® group. Histopathological evaluation of vascular proliferation, categorized as minimal, moderate, or significant, revealed a statistically significant increase in vascular proliferation in the control group (p < 0.001). Synovial chondrometaplasia Furthermore, synovial chondrometaplasia was observed in 2 rabbits (25%) at moderate levels and in 3 rabbits (37.5%) at minimal levels in the control group, while 3 rabbits (37.5%) exhibited minimal levels of synovial chondrometaplasia in the Seprafilm® group, with no cases of synovial chondrometaplasia observed in 5 rabbits (62.5%). No significant difference was observed in synovial chondrometaplasia intensity between the two groups (p > 0.05). Edema For edema evaluation, 1 rabbit (12.5%) in the control group exhibited significant edema, 1 rabbit (12.5%) had moderate, 2 rabbits (25%) had minimal edema, and 4 rabbits (50%) had no edema. In contrast, 5 rabbits (62.5%) in the Seprafilm® group exhibited no edema, and 3 rabbits (37.5%) displayed minimal edema. A statistical analysis based on histopathological assessment of minimal, moderate, or significant edema revealed a significantly greater level of edema in the control group (p < 0.001). Neutrophil (PMNL) infiltration Regarding neutrophil (PMNL) infiltration, 7 rabbits (87.5%) in the control group exhibited significant neutrophil (PMNL) infiltration, while 1 rabbit (12.5%) exhibited moderate neutrophil infiltration. In contrast, all rabbits (100%) in the Seprafilm® group showed no neutrophil (PMNL) infiltration. A statistical analysis of the minimal, moderate, or significant neutrophil (PMNL) infiltration levels revealed a significantly greater level of neutrophil (PMNL) infiltration in the control group (p < 0.001). Lymphocyte Intensity According to the lymphocyte intensity assessment, 4 rabbits (50%) in the control group exhibited minimal lymphocyte intensity, 3 rabbits (37.5%) had moderate lymphocyte intensity, and 1 rabbit (12.5%) had significant lymphocyte intensity, while. Similarly, the proportions of the Seprafilm® group were 75%, 25%, and 0% for the minimal, moderate, and significant lymphocyte intensities, respectively. There was no statistically significant difference in lymphocyte intensity between the two rabbit groups (p > 0.05). Macrophage intensity For the assessment of macrophage intensity, 3 rabbits (37.5%) in the control group exhibited minimal macrophage intensity, 4 (50%) had moderate macrophage intensity, and 1 (12.5%) had significant macrophage intensity. Similarly, 3 (37.5%) in the Seprafilm® group exhibited minimal macrophage intensity, 1 (12.5%) had moderate, and 1 (12.5%) had significant macrophage intensity; moreover, 3 (37.5%) had no significant difference in macrophage intensity (p > 0.05). (Table 3) (Fig. 2 ) DISCUSSION Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathological periarticular fibrosis with subsequent symptomatic limitations in joint range of motion (ROM). Capsular contracture via aberrant extracellular matrix (ECM) deposition is the hallmark of AF and can manifest secondary to periarticular trauma, surgical insult, postinfectious arthritis, or hemarthrosis. Although uncommon, primary (idiopathic) AF can occur in the setting of an unidentifiable trigger. 24 – 26 Ryan Will and his colleagues demonstrated that one of the most significant complications in trigger finger surgery is proximal interphalangeal joint arthrofibrosis. 27 The pathogenesis of arthrofibrosis has not been fully elucidated, but research suggests a potential genetic predisposition to fibrosis in musculoskeletal tissues, particularly in association with Dupuytren’s contracture. 10 Fibrotic conditions such as Dupuytren’s, Ledderhose, and Peyronie’s diseases are characterized by excessive production of transforming growth factor-beta, resulting in fibroproliferation and abnormal collagen deposition. 28 – 30 It is therefore understood that treatments applied for arthrofibrosis may also be able to treat other diseases that cause fibrotic adhesions. In the literature, intermittent injection of hyaluronic acid and continuous infusion of TGF-B inhibitors with neutralizing antibodies against FGF-2 have been reported to be effective at preventing adhesion. 18 , 31 However, such frequent interventions during the postoperative period increase the risk of infection. Considering this, we chose to use Seprafilm® in membrane form during the perioperative period instead of the intermittent injection of hyaluronic acid, aiming to avoid increasing the risk of infection. 17 Seprafilm® is a bioresorbable material composed of hyaluronic acid and carboxymethylcellulose. Since the early 1990s, it has been used intraabdominally to reduce postoperative adhesions. Experimental models have shown that the use of Seprafilm® as a physical barrier serosal tissues in an organized manner. 32 Seprafilm® has been reported to be an effective adhesion prevention barrier in radical pelvic surgeries involving the uterus, fallopian tubes, and ovaries, as well as in open myomectomy and colorectal surgery. 33 , 34 Hayashi et al. induced arthrofibrosis in rabbit knees in a similar manner to our study and applied the Seprafilm®. However, they focused not on the cellular components of adhesion but rather on the degree of reduction in joint movement due to arthrofibrosis and how well Seprafilm® macroscopically improved extensor contracture. 17 In our study, we evaluated the effect of Seprafilm® on arthrofibrosis both macroscopically and histologically. According to our findings, adhesion and fibrosis significantly decreased in the group treated with Seprafilm®, both macroscopically and microscopically. We observed a significant decrease in parameters such as edema and an increase in parameters related to acute inflammation, such as neutrophils, in the Seprafilm®-treated group. However, there were no statistically significant changes in chronic inflammation parameters, including lymphocyte and macrophage density, synovial chondrometaplasia, or vascular proliferation, between the Seprafilm®-treated group and the control group. We believe that this correlation can be attributed to the findings obtained in rabbits at the 6th week. Furthermore, according to the statistical analysis, a statistically significant, very high-level positive correlation was observed between fibrosis (fibroblast proliferation) intensity and the macroscopic adhesion score, as well as microscopic adhesion. Additionally, a statistically significant, moderate positive correlation was observed between neutrophil density and lymphocyte, macrophage, and edema intensity. In a study conducted by Brunelli et al., an experimental arthrofibrosis model was created in 20 rabbits, and hyaluronan-derived gel (Hyaloglide®) was used post-surgery in 10 rabbits. The study concluded that the adhesion rate observed in the Hyaloglide® group was significantly lower than that in the control group. In the Hyaloglide® group (hyaluronic acid gel formulation without carboxymethylcellulose), a weak macroscopic adhesion rate of 22% was observed. 22 In our study, the plants in the treatment group were treated with Seprafilm® (hyaluronic acid + carboxymethylcellulose), and the macroscopic adhesion rate was adhesion score: 0). Fukui et al. investigated the dose-dependent effect of decorin on arthrofibrosis in rabbits via both macroscopic and histopathological evaluations at 4 weeks postsurgery. The results showed thick fibrous adhesions on the lateral side of the femoral condyle in the control group, whereas in the high-dose (500 µg/ml) decorin group, soft and weak adhesions were observed. Both the control group and the high-dose decorin treatment group exhibited a predominance of inflammatory cells and fibroblasts in the adhesion tissue, but there was no statistically significant difference in these cells between the two groups. 18 Ariyan et al. histologically examined Dupuytren's disease, Peyronie's disease, and capsular contracture of the breast and reported increased fibroblast proliferation, edema, and neutrophil density, similar to our control group with arthrofibrosis. This finding suggested that Seprafilm® may be used when such adhesion and inflammation occur. 35 The sample size of 8 rabbits per group was determined based on a power analysis. The analysis assumed an expected difference in mean adhesion scores of 1.5 between the control and Seprafilm® groups, a standard deviation of 0.75, a power of 80%, and a significance level (alpha) of 0.05. Based on these assumptions, a sample size of 8 rabbits per group was deemed sufficient to detect statistically significant differences in the primary outcomes of adhesion and fibrosis formation. This approach ensures that the study is adequately powered to identify meaningful differences between groups while minimizing the number of animals used in compliance with ethical guidelines for animal research. Limitations of the study on the effect of carboxymethylcellulose (Seprafilm®) on arthrofibrosis in rabbit knees include the use of a relatively small sample size of sixteen rabbits, which may limit the generalizability of the findings. The use of artificial intelligence seems to be promising for future studies to decrease the required sample sizes. 36 While rabbit models are commonly used in research, they may not fully replicate the complexity of human arthrofibrosis, potentially impacting the translatability of the results to clinical practice. The follow-up period of six weeks after Seprafilm® application may not capture long-term effects or potential complications that could arise over an extended period. This study focused primarily on macroscopic and histological evaluations of adhesions and fibrosis, potentially overlooking other important aspects, such as functional outcomes or immune responses. Despite these limitations, the ARRIVE Guidelines for Reporting Animal Research were utilized in this study to enhance the reliability of the investigation. 37 Recommendations for Future Research To address concerns about evaluating multiple intervention methods, we propose conducting follow-up studies that incorporate additional control groups with different interventions. This approach allows for a comparative analysis of Seprafilm® against various alternative treatments and provides a more comprehensive understanding of its relative efficacy. CONCLUSION In conclusion, our study demonstrated that carboxymethylcellulose (Seprafilm®) is effective at reducing adhesion and fibrosis in a rabbit model of arthrofibrosis. The significant differences observed in macroscopic and histological evaluations between the Seprafilm® group, and the control group highlight its potential as a therapeutic intervention for preventing joint complications following surgical procedures. However, while the results are promising, it is essential to acknowledge the limitations of the study, including the small sample size and the short follow-up period, which may affect the generalizability of the findings. Future research should aim to explore the long-term effects of Seprafilm® and its mechanisms of action, as well as to evaluate its efficacy in human subjects. By addressing these aspects, we can better understand the clinical implications of Seprafilm® in the management of arthrofibrosis and improve treatment strategies for affected patients. References Cosgarea AJ, Sebastianelli WJ, DeHaven KE (1995) Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft. Am J Sports Med 23:87–92 Jackson DW, Schaefer RK (1990) Cyclops syndrome: Loss of extension following intra-articular anterior cruciate ligament reconstruction. 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J Hand Surg Amer 16:694–700 Ibrahim IO, Nazarian A, Rodriguez EK (2020) Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook. JBJS Rev 8:e1900223 Chen AF, Lee YS, Seidl AJ et al (2019) Arthrofibrosis and large joint scarring. Connect Tissue Res 60:21–28 Abdel MP, Morrey ME, Barlow JD et al (2012) Myofibroblasts are preferentially expressed early in a rabbit model of joint contracture. J Orthop Res 30:713–719 Will R, Lubahn J (2010) Complications of open trigger finger release. J Hand Surg Am 35:594–596 Mohede DCJ et al (2020) Prevalence of peyronie and ledderhose diseases in a series of 730 patients with dupuytren disease. Plast Reconstr Surg 145:978–984 Akdag O et al (2016) Dupuytren-like contracture of the foot: ledderhose disease. Surg J (N Y) 2:e102–104 Young JR et al (2018) The etiology, evaluation, and management of plantar fibromatosis. Orthop Res Rev 11:1–7 Amiel D, Frey C, Woo SL-Y, Harwood F, Akeson W (1985) Value of hyaluronic acid in the prevention of contracture formation. Clin Orthop 196:306–311 Parker MC, Ellis H, Moran BJ, Thompson JN, Wilson MS, Menz D et al (2001) Postoperative adhezions: Ten-year follow-up of 12584 patients undergoing lover abdominal surgery. Dis Colon Rectum. ;44.822–830 Becker JM, Dayton MT, Fazio VW et al (1996) Prevention of postoperative abdominal adhesions by a sodium hyalurinate based bioresorbabl membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg 183:297–306 Diamond MP (1996) Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F): a prospective, randomized, multicenter clinical study. Fertil Steril 6:904–910 Ariyan S, Enriquez R, Krizek TJ (1978) Wound contraction and fibrocontractive disorders. Arch Surg 113:1034–1046 Choudhary OP, Saini J, Challana (2023) Amit. ChatGPT for Veterinary Anatomy Education: An Overview of the Prospects and Drawbacks. Int J Morphol 41:1198–1202 Kilkenny C, Browne WJ, Cuthill IC, Emerson M, Altman DG (2010) Improving Bioscience Research Reporting: The ARRIVE Guidelines for Reporting Animal Research. PLoS Biol 8(6):e1000412 Tables Table 1: The macroscopic evaluation based on the modified adhesion scoring(MAS) system used in the study: Score Description 0 No adhesion - Absence of adhesion between the quadriceps and the anterior cortex of the femur. 1 Weak, soft film-like adhesion - Adhesion present but easily eliminated with minimal manual traction. 2 Moderate adhesion - Adhesion present and can be eliminated with manual traction. 3 Intense adhesion - Adhesion is intense and requires surgical intervention for removal. Table 2: The results of the macroscopic adhesion scoring in the control group rabbits compared to the Seprafilm® group: Group MAS: 0 (No Adhesion) MAS: 1 (Minimal) MAS: 2 (Moderate) MAS: 3 (High Level) Mean MAS Mann Whitney U p-value Control Group N/A 1 rabbit (12.5%) 2 rabbits (25%) 5 rabbits (62.5%) 2.5 ± 0.75 p <0.0001 Seprafilm® Group All rabbits (100%) N/A N/A N/A 0 N/A - "MAS" refers to the macroscopic adhesion score. - The percentages represent the proportion of rabbits in each group with the corresponding MAS. - "Mean MAS" represents the average macroscopic adhesion score in each group. - "Mann Whitney U p-value" indicates the statistical significance of the difference in adhesion presence between the control and Seprafilm® groups. Table 3: The histopathological findings and statistical analysis results between the control group and the Seprafilm® group for various parameters. Parameter Control Group Seprafilm® Group p-value Microscopic Adhesion Detected in all rabbits Not detected in any rabbits <0.0001 Fibrosis Levels High (62.5%), Moderate (37.5%) Minimal (100%) <0.001 Vascular Proliferation Levels Moderate (25%), Minimal (37.5%), None ( 37.5%) Minimal (50%), None (50%) <0.001 Synovial Chondrometaplasia Moderate (25%), Minimal (37.5%), None ( 37.5%) Minimal (37.5%), None (62.5%) Not significant Edema Levels Significant (12.5%), Moderate (12.5%), Minimal (25%), None (50%) None (62.5%), Minimal (37.5%) <0.001 Neutrophil Infiltration (PMNL |Significant (87.5%), Moderate (12.5%) None (100%) <0.001 Lymphocyte Intensity Minimal (50%), Moderate (37.5%), Significant (12.5%) Minimal (75%), Moderate (25%), Significant (0%) Not significant Macrophage Intensity Minimal (37.5%), Moderate (50%), Significant (12.5%) Minimal (37.5%), Moderate (12.5%), Significant (12.5%), None (37.5%) Not significant - "p-value" represents the statistical significance of the difference between the control and Seprafilm® groups for each parameter. Values less than 0.05 indicate statistically significant differences. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Published Journal Publication published 04 Sep, 2025 Read the published version in Life → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7047607","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":480782132,"identity":"6f347d34-4b6b-4db7-a6b0-e642264699f0","order_by":0,"name":"Ismail Tugay Yagci","email":"","orcid":"","institution":"Liv Hospital, Department of Orthopedics and Traumatology, Istanbul, Turkey","correspondingAuthor":false,"prefix":"","firstName":"Ismail","middleName":"Tugay","lastName":"Yagci","suffix":""},{"id":480782161,"identity":"8c9f0c57-80d3-4958-95df-78340e8956e3","order_by":1,"name":"Ovunc Akdemir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYPCCBMYGBiD6wMDA2Abi8xCrhXEGkhYJIrQwMDADVYIZeLXwS+SYPfhRkybbL3a47bNNzWHZPukGxgdv2xjqzBuwa5GckWNu2HMsx3jm7MTm2TnHDhu3yRxgNpzbxiAhcwC7FoMzZ8ykGdgqEjfcTmxmzmE7nNgmkcAmzQvUgstlEC3/KhL3g7RY/ANrYf+NV8vxHjNpxracxA3SQC2MbRBbmPFpkWxvK5Ps7UszngG0hbG3L924TSKxWXLOOQnJGbhCjJl5m8SPb8my/bPTHzP8+GYtO39G8sEPb8ps+AlFDAw0M0CjhlgNDAx1RKscBaNgFIyCkQMAREZWohjrfpIAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-1167-5890","institution":"Istanbul Aydin University, Department Plastic,Aesthetic and Reconstructive Surgery","correspondingAuthor":true,"prefix":"","firstName":"Ovunc","middleName":"","lastName":"Akdemir","suffix":""},{"id":480788127,"identity":"15e7252c-76d0-4a3b-aa7a-b9de3f5f7193","order_by":2,"name":"Atilla Eyuboglu","email":"","orcid":"","institution":"Istanbul Arel University, Department Plastic,Aesthetic and Reconstructive Surgery","correspondingAuthor":false,"prefix":"","firstName":"Atilla","middleName":"","lastName":"Eyuboglu","suffix":""},{"id":480788128,"identity":"37c5d8eb-72c8-4233-9464-2ca835384599","order_by":3,"name":"Murat Sezak","email":"","orcid":"","institution":"Ege University, Department of Pathology, Izmir, Turkey","correspondingAuthor":false,"prefix":"","firstName":"Murat","middleName":"","lastName":"Sezak","suffix":""},{"id":480788129,"identity":"c8304cf9-f611-4c24-be10-e87c1331a718","order_by":4,"name":"Semih Aydogdu","email":"","orcid":"","institution":"Ege University, Department of Orthopedics and Traumatology, Izmir, Turkey","correspondingAuthor":false,"prefix":"","firstName":"Semih","middleName":"","lastName":"Aydogdu","suffix":""}],"badges":[],"createdAt":"2025-07-04 14:21:49","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-7047607/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7047607/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.3390/life15091405","type":"published","date":"2025-09-05T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86257735,"identity":"7b8c0c8f-b278-4f22-b501-cd46f40f61d1","added_by":"auto","created_at":"2025-07-08 13:54:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130746,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea.\u003c/strong\u003e Talasization of the patellar joint surface and the supratubercular area of the anterior cortexof the femur. b. her appearance after completion of the talasization procedures; and \u003cstrong\u003ec.\u003c/strong\u003e Image of the Seprafilm placement, \u003cstrong\u003ed.\u003c/strong\u003e Image of a wire suture passing through the groin and ankle posteriorly, providing immobilization of the knee in flexion.\u003c/p\u003e","description":"","filename":"Figure1upscaled.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7047607/v1/a5d9e59025665d3a55588bd1.jpg"},{"id":86257737,"identity":"c60f7faf-ff8b-498b-8be3-dd246b6adb78","added_by":"auto","created_at":"2025-07-08 13:54:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":195645,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea.\u003c/strong\u003e Adhesion observed in the suprapatellar region of the control group (2x magnification). (Black arrow: quadriceps tendon, white arrow: adhesive tissue and fibrosis, blue arrow: cartilage tissue, red arrow: bone tissue). \u003cstrong\u003eb.\u003c/strong\u003e No adhesion or fibrosis was observed in the suprapatellar space of the Seprafilm® group (2x magnification). \u003cstrong\u003ec.\u003c/strong\u003eAdhesive tissue with fibrovascular features was observed in the control group, along with pronounced edema, vascular dilation and proliferation, fibroblasts, and predominant neutrophil (PMNL) inflammatory cells (20x magnification). (White arrows: vascular dilation and proliferation; black arrow: neutrophil (PMNL) infiltration; blue arrow: edema). \u003cstrong\u003ed.\u003c/strong\u003e Minimal vascular dilation and proliferation were observed in the Seprafilm® group (20x magnification). (White arrows: vascular dilation and proliferation). \u003cstrong\u003ee.\u003c/strong\u003eAppearance of moderate synovial chondrometaplasia below the quadriceps tendon in the control group (2x magnification). (White arrow: synovial chondrometaplasia area). \u003cstrong\u003ef.\u003c/strong\u003e Appearance of minimal synovial chondrometaplasia below the quadriceps tendon in the Seprafilm® group (2x magnification). (White arrow: synovial chondrometaplasia area).\u003c/p\u003e","description":"","filename":"Figure2upscaled.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7047607/v1/8e6aa5432254ce88411b0a2d.jpg"},{"id":90765038,"identity":"e54d6c0c-d37a-4433-b8e1-74d8329a3a5a","added_by":"auto","created_at":"2025-09-07 17:59:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1312627,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7047607/v1/cbc85973-ce07-4a82-94d8-80a465073bcb.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEffect of Carboxymethylcellulose Hyaluronan (SEPRAFİLM®) on an Arthrofibrosis Model Created in Rabbit Knees\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe term \"arthrofibrosis\" was first coined by J. Vernon Luck and is defined as a loss of range of motion secondary to intra-articular scar tissue formation. The incidence of arthrofibrosis ranges from 2\u0026ndash;35%.\u003csup\u003e1,2\u003c/sup\u003e The frequency of arthrofibrosis is increasing among older patients and those with degenerative arthritis.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Arthrofibrosis disrupts normal knee kinematics and may lead to progressive degenerative changes in the knee.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The etiology of arthrofibrosis includes surgical technique, surgical timing, immobilization, additional ligament surgery, infection, and reflex sympathetic dystrophy. Arthrofibrosis can develop not only following nonsurgical joint injuries but also after surgical intervention.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Motion-limiting arthrofibrosis has been described in numerous joints, including the knee, shoulder, ankle, elbow, and hand.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eArthrofibrosis occurs when there is an excessive fibrotic response during the healing process, resulting in the deposition of fibrous tissue within or around the joint. This buildup ultimately leads to a progressive loss of joint motion.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Certain fibrotic disorders share histological similarities with arthrofibrosis but fall outside the scope of this joint-specific model.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eArthrofibrosis is driven by an excessive inflammatory response in the synovium, leading to the activation and proliferation of fibroblasts and a significant increase in extracellular matrix protein deposition. The pathophysiology initially encompasses synovial inflammation, followed by subsynovial fibrosis, culminating in capsular thickening and eventual contracture of the affected joint.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e However, the exact cause of arthrofibrosis is unclear. One possible explanation is that tissue damage triggers immune cell activation, leading to oxidative stress and the release of proinflammatory cytokines, including platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-beta), and interleukin (IL)-1.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eApproaches to the treatment of ankle fibrosis include manipulation under anesthesia, debridement, and physical therapy, but the ideal measure is to prevent the development of arthrofibrosis. Several agents, including hydrogel microspheres, temperature-sensitive antiadhesive poloxamer (TAP) hydrogels, hyaluronic acid, carboxymethylcellulose, decorin, chitosan, lovastatin, rapamycin, and hydroxycaptotensin, have shown antiadhesive effects. Chitosan and TAP hydrogels have shown efficacy in clinical trials.\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Nevertheless, these agents have not been commercialized, and no surgical methods for preventing adhesions following ankle surgery have been established.\u003c/p\u003e\u003cp\u003eWhen used on its own, hyaluronic acid has a short local retention time, limiting its effectiveness in preventing adhesions. To extend its retention, it is chemically bonded with carboxymethylcellulose to form a protective film. This film, known as Seprafilm\u0026reg; (Genzyme Corp., Cambridge, Massachusetts, USA), is already used clinically by gynecologists and general surgeons to prevent adhesions in the intestinal tract and uterine appendages. According to Burns et al., the carboxymethylcellulose placed within the abdominal cavity transforms into a gel within 24\u0026ndash;48 hours after application and remains at the site of application for approximately 7 days. During this period, carboxymethylcellulose acts as an effective barrier, preventing adhesions by physically isolating damaged tissue from surrounding tissues. After local absorption, the carboxymethylcellulose primarily decomposes in the liver and is excreted in the urine within 28 days. Its ability for accessing organs outside the abdominal cavity has not been conclusively confirmed. Hayashi and colleagues have indicated that Seprafilm\u0026reg; reduces adhesion in the rabbit joint. However, their study explained the mechanism of action through the relationship between fibroblasts and fibrosis.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this study, we aimed to evaluate the effect of carboxymethylcellulose (Seprafilm\u0026reg;) on arthrofibrosis occurring in joints and its underlying mechanisms in greater detail. Furthermore, we evaluated the effectiveness of Seprafilm\u0026reg; application against fibrosis and adhesions.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e This study was conducted at the Experimental Animal Production and Research Laboratory and approved by the authors' affiliated institutions. The experimental protocol adhered to the guidelines outlined by the National Research Council for the Care and Use of Laboratory Animals. The present study adhered to the guidelines for humane animal treatment. All procedures performed on animals were in accordance with ethical standards and guidelines established for the care and use of laboratory animals. The study protocol was reviewed and approved by the institutional animal care and use committee (IACUC). Efforts were made to minimize animal suffering and to reduce the number of animals used in the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample Size and Animal Allocation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA preliminary power analysis was performed to determine the appropriate sample size, considering the expected effect size, variability of outcome measures, and a statistical power of 80%. Sixteen skeletally mature male New Zealand White rabbits (3500\u0026ndash;4000 g, \u0026ge;\u0026thinsp;6 months) were randomly assigned into two equal groups (n\u0026thinsp;=\u0026thinsp;8). Male rabbits were chosen to avoid hormonal variability, which could influence fibrosis and adhesion outcomes.\u003c/p\u003e\u003cp\u003eRandomization was performed using a computer-generated sequence (Randomizer\u0026reg;, Austria) by an independent researcher to minimize allocation bias. Animals were housed in numbered cages without any other selection criteria.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGroup 1 (control) (n\u0026thinsp;=\u0026thinsp;8)\u003c/b\u003e: No additional procedures were performed on the rabbit knee joint after the arthrofibrosis procedure.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGroup 2 (treatment) (n\u0026thinsp;=\u0026thinsp;8)\u003c/b\u003e: After inducing arthrofibrosis in the rabbit knee joint similar to that in the control group, Seprafilm\u0026reg; was placed in the knee joint.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnimal Husbandry and Environmental Control\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll procedures were conducted in an IACUC-approved facility under controlled temperature (20\u0026ndash;22\u0026deg;C), humidity (50\u0026ndash;60%), and a 12-hour light/dark cycle. Rabbits were housed individually (5.43 ft\u0026sup2; floor area) and provided ad libitum access to water and a standardized high-fiber rabbit diet (Invigo 2031). Environmental enrichment, including chew toys and hiding spaces, was provided to reduce stress-related variables.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStandardization and Bias Control\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo reduce interindividual variability, surgical and postoperative procedures were standardized and performed by a single surgeon. Animal health and behavior were monitored daily, with deviations recorded and assessed.\u003c/p\u003e\u003cp\u003eHistopathological evaluations were performed by a single pathologist blinded to the treatment groups to prevent assessment bias. While the operating surgeon was aware of group allocation, all subsequent evaluations were conducted under blinding protocols to minimize subjective influence.\u003c/p\u003e\u003cp\u003eThis study was reported in accordance with the \u003cb\u003eARRIVE guidelines\u003c/b\u003e for in vivo experimental research.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical methods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA standardized surgical procedure was employed for both groups. Anesthesia was induced via intramuscular injection of a mixture of ketamine (Alfamine\u0026reg; 10% injectable - ALFASAN) at 35 mg/kg and xylazine hydrochloride (Xylazol\u0026reg; - PROVET) at 8 mg/kg. To ensure consistency, the same surgeon performed all surgeries. The rabbits were placed in a supine position, and a longitudinal skin incision was made on the anterior aspect of the right knee, which was flexed at 90\u0026deg;. The quadriceps muscle was exposed, and the knee joint was accessed using a medial parapatellar approach with a parallel incision following the muscle fibers. The lateral and medial femoral condyles were exposed. Abrasion was performed using a No. 11 blade on the patellar joint surface and the anterior region of the supracondylar femur.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn Group 1, after the surgical procedure described above, capsulorrhaphy was performed with Vicryl 3\u0026thinsp;\u0026minus;\u0026thinsp;0, followed by skin closure with Nylon 4\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn Group 2, a sterile Seprafilm\u0026reg; patch measuring 2.5x1.5 cm, intended to prevent adhesion formation, was placed in the supracondylar anterior femur region where abrasion was performed. Subsequently, capsulorrhaphy was performed with Vicryl 3\u0026thinsp;\u0026minus;\u0026thinsp;0, and skin closure was completed with Nylon 4\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures. Following closure, the immobilization of the knee joint of rabbits in both groups was achieved with No. 5 wire sutures.\u003c/p\u003e\u003cp\u003eSix weeks after the procedure, all rabbits were euthanized with a high dose of intravenous barbiturate. Wire sutures were removed. For macroscopic and histopathological evaluation, soft tissues were dissected up to the medial condyle of the femur without damaging the extensor mechanism using a No. 11 blade (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). During the 6-week period following trauma induction, the animals were monitored daily. No mortalities were observed among the rabbits\u0026rsquo; post procedure.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMACROSCOPIC EVALUATION\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA modified adhesion scoring system (MAS) was used to macroscopically assess adhesions in the suprapatellar region between the quadriceps and the anterior cortex of the femur.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e This system categorizes adhesions into four grades based on their severity: Grade 0 indicates no adhesion present; Grade 1 denotes a weak, soft film-like adhesion that can be easily eliminated with minimal manual traction; Grade 2 represents a moderate adhesion that can be removed with manual traction; and Grade 3 signifies intense adhesion requiring surgical intervention for removal (Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003e\u003cb\u003eHISTOPATHOLOGICAL EVALUATION\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAfter fixation in 10% neutral buffered formalin for approximately 24 hours, all connective tissues containing fibrotic adhesive scars were preserved, and the knee joints were decalcified in 20% formic acid for 48 hours at room temperature. Four 5 mm-thick sections were obtained from each sample, starting 2 cm proximally to the femoral joint surface and extending into the suprapatellar pouch. Following routine tissue processing with a Leica ASP 3005, the samples were embedded in paraffin blocks. Eight 4 \u0026micro;m sections were cut from the paraffin blocks using a Leica RM 2145 microtome. Hematoxylin-eosin staining was applied to the sections.\u003c/p\u003e\u003cp\u003eA single pathologist performed the evaluation in a blind manner. We employed a semiquantitative scoring system to assess the parameters. The presence of adhesions in rabbit knees, along with the intensity of fibrosis (fibroblast proliferation), inflammatory cell types (lymphocytes, neutrophils (PMNL), macrophages), edema, vascular proliferation, the giant cell response, and the formation and intensity of synovial chondrometaplasia, were semiquantitatively scored. These parameters (neutrophils, lymphocytes, macrophages, fibrosis, edema, vascular proliferation, giant cell response, and synovial chondrometaplasia) were semi quantitatively scored in 10 randomly selected fields at \u0026times;20 and \u0026times;100 magnification by a pathologist. The criteria for each score level were rigorously defined and applied uniformly.\u003c/p\u003e\u003cp\u003e\u003cb\u003e1. Distinguishing and scoring of cell types\u003c/b\u003e: Neutrophils, lymphocytes, and macrophages\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNeutrophils\u003c/strong\u003e\u003cp\u003eIdentified by their characteristic multilobed nuclei and pale-staining cytoplasm in hematoxylin-eosin (H\u0026amp;E)-stained sections.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLymphocytes\u003c/strong\u003e\u003cp\u003eRecognizable by their small, round nuclei and scant cytoplasm. The H\u0026amp;E sections generally exhibited a darker staining pattern.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMacrophages\u003c/strong\u003e\u003cp\u003eThese cells were identified by their larger, more irregular nuclei and abundant cytoplasm, which may also contain phagocytosed material.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eThe cells of each type were counted and scored semi quantitatively in 10 fields at x20 and x100 magnification. The scoring system ranged from 0 to 3, where 0\u0026thinsp;=\u0026thinsp;absent, 1\u0026thinsp;=\u0026thinsp;minimal, 2\u0026thinsp;=\u0026thinsp;moderate, and 3\u0026thinsp;=\u0026thinsp;abundant.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2. Fibrosis\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFibroblast Proliferation\u003c/strong\u003e\u003cp\u003eEvaluated based on the density of fibrous tissue and the extent of fibroblast proliferation. Areas with a high density of collagen and fibroblasts were scored as 3, while areas with minimal fibrosis were scored as 1. The scoring was performed semiquantitatively in the same 10 fields.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIdentification\u003c/strong\u003e\u003cp\u003eFibrosis is characterized by the accumulation of dense fibrous connective tissue, predominantly collagen fibers. In H\u0026amp;E-stained sections, fibrosis appears as thickening or scarring of the tissue, often accompanied by an increase in fibroblast proliferation.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEvaluation technique\u003c/strong\u003e\u003cp\u003eAreas with extensive collagen deposition and fibroblast proliferation was identified by their eosinophilic staining and dense appearance compared to those of the surrounding tissue. The degree of fibrosis was evaluated semi-quantitatively, considering the density and distribution of the fibrous tissue.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3. Edema\u003c/b\u003e: Edema was assessed based on the amount of interstitial fluid and tissue swelling observed. The severity of the disease was scored as 0\u0026thinsp;=\u0026thinsp;none, 1\u0026thinsp;=\u0026thinsp;mild, 2\u0026thinsp;=\u0026thinsp;moderate, or 3\u0026thinsp;=\u0026thinsp;severe.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIdentification\u003c/strong\u003e\u003cp\u003eEdema is characterized by an accumulation of interstitial fluid leading to swelling of the tissue. It can be observed as an increase in the space between cells and clear spaces or vacuoles can be observed in the tissue sections.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEvaluation technique\u003c/strong\u003e\u003cp\u003eEdema is identified by the presence of these spaces or vacuoles in the tissue. The severity of edema was scored based on the extent of swelling observed in the tissue sections.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e4. Vascular Proliferation\u003c/b\u003e: The extent of vascularization was evaluated by counting the number of newly formed blood vessels. Vascular proliferation was scored as 0\u0026thinsp;=\u0026thinsp;absent, 1\u0026thinsp;=\u0026thinsp;few, 2\u0026thinsp;=\u0026thinsp;moderate, or 3\u0026thinsp;=\u0026thinsp;numerous.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIdentification\u003c/strong\u003e\u003cp\u003eVascular proliferation involves the formation of new blood vessels within the tissue. This is typically observed as an increased number of capillaries or small blood vessels in the tissue.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEvaluation technique\u003c/strong\u003e\u003cp\u003eVascular proliferation was assessed by counting the number of new blood vessels in the tissue sections. The presence of newly formed vessels was noted, and the extent of vascularization was scored based on the number of vessels and their distribution.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e5. Giant Cell Response\u003c/b\u003e: The presence of multinucleated giant cells was noted, and the extent of their formation was scored similarly to other parameters: 0\u0026thinsp;=\u0026thinsp;absent, 1\u0026thinsp;=\u0026thinsp;few, 2\u0026thinsp;=\u0026thinsp;moderate, and 3\u0026thinsp;=\u0026thinsp;many.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIdentification\u003c/strong\u003e\u003cp\u003eGiant cells are multinucleated cells formed by the fusion of macrophages in response to chronic inflammation. They are identified by their large size and multiple nuclei.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEvaluation technique\u003c/strong\u003e\u003cp\u003eThe presence of giant cells was noted by their distinctive morphology. The extent of giant cell formation was assessed semi quantitatively based on the number and size of the giant cells present in the tissue.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e6. Formation and Intensity of Synovial Chondrometaplasia\u003c/b\u003e: Synovial Chondrometaplasia: The formation and intensity of this morphology were assessed based on the presence and distribution of cartilaginous metaplasia within the synovial tissue. The scores ranged from 0\u0026thinsp;=\u0026thinsp;none to 1\u0026thinsp;=\u0026thinsp;focal, 2\u0026thinsp;=\u0026thinsp;moderate, and 3\u0026thinsp;=\u0026thinsp;extensive.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIdentification\u003c/strong\u003e\u003cp\u003eSynovial chondrometaplasia involves the formation of cartilage-like tissue within the synovial membrane. It is identified by the presence of cartilage nodules or islands within the synovial lining.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEvaluation technique\u003c/strong\u003e\u003cp\u003eThe formation and intensity of chondrometaplasia were assessed based on the number and size of these cartilage formations within the synovial membrane. The presence and extent of chondrometaplasia were scored according to the distribution and intensity of the cartilage-like tissue.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eQuality Control\u003c/strong\u003e\u003cp\u003eTo ensure accuracy and consistency in histopathological scoring, the pathologist was trained and calibrated in the scoring system before the evaluations. Interobserver variability was minimized by standardizing the evaluation procedures. Regular quality checks were incorporated to maintain adherence to the defined scoring criteria.\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSTATISTICAL ANALYSIS:\u003c/h2\u003e\u003cp\u003eAll the statistical analyses were performed using SPSS 16.0 (Windows\u0026reg;) software. The data are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) where applicable. The means and standard deviations were calculated for the data from the Seprafilm\u0026reg; application group and the control group. Histopathological findings for both groups {adhesion, fibrosis (fibroblast proliferation), vascular proliferation, synovial chondrometaplasia, giant cell response, edema, lymphocyte, neutrophil (PMNL), and macrophage} and macroscopic adhesion scores\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e were evaluated using the Mann‒Whitney U test, and a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cb\u003eMacroscopic adhesion scores\u003c/b\u003e: Macroscopic adhesion scoring was performed according to the modified adhesion scoring system for the control group rabbits, revealing significant adhesion in 5 rabbits (62.5%) at a high level (MAS: 3), moderate adhesion in 2 rabbits (25%) (MAS: 2), and minimal adhesion in 1 rabbit (12.5%) (MAS: 1). No macroscopic adhesion was observed in rabbits from the Seprafilm\u0026reg; group (MAS: 0). The mean macroscopic adhesion score in the control group was 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75, while no macroscopic adhesion was observed in the Seprafilm\u0026reg; group. The Mann‒Whitney U test was used to compare the groups based on the presence of macroscopic adhesions, revealing a significantly greater incidence of adhesions in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). (Table\u0026nbsp;2) According to these results, adhesion formation was observed in 100% of the patients (8/8) in the control group, whereas no instances of adhesion formation were observed in the Seprafilm-treated group.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHistopathological Findings\u003c/strong\u003e\u003cp\u003eHistopathologically, microscopic adhesion was observed in all rabbits in the control group, while no microscopic adhesion was detected in rabbits from the Seprafilm\u0026reg; group. This histological difference resulted in a significantly greater amount of adhesion in the control group than in the Seprafilm\u0026reg; group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the control group, significant fibrosis (fibroblast proliferation) was observed in 5 rabbits (62.5%), and moderate fibrosis was observed in 3 rabbits (37.5%), while all rabbits in the Seprafilm\u0026reg; group exhibited minimal fibrosis (fibroblast proliferation).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFibrosis (Fibroblast Proliferation)\u003c/strong\u003e\u003cp\u003eAfter comparing the fibrosis levels between the control and Seprafilm\u0026reg; groups based on histopathological assessment of minimal, moderate, or significant fibrosis (fibroblast proliferation), a significantly greater degree of fibrosis was observed in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eVascular Proliferation\u003c/strong\u003e\u003cp\u003eRegarding vascular proliferation, 2 rabbits (25%) in the control group exhibited moderate vascular proliferation, 3 (37.5%) had minimal vascular proliferation, and 4 (50%) had no vascular proliferation in the Seprafilm\u0026reg; group. Histopathological evaluation of vascular proliferation, categorized as minimal, moderate, or significant, revealed a statistically significant increase in vascular proliferation in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSynovial chondrometaplasia\u003c/strong\u003e\u003cp\u003eFurthermore, synovial chondrometaplasia was observed in 2 rabbits (25%) at moderate levels and in 3 rabbits (37.5%) at minimal levels in the control group, while 3 rabbits (37.5%) exhibited minimal levels of synovial chondrometaplasia in the Seprafilm\u0026reg; group, with no cases of synovial chondrometaplasia observed in 5 rabbits (62.5%). No significant difference was observed in synovial chondrometaplasia intensity between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEdema\u003c/strong\u003e\u003cp\u003eFor edema evaluation, 1 rabbit (12.5%) in the control group exhibited significant edema, 1 rabbit (12.5%) had moderate, 2 rabbits (25%) had minimal edema, and 4 rabbits (50%) had no edema. In contrast, 5 rabbits (62.5%) in the Seprafilm\u0026reg; group exhibited no edema, and 3 rabbits (37.5%) displayed minimal edema. A statistical analysis based on histopathological assessment of minimal, moderate, or significant edema revealed a significantly greater level of edema in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNeutrophil (PMNL) infiltration\u003c/strong\u003e\u003cp\u003eRegarding neutrophil (PMNL) infiltration, 7 rabbits (87.5%) in the control group exhibited significant neutrophil (PMNL) infiltration, while 1 rabbit (12.5%) exhibited moderate neutrophil infiltration. In contrast, all rabbits (100%) in the Seprafilm\u0026reg; group showed no neutrophil (PMNL) infiltration. A statistical analysis of the minimal, moderate, or significant neutrophil (PMNL) infiltration levels revealed a significantly greater level of neutrophil (PMNL) infiltration in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLymphocyte Intensity\u003c/strong\u003e\u003cp\u003eAccording to the lymphocyte intensity assessment, 4 rabbits (50%) in the control group exhibited minimal lymphocyte intensity, 3 rabbits (37.5%) had moderate lymphocyte intensity, and 1 rabbit (12.5%) had significant lymphocyte intensity, while. Similarly, the proportions of the Seprafilm\u0026reg; group were 75%, 25%, and 0% for the minimal, moderate, and significant lymphocyte intensities, respectively. There was no statistically significant difference in lymphocyte intensity between the two rabbit groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMacrophage intensity\u003c/strong\u003e\u003cp\u003eFor the assessment of macrophage intensity, 3 rabbits (37.5%) in the control group exhibited minimal macrophage intensity, 4 (50%) had moderate macrophage intensity, and 1 (12.5%) had significant macrophage intensity. Similarly, 3 (37.5%) in the Seprafilm\u0026reg; group exhibited minimal macrophage intensity, 1 (12.5%) had moderate, and 1 (12.5%) had significant macrophage intensity; moreover, 3 (37.5%) had no significant difference in macrophage intensity (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). (Table\u0026nbsp;3) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eArthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathological periarticular fibrosis with subsequent symptomatic limitations in joint range of motion (ROM). Capsular contracture via aberrant extracellular matrix (ECM) deposition is the hallmark of AF and can manifest secondary to periarticular trauma, surgical insult, postinfectious arthritis, or hemarthrosis. Although uncommon, primary (idiopathic) AF can occur in the setting of an unidentifiable trigger.\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Ryan Will and his colleagues demonstrated that one of the most significant complications in trigger finger surgery is proximal interphalangeal joint arthrofibrosis.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe pathogenesis of arthrofibrosis has not been fully elucidated, but research suggests a potential genetic predisposition to fibrosis in musculoskeletal tissues, particularly in association with Dupuytren\u0026rsquo;s contracture. \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Fibrotic conditions such as Dupuytren\u0026rsquo;s, Ledderhose, and Peyronie\u0026rsquo;s diseases are characterized by excessive production of transforming growth factor-beta, resulting in fibroproliferation and abnormal collagen deposition.\u003csup\u003e\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e It is therefore understood that treatments applied for arthrofibrosis may also be able to treat other diseases that cause fibrotic adhesions.\u003c/p\u003e\u003cp\u003eIn the literature, intermittent injection of hyaluronic acid and continuous infusion of TGF-B inhibitors with neutralizing antibodies against FGF-2 have been reported to be effective at preventing adhesion.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e However, such frequent interventions during the postoperative period increase the risk of infection. Considering this, we chose to use Seprafilm\u0026reg; in membrane form during the perioperative period instead of the intermittent injection of hyaluronic acid, aiming to avoid increasing the risk of infection.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Seprafilm\u0026reg; is a bioresorbable material composed of hyaluronic acid and carboxymethylcellulose. Since the early 1990s, it has been used intraabdominally to reduce postoperative adhesions. Experimental models have shown that the use of Seprafilm\u0026reg; as a physical barrier serosal tissues in an organized manner.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Seprafilm\u0026reg; has been reported to be an effective adhesion prevention barrier in radical pelvic surgeries involving the uterus, fallopian tubes, and ovaries, as well as in open myomectomy and colorectal surgery.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Hayashi et al. induced arthrofibrosis in rabbit knees in a similar manner to our study and applied the Seprafilm\u0026reg;. However, they focused not on the cellular components of adhesion but rather on the degree of reduction in joint movement due to arthrofibrosis and how well Seprafilm\u0026reg; macroscopically improved extensor contracture.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e In our study, we evaluated the effect of Seprafilm\u0026reg; on arthrofibrosis both macroscopically and histologically. According to our findings, adhesion and fibrosis significantly decreased in the group treated with Seprafilm\u0026reg;, both macroscopically and microscopically. We observed a significant decrease in parameters such as edema and an increase in parameters related to acute inflammation, such as neutrophils, in the Seprafilm\u0026reg;-treated group. However, there were no statistically significant changes in chronic inflammation parameters, including lymphocyte and macrophage density, synovial chondrometaplasia, or vascular proliferation, between the Seprafilm\u0026reg;-treated group and the control group. We believe that this correlation can be attributed to the findings obtained in rabbits at the 6th week. Furthermore, according to the statistical analysis, a statistically significant, very high-level positive correlation was observed between fibrosis (fibroblast proliferation) intensity and the macroscopic adhesion score, as well as microscopic adhesion. Additionally, a statistically significant, moderate positive correlation was observed between neutrophil density and lymphocyte, macrophage, and edema intensity. In a study conducted by Brunelli et al., an experimental arthrofibrosis model was created in 20 rabbits, and hyaluronan-derived gel (Hyaloglide\u0026reg;) was used post-surgery in 10 rabbits. The study concluded that the adhesion rate observed in the Hyaloglide\u0026reg; group was significantly lower than that in the control group. In the Hyaloglide\u0026reg; group (hyaluronic acid gel formulation without carboxymethylcellulose), a weak macroscopic adhesion rate of 22% was observed.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e In our study, the plants in the treatment group were treated with Seprafilm\u0026reg; (hyaluronic acid\u0026thinsp;+\u0026thinsp;carboxymethylcellulose), and the macroscopic adhesion rate was adhesion score: 0). Fukui et al. investigated the dose-dependent effect of decorin on arthrofibrosis in rabbits via both macroscopic and histopathological evaluations at 4 weeks postsurgery. The results showed thick fibrous adhesions on the lateral side of the femoral condyle in the control group, whereas in the high-dose (500 \u0026micro;g/ml) decorin group, soft and weak adhesions were observed. Both the control group and the high-dose decorin treatment group exhibited a predominance of inflammatory cells and fibroblasts in the adhesion tissue, but there was no statistically significant difference in these cells between the two groups.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Ariyan et al. histologically examined Dupuytren's disease, Peyronie's disease, and capsular contracture of the breast and reported increased fibroblast proliferation, edema, and neutrophil density, similar to our control group with arthrofibrosis. This finding suggested that Seprafilm\u0026reg; may be used when such adhesion and inflammation occur. \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e The sample size of 8 rabbits per group was determined based on a power analysis. The analysis assumed an expected difference in mean adhesion scores of 1.5 between the control and Seprafilm\u0026reg; groups, a standard deviation of 0.75, a power of 80%, and a significance level (alpha) of 0.05. Based on these assumptions, a sample size of 8 rabbits per group was deemed sufficient to detect statistically significant differences in the primary outcomes of adhesion and fibrosis formation. This approach ensures that the study is adequately powered to identify meaningful differences between groups while minimizing the number of animals used in compliance with ethical guidelines for animal research.\u003c/p\u003e\u003cp\u003eLimitations of the study on the effect of carboxymethylcellulose (Seprafilm\u0026reg;) on arthrofibrosis in rabbit knees include the use of a relatively small sample size of sixteen rabbits, which may limit the generalizability of the findings. The use of artificial intelligence seems to be promising for future studies to decrease the required sample sizes.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e While rabbit models are commonly used in research, they may not fully replicate the complexity of human arthrofibrosis, potentially impacting the translatability of the results to clinical practice. The follow-up period of six weeks after Seprafilm\u0026reg; application may not capture long-term effects or potential complications that could arise over an extended period. This study focused primarily on macroscopic and histological evaluations of adhesions and fibrosis, potentially overlooking other important aspects, such as functional outcomes or immune responses. Despite these limitations, the ARRIVE Guidelines for Reporting Animal Research were utilized in this study to enhance the reliability of the investigation.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eRecommendations for Future Research\u003c/strong\u003e\u003cp\u003eTo address concerns about evaluating multiple intervention methods, we propose conducting follow-up studies that incorporate additional control groups with different interventions. This approach allows for a comparative analysis of Seprafilm\u0026reg; against various alternative treatments and provides a more comprehensive understanding of its relative efficacy.\u003c/p\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, our study demonstrated that carboxymethylcellulose (Seprafilm\u0026reg;) is effective at reducing adhesion and fibrosis in a rabbit model of arthrofibrosis. The significant differences observed in macroscopic and histological evaluations between the Seprafilm\u0026reg; group, and the control group highlight its potential as a therapeutic intervention for preventing joint complications following surgical procedures. However, while the results are promising, it is essential to acknowledge the limitations of the study, including the small sample size and the short follow-up period, which may affect the generalizability of the findings. Future research should aim to explore the long-term effects of Seprafilm\u0026reg; and its mechanisms of action, as well as to evaluate its efficacy in human subjects. By addressing these aspects, we can better understand the clinical implications of Seprafilm\u0026reg; in the management of arthrofibrosis and improve treatment strategies for affected patients.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCosgarea AJ, Sebastianelli WJ, DeHaven KE (1995) Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft. Am J Sports Med 23:87\u0026ndash;92\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJackson DW, Schaefer RK (1990) Cyclops syndrome: Loss of extension following intra-articular anterior cruciate ligament reconstruction. Arthroscopy 6:171\u0026ndash;178\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSachs R, Daniel D, Stone M et al (1989) Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med 17:760\u0026ndash;765\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShelbourne KD, Patel DV, Martilli DJ (1996) Classification and management of arthrofibrosis of the knee after anterior cruciate ligament reconstruction. Am J Sports Med 24:857\u0026ndash;862\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGood L, Johnson RJ (1995) The dislocated knee. J Am Acad Ortho Surg 3:284\u0026ndash;292\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWarner JJ, Allen AA, Marks PH et al (1997) Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg 79A:1151\u0026ndash;1158\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJones GS, Savoie FH 3 (1993) Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow. Arthroscopy 9:277\u0026ndash;283\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePhilips BB, Strasburger S (1998) Arthroscopic treatment of arthrofibrosis of the elbow joint. Arthroscopy 14:38\u0026ndash;44\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBosch U (2002) Arthrofibrosis Orthopade 31:785\u0026ndash;790\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang CX, Flick TR, Patel AH, Sanchez F, Sherman WF (2021) Patients with Dupuytren's Contracture, Ledderhose Disease, and Peyronie's Disease are at higher risk of arthrofibrosis following total knee arthroplasty. Knee 29:190\u0026ndash;200\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee SK, Gargano F, Hausman MR (2006) Wrist arthrofibrosis. Hand Clin 22:529\u0026ndash;538\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUsher KM, Zhu S, Mavropalias G, Carrino JA, Zhao J, Xu J (2019) Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Res 7:9\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatson RS, Gouze E, Levings PP, Bush ML, Kay JD, Jorgensen MS, Dacanay EA, Reith JW, Wright TW, Ghivizzani SC (2010) Gene delivery of TGF-_1 induces arthrofibrosis and chondrometaplasia of synovium in vivo. Lab Investig 90:1615\u0026ndash;1627\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheuy VA, Foran JRH, Paxton RJ, Bade MJ, Zeni JA, Stevens-Lapsley JE (2017) Arthrofibrosis associated with total knee arthroplasty. J Arthroplast 32:2604\u0026ndash;2611\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHan Y, Yang J, Zhao W, Wang H, Sun Y, Chen Y, Luo J, Deng L, Xu X, Cui W et al (2021) Biomimetic injectable hydrogel microspheres with enhanced lubrication and controllable drug release for the treatment of osteoarthritis. Bioact Mater 6:3596\u0026ndash;3607\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim JK, Park JY, Lee DW, Ro DH, Lee MC, Han HS (2019) Temperature-sensitive anti-adhesive poloxamer hydrogel decreases fascial adhesion in total knee arthroplasty: A prospective randomized controlled study. J Biomater Appl 34:386\u0026ndash;395\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHayashi M, Sekiya H, Takatoku K, Kariya Y, Hoshino Y (2004) Experimental model of knee contracture in extension: Its prevention using a sheet made from hyaluronic acid and carboxymethylcellulose. Knee Surg Sports Traumatol Arthrosc 12:545\u0026ndash;551\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFukui N, Fukuda A, Kojima K, Nakajima K, Oda H, Nakamura K (2001) Suppression of fibrous adhesion by proteoglycan decorin. J Orthop Res 19:456\u0026ndash;462\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu RS, Hou CL, Yin CH, Wang YS, Chen AM (2002) Clinical study on chitosan in prevention of knee adhesion after patellar operation. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 16:240\u0026ndash;241\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi X, Sun Y, Chen H, Zhu G, Liang Y, Wang Q, Wang J, Yan L (2016) Hydroxycamptothecin induces apoptosis of fibroblasts and prevents intraarticular scar adhesion in rabbits by activating the IRE-1 signaling pathway. Eur J Pharmacol 781:139\u0026ndash;147\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao S, Sun Y, Li X, Wang J, Yan L, Chen H, Wang D, Dai J, He J (2016) Reduction of intraarticular adhesion of knee by local application of rapamycin in rabbits via inhibition of fibroblast proliferation and collagen synthesis. J Orthop Surg Res 11:45\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrunelli G, Longinotti C, Bertazzo C, Pavesio A, Pressato D (2005) Adhesion reduction after knee surgery in a rabbit model by Hyaloglide\u0026reg;, a hyaluronan derivative gel. J Orthop Res 23:1377\u0026ndash;1382\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRothkopf DM, Webb S et al (1991) An experimental model for the study of canine flexor tendon adhesions. J Hand Surg Amer 16:694\u0026ndash;700\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIbrahim IO, Nazarian A, Rodriguez EK (2020) Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook. JBJS Rev 8:e1900223\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen AF, Lee YS, Seidl AJ et al (2019) Arthrofibrosis and large joint scarring. Connect Tissue Res 60:21\u0026ndash;28\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdel MP, Morrey ME, Barlow JD et al (2012) Myofibroblasts are preferentially expressed early in a rabbit model of joint contracture. J Orthop Res 30:713\u0026ndash;719\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWill R, Lubahn J (2010) Complications of open trigger finger release. J Hand Surg Am 35:594\u0026ndash;596\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohede DCJ et al (2020) Prevalence of peyronie and ledderhose diseases in a series of 730 patients with dupuytren disease. Plast Reconstr Surg 145:978\u0026ndash;984\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkdag O et al (2016) Dupuytren-like contracture of the foot: ledderhose disease. Surg J (N Y) 2:e102\u0026ndash;104\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoung JR et al (2018) The etiology, evaluation, and management of plantar fibromatosis. Orthop Res Rev 11:1\u0026ndash;7\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmiel D, Frey C, Woo SL-Y, Harwood F, Akeson W (1985) Value of hyaluronic acid in the prevention of contracture formation. Clin Orthop 196:306\u0026ndash;311\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParker MC, Ellis H, Moran BJ, Thompson JN, Wilson MS, Menz D et al (2001) Postoperative adhezions: Ten-year follow-up of 12584 patients undergoing lover abdominal surgery. Dis Colon Rectum. ;44.822\u0026ndash;830\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBecker JM, Dayton MT, Fazio VW et al (1996) Prevention of postoperative abdominal adhesions by a sodium hyalurinate based bioresorbabl membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg 183:297\u0026ndash;306\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiamond MP (1996) Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F): a prospective, randomized, multicenter clinical study. Fertil Steril 6:904\u0026ndash;910\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAriyan S, Enriquez R, Krizek TJ (1978) Wound contraction and fibrocontractive disorders. Arch Surg 113:1034\u0026ndash;1046\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoudhary OP, Saini J, Challana (2023) Amit. ChatGPT for Veterinary Anatomy Education: An Overview of the Prospects and Drawbacks. Int J Morphol 41:1198\u0026ndash;1202\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKilkenny C, Browne WJ, Cuthill IC, Emerson M, Altman DG (2010) Improving Bioscience Research Reporting: The ARRIVE Guidelines for Reporting Animal Research. PLoS Biol 8(6):e1000412\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e The macroscopic evaluation based on the modified adhesion scoring(MAS) system used in the study:\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 500px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 500px;\"\u003e\n \u003cp\u003eNo adhesion - Absence of adhesion between the quadriceps and the anterior cortex of the femur.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 500px;\"\u003e\n \u003cp\u003eWeak, soft film-like adhesion - Adhesion present but easily eliminated with minimal manual traction.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 500px;\"\u003e\n \u003cp\u003eModerate adhesion - Adhesion present and can be eliminated with manual traction.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 500px;\"\u003e\n \u003cp\u003e\u0026nbsp;Intense adhesion - Adhesion is intense and requires surgical intervention for removal.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e The results of the macroscopic adhesion scoring in the control group rabbits compared to the Seprafilm\u0026reg; group:\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAS: 0 (No Adhesion)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAS: 1 (Minimal)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAS: 2 (Moderate)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAS: 3 (High Level)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean MAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMann \u0026nbsp; \u0026nbsp; Whitney U p-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 rabbit (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2 rabbits (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e5 rabbits (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2.5 \u0026plusmn; 0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003ep \u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeprafilm\u0026reg; Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eAll rabbits (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e- \u0026quot;MAS\u0026quot; refers to the macroscopic adhesion score.\u003c/p\u003e\n\u003cp\u003e- The percentages represent the proportion of rabbits in each group with the corresponding MAS.\u003c/p\u003e\n\u003cp\u003e- \u0026quot;Mean MAS\u0026quot; represents the average macroscopic adhesion score in each group.\u003c/p\u003e\n\u003cp\u003e- \u0026quot;Mann Whitney U p-value\u0026quot; indicates the statistical significance of the difference in adhesion presence between the control and Seprafilm\u0026reg; groups.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e The histopathological findings and statistical analysis results between the control group and the Seprafilm\u0026reg; group for various parameters.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeprafilm\u0026reg; Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMicroscopic Adhesion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eDetected in all rabbits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNot detected in any rabbits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFibrosis Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHigh (62.5%), Moderate (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMinimal (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVascular Proliferation Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eModerate (25%), Minimal (37.5%),\u003c/p\u003e\n \u003cp\u003eNone ( 37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMinimal (50%), None (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSynovial Chondrometaplasia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eModerate (25%), Minimal (37.5%), \u0026nbsp;None ( 37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMinimal (37.5%), None (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEdema Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eSignificant (12.5%), Moderate (12.5%), Minimal (25%),\u003c/p\u003e\n \u003cp\u003eNone (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNone (62.5%), Minimal (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutrophil Infiltration (PMNL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e|Significant (87.5%), Moderate (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNone (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLymphocyte Intensity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMinimal (50%), Moderate (37.5%), Significant (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMinimal (75%), Moderate (25%), Significant (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMacrophage Intensity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMinimal (37.5%), Moderate (50%), Significant (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMinimal (37.5%), Moderate (12.5%), Significant (12.5%), None (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e- \u0026quot;p-value\u0026quot; represents the statistical significance of the difference between the control and Seprafilm\u0026reg; groups for each parameter. Values less than 0.05 indicate statistically significant differences.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"Ege University","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adhesion reduction, Arthrofibrosis, Fibrosis prevention rabbit knee model, Seprafilm®","lastPublishedDoi":"10.21203/rs.3.rs-7047607/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7047607/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThis study aimed to evaluate the efficacy of carboxymethylcellulose (Seprafilm®) for preventing and treating arthrofibrosis in rabbit knees. Additionally, we aimed to assess the underlying mechanisms of action of Seprafilm® against fibrosis and adhesions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eSixteen male New Zealand white rabbits were randomly assigned to two groups: a control group and a treatment group receiving Seprafilm® after arthrofibrosis in the knee joint was induced. Macroscopic and histological evaluations were also conducted to assess various parameters, including adhesion, fibrosis, inflammation, and edema.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eMacroscopic adhesion scoring revealed significant adhesion in 5 rabbits (62.5%) in the control group (MAS: 3), moderate adhesion in 2 rabbits (25%) (MAS: 2), and minimal adhesion in 1 rabbit (12.5%) (MAS: 1). No macroscopic adhesion was observed in the Seprafilm® group (MAS: 0). The mean macroscopic adhesion score was 2.5 ± 0.75 in the control group, while there was no adhesion in the Seprafilm® group (p \u0026lt; 0.001). Significant fibrosis was observed in 5 rabbits (62.5%),and moderate fibrosis was observed in 3 rabbits (37.5%) in the control group; however, all the Seprafilm® group rabbits exhibited minimal fibrosis, indicating a significant difference (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eSeprafilm® demonstrated efficacy in reducing adhesion and fibrosis in arthrofibrosis models in rabbit knees. These results highlight the potential of Seprafilm® as a preventive and therapeutic measure for arthrofibrosis and related conditions.\u003c/p\u003e","manuscriptTitle":"Effect of Carboxymethylcellulose Hyaluronan (SEPRAFİLM®) on an Arthrofibrosis Model Created in Rabbit Knees","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-08 13:54:45","doi":"10.21203/rs.3.rs-7047607/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6bec5476-08f0-4901-93c1-7e8cf801127b","owner":[],"postedDate":"July 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":51061642,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2025-09-07T17:59:31+00:00","versionOfRecord":{"articleIdentity":"rs-7047607","link":"https://doi.org/10.3390/life15091405","journal":{"identity":"life","isVorOnly":true,"title":"Life"},"publishedOn":"2025-09-05 00:00:00","publishedOnDateReadable":"September 5th, 2025"},"versionCreatedAt":"2025-07-08 13:54:45","video":"","vorDoi":"10.3390/life15091405","vorDoiUrl":"https://doi.org/10.3390/life15091405","workflowStages":[]},"version":"v1","identity":"rs-7047607","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7047607","identity":"rs-7047607","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}