Effect of Cell Therapy With Adipose-Derived Stem Cells in the Treatment of Acute Rupture of the Achilles Tendon in Humans

Effect of Cell Therapy With Adipose-Derived Stem Cells in the Treatment of Acute Rupture of the Achilles Tendon in Humans | 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 Cell Therapy With Adipose-Derived Stem Cells in the Treatment of Acute Rupture of the Achilles Tendon in Humans Maria Helena Costa Vieira, Laynna de Carvalho Schweich-Adami, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3867626/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract The aim of this study was to evaluate the effect of adipose-derived stem cells (ADSCs) in the treatment of acute rupture of the Achilles tendon. It was a cross-sectional study involving 15 patients. Patients were randomly divided: group 1 - rupture; group 2 – suture; group 3 – rupture + ADSCs. In the AOFAS score, the score was higher in group 3 with a significant difference. In the ATRS score, the score was higher in groups 2 and 3, also with a significant difference. As for the ultrasound score, there was a significant difference between the experimental groups in relation to this score, however, in the multiple comparisons test, comparing two groups at a time, it was possible to observe a significant difference of the experimental groups. It can be concluded that cell therapy in this condition may be a treatment option due to tissue regeneration and significant recovery of function. Cell Therapy Achilles tendon ADSCs Orthopedics Regenerative Medicine Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Rupture is a serious injury and one of the most common, affecting approximately 1.85 per 1.000 inhabitants, and the prevalence of this condition is estimated at 0.2% in sedentary individuals and 9% in athletes, with an increasing aspect in recent decades (Mansur et al. 2020a ). Most injuries occur during participation in sports activities, without preparing this structure for the overload of the movements required (Mansur et al. 2020b ). Among the existing treatments (conservative and surgical), it should be noted that the scar tissue that will be formed at the site of the cicatricial injury has a high cell density and decreased collagen organization compared to the pre-injured tissue. This altered cellular organization serves as a basis for poor outcomes such as rupturing, restrictive adhesions, and poor function following treatment of tendon tears (Mansur et al. 2020a ; Mansur et al. 2020b ). Therefore, innovative treatment options to improve tendon healing are of great interest to de regenerative medicine comunity. Current research cell therapy with adipose-derived stem cells (ADSCs) shows excellent results in animal models (Arnaud-Franco et al. 2022 ; Chailakhyan et al. 2021 ; Shen et al. 2020 ). However, the clinical approach in humans is still not well understood. Our group has expertise on the subject due to experience with the animal model (Vieira et al. 2014 ), therefore, the objective of this work was to take this step further and analyze this type of treatment in humans, and be a pioneering study in our region. In view of this, the objective of this study was to evaluate the therapeutic potential of ADSCs in the repair of acute rupture of the Achilles tendon in humans. Materials and Methods Casuistry and ethical approval This research has the approval of the Ethics Committee in Human Research of the Federal University of Mato Grosso do Sul (CEP) nº 2.257.789, and of the National Commission and Ethics in Research (CONEP), nº 2.296.516, CAAE: 73178417.5. 0000.0021. From January 2019 to January 2020, 15 adult patients of both sexes, aged over 18 years, with a history of acute rupture of the Achilles tendon (maximum 72 hours after the trauma) were treated at the emergency room of the Maria Aparecida Pedrossian University Hospital (HUMAP). The patients signed the Informed Consent Form. Exclusion criteria were patients with a history of previous tendon rupture or rupture time longer than 72 hours. The groups were not blinded to the interventions they would receive, due to the specificity of the procedures that were performed. Patients were randomly divided into three groups of five with 5 patients randomly according to hospital emergency admission, as follows: Group 1 - patients submitted to immobilization with long immobilizing boot with foot in plantar flexion of 20 degrees (use of hindfoot wedge) for six weeks with partial support (use of crutches) and another 4 weeks with long immobilizing boot with foot in position neutral with full support. Group 2 - patients submitted to suturing using a minimally invasive technique (Webb and Bannister 1999 ) and immobilization with immobilizing boot as described above. Group 3 - patients submitted to immobilization with an immobilizing boot as described above, in the 3rd week they received a local injection of ADSCs. After this period, the patient remained for another 4 weeks with a long immobilizing boot, with the foot in a neutral position with full support. Surgical procedures : Achilles tendon tenorrhaphy To perform the Achilles tendon tenorrhaphy surgery, sedation was performed associated with spinal anesthesia. The technique used in this work was performed according to Webb and Bannister ( 1999 ), with modifications (Webb and Bannister 1999 ). Patients were placed in the prone position on a surgical table and skin incisions were marked on the posterior surface of the Achilles tendon. The first incision was made at the rupture site, the second 5 cm proximal to this and the third 5 cm distal. The proximal incision is made over the medial half of the Achilles tendon to reduce the risk of injury to the sural nerve as it approaches the midline in its proximal course. The paratenon is incised transversely and with a hemostat the stumps of the tendon are exposed. The tendon suture was performed using the Krackow technique (Fig. 1 ) using vicryl thread No. 2 and skin closure using 3 − 0 polyamide thread. Local dressing and limb immobilization were performed as described above. Procedure for fat collection, extraction and cultivation of ADSCs Liposuction surgery was performed as described in Pesarini, et al . (2017) (Pesarini et al. 2017 ) on average 200 ml of biological material were extracted from the lower abdomen region. Subsequently, the container containing the liposuction was sent to the Center for Studies in Stem Cells, Cell Therapy and Toxicological Genetics (CeTroGen/HUMAP/EBSERH), to proceed with the extraction and cultivation protocol that was performed as described in Schweich-Adami, et al (2022) (Carvalho Schweich-Adami et al. 2022 ) (Fig. 2 ). The cell culture process was carried out until the amount of 4x10 6 cells was reached (≅ 21 days). Between the passages, an aliquot of cells was reserved and expanded separately, so that biological assays could be performed to confirm the actual presence of ADSCs in the 1st passage (flow cytometry (CD105, CD90, CD34 and CD133) and cell differentiation ( adipogenic, osteogenic, and chondrogenic) as described in Schweich, et al. (2017) (de Carvalho Schweich et al. 2017 ) (Fig. 3 ). All biological materials used for transplantation were previously submitted to analysis of cell viability and membrane integrity using Propidium Iodide (50ug/mL) with acquisition in an ACCURI C6 (Becton Dickinson, USA), and conventional microbiological routine (aerobiosis and microaerophilia), for 72 hours of incubation. Syringe preparation with ADSCs for application Upon reaching the ideal number of cells (4x10 6 ), the culture was prepared as described in Schweich-Adami, et al (2022) (Carvalho Schweich-Adami et al. 2022 ). At the end, the pellet was resuspended in 1mL of saline solution and transferred to a syringe (Fig. 2 ). The patient was contacted one day before the procedure to attend the HUMAP-UFMS Orthopedics outpatient clinic. The procedure was performed using local asepsis in the topography of the rupture area and local anesthesia with 0.5mL of Lidocaine 2% without vasoconstrictor. ADSCs were injected directly into the lesion area (Fig. 2 ). Clinical and ultrasound evaluation The clinical evaluations (AOFAS and ATRS BrP scale) as well as the ultrasound examination were performed 12 weeks after the rupture, the first two being performed by an orthopedist and the last by an ultrasonographer. Both blindly. The ultrasound device used was the Sonoace R7 (Samsung) with a linear transducer. Statistical analysis The comparison between the experimental groups, in relation to the quantitative variables evaluated in this study (age, AOFAS score, ATRS BrP and ultrasound score), was performed using the one-way ANOVA test, followed by the Tukey post-test. The evaluation of the association between the experimental group and the categorical variables evaluated in this study (gender and side) was performed using the chi-square test. The other results of the variables evaluated in this study were presented in the form of descriptive statistics or in the form of tables and graphs. Statistical analysis was performed using the SigmaPlot statistical program, version 12.5, considering a significance level of 5% (Shott 1990 ). Results There was no difference between the experimental groups regarding the age of the study participants (p > 0.05). The median age was 49 years. There was also no association between the experimental group and the categorical variables gender and side of tendon rupture (p > 0.05). The results of the comparison between the experimental groups in terms of age, gender, side of the tendon injury and tendon evaluation using the AOFAS, ATRS BrP and ultrasound scores are shown in Table 1. Table 3 Results of the comparison between the experimental groups in relation to age, gender, side of tendon injury and tendon evaluation using AOFAS, ATRS BrP scores and ultrasonography. VARIÁVEL CONTROL GROUP EXPERIMENTAL GROUP P value Rupture (n = 5) Rupture+ suture (n = 5) Rupture+ ADSCs (n = 5) Age 56,60 ± 4,14 44,80 ± 6,09 46,40 ± 6,04 0,295 Gender Male 80,0 (4) 100,0 (5) 100,0 (5) 0,343 Female 20,0 (1) 0,0 (0) 0,0 (0) Side Right 60,0 (3) 20,0 (1) 20,0 (1) 0,301 Left 40,0 (2) 80,0 (4) 80,0 (4) Avaliação do tendão AOFAS score 83,60 ± 4,23 b 92,00 ± 1,87 ab 98,40 ± 0,75 a 0,008 ATRS BrP score 52,40 ± 2,71 b 70,20 ± 2,91 a 82,60 ± 5,03 a < 0,001 Ultrasound score 4,80 ± 0,86 b 8,40 ± 0,98 a 8,80 ± 1,11 a 0,002 Results are presented as mean ± standard error of mean or relative frequency (absolute frequency). The p values ​​presented are in the one-way ANOVA test (quantitative variables) or in the chi-square test (categorical variables). Different letters on the line indicate a significant difference between the experimental groups (Tukey's post-test, p < 0.05). AOFAS: American Orthophaedic Foot And Ankle Society; ATRS BrP: Brazilian Version of the Achilles Tendon Total Rupture Score. On the other hand, there was a significant difference between the experimental groups in relation to the AOFAS score (p < 0.05), and this score was higher in the participants of the Rupture + ADSCs group, when compared with that among the participants in the Rupture group (p < 0.05). However, the AOFAS score observed among the participants in the Rupture + Suture group was not significantly different from that of the participants in the Rupture only group nor from that of the participants in the Rupture + ADSCs group (p > 0.05) (Fig. 4 ). Regarding the ATRS BrP score, there was also a significant difference between the experimental groups (p < 0.05), and this score was higher in the participants of the Rupture + Suture and Rupture + ADSCs groups, when compared to that of the participants in the Rupture group (p 0.05) (Fig. 4 ). As for the ultrasound score, there was a significant difference between the experimental groups in relation to this score (p < 0.05), in the multiple comparisons test, comparing two groups at a time, it was possible to observe a significant difference between the experimental groups and the rupture group (p < 0.05) (Fig. 4 ). Discussion Achilles tendon injuries are considered common and have a slow, complex and ineffective natural repair process because of its low intrinsic cellularity and low vascularity (Arnaud-Franco et al. 2022 ). Rerupture rates after conservative treatment in acute Achilles tendon ruptures (less than 72 hours after the trauma) are similar to the group of patients undergoing surgical treatment, with the advantage of not presenting complications from the surgical wound and running the risk, even if below, from injury to the sural nerve, which is one of the complications of the procedure (Krogh et al. 2016 ). No significant difference was observed between the Rupture + Suture and Rupture + ADSCs groups in any of the scores used. The choice of method used in this work, which may be the factor responsible for the lack of difference between groups (Webb and Bannister 1999 ). The fact of adding cell therapy to conservative treatment would make it possible for patients not to need the surgical procedure when suffering a tendon rupture and still have strength and work capacity similar to individuals without injury. The current literature about regenerative medicine in this condition has proven, even if only in animals, the specific cell differentiation capacity of ADSCs, paracrine and immunomodulatory effect by changing the phenotypic response of macrophages to tendon injury from a standard pro-inflammatory M1 phenotype for a pro-regenerative M2 phenotype in the acute phase of the injury, maintenance of the original architecture of the tendon by the arrangement of collagen fibers in the histological analysis and even in relation to the greater amount of synthesis of collagen I and III which are important components for the function tendon (Arnaud-Franco et al. 2022 ; Chailakhyan et al. 2021 ; Krogh et al. 2016 ; Shen et al. 2020 ; Vieira et al. 2014 ). Correlating the histology with the ultrasound image (used in the present study), it is observed that, at 12 weeks, the tendon is already in the remodeling phase of the healing process, despite still having high cellularity and a fibrous appearance. These characteristics will give rise to aligned collagen fibers and a decrease in the number of cells around one to two years after the rupture. Perhaps for this reason, regarding the ultrasound score, the Rupture group had a lower score, as the cells were beginning to organize themselves without other factors such as the suture thread (which acts as a tutor for directing the collagen fibers) and the ADSCs which participate in tendon repair by directly contributing by differentiating into tissue-specific cell phenotypes and the production of extracellular matrix. Further clarification would have been provided if we had performed histological analysis in our study, but we were not authorized by the ethics committee to perform this procedure. But, although there is a significant difference between the groups studied in relation to the ultrasound examination, Möller et al ( 2002 ) observed in their work with the use of Nuclear Magnetic Resonance and Ultrasound examination after conservative or surgical treatment of acute rupture of the Achilles tendon, that there was no correlation between the exam findings and the clinical parameters found (Möller et al. 2002 ), that is, the patients had alterations in the exams but clinically they were without symptoms, the same being observed in this work through the results found in the AOFAS and ATRS BrP scores. The microenvironment in which ADSCs reside in vivo provides signals (secreted receptors and soluble factors for cell-cell communication, extracellular matrix, oxidative stress, and vascularization) that direct them to metabolize, self-renew, differentiate, or remain inactive. Both intrinsic cell deficits and the aging microenvironment, along with the systemic changes associated with age-associated hormonal and metabolic signals, can inhibit or alter the functions of tendon stem cells, resulting in less physical conditioning of these primitive cells and, therefore, more injuries. frequent and poor results of tendon repair (Zabrzyński et al. 2018 ). In this way, it is important to emphasize that the health of the individual who will receive the ADSCs is an essential factor for the cellular function after being injected. Conclusion As discussed, despite the literature showing that conservative treatment has similar results to surgical treatment in centers that offer early rehabilitation, scar tissue is of lower quality than non-injured tissue. In our work, there was no statistical difference between the experimental groups, only when compared to the control group. Although the number of participants is small, these initial results in humans already allow us to infer that patients who are in a hospital that does not provide early rehabilitation and cannot be referred to the operating room, when they receive ADSCs, they will also have an effective treatment for your condition. The use of ADSCs can be a treatment option, especially for athletes, due to tissue regeneration and significant recovery of function. Declarations Acknowledgements Thank you for the availability of resources provided for this study by FUNDECT (FUNDECT N° 10/2015, UNIVERSAL-MS Nº 092/2016). Thank you to the Federal University of Mato Grosso do Sul – UFMS/MEC – Brazil and University Hospital Maria Aparecida Pedrossian (HUMAP/EBSERH), for allowing this research to be carried out. Authors contribution MHCV screening patients, performed the tendon surgeries and made the application of ADSCS and PRP; LCSA performed the extraction and cultivation of ADSCs and prepared them for application; MHCV and ACMBAS had the idea for the article, performed the literature search, assays, data analysis and write the article; and RJO performed the data analysis and revised the article. Disclosure of Interest The authors report no conflict of interest. Data availability statement Data will be made available if there is a reasonable requirement References Arnaud-Franco Á, Lara-Arias J, Marino-Martínez IA, Cienfuegos-Jiménez O, Barbosa-Quintana Á, Peña-Martínez VM (2022) Effect of Adipose-Derived Mesenchymal Stem Cells (ADMSCs) Application in Achilles-Tendon Injury in an Animal Model Current Issues in Molecular Biology 44:5827–5838 Carvalho Schweich-Adami L et al. (2022) The intra‐articular injection of adipose‐derived stem cells decreases pain and reduces inflammation in knee osteoarthritis, with or without the addition of platelet‐rich plasma also improves functionality Journal of tissue engineering and regenerative medicine 16:900–912 Chailakhyan RK et al. (2021) Autologous bone marrow-derived mesenchymal stem cells provide complete regeneration in a rabbit model of the Achilles tendon bundle rupture International Orthopaedics 45:3263–3276 de Carvalho Schweich L et al. (2017) All-trans retinoic acid induces mitochondria-mediated apoptosis of human adipose-derived stem cells and affects the balance of the adipogenic differentiation Biomedicine & Pharmacotherapy 96:1267–1274 Krogh TP, Ellingsen T, Christensen R, Jensen P, Fredberg U (2016) Ultrasound-guided injection therapy of Achilles tendinopathy with platelet-rich plasma or saline: a randomized, blinded, placebo-controlled trial The American journal of sports medicine 44:1990–1997 Mansur NSB, Fonseca LF, Matsunaga FT, Baumfeld DS, de Souza Nery CA, Tamaoki MJS (2020a) Lesões do Aquiles–Parte 1: Tendinopatias Revista Brasileira de Ortopedia Mansur NSB, Fonseca LF, Matsunaga FT, Baumfeld DS, de Souza Nery CA, Tamaoki MJS (2020b) Lesões do Aquiles–Parte 2: Rupturas Revista Brasileira de Ortopedia Möller M, Kälebo P, Tidebrant G, Movin T, Karlsson J (2002) The ultrasonographic appearance of the ruptured Achilles tendon during healing: a longitudinal evaluation of surgical and nonsurgical treatment, with comparisons to MRI appearance Knee Surgery, Sports Traumatology, Arthroscopy 10:49–56 Pesarini JR et al. (2017) Vitamin D: Correlation with biochemical and body composition changes in a southern Brazilian population and induction of cytotoxicity in mesenchymal stem cells derived from human adipose tissue Biomedicine & Pharmacotherapy 91:861–871 Shen H, Yoneda S, Abu-Amer Y, Guilak F, Gelberman RH (2020) Stem cell‐derived extracellular vesicles attenuate the early inflammatory response after tendon injury and repair Journal of Orthopaedic Research® 38:117–127 Shott S (1990) Statistics for health professionals Vieira M et al. (2014) Therapeutic potential of mesenchymal stem cells to treat Achilles tendon injuries Genet Mol Res 13:10434–10449 Webb J, Bannister G (1999) Percutaneous repair of the ruptured tendo Achillis The Journal of bone and joint surgery British volume 81:877–880 Zabrzyński J, Zabrzyńska A, Grzanka D (2018) Tendon—function-related structure, simple healing process and mysterious ageing Folia morphologica 77:416–427 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 May, 2024 Reviews received at journal 10 May, 2024 Reviewers agreed at journal 28 Apr, 2024 Reviewers invited by journal 16 Jan, 2024 Editor assigned by journal 16 Jan, 2024 Submission checks completed at journal 16 Jan, 2024 First submitted to journal 15 Jan, 2024 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-3867626","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":267354654,"identity":"78a4b50f-c569-4b8b-9263-b82a45f10851","order_by":0,"name":"Maria Helena Costa Vieira","email":"","orcid":"","institution":"Hospital Universitário Maria Aparecida Pedrossian – HUMAP, Universidade Federal de Mato Grosso do Sul – UFMS","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Helena Costa","lastName":"Vieira","suffix":""},{"id":267354655,"identity":"685d18ea-aeb9-4fcf-b1d6-f392ca0002d8","order_by":1,"name":"Laynna de Carvalho Schweich-Adami","email":"","orcid":"","institution":"Terapia Celular e Genética Toxicológica – CeTroGen, Hospital Universitário Maria Aparecida Pedrossian - HUMAP, Universidade Federal de Mato Grosso do Sul - UFMS","correspondingAuthor":false,"prefix":"","firstName":"Laynna","middleName":"de Carvalho","lastName":"Schweich-Adami","suffix":""},{"id":267354656,"identity":"c087ab82-fc9a-4e82-b826-29a2f583fb3d","order_by":2,"name":"Rodrigo Juliano Oliveira","email":"","orcid":"","institution":"Terapia Celular e Genética Toxicológica – CeTroGen, Hospital Universitário Maria Aparecida Pedrossian - HUMAP, Universidade Federal de Mato Grosso do Sul - UFMS","correspondingAuthor":false,"prefix":"","firstName":"Rodrigo","middleName":"Juliano","lastName":"Oliveira","suffix":""},{"id":267354657,"identity":"9000a252-d74a-4d41-89ee-10ea78224cd7","order_by":3,"name":"Andréia Conceição Milan Brochado Antoniolli-Silva","email":"data:image/png;base64,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","orcid":"","institution":"Terapia Celular e Genética Toxicológica – CeTroGen, Hospital Universitário Maria Aparecida Pedrossian - HUMAP, Universidade Federal de Mato Grosso do Sul - UFMS","correspondingAuthor":true,"prefix":"","firstName":"Andréia","middleName":"Conceição Milan Brochado","lastName":"Antoniolli-Silva","suffix":""}],"badges":[],"createdAt":"2024-01-15 20:30:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3867626/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3867626/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49889736,"identity":"51b626cf-b5d6-4af3-a20a-3ecc0945e1f3","added_by":"auto","created_at":"2024-01-19 19:55:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":832449,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical technique for tenorrhaphy of the Achilles tendon A) The first incision was made at the rupture site, the second 5 cm proximally to this and the third 5 cm distally; B) Proximal incision was made over the medial half of the Achilles tendon; C) Paratenon was incised transversally and with a hemostat; D) Suture of the tendon with the Krackow technique and E) Closure of the surgery externally.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3867626/v1/a0ff02a2026e0f31edd8b8f9.png"},{"id":49889440,"identity":"9cd83762-da23-45d4-a86e-ea235b7f4c40","added_by":"auto","created_at":"2024-01-19 19:47:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":171970,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of procedures performed for liposuction processing, ADSCs extraction, cultivation, syringe preparation until ADSCs application in the tendon rupture area.\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3867626/v1/317142bfe1bd4edb53358396.png"},{"id":49889439,"identity":"f36c7c42-5e7d-4e78-ab6f-121273de864b","added_by":"auto","created_at":"2024-01-19 19:47:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":883688,"visible":true,"origin":"","legend":"\u003cp\u003eMorphology, characterization and differentiation potential of mesenchymal stem cells derived from adipose tissue: (A) Undifferentiated culture demonstrating cells with characteristics of fibroblasts, (B) culture of osteogenic differentiation and calcium deposits stained with Alizarin Red, ( C) culture of adipogenic differentiation and lipid vacuoles stained with Oil Red O and (D) culture of chondrogenic differentiation and extracellular matrix rich in glycosaminoglycans stained with Alcian Blue. Bars represent 50 µm. E) Immunophenotypic profile of mesenchymal stem cells derived from adipose tissue. The cells expressed CD105 and CD90 markers and did not express CD34 and CD133.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3867626/v1/65891c6b1f648fd674ed836c.png"},{"id":49889436,"identity":"ae307a38-e6c6-4e1c-a83e-23a419659904","added_by":"auto","created_at":"2024-01-19 19:47:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":45415,"visible":true,"origin":"","legend":"\u003cp\u003eA) Graph showing the score on the AOFAS scale in each experimental group; B) Graph showing the ATRS BrP scale score in each experimental group and C) Graph showing the ultrasound score in each experimental group The column represents the mean and the bar the standard error of the mean. Different letters between the columns represent a significant difference between the experimental groups (Tukey's post-test, p\u0026lt;0.05).\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-3867626/v1/2d8b1ce4a31430c4fd848586.png"},{"id":49890200,"identity":"cfdf926b-9aef-4095-b74a-90d302b067d8","added_by":"auto","created_at":"2024-01-19 20:03:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3338731,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3867626/v1/564a26b8-cce3-4679-b9ab-cd65270e5280.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffect of Cell Therapy With Adipose-Derived Stem Cells in the Treatment of Acute Rupture of the Achilles Tendon in Humans\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRupture is a serious injury and one of the most common, affecting approximately 1.85 per 1.000 inhabitants, and the prevalence of this condition is estimated at 0.2% in sedentary individuals and 9% in athletes, with an increasing aspect in recent decades (Mansur et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020a\u003c/span\u003e). Most injuries occur during participation in sports activities, without preparing this structure for the overload of the movements required (Mansur et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020b\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the existing treatments (conservative and surgical), it should be noted that the scar tissue that will be formed at the site of the cicatricial injury has a high cell density and decreased collagen organization compared to the pre-injured tissue. This altered cellular organization serves as a basis for poor outcomes such as rupturing, restrictive adhesions, and poor function following treatment of tendon tears (Mansur et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020a\u003c/span\u003e; Mansur et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020b\u003c/span\u003e). Therefore, innovative treatment options to improve tendon healing are of great interest to de regenerative medicine comunity.\u003c/p\u003e \u003cp\u003eCurrent research cell therapy with adipose-derived stem cells (ADSCs) shows excellent results in animal models (Arnaud-Franco et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Chailakhyan et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Shen et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, the clinical approach in humans is still not well understood. Our group has expertise on the subject due to experience with the animal model (Vieira et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), therefore, the objective of this work was to take this step further and analyze this type of treatment in humans, and be a pioneering study in our region. In view of this, the objective of this study was to evaluate the therapeutic potential of ADSCs in the repair of acute rupture of the Achilles tendon in humans.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCasuistry and ethical approval\u003c/h2\u003e \u003cp\u003e This research has the approval of the Ethics Committee in Human Research of the Federal University of Mato Grosso do Sul (CEP) n\u0026ordm; 2.257.789, and of the National Commission and Ethics in Research (CONEP), n\u0026ordm; 2.296.516, CAAE: 73178417.5. 0000.0021.\u003c/p\u003e \u003cp\u003eFrom January 2019 to January 2020, 15 adult patients of both sexes, aged over 18 years, with a history of acute rupture of the Achilles tendon (maximum 72 hours after the trauma) were treated at the emergency room of the Maria Aparecida Pedrossian University Hospital (HUMAP). The patients signed the Informed Consent Form.\u003c/p\u003e \u003cp\u003eExclusion criteria were patients with a history of previous tendon rupture or rupture time longer than 72 hours.\u003c/p\u003e \u003cp\u003eThe groups were not blinded to the interventions they would receive, due to the specificity of the procedures that were performed. Patients were randomly divided into three groups of five with 5 patients randomly according to hospital emergency admission, as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGroup 1\u003c/b\u003e - patients submitted to immobilization with long immobilizing boot with foot in plantar flexion of 20 degrees (use of hindfoot wedge) for six weeks with partial support (use of crutches) and another 4 weeks with long immobilizing boot with foot in position neutral with full support.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGroup 2\u003c/b\u003e - patients submitted to suturing using a minimally invasive technique (Webb and Bannister \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) and immobilization with immobilizing boot as described above.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGroup 3\u003c/b\u003e - patients submitted to immobilization with an immobilizing boot as described above, in the 3rd week they received a local injection of ADSCs. After this period, the patient remained for another 4 weeks with a long immobilizing boot, with the foot in a neutral position with full support.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedures : Achilles tendon tenorrhaphy\u003c/h2\u003e \u003cp\u003eTo perform the Achilles tendon tenorrhaphy surgery, sedation was performed associated with spinal anesthesia. The technique used in this work was performed according to Webb and Bannister (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1999\u003c/span\u003e), with modifications (Webb and Bannister \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). Patients were placed in the prone position on a surgical table and skin incisions were marked on the posterior surface of the Achilles tendon. The first incision was made at the rupture site, the second 5 cm proximal to this and the third 5 cm distal. The proximal incision is made over the medial half of the Achilles tendon to reduce the risk of injury to the sural nerve as it approaches the midline in its proximal course. The paratenon is incised transversely and with a hemostat the stumps of the tendon are exposed. The tendon suture was performed using the Krackow technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) using vicryl thread No. 2 and skin closure using 3\u0026thinsp;\u0026minus;\u0026thinsp;0 polyamide thread. Local dressing and limb immobilization were performed as described above.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eProcedure for fat collection, extraction and cultivation of ADSCs\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eLiposuction surgery was performed as described in Pesarini, \u003cem\u003eet al\u003c/em\u003e. (2017) (Pesarini et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) on average 200 ml of biological material were extracted from the lower abdomen region. Subsequently, the container containing the liposuction was sent to the Center for Studies in Stem Cells, Cell Therapy and Toxicological Genetics (CeTroGen/HUMAP/EBSERH), to proceed with the extraction and cultivation protocol that was performed as described in Schweich-Adami, \u003cem\u003eet al\u003c/em\u003e (2022) (Carvalho Schweich-Adami et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe cell culture process was carried out until the amount of 4x10\u003csup\u003e6\u003c/sup\u003e cells was reached (\u0026cong;\u0026thinsp;21 days). Between the passages, an aliquot of cells was reserved and expanded separately, so that biological assays could be performed to confirm the actual presence of ADSCs in the 1st passage (flow cytometry (CD105, CD90, CD34 and CD133) and cell differentiation ( adipogenic, osteogenic, and chondrogenic) as described in Schweich, \u003cem\u003eet al.\u003c/em\u003e (2017) (de Carvalho Schweich et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). All biological materials used for transplantation were previously submitted to analysis of cell viability and membrane integrity using Propidium Iodide (50ug/mL) with acquisition in an ACCURI C6 (Becton Dickinson, USA), and conventional microbiological routine (aerobiosis and microaerophilia), for 72 hours of incubation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSyringe preparation with ADSCs for application\u003c/h2\u003e \u003cp\u003eUpon reaching the ideal number of cells (4x10\u003csup\u003e6\u003c/sup\u003e), the culture was prepared as described in Schweich-Adami, \u003cem\u003eet al\u003c/em\u003e (2022) (Carvalho Schweich-Adami et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). At the end, the pellet was resuspended in 1mL of saline solution and transferred to a syringe (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The patient was contacted one day before the procedure to attend the HUMAP-UFMS Orthopedics outpatient clinic. The procedure was performed using local asepsis in the topography of the rupture area and local anesthesia with 0.5mL of Lidocaine 2% without vasoconstrictor. ADSCs were injected directly into the lesion area (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eClinical and ultrasound evaluation\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe clinical evaluations (AOFAS and ATRS BrP scale) as well as the ultrasound examination were performed 12 weeks after the rupture, the first two being performed by an orthopedist and the last by an ultrasonographer. Both blindly. The ultrasound device used was the Sonoace R7 (Samsung) with a linear transducer.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003e The comparison between the experimental groups, in relation to the quantitative variables evaluated in this study (age, AOFAS score, ATRS BrP and ultrasound score), was performed using the one-way ANOVA test, followed by the Tukey post-test. The evaluation of the association between the experimental group and the categorical variables evaluated in this study (gender and side) was performed using the chi-square test. The other results of the variables evaluated in this study were presented in the form of descriptive statistics or in the form of tables and graphs. Statistical analysis was performed using the SigmaPlot statistical program, version 12.5, considering a significance level of 5% (Shott \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1990\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere was no difference between the experimental groups regarding the age of the study participants (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The median age was 49 years. There was also no association between the experimental group and the categorical variables gender and side of tendon rupture (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe results of the comparison between the experimental groups in terms of age, gender, side of the tendon injury and tendon evaluation using the AOFAS, ATRS BrP and ultrasound scores are shown in Table\u0026nbsp;1.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of the comparison between the experimental groups in relation to age, gender, side of tendon injury and tendon evaluation using AOFAS, ATRS BrP scores and ultrasonography.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVARI\u0026Aacute;VEL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCONTROL GROUP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEXPERIMENTAL GROUP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRupture\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;5)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eRupture+\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003esuture\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;5)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eRupture+\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eADSCs\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;5)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56,60\u0026thinsp;\u0026plusmn;\u0026thinsp;4,14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e44,80\u0026thinsp;\u0026plusmn;\u0026thinsp;6,09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46,40\u0026thinsp;\u0026plusmn;\u0026thinsp;6,04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80,0 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e100,0 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100,0 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,343\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20,0 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0,0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60,0 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e20,0 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20,0 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,301\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40,0 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e80,0 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80,0 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvalia\u0026ccedil;\u0026atilde;o do tend\u0026atilde;o\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAOFAS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83,60\u0026thinsp;\u0026plusmn;\u0026thinsp;4,23\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e92,00\u0026thinsp;\u0026plusmn;\u0026thinsp;1,87\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98,40\u0026thinsp;\u0026plusmn;\u0026thinsp;0,75\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eATRS BrP score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52,40\u0026thinsp;\u0026plusmn;\u0026thinsp;2,71\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e70,20\u0026thinsp;\u0026plusmn;\u0026thinsp;2,91\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82,60\u0026thinsp;\u0026plusmn;\u0026thinsp;5,03\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasound score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,80\u0026thinsp;\u0026plusmn;\u0026thinsp;0,86 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8,40\u0026thinsp;\u0026plusmn;\u0026thinsp;0,98\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8,80\u0026thinsp;\u0026plusmn;\u0026thinsp;1,11\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eResults are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error of mean or relative frequency (absolute frequency). The p values ​​presented are in the one-way ANOVA test (quantitative variables) or in the chi-square test (categorical variables). Different letters on the line indicate a significant difference between the experimental groups (Tukey's post-test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). AOFAS: American Orthophaedic Foot And Ankle Society; ATRS BrP: Brazilian Version of the Achilles Tendon Total Rupture Score.\u003c/p\u003e \u003cp\u003eOn the other hand, there was a significant difference between the experimental groups in relation to the AOFAS score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and this score was higher in the participants of the Rupture\u0026thinsp;+\u0026thinsp;ADSCs group, when compared with that among the participants in the Rupture group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, the AOFAS score observed among the participants in the Rupture\u0026thinsp;+\u0026thinsp;Suture group was not significantly different from that of the participants in the Rupture only group nor from that of the participants in the Rupture\u0026thinsp;+\u0026thinsp;ADSCs group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding the ATRS BrP score, there was also a significant difference between the experimental groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and this score was higher in the participants of the Rupture\u0026thinsp;+\u0026thinsp;Suture and Rupture\u0026thinsp;+\u0026thinsp;ADSCs groups, when compared to that of the participants in the Rupture group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), however, with no significant difference between them (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs for the ultrasound score, there was a significant difference between the experimental groups in relation to this score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), in the multiple comparisons test, comparing two groups at a time, it was possible to observe a significant difference between the experimental groups and the rupture group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAchilles tendon injuries are considered common and have a slow, complex and ineffective natural repair process because of its low intrinsic cellularity and low vascularity (Arnaud-Franco et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Rerupture rates after conservative treatment in acute Achilles tendon ruptures (less than 72 hours after the trauma) are similar to the group of patients undergoing surgical treatment, with the advantage of not presenting complications from the surgical wound and running the risk, even if below, from injury to the sural nerve, which is one of the complications of the procedure (Krogh et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). No significant difference was observed between the Rupture\u0026thinsp;+\u0026thinsp;Suture and Rupture\u0026thinsp;+\u0026thinsp;ADSCs groups in any of the scores used. The choice of method used in this work, which may be the factor responsible for the lack of difference between groups (Webb and Bannister \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1999\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe fact of adding cell therapy to conservative treatment would make it possible for patients not to need the surgical procedure when suffering a tendon rupture and still have strength and work capacity similar to individuals without injury. The current literature about regenerative medicine in this condition has proven, even if only in animals, the specific cell differentiation capacity of ADSCs, paracrine and immunomodulatory effect by changing the phenotypic response of macrophages to tendon injury from a standard pro-inflammatory M1 phenotype for a pro-regenerative M2 phenotype in the acute phase of the injury, maintenance of the original architecture of the tendon by the arrangement of collagen fibers in the histological analysis and even in relation to the greater amount of synthesis of collagen I and III which are important components for the function tendon (Arnaud-Franco et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Chailakhyan et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Krogh et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Shen et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Vieira et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCorrelating the histology with the ultrasound image (used in the present study), it is observed that, at 12 weeks, the tendon is already in the remodeling phase of the healing process, despite still having high cellularity and a fibrous appearance. These characteristics will give rise to aligned collagen fibers and a decrease in the number of cells around one to two years after the rupture. Perhaps for this reason, regarding the ultrasound score, the Rupture group had a lower score, as the cells were beginning to organize themselves without other factors such as the suture thread (which acts as a tutor for directing the collagen fibers) and the ADSCs which participate in tendon repair by directly contributing by differentiating into tissue-specific cell phenotypes and the production of extracellular matrix. Further clarification would have been provided if we had performed histological analysis in our study, but we were not authorized by the ethics committee to perform this procedure.\u003c/p\u003e\u003cp\u003eBut, although there is a significant difference between the groups studied in relation to the ultrasound examination, M\u0026ouml;ller et al (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2002\u003c/span\u003e) observed in their work with the use of Nuclear Magnetic Resonance and Ultrasound examination after conservative or surgical treatment of acute rupture of the Achilles tendon, that there was no correlation between the exam findings and the clinical parameters found (M\u0026ouml;ller et al. \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2002\u003c/span\u003e), that is, the patients had alterations in the exams but clinically they were without symptoms, the same being observed in this work through the results found in the AOFAS and ATRS BrP scores.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe microenvironment in which ADSCs reside in vivo provides signals (secreted receptors and soluble factors for cell-cell communication, extracellular matrix, oxidative stress, and vascularization) that direct them to metabolize, self-renew, differentiate, or remain inactive. Both intrinsic cell deficits and the aging microenvironment, along with the systemic changes associated with age-associated hormonal and metabolic signals, can inhibit or alter the functions of tendon stem cells, resulting in less physical conditioning of these primitive cells and, therefore, more injuries. frequent and poor results of tendon repair (Zabrzyński et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In this way, it is important to emphasize that the health of the individual who will receive the ADSCs is an essential factor for the cellular function after being injected.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAs discussed, despite the literature showing that conservative treatment has similar results to surgical treatment in centers that offer early rehabilitation, scar tissue is of lower quality than non-injured tissue. In our work, there was no statistical difference between the experimental groups, only when compared to the control group. Although the number of participants is small, these initial results in humans already allow us to infer that patients who are in a hospital that does not provide early rehabilitation and cannot be referred to the operating room, when they receive ADSCs, they will also have an effective treatment for your condition. The use of ADSCs can be a treatment option, especially for athletes, due to tissue regeneration and significant recovery of function.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank you for the availability of resources provided for this study by FUNDECT (FUNDECT N\u0026deg; 10/2015, UNIVERSAL-MS N\u0026ordm; 092/2016). Thank you to the Federal University of Mato Grosso do Sul \u0026ndash; UFMS/MEC \u0026ndash; Brazil and University Hospital Maria Aparecida Pedrossian (HUMAP/EBSERH), for allowing this research to be carried out.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMHCV screening patients, \u0026nbsp;performed the tendon surgeries and made the application of ADSCS and PRP; \u0026nbsp; LCSA performed the extraction and cultivation of ADSCs and prepared them for application; MHCV and ACMBAS had the idea for the article, performed the literature search, assays, data analysis and write the article; and RJO performed the data analysis and revised the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be made available if there is a reasonable requirement\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArnaud-Franco \u0026Aacute;, Lara-Arias J, Marino-Mart\u0026iacute;nez IA, Cienfuegos-Jim\u0026eacute;nez O, Barbosa-Quintana \u0026Aacute;, Pe\u0026ntilde;a-Mart\u0026iacute;nez VM (2022) Effect of Adipose-Derived Mesenchymal Stem Cells (ADMSCs) Application in Achilles-Tendon Injury in an Animal Model Current Issues in Molecular Biology 44:5827\u0026ndash;5838\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarvalho Schweich-Adami L et al. (2022) The intra‐articular injection of adipose‐derived stem cells decreases pain and reduces inflammation in knee osteoarthritis, with or without the addition of platelet‐rich plasma also improves functionality Journal of tissue engineering and regenerative medicine 16:900\u0026ndash;912\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChailakhyan RK et al. (2021) Autologous bone marrow-derived mesenchymal stem cells provide complete regeneration in a rabbit model of the Achilles tendon bundle rupture International Orthopaedics 45:3263\u0026ndash;3276\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Carvalho Schweich L et al. (2017) All-trans retinoic acid induces mitochondria-mediated apoptosis of human adipose-derived stem cells and affects the balance of the adipogenic differentiation Biomedicine \u0026amp; Pharmacotherapy 96:1267\u0026ndash;1274\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrogh TP, Ellingsen T, Christensen R, Jensen P, Fredberg U (2016) Ultrasound-guided injection therapy of Achilles tendinopathy with platelet-rich plasma or saline: a randomized, blinded, placebo-controlled trial The American journal of sports medicine 44:1990\u0026ndash;1997\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMansur NSB, Fonseca LF, Matsunaga FT, Baumfeld DS, de Souza Nery CA, Tamaoki MJS (2020a) Les\u0026otilde;es do Aquiles\u0026ndash;Parte 1: Tendinopatias Revista Brasileira de Ortopedia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMansur NSB, Fonseca LF, Matsunaga FT, Baumfeld DS, de Souza Nery CA, Tamaoki MJS (2020b) Les\u0026otilde;es do Aquiles\u0026ndash;Parte 2: Rupturas Revista Brasileira de Ortopedia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026ouml;ller M, K\u0026auml;lebo P, Tidebrant G, Movin T, Karlsson J (2002) The ultrasonographic appearance of the ruptured Achilles tendon during healing: a longitudinal evaluation of surgical and nonsurgical treatment, with comparisons to MRI appearance Knee Surgery, Sports Traumatology, Arthroscopy 10:49\u0026ndash;56\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePesarini JR et al. (2017) Vitamin D: Correlation with biochemical and body composition changes in a southern Brazilian population and induction of cytotoxicity in mesenchymal stem cells derived from human adipose tissue Biomedicine \u0026amp; Pharmacotherapy 91:861\u0026ndash;871\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShen H, Yoneda S, Abu-Amer Y, Guilak F, Gelberman RH (2020) Stem cell‐derived extracellular vesicles attenuate the early inflammatory response after tendon injury and repair Journal of Orthopaedic Research\u0026reg; 38:117\u0026ndash;127\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShott S (1990) Statistics for health professionals\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVieira M et al. (2014) Therapeutic potential of mesenchymal stem cells to treat Achilles tendon injuries Genet Mol Res 13:10434\u0026ndash;10449\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWebb J, Bannister G (1999) Percutaneous repair of the ruptured tendo Achillis The Journal of bone and joint surgery British volume 81:877\u0026ndash;880\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZabrzyński J, Zabrzyńska A, Grzanka D (2018) Tendon\u0026mdash;function-related structure, simple healing process and mysterious ageing Folia morphologica 77:416\u0026ndash;427\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cell-and-tissue-banking","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"catb","sideBox":"Learn more about [Cell and Tissue Banking](http://link.springer.com/journal/10561)","snPcode":"10561","submissionUrl":"https://submission.nature.com/new-submission/10561/3","title":"Cell and Tissue Banking","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cell Therapy, Achilles tendon, ADSCs, Orthopedics, Regenerative Medicine","lastPublishedDoi":"10.21203/rs.3.rs-3867626/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3867626/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"The aim of this study was to evaluate the effect of adipose-derived stem cells (ADSCs) in the treatment of acute rupture of the Achilles tendon. It was a cross-sectional study involving 15 patients. Patients were randomly divided: group 1 - rupture; group 2 – suture; group 3 – rupture + ADSCs. In the AOFAS score, the score was higher in group 3 with a significant difference. In the ATRS score, the score was higher in groups 2 and 3, also with a significant difference. As for the ultrasound score, there was a significant difference between the experimental groups in relation to this score, however, in the multiple comparisons test, comparing two groups at a time, it was possible to observe a significant difference of the experimental groups. It can be concluded that cell therapy in this condition may be a treatment option due to tissue regeneration and significant recovery of function.","manuscriptTitle":"Effect of Cell Therapy With Adipose-Derived Stem Cells in the Treatment of Acute Rupture of the Achilles Tendon in Humans","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-19 19:47:08","doi":"10.21203/rs.3.rs-3867626/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-17T06:14:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-10T16:06:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"a37475cb-fd80-45f7-badb-cee605282a64","date":"2024-04-28T15:19:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-16T08:58:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-16T05:26:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-16T05:26:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cell and Tissue Banking","date":"2024-01-15T20:14:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cell-and-tissue-banking","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"catb","sideBox":"Learn more about [Cell and Tissue Banking](http://link.springer.com/journal/10561)","snPcode":"10561","submissionUrl":"https://submission.nature.com/new-submission/10561/3","title":"Cell and Tissue Banking","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"56cf4921-3a3e-4bf4-b1d4-36ad4b17ef11","owner":[],"postedDate":"January 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-25T13:29:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-19 19:47:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3867626","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3867626","identity":"rs-3867626","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}