Microfracture and bone morphogenetic protein 7 (BMP-7) synergistically stimulate articular cartilage repair A.C. Kuo, M.D., Ph.D., J.J. Rodrigo, M.D.,

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Microfracture and bone morphogenetic protein 7 (BMP-7) synergistically stimulate articular cartilage repair A.C. Kuo, M.D., Ph.D., J.J. Rodrigo, M.D., A.H. Reddi, Ph.D., S. Curtiss, A.S., E. Grotkopp, Ph.D., M. Chiu, M.Sc. Osteoarthritis and Cartilage Volume 14, Issue 11, Pages 1126-1135 (November 2006) DOI: 10.1016/j.joca.2006.04.004 Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 1 Gross appearance of a chondral defect. (A) Intraoperative appearance of a chondral defect. The specimen has been treated with microfracture and a collagen sponge. The collagen sponge has been press-fit into the microfracture hole on the right. The ruler shows millimeter spacing. (B) Appearance of a chondral defect at sacrifice. The lesion shown in (A) has been filled with two large areas of repair tissue. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 2 Calculation of the percentage of the original defect surface area covered with repair tissue at sacrifice. In order to quantitate the percentage of the original defect surface area covered with repair tissue, photographs were taken of the defects at the time of surgery (top panel) and sacrifice (bottom panel). The surface areas of the defects at surgery (B) and at sacrifice (C) were quantitated and used to calculate the percentage of surface area covered as shown. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 3 Histological results. Representative specimens of normal, control articular cartilage (combination treatment group), hyaline repair tissue (combination treatment group), fibrocartilage (microfracture single treatment group), and fibrous repair tissue (control defect group) are shown. Please see text for a discussion of staining patterns. The specimens in the far left column have been stained with safranin-O and fast green and visualized with white light. The second column shows type II collagen immunostaining. The third column shows type I collagen immunostaining. The specimens in the far right column have been stained with safranin-O and fast green and visualized with polarized light. Scale is as indicated in the lower right panel (objective, 20×). Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 4 Calculation of average tissue thickness. Image analysis of histology specimens was used to quantitate the average thickness of both repair tissue and normal adjacent articular cartilage. The total length of the tissue (L) and the total area of the tissue (dotted area A) were quantitated and then used to calculate average thickness as shown. Specimens were stained with H&E and viewed using the 20× objective. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 5 Histological appearance of a chondral defect immediately after creation. (A) Low power (objective, 2.5×). (B) High power (objective, 10×). Scale is as indicated. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 6 Comparison of microfracture with controls (hypothesis 1). Comparison of the microfracture single treatment group and the control defect group for percentage surface area covered, percentage thickness, percentage of specimens with smooth surface (ICRS 3), percentage of specimens with superior matrix (ICRS 2 and 3), and percentage of specimens with superior cell distribution (ICRS 2 and 3). *Indicates P<0.05; ***indicates P<0.001. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 7 Comparison of BMP-7 with controls (hypothesis 2). Comparison of the BMP-7 single treatment group and the control defect group for percentage surface area covered, percentage thickness, percentage of specimens with smooth surface (ICRS 3), percentage of specimens with superior matrix (ICRS 2 and 3), and percentage of specimens with superior cell distribution (ICRS 2 and 3). ***Indicates P<0.001. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 8 Comparison of the combination treatment with microfracture (hypothesis 3). Comparison of the combination treatment group (microfracture with BMP-7 in a collagen sponge) with the microfracture single treatment group for percentage surface area covered, percentage thickness, percentage of specimens with smooth surface (ICRS 3), percentage of specimens with superior matrix (ICRS 2 and 3), and percentage of specimens with superior cell distribution (ICRS 2 and 3). *Indicates P<0.05. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 9 Comparison of the combination treatment with BMP-7 (hypothesis 4). Comparison of the combination treatment group (microfracture with BMP-7 in a collagen sponge) with the BMP-7 single treatment group for percentage surface area covered, percentage thickness, percentage of specimens with smooth surface (ICRS 3), percentage of specimens with superior matrix (ICRS 2 and 3), and percentage of specimens with superior cell distribution (ICRS 2 and 3). **Indicates P<0.01; ***indicates P<0.001. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions

Fig. 10 Comparison of the combination treatment with controls. Comparison of the combination treatment group (microfracture with BMP-7 in a collagen sponge) with the control defect group for percentage surface area covered, percentage thickness, percentage of specimens with smooth surface (ICRS 3), percentage of specimens with superior matrix (ICRS 2 and 3), and percentage of specimens with superior cell distribution (ICRS 2 and 3). *Indicates P<0.05; ***indicates P<0.001. Osteoarthritis and Cartilage 2006 14, 1126-1135DOI: (10.1016/j.joca.2006.04.004) Copyright © 2006 OsteoArthritis Research Society International Terms and Conditions