Arthrosocpic Treatment of Knee Chondral Lesions: Clinical, MRI and Histologic Comparison Between the Use of PRP vs ADSCs in Addition to Marrow Stimulation Techniques
Phase: PHASE4
Conditions: Knee Chondral Lesion
Sponsor: Università degli Studi dell'Aquila

Arthrosocpic Treatment of Knee Chondral Lesions: Clinical, MRI and Histologic 
Comparison Between the Use of PRP vs ADSCs in Addition to Marrow Stimulation 
Techniques  
NCT ID not yet assigned 
Unique protocol id 23/2019 
Document date: March 25, 2019. Traslated into English on August 27, 2025 
 
As the original documents were written exclusively in Italian, the following is the complete 
translation of each document into English, presented alongside the original text.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Proposing institution: MESVA Department, Residency Programme in Orthopedics and 
Traumatology, University of L'Aquila. 
 
Project Title: Arthroscopic Treatment of Knee Chondral lesions: Clinical, MRI and Histologic 
comparisons between the use of PRP vs ADSCs in addition to Marrow stimulation techniques 
 
Protocol version and date: version 1/19 - protocol March 2019 
 
Project manager: Vittorio Calvisi, Associate Professor, Department of Life, Health and 
Environmental Sciences, University of L'Aquila, Via Vetoio-Coppito 2, 67100, L'Aquila, 
Italy Tel.: +39 337 743107 e-mail:  
 
Research location: U.O.S.D. D.U. Minimally Invasive and Computer-Assisted Orthopedic 
Surgery directed by Prof. Calvisi at the San Salvatore Hospital in L'Aquila. 
 
Introduction 
Today, chondral lesions are one of the most frequently diagnosed knee joint pathologies in 
clinical practice, as the primary cause of pain and reduced joint function in an active patient 
population. At a time when regenerative medicine is facing increasingly demanding 
expectations, by implementing the development of new surgical techniques based on tissue 
engineering, we have reconsidered therapeutic algorithms for the treatment of chondral 
lesions, which involve mesenchymal stimulation techniques proposed in the 1980s and 
1990s., using chondroplasty for abrasion (L.L. Johnson 1986) or microfractures according to 
Steadman (1997), which are still relevant today in the treatment of such lesions, remaining the 
first therapeutic option given their simplicity of execution, low cost, and minimal invasiveness 
(1,2). Medullary stimulation through abrasion chondroplasty is based on the abrasion of the 
subchondral bone using a motorized instrument (ABRADER), while the microfracture 
technique is based on the creation of small perforations using special punches that penetrate 
the subchondral bone: both procedures aim to remove necrotic osteons and allow bleeding 
from the subchondral tissue where mesenchymal cells are present. The clot thus formed 
should evolve, if not subjected to an immediate load, toward the formation of a 
fibrocartilaginous tissue that, although with debated biomechanical and biological qualities, 
allows the formation of a fibrocartilaginous tissue that "repairs" the osteochondral damage 
(Calvisi V, 1990) (3,4).  
 
Platelet-rich plasma (PRP) was first utilized in a surgical context in 1998 and has since 
become the subject of extensive research due to its potential in promoting tissue regeneration 
and repair. This treatment has gained significant traction in the medical field, leading to a wide 
range of applications (5). Its definition, a point that has been extensively discussed in the 
composition of the aforementioned, is generally understood to be a platelet concentrate that 
exhibits significant variability in its amount of mononuclear material. 
The elements were found to be capable of activating degranulation, which consequently led to 
the release of bioactive factors (GF, PDGF, TGF-b, PEDGF, VEGF, IGF-1, FGF, EGF, ecc) with 
tissue-specific action, playing a key role in chemotaxis, cell proliferation, and modulation of 
the inflammatory response. At the cartilage level, in vitro studies have revealed the potential of 

PRP to orient mesenchymal cells in a chondrogenic direction, while in vivo studies on animal 
models have shown histological improvement in the tissue reformed to cover the lesion after 
treatment with microfractures and repeated PRP injections (5,6,7,8,9). 
 
The use of autologous mesenchymal cells has also been the subject of study and debate 
for years regarding their regenerative potential in cartilage lesions (10). Mesenchymal cells are 
present in numerous tissues of the body, but the stromal fraction of subcutaneous adipose 
tissue is certainly the easiest site for extraction: adipose tissue contains two main populations, 
mature adipocytes and stromal vascular fraction (SVF) cells; the latter comprises a 
heterogeneous fraction that includes preadipocytes, endothelial cells, smooth muscle cells, 
pericytes, macrophages, fibroblasts, and adipose-derived stem cells, which share several 
characteristics with subchondral bone stem cells. These cells are promising candidates for 
use in a wide range of innovative therapies, from regenerative medicine to tissue engineering; 
furthermore, the use of adipose-derived stem cells has been proposed in the treatment of 
autoimmune, chronic (i.e. Crohn's disease), and allergic diseases (11,12,13,14). The 
effectiveness in this wide range of diseases can be explained by the immunoregulatory and 
anti-inflammatory 
action 
of 
both 
ADSCs 
and 
non-expanded 
SVF 
cells 
(15).  
Specifically, in the context of joint pathology, these cells have been demonstrated to possess 
the capacity to differentiate into the osteoblastic and chondrogenic lineages, depending on the 
environmental conditions in which they are cultured (15,16,17). The therapeutic mechanisms 
of ADSCs include the reduction of cartilage degeneration and synovial inflammation, the 
inhibition of fibrotic remodeling and apoptosis, the enhancement of recruitment and 
proliferation of endogenous stem cells, and the reduction of immune responses 
(18,19,20,21,22). 
The combination of PRP and SVF combines both the benefits of platelet-rich plasma and the 
potential regenerative stem cells from adipose tissue (23): this combination has been 
proposed as the most effective approach to cartilage repair. Supplementation of cell culture 
media with a system currently available on the market ("Arthrex ACP") has resulted in dose-
dependent cell growth and proliferation of adipose tissue stem cells (ADSCs) in vitro (24). 
Promising preclinical and clinical results have been published for treating osteoarthritis with 
PRP and the combination of PRP and autologous ADSCs, suggesting the potential regenerative 
capacity of this new biological treatment option: it has been demonstrated that the synergistic 
effect of PRP promotes the proliferation and cellular differentiation of stem cells derived from 
adipose tissue (25,26). For these reasons, the combination of PRP and autologous ADSCs is 
frequently used in joint surgery, given the safety of the treatment (20, 21, 27, 28, 29). 
 
In patients exhibiting gross deviation of the mechanical axis of the lower limbs, 
fibrocartilage regeneration, if obtained, upon resumption of normal activity, would be 
subjected to the same pre-intervention overloads. Consequently, this would result in a short 
lifespan for the regenerated fibrocartilage. Therefore, the promotion of effective formation of a 
repair cartilage with an appearance and architectural structure that can withstand the daily 
mechanical loads after surgery is imperative. In patients under 60 years of age who exhibit 
severe deformities (varus greater than 10° and valgus greater than 20° deviation), as 
substantiated by extant literature and extensive clinical experience, there is a compelling 
indication for corrective osteotomy surgery. In such cases, our established protocol entails an 
arthroscopic second-look procedure, planned in accordance with the patient's consent, which 
enables a comprehensive evaluation of the newly formed fibrocartilage. This evaluation 
encompasses both macroscopic analysis and, if necessary, histologic examination, ensuring 
a thorough assessment of the quality and integrity of the tissue (30, 31, 32, 33, 34, 35). 
In patients aged 70 years and older or for whom repair tissue formation has not occurred, we 

will bypass the osteotomy procedure, thereby establishing the indication for knee 
replacement. The decision regarding the type of prosthesis, whether unipartimental or total 
knee, is contingent upon the particulars of each case (This approach enables the acquisition 
of histological preparations suitable for the evaluation of regeneration obtained after index 
procedure with PRP and ADSCs). 
 
A critical review of the extant literature on the "all-style" treatment of cartilage pathology 
reveals several methodological shortcomings. Firstly, the lesions to be treated and the 
procedures used exhibit a lack of homogeneity, which calls into question the efficacy of the 
treatment methods. Secondly, the evidence regarding the morphology and histochemistry of 
the regenerate obtained in arthroscopic treatment is particularly limited, and there is a paucity 
of data on the comparison of PRP infiltration vs. PRP + ADSCs: Having made these premises, 
we would like with this project, which includes the classical clinical and imaging outcomes, to 
give clear and unambiguous answers that can clarify the real efficacy of a combination of these 
two derivatives in the treatment of chondral lesions by evaluating the macro morphology of the 
regenerate through an arthroscopic second look, during scheduled osteotomy and/or joint 
arthroplasty surgery and in this way obtain finally definitive histological and histochemical 
findings. 
 
Objectives 
The aim of this study is to evaluate the clinical efficacy of arthroscopic mesenchymal 
stimulation treatment associated with intraoperative infiltration of autologous PRP combined 
with adipose-derived stem cells, frequently used in clinical practice, compared to 
arthroscopic mesenchymal stimulation associated with infiltration of PRP alone. Over time, 
the objective results obtained from diagnostic imaging (i.e. follow-up MRI scans) and, if 
available, histological results obtained from second-look arthroscopic sampling will also be 
evaluated. 
 
Description of the experimental protocol 
The proposed study is a single-center, randomized, parallel-group clinical trial. 
- The study will enroll patients for at least three years from the start date, with 
follow-up continuing for at least three years after each patient's enrollment. 
- At least 80 patients recruited from the "U.O.S.D. D.U. Minimally Invasive and Computer-
Assisted Orthopedic Surgery" unit at San Salvatore Hospital in L'Aquila will be involved in the 
study. 
The inclusion criteria will be as follows: 
• Patients who provide consent to participate in the research study 
• Patients with a diagnosis of osteoarthritis of the knee joint 
• Patients with grade III-IV Outerbridge monocompartmental chondropathy, varus < 
15°, valgus <25°, grade 1-II Kellegren-Lawrence osteoarthritis, aged between 40 and 
65 years of both sexes) 
 
The exclusion criteria will be as follows: multi-compartmental chondral lesions, varus >15°, 
valgus >25°, grade III-IV Kellegren-Lawrence osteoarthritis, presence of rheumatic or 
connective tissue diseases, diabetes, heart disease, kidney disorders, thrombocytopenia 
<200,000, coagulation difficulties, varicose veins, phlebitis and very visible capillaries, use of 
anticoagulant drugs, active infections. 

 
The study will not require any different or additional procedures to those normally used 
for arthroscopic treatment, except for the injection at the end of the procedure of autologous 
PRP or PRP + autologous adipose tissue stem cells, which have been commonly used for years 
in orthopedic clinical practice: this will involve a venous blood sampling, which will then be 
appropriately processed in the former case, and also a sampling of adipose tissue from the 
abdominal subcutis in the latter (which will later be appropriately processed). A specific 
informed consent will be obtained for the acquisition, handling, and utilization of these 
derivatives. As per standard protocol, patients will undergo a series of preoperative evaluations 
including laboratory testing, EKG, anesthesiologic examination, and any patient-specific 
consultations, if needed. Additionally, patients will undergo weight bering knee X-ray and MRI 
of the knee. 
In cases where the initial arthroscopic procedure marks the preliminary stage preceding 
subsequent corrective osteotomies, explicit consent will be obtained for the execution of an 
arthroscopic second-look procedure. At the time of the subsequent procedure, an atraumatic 
Bordier needle (2 mm in diameter) will be used to obtain a biopsy sample from the treatment 
site for histologic evaluation. This will allow for the evaluation of the cartilage status and 
confirmation of previously planned corrective osteotomy. 
As is standard practice in orthopedics, the clinical condition of the knee will also be monitored 
with the aid of postoperative MRI scans. 
Patients will be randomly assigned to two groups: 
Group A: 40 patients who are candidates for mesenchymal stimulation using chondroplasty 
for 
abrasion and/or microfractures according to Steadman and PRP infiltration at the end of the 
arthroscopic procedure. 
Patients will sign an informed consent form regarding both the arthroscopic procedure and the 
collection of venous blood to obtain autologous PRP. Once in the operating room, before 
the surgery and spinal anesthesia, a blood sample (approximately 15 ml) will be taken using a 
special syringe ("Arthrex ACP® Double Syringe") which will then be placed in a special 
centrifuge at 1500 rpm for 5 minutes. Once centrifugation is complete, the double syringe will 
allow the supernatant (the PRP to be injected later) to be isolated. This will be placed in a sterile 
position on the sterile table for intraoperative use. At the same time as the procedure described 
above, spinal and/or general anesthesia will be administered. Once this is complete, patients 
will be placed in the arthroscopic position and the sterile surgical field will be prepared for 
arthroscopy: diagnostic arthroscopy will therefore be performed to confirm the therapeutic 
indication described above, and at the same time joint debridement (and any associated 
procedures) will be performed. Chondroplasty by abrasion and/or microfractures according to 
Steadman will then be performed at the site of the cartilage lesions, assessing the desirable 
blood supply. Under arthroscopic guidance, a needle will be positioned at the stimulated area, 
the arthroscopic fluid will be drained from the joint, and the portals will be sutured. At this 
point, the previously prepared PRP will be injected through the needle into the joint. If 
diagnostic arthroscopy does not confirm the surgical indication for the treatment of cartilage 
pathology, only the surgical procedures necessary for the specific pathology found (e.g., 
meniscectomy, synovectomy, biopsy, etc.) will be performed. The patients in question will still 
be monitored until the end of the follow-up period in the manner provided for, and included in 
the intention-to-treat analysis. 
Group B: 40 patients who are candidates for mesenchymal stimulation using chondroplasty 
for abrasion and/or microfractures according to Steadman and infiltration of PRP + ADSCs at 
the end of the arthroscopic procedure. Patients will sign an informed consent form regarding 

both the arthroscopic procedure and the collection and use, after centrifugation, of PRP + 
subcutaneous adipose tissue. Once in the operating room, before the surgery and spinal 
anesthesia, a blood sample (approximately 15 ml) will be taken using a special syringe ("Arthrex 
ACP® Double Syringe") which will then be placed in a special centrifuge at 1500 rpm for 5 
minutes. Once centrifugation is complete, the double syringe will allow the sumatant (the PRP 
to be combined later with the stem cells obtained from adipose tissue) to be isolated, which 
will be placed in a sterile position on the sterile table for intraoperative use. Simultaneously 
with the procedure just described, spinal and/or general anesthesia will be performed, and 
once finished, a sterile field will be set up at the abdominal level, a sampling of loose 
connective tissue associated with subcutaneous abdominal adipose tissue will be performed. 
first a subcutaneous infiltration of 250 ml of anesthetic solution will be made as follows: 500 
ml of NaCl, 30 ml of 2% Lidocaine, ¼ of a 1-mL vial of 1% Adrenaline, 1 ml of sodium 
bicarbonate. The tumescent fluid will be allowed to stand for 15 minutes; after this time period 
has elapsed, a withdrawal will be made by vacuum suction syringe and cannulated needle of 
the subcutaneous connective tissue (40 cc). A compressive dressing will be applied at the 
abdominal level. The lipoaspirate, kept in the appropriate syringes, will be centrifuged with 
Rotofix 32 A Centrifuge at 2500 rpm for 4 minutes. Following the centrifugation process, three 
distinct components will have been isolated within the syringes: the oil and the aqueous 
fraction, which will be disposed of, and the adipose tissue graft, which will undergo a sterile 
homogenization process (exchange between two appropriately connected syringes). Once 
homogenization is complete, the graft will be placed back in the centrifuge for 4 minutes at 
2500 rpm. This step will further isolate the mesenchymal vascular stromal fraction leaving an 
oily supernatant that will be, in a sterile manner, discarded. The residual mesenchymal 
vascular fraction (approximately 2 ml) will be combined with the previously prepared PRP for 
subsequent infiltration.  
At the same time as the centrifugation process, patients will be placed in the arthroscopic 
position and the sterile surgical field will be prepared for arthroscopy: diagnostic arthroscopy 
will therefore be performed to confirm the therapeutic indication described above, and at the 
same time joint debridement (and any associated procedures) will be performed; 
Chondroplasty by abrasion and/or microfractures according to Steadman will then be 
performed at the site of the cartilage lesions, assessing the desirable blood supply. Under 
arthroscopic guidance, a needle will be positioned at the stimulated area, the arthroscopic 
fluid will be drained from the joint, and the portals will be sutured. At this point, the previously 
prepared PRP will be injected through the needle into the joint. At this point, the previously 
prepared PRP and subcutaneous adipose tissue will be injected through the needle into the 
joint. If diagnostic arthroscopy does not confirm the surgical indication for the treatment of 
cartilage pathology, only the surgical procedures necessary for the specific pathology found 
(e.g., meniscectomy, synovectomy, biopsy, etc.) will be performed. The patients in question 
will still be monitored until the end of the follow-up period in the manner provided for, and 
included in the intention-to-treat analysis. 
All patients in both groups will undergo the same postoperative rehabilitation protocol, 
including no weight bearing on the operated limb for 4 weeks and subsequent cautious gait re-
education and isometric exercises. All patients will have to give consent for the use for 
research purposes of questionnaires containing outcome measures on knee function and 
general health status: over time (preoperative, At 2 and 6 weeks, then at 6, 12, 24, and 36 
months postoperatively) patients will be monitored clinically by SF-12, subjective IKDC, VAS, 
and KOOS score. The study will require patients to undergo pre- and post-operative MRI scans 
of the knee (at 12, 24, and 36 months), a commonly used investigation to first determine the 

indication for surgical treatment and then verify the state of tissue healing following surgical 
treatment, evaluated blindly by the radiologists involved in this research project. Patients who 
give their consent and who are indicated for subsequent corrective osteotomy will undergo a 
second-look arthroscopy to assess the healing status of the cartilage by evaluating its 
macroscopic appearance, compactness by palpation, and microscopic appearance (blindly 
evaluated by the pathologist involved in this research project) through biopsy sampling 
with a Bordier needle (2 mm in diameter), using Safranin O and type II collagen staining. 
Over time, the following will also be monitored adverse events such as swelling, fever, reduced 
joint mobility, systemic effects, any abnormal request for analgesics, date of discharge from 
the surgical ward, satisfaction with the technique, any unexpected events (severity or 
frequency), events related to participation in the research, the incidence of postoperative side 
effects related to the techniques. 
The following will also be monitored: postoperative side effects/complications and other side 
effects related to the use of the techniques described in the protocol (deep or superficial 
infections, allergies or other reactions to device materials, hematoma, damage to blood 
vessels and nerves resulting in pain or numbness following autologous sampling, delayed 
wound healing). 
For reasons of informed consent in the surgical field, it will not be possible to perform blinded 
treatments either for patients (who will therefore know which group they belong to) or for 
the individual surgeon. 
However, the questionnaire evaluator and the statistician who will process the relevant 
data, the radiologist, and the pathologist who will express an opinion on the results 
obtained in the MRI and histological preparation, respectively, will be blinded. 
 
Statistical analisys 
Randomization will be performed by assigning each patient a random number 
corresponding to a list of numbers, randomly associated with one of the two treatments, 
developed by the statistician. The mean values + standard deviation of the results of each 
questionnaire (SF-12, subjective IKDC, KOOS Score, and VAS) will be evaluated, after 
logarithmic transformation, using analysis of variance with two factors, time and type of 
treatment. Statistical significance will be set at p<0.05.  
The study will be based on an estimated value of 80 subjects, with a 1:1 ratio for the two 
treatment groups that was calculated to be sufficient to achieve a power greater than 95% in 
order to test an Effect Size of 0.25 and a of 0.05 on the values of the questionnaire averages 
among the three treatment groups. Statistical power was calculated using G*POWER Version 
3.1.9.2. 
An intention-to-treat analysis will be performed, including all subjects randomized into the two 
groups, and a per-protocol analysis will be performed, excluding subjects in whom exploratory 
arthroscopy did not confirm the indication for treatment in the study. 
 
Storage of collected data and research project results 
During the study, only the medical staff will have access to patients' personal data. 
The results of the questionnaires, MRIs, and histological preparations will be 
associated with a unique code for each patient, which only Prof. Calvisi and Dr. Goderecci 
will be able to access, and which will remain anonymous. The results of this study will be 
published or presented at conferences by the promoters. The identity of the study participants 
will, 
in 
any 
case, 
remain 
anonymous 
in 
accordance 
with 
privacy 
laws. 
Sensitive data will be stored both in paper archives and in computerized format in dedicated 

archives (in a locked room of the U.O.S.D. D.U. of Minimally Invasive and Computer-Assisted 
Orthopedic Surgery directed at the San Salvatore Hospital in L'Aquila), in 
compliance with current regulations. The person responsible for data processing and storage 
is the department director. 
Identification data will not be stored for more than 5 years after the start of the study. 
 
Risks related to research 
As far as the scientific research aspect of this project is concerned, patients will not be 
exposed to any greater risks than those normally associated with arthroscopic surgery, for 
which they will sign the usual informed consent form. The infiltration of PRP and/or ADSCs may 
rarely, like all infiltrations of any substance, cause self-limiting synovial irritation and 
inflammation or easily treatable with anti-inflammatories, ice, and arthrocentesis if necessary. 
The removal of subcutaneous abdominal connective tissue, given the small amount of 
lipoaspirate (approximately 40 cc), does not pose any real risk of thromboembolism, for which 
the usual antiplatelet prophylaxis prescribed for arthroscopic surgery is administered in any 
case. Any hematomas at the aspiration site, the risk of which is reduced by the administration 
of the anesthetic cocktail combined with a minimal dose of adrenaline, are prevented by 
maintaining a compressive abdominal dressing for 7 days post-surgery and, if necessary, 
limited by the use of ice and anti-inflammatories. 
 
Bibliography 
1. Johnson LL. Arthroscopic abrasion arthroplasty-historical and pathological perspective: 
present status. Arthroscopy 1986 2: 54-69. 
2. Steadman, J. Richard, et al. Microfracture technique for full-thickness chondral defects: 
Technique and clinical results. Oper Tech Orthop 1997; 7 (4): 300-304. 
3. Mithoefer K, Williams RJ, Warren RF et al. The microfracture technique for the treatment 
of articular cartilage lesions in the knee: a prospective cohort study. J Bone Joint Surg 
Am 2005; 87:1911-1920. 
4. Calvisi V, Pappalardo S, Niceforo A, et al. Evoluzione morfologica ed istologica del 
rigenerato fibrocartilagineo dopo condroabrasione. GIOT. 1990;XVI (suppl)(1):155-162. 
5. Marx R. Platelet-Rich Plasma (PRP): What Is PRP and What Is Not PRP? Implant Dentistry: 
December 2001 - Volume 10 - Issue 4 - p 225-228 
6. Kon E, et al. Platelet-rich plasma intra-articular knee injections for the treatment of 
degenerative cartilage lesions and osteoarthritis. Knee Surgery, Sports Traumatology, 
Arthroscopy 2011; 19 (4): 528-535 
7. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR: Platelet-
rich plasma growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol 
Oral Radiol Endod 1998; 85: 638-646. 
8. Mishra A, Tummala P, King A, Lee B, Kraus M, Tse V, et al. Buffered platelet rich plasma 
enhances mesenchymal stem cell proliferation and chondrogenic differentiation. 
Tissue Eng Part C Methods 2009; |15:431-5. 
9. Milano G, Sanna Passino E, Deriu L, et al. The effect of platelet rich plasma combined 
with microfractures on the treatment of chondral defects: an experimental study in a 
sheep model. Osteoarthr Cartil 2010; 18: 971-80. 
10. Chen Y et al: Mesenchymal stem cells: a promising candidate in regenerative medicine. 
Int J Biochem Cell Biol, 2008;40(5):815-20 
11. The MSC: An Injury Drugstore. Arnold I. Caplan, and Diego Correa. Cel Stem Cel 9, July 
8, 2011 

12. Maumus M, Jorgensen C, Noël D: Mesenchymal stem cells in regenerative medicine 
applied to rheumatic diseasesi role of secretome and exosomes. Biochimie, 
2013;95(12):2229-34 
13. Zuk PA et al: Human/adipose tissue is a source of multipotent stem cells. Molecular 
Biology of the Cell, 2002;13(12):4279-95 
14. Kilroy GE et al: Cytokine profile of human adipose-derived stem cells: expression of 
angiogenic, 
hematopoietic, 
and 
pro-inflammatory 
factors. 
J 
Cell 
Physiol, 
2007;212(3);702-9 
15. Michalek et al: Autologous adipose tissue-derived stromal vascular fraction cells 
application in patients with osteoarthritis. Cell Transplant, 2015 
16. Conese M et al: Paracine effects and eterogeneity of marrow-derived stem/progenitor 
cells: relevance for the treatment of respiratory diseases. Cells Tissues Organs, 
2013;197(6):445-73 
17. Pers YM et al: Adipose Mesenchymal Stromal Cell-Based Therapy for Severe 
Osteoarthritis of the Knee: A Phase I Dose-Escalation Trial. 2016;5(7):847-56 
18. Djouad F et al: Mesenchymal stem cells: innovative therapeutic tools for reumatic 
diseases.Nat Rev Rheuatol, 2009;5:392-9 
19. Im GI: Regeneration of articular cartilage using adipose stem cells. Journal of 
Biomedical Materials Research, 2016;104(7):1830-44 
20. Yong-Gon Koh, Oh-Ryong Kwon, Yong-Sang Kim, Yun-Jin Choi, and Dae-Hyun Tak 
Adipose-Derived Mesenchymal Stem Cells With Microfracture Versus Microfracture 
Alone: 2-Year Follow-up of a Prospective Randomized Trial. Arthroscopy: The Journal of 
Arthroscopic and Related Surgery, Vol 32, No 1 (January), 2016: pp 97-109 
21. Naomasa Yokota, Masayuki Yamakawa, Tomohiko Shirata, Tetsuya Kimura, Hideto 
Kaneshima Clinical results following intra-articular injection of adipose-derived stromal 
vascular fraction cells in patients with osteoarthritis of the knee. Regenerative Therapy 
6 (2017) 108-112. 
22. Y.S. Kim, Y.J. Choi, S.W. Lee, O.R. Kwon, D.S. Suh, D.B. Heo, Y.G. Koh Assessment of 
clinical and MRI outcomes after mesenchymal stem cell implantation in patients with 
knee ostéoarthritis: a prospective study. Osteoarthritis and Cartilage 24 (2016) 237-245 
23. Loibl M et al: The effect of leukocyte-reduced platelet-rich plasma on the proliferation 
of autologous adipose-tissue derived mesenchymal stem cells. Clin Hemorheol 
Microcirc, 2016;61(4):599-614 
24. Bianchi F, Maioli M, Leonardi E, Olivi E, Pasquinelli G, Valente S, Mendez AJ, Ricordi C, 
Raffaini M, Tremolada C, and Ventura C. A New Nonenzymatic Method and Device to 
Obtain a Fat Tissue Derivative Highly Enriched in Pericyte-Like Elements by Mild 
Mechanical Forces From Human Lipoaspirates. Cell Transplantation, Vol. 22, pp. 2063-
2077, 2013 
25. Yong-Gon Koh, M.D., Oh-Ryong Kwon, M.D., Yong-Sang Kim, M.D., and Yun-Jin Choi, 
M.D. Comparative Outcomes of Open-Wedge High Tibial Osteotomy With Platelet-Rich 
Plasma Alone or in Combination With Mesenchymal Stem Cell Treatment: A 
Prospective Study. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 
30, No 1(November), 2014: pp 1453-1460 
26. Khanh Hong-Thien Bui, Triet Dinh Duong, Nhan Thanh Nguyen, Thanh Duc Nguyen, Vien 
Tuong Le, Viet Thanh Mai, Nhan Lu-Chinh Phan, Dung Minh Le, Ngoc Kim Ngoc, Phuc 
Van Pham Symptomatic knee osteoarthritis treatment using autologous adipose 
derived stem cells and platelet-rich plasma: a clinical study. Biomedical Research and 
Therapy, 2014 (1):02-08 

27. Lee, G. W., Son, J. H., Kim, J. D. & Jung, G. H. Is platelet-rich plasma able to enhance 
the results of arthroscopic microfracture in early osteoarthritis and cartilage lesion over 
40 years of age? Eur J Orthop Surg Traumatol 2013; 23: 581-587 
28. Mancò, A., Goderecci, R., Rughetti, A., De Giorgi, S., Necozione, S., Bernardi, A., & 
Calvisi, V. (2016). Microfracture versus microfracture and platelet-rich plasma: 
arthroscopic treatment of knee chondral lesions. A two-year follow-up study. Joints, 
4(3), 142-147. 
29. Koh et al: Adipose-Derived Mesenchymal Stem Cells With Microfracture versus 
Microfracture alone: 2-Year Follow-up of a Prospective Randomized Trial. Arthroscopy, 
2016;32(1):97-109 
30. Mainil-Varlet P, Van Damme B, Nesic D, Knutsen G, Kandel R and Roberts S. A New 
Histology Scoring System for the Assessment of the Quality of Human Cartilage Repair: 
ICRS II. The American Journal of Sports Medicine. Vol. 38, No. 5, 2010 
31. Pascale W, Simone Luraghi S, Laura Perico L, Valerio Pascale V. Do Microfractures 
Improve High Tibial Osteotomy Outcome? Orthopedics. 2011;34(7):e251-e255 
32. Akizuki S, Yasukawa Y, Takizawa T. Does Arthroscopic Abrasion Arthroplasty Promote 
Cartilage Regeneration in Osteoarthritic Knees With Eburnation? A Prospective Study of 
High Tibial Osteotomy With Abrasion Arthroplasty Versus High Tibial Osteotomy Alone. 
Arthroscopy: The Journal of Arthroscopic and Related Surgery. Vol 13, 1, 1997: pp 9-17 
33. Saw KY, Anz A, Jee CS, Ng RC, Mohtarrudin N, Ragavanaidu K. High Tibial Osteotomy in 
Combination With Chondrogenesis After Stem Cell Therapy: A Histologic Report of 8 
Cases. Arthroscopy. 2015 Oct;31(10):1909-20. 
34. T. T. NiinimäKi, A. Eskelinen, B. S. Mann, M. Junnila, P. Ohtonen, J. Leppilahti. 
Survivorship of high tibial osteotomy in the treatment of osteoarthritis of the knee. 
FINNISH REGISTRY-BASED STUDY OF 3195 KNEES. J Bone Joint Surg Br 2012;94-B: 
1517-21. 
35. Sterrett WI, Steadman JR. Chondral Resurfacing and High Tibial Osteotomy in the Varus 
Knee. Am J Sports Med 2004;32:1243-1249. 

Arthrosocpic Treatment of Knee Chondral Lesions: Clinical, MRI and Histologic 
Comparison Between the Use of PRP vs ADSCs in Addition to Marrow Stimulation 
Techniques  
Informed consent for the processing of sensitive data 
NCT ID not yet assigned 
Unique protocol id 23/2019 
Document date: March 25, 2019. Traslated into English on August 27, 2025 
 
As the original documents were written exclusively in Italian, the following is the complete 
translation of each document into English, presented alongside the original text.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Patient Information Note 
In accordance with Legislative Decree No. 196 of June 30, 2003 (Personal Data Protection 
Code) and Authorization to Process Sensitive Data for Observational Studies 
TITLE 
Arthroscopic Treatment of Knee Chondral lesions: Clinical, 
MRI and Histologic comparisons between the use of PRP vs 
ADSCs in addition to Marrow stimulation techniques 
ID NUMBER 
 
VERSION AND DATE OF THE 
PROTOCOL 
version 1/19 - protocol March 2019 
HEAD OF THE PROJECT 
ttorio Calvisi, Associate Professor, Department of Life, 
Health and Environmental Sciences, University of L'Aquila, 
Via Vetoio-Coppito 2, 67100, L'Aquila, 
Italy Tel.: +39 337 743107 e-mail:  
RESEARCH LOCATION 
U.O.S.D. D.U. Minimally Invasive and Computer-Assisted 
Orthopedic Surgery directed by Prof. Calvisi at the San 
Salvatore Hospital in L'Aquila. 
 
 
PURPOSE OF TREATMENT 
The “U.O.S.D. Minimally Invasive and Computer-Assisted Orthopedic Surgery” of the San 
Salvatore Hospital of L'Aquila, as Study Center and Data Controller, in accordance with 
alleresponsibilities provided by the rules of good clinical practice (d.l. 211/2003) and to the 
current legislation on the processing of personal data (Dlgs 196/2003 and subsequent 
amendments and/or integrations), will process your personal data, in particular health data 
and, only to the extent that they are indispensable in relation to the objective of the study, other 
data relating to date of birth, sex, weight, height, according to the implementation of the study. 
Processing your personal data related to general and specific clinical conditions in the field of 
orthopedics is essential to conducting the study. Refusing to provide this data will prevent you 
from participating. Prof. Vittorio Calvisi, the study initiator, will be identified as the data 
controller. 
The 
study's 
scientific 
staff 
includes: 
[omissis] 
This staff will process your personal data—in particular, data concerning your health and 
medical history—and other sensitive data only to the extent that it is indispensable in relation 
to the objective of the study, exclusively for the purpose of conducting the study itself. 
 
NATURE OF DATA 
The doctor who will follow you in the study will identify you by a code. The data collected about 
you in the course of the study, with the exception of your name, will be transmitted to the 
departments of diagnostic imaging, pathological anatomy, and statistics. The investigators 
working in these departments will score the quality of the cartilage found in the control MRIs 
and biopsies performed during the second-look arthroscopy. They will also statistically analyze 

the 
results 
obtained 
from 
the 
questionnaires 
you 
will 
fill 
out. 
This data will be recorded, processed, and stored together with this code, your date of birth, 
gender, weight, and height. Only the doctor and authorized persons will be able to 
link this code to your name. 
 
TREATMENT MODALITIES 
The data will be processed using paper and electronic tools.The data concerning you, collected 
during the study will be recorded, processed and storedfor 5 years along with this code. The 
data will be kept in a locked room pressol UOSD University Knee Surgery of San Salvatore 
Hospital in L'Aquila.The person in charge of data processing and storage is The Director of the 
Department, Prof.Calvisi. 
Your participation in the study implies that, in accordance with clinical trial regulations, the 
staff conducting the study and the Internal Review Board may have access to data concerning 
you, including identifying information, which may include data contained in your original 
clinical documentation. The data may be disclosed, for example through scientific 
publications, statistics, and scientific conferences, only in strictly anonymous form. 
 
EXERCISING RIGHTS 
You may also exercise your rights under Article 7 of the Privacy Code (e.g., accessing your 
personal data, supplementing them, updating them, rectifying them, objecting to their 
processing for legitimate reasons, etc.) by contacting the testing center directly (
 
, Department of Life, Health and Environmental Sciences, University of L’Aquila, Via 
Vetoio-Coppito 
2, 
67100, 
L’Aquila, 
Italy 
Tel.: 
 
e-mail: 
. 
You may withdraw from the study at any time without providing justification. In this case, your 
biological samples will be destroyed. No additional data will be collected about you, without 
prejudice to the use of any data already collected to determine the results of the research 
without altering them. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
AUTHORIZATION FOR THE PROCESSING OF SENSITIVE DATA 
OF PARTICIPANTS IN OBSERVATIONAL STUDIES 
 
Place and Date 
I, (First and last name of participant in block letters) _________________________________, 
accept the information provided by the data controller pursuant to art. 13 of Legislative Decree 
No. 196/2003. I am aware that the processing will concern the "sensitive" data referred to in 
Art. 4, Paragraph 1, Letter d), as well as Art. 26 of D.lgs. 196/2003. This includes data "capable 
of revealing racial and ethnic origin, religious, philosophical, or other beliefs; political opinions; 
membership in parties, trade unions, associations, or organizations of a religious, 
philosophical, political, or trade union nature; as well as personal data disclosing health and 
sexual life." 
 
-I give my consent to the processing of data necessary for the performance of the operations 
indicated in the privacy policy. 
 
Signature ....................................................................... 
 
 
- gives consent for the communication of data to the subjects indicated in the privacy policy. 
(in the event that the communication of sensitive data of the data subject is also envisaged) 
 
Signature ......................................................... .............. 
 
 
- gives consent for the dissemination of data within the scope indicated in the privacy policy. 
(if the dissemination of sensitive data other than that which may reveal the 
state of health of the data subject is also envisaged; the latter, in fact, cannot be 
disseminated). 
 
Signature ....................................................................... 
 
 
 

Arthrosocpic Treatment of Knee Chondral Lesions: Clinical, MRI and Histologic 
Comparison Between the Use of PRP vs ADSCs in Addition to Marrow Stimulation 
Techniques  
Informed consent for partecipation in the Study 
NCT ID not yet assigned 
Unique protocol id 23/2019 
Document date: March 25, 2019. Traslated into English on August 27, 2025 
 
As the original documents were written exclusively in Italian, the following is the complete 
translation of each document into English, presented alongside the original text.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
INFORMATION SHEET AND INFORMED CONSENT FOR PARTICIPATION IN A 
RESEARCH STUDY TO SUPPLEMENT CONSENT FOR TREATMENT 
TITLE 
Arthroscopic Treatment of Knee Chondral lesions: Clinical, 
MRI and Histologic comparisons between the use of PRP vs 
ADSCs in addition to Marrow stimulation techniques 
ID NUMBER 
 
VERSION AND DATE OF THE 
PROTOCOL 
version 1/19 - protocol March 2019 
HEAD OF THE PROJECT 
ttorio Calvisi, Associate Professor, Department of Life, 
Health and Environmental Sciences, University of L'Aquila, 
Via Vetoio-Coppito 2, 67100, L'Aquila, 
Italy Tel.: +39 337 743107 e-mail:  
RESEARCH LOCATION 
U.O.S.D. D.U. Minimally Invasive and Computer-Assisted 
Orthopedic Surgery directed by Prof. Calvisi at the San 
Salvatore Hospital in L'Aquila. 
 
 
Dear Sir/Madam, 
You have been invited to participate in a research project. In order for this study to take place, 
we need the cooperation of patients who possess the characteristics necessary for the study, 
which we will explain. Professional ethics require the fully informed consent of each 
participant in any medical research. This statement and consent form contain information that 
may help you decide. The document describes the purpose of the research, the procedures 
that will be used, and the names of physicians (and/or researchers) who can answer your 
questions. If you agree to participate in the study, you will be asked to sign the consent form. 
Your decision to participate in this study is voluntary. This means that you may participate if 
you wish, or not participate if you do not wish to. Your decision to participate or not participate 
will not affect your medical care. You may also withdraw from the study at any time without 
explanation and without affecting your disease management. 
Please read the information in this document carefully. If you wish, you may discuss it with your 
family members and your family doctor, taking as much time as you need. Please ask us for 
clarification if any of the information is unclear. 
The doctors at the U.O.S.D. of Minimally Invasive and Computer-Assisted Orthopedic Surgery 
are available to answer any questions you or your doctor may have. 
 
STUDY DESCRIPTION 
Our study aims to evaluate the efficacy differences between two autologous products. 
(i.e., obtained from your own body) for treating cartilage defects (chondropathies) of the knee. 
We aim to evaluate the effectiveness of platelet-rich plasma (PRP) infiltrated alone or in 
combination with adipose-derived stem cells at the end of arthroscopic treatment for knee 
chondropathies, using clinical, diagnostic, and histological methods. 
The study will last approximately three years. 
About 80 male and female subjects, aged 30 to 60 years, with severe knee chondropathy are 
planned to participate in the present single-center study. Treatment effect monitoring will last 
for at least three years. 

 
WHAT WILL MY PARTICIPATION IN THE STUDY INVOLVE? 
You have been invited to participate in this study because you have been diagnosed with 
chondropathy of the knee, for which surgical treatment by arthroscopy has been 
recommended. You have signed the relevant informed consent form for this procedure. If you 
decide to participate in the study, you will be randomly assigned to one of two groups: The 
"control group" or the "study group." You will be offered the option of adding mesenchymal 
stimulation (cartilage repair stimulation) to the arthroscopic treatment, along with PRP 
infiltration, with or without adipose-derived stem cells. Specifically in the operating room, prior 
to arthroscopic surgery, whether you are in the control or study group, a venous blood sample 
(approximately 15 mL) will be taken and centrifuged to obtain PRP (platelet-rich plasma). If you 
are in the study group, a sample of subcutaneous abdominal adipose tissue (approximately 40 
mL) will be taken using minimally invasive needles. This sample will then be centrifuged to 
extract the fraction containing stem cells, which will be combined with the previously obtained 
PRP. At the end of the surgical treatment, these derivatives (PRP or PRP + Stem Cells) will be 
injected into the joint. After the operation, you will be monitored continuously for up to 3 years 
of follow-up. In particular, we will evaluate you clinically at regular intervals, asking you to 
complete specific questionnaires on the functionality of your knee independently. As is 
standard practice for treating your condition, you will be required to undergo an MRI scan of 
your knee before surgery and again at 12, 24, and 36 months after surgery. These scans will help 
assess the healing of your injury. If your condition indicates the need for a subsequent knee 
osteotomy (the resection of a wedge of bone at the tibial level and its subsequent synthesis 
with a specific plate), this will be proposed as a solution to correct the mechanical axis 
deviation of your limbs. If you agree, you will undergo a second-look arthroscopy on this 
occasion. This procedure involves observing, palpating, and taking a microscopic biopsy of the 
cartilage with a minimally invasive needle. The goal is to assess whether the joint surface has 
"healed" enough to support the effects of the osteotomy. These results will also be used to 
evaluate the effectiveness of the two treatments in this study. 
The following cooperation is required on your part: consent to arthroscopic mesenchymal 
stimulation and infiltration at the end of the PRP or PRP + Stem Cells procedure, depending on 
the group you are assigned to. In the post-operative period, you will be asked to: 
- 
undergo free check-ups by filling out specific questionnaires 
- 
Undergo follow-up MRI scans at 12, 24, and 36 months, as routinely required when 
monitoring the progress of cartilage repair. 
- 
If necessary, and if specifically indicated and if you agree, undergo an arthroscopic 
second look after 12 months and subsequent corrective osteotomy. 
 
WHAT ARE THE FORESEEABLE RISKS OF THE STUDY? 
Participation in the planned treatments and/or investigations does not involve any additional 
risks beyond those considered for the surgical risk of knee arthroscopy and PRP infiltration and 
purified autologous adipose tissue grafting; all of the above procedures have been practiced 
worldwide for several years, and there have been no significant complications reported in the 
literature associated with these techniques. Specifically, for each of the three procedures 
(arthroscopy, obtaining and infiltrating autologous PRP, and obtaining and infiltrating stem cells 
purified from autologous adipose tissue) you have been informed of the purposes, 
characteristics, and possible complications through specific consent forms. This document is 
an addition to those forms. It should be noted that both the PRP and the stem cells that will be 

collected and centrifuged are entirely autologous (i.e., derived from the patient's own body) and 
therefore there is no external contamination with tissue derived from other human beings. If 
corrective osteotomy is necessary during treatment, you will be offered an arthroscopy to 
evaluate the healing of the injury in real time through observation and palpation. During this 
procedure, a microscopic biopsy will be performed on the repair site. Given the microscopic 
size of the needle, this procedure will not damage the repair area. These procedures are 
necessary to confirm the need for corrective osteotomy and will also provide data for this study. 
If you have any questions or concerns during the study, the medical staff will be available to 
assist you, either directly or with the help of other specialists. 
 
WHAT ARE THE EXPECTED BENEFITS OF THE STUDY? 
The results of this study will further knowledge of innovative techniques for treating cartilage 
lesions, a challenge that orthopedic surgeons still face today. Conservative treatments based 
on physiokinesitherapy and viscosupplementation do not always allow for complete healing 
and resolution of symptoms in this specialized connective tissue, which has great difficulty 
healing intrinsically. Platelet-rich plasma (PRP) and adipose-derived stem cells represent the 
latest frontier in treating this condition; they have shown promising results in laboratory and 
clinical studies on humans. This study aims to determine whether adding stem cells to PRP (an 
autologous derivative rich in growth factors) enhances its effect by increasing its reparative 
capacity on cartilage. We will observe the patients' clinical condition, as well as the images 
obtained by magnetic resonance imaging. Where indicated, we will also perform histology.  
The desired benefits for you could result from implementing, through the infiltration of 
autologous substances (i.e., derived from your own body), the results of established 
arthroscopic techniques that will be performed in any case. 
 
FREE CHOICE TO PARTICIPATE IN THE STUDY 
Whether or not to participate in the study is entirely up to you. If you choose to participate, you 
will be given an informed consent form to sign. You will also be given specific consent forms for 
the autologous blood collection necessary to prepare PRP and for the transplantation of 
purified autologous tissue. If corrective osteotomy is indicated and you give your consent, you 
will be offered a second-look arthroscopy to evaluate the healing of the cartilage, take a 
microscopic sample of the repaired tissue, and make a final decision on the osteotomy. 
 
WHAT HAPPENS IF YOU DECIDE NOT TO PARTICIPATE OR TO WITHDRAW FROM THE STUDY 
You are free to withdraw from the study at any time by informing the investigating physician. You 
do not need to provide a reason, and this will not affect the quality of healthcare services you 
receive from this Center. If you withdraw your consent and wish to discontinue contact with us, 
we will delete all information concerning you. You have the right to be informed of any changes 
to the study protocol that may affect you. In this case, you will be asked to sign a new informed 
consent form. 
 
EXPENSES AND FINANCIAL COMPENSATION RESULTING FROM PARTICIPATION IN THE 
STUDY 
Participation in the study is free of charge. You will not receive monetary compensation for 
participating. You will not be reimbursed for any travel expenses to the center/hospital where 
the study is being conducted. 
 
 

CONFIDENTIALITY OF INFORMATION COLLECTED 
If you choose to participate in this study, please know that all data collected will be processed 
and stored anonymously, in accordance with Legislative Decree 196/2003. This decree went 
into effect on June 30, 2003, and addresses the protection of individuals with regard to the 
processing of personal data, as well as subsequent amendments and additions. 
Only personnel involved in the study will have access to this information. The researcher will 
protect access to this data. Your signature confirming your participation will guarantee 
confidentiality. 
If you wish, you may be informed of the results of the experiment. The results of the study will 
be used exclusively for scientific research purposes. They may be published, but your identity 
will always remain confidential. 
 
NEW INFORMATION AND/OR RESULTS REGARDING THE STUDY 
If new information or results about the study become available, we will promptly provide you 
with any relevant information that could affect your decision to continue participating. If we find 
information about the condition being studied that could affect your condition or health, we will 
inform you. 
 
WHO SHOULD I CONTACT FOR MORE INFORMATION OR IF I NEED HELP? 
If you have any questions about the research or communication related to the study, or if you 
experience any damage related to the study, please contact the U.O.S.D. D.U. Minimally 
Invasive and Computer-Assisted Orthopedic Surgery at San Salvatore Hospital in L'Aquila and 
speak with the study doctor or one of his colleagues. Below is a list of all the people at this 
center who provide assistance to study participants and their telephone numbers. You will be 
informed verbally if this list changes during the course of the study. 
[omissis] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

INFORMED CONSENT FORM  
for participation in scientific research to supplement the informed consent to treatment 
 
I, (First and last name of participant in block letters) _________________________________,  
By signing this form, I declare the following:  
• I have read and understood the contents of this information sheet, which have been explained 
to me clearly and comprehensively.  
• I was given the opportunity to ask questions and received clear and comprehensive answers. 
• Participation in the study is completely voluntary, and I may withdraw at any time by informing 
the study doctor of my decision without losing any benefits, medical treatment, or legal rights 
to which I am otherwise entitled. 
• I was informed of the reasonably foreseeable risks and benefits and was given sufficient time 
to decide. 
• I am aware that my clinical data may be used for scientific publications and will remain strictly 
confidential in accordance with current legislation and subsequent amendments and 
additions. 
• I understand that I will be informed of any new information or findings that may affect my 
participation in the study. 
• I understand that I must sign two identical copies of this informed consent form. One copy 
will be kept by the doctor, and I will receive the other. 
 
Participant's First and Last Name (in block letters): _______________________________________ 
Place and Date: _______________________________________ 
Participant's Signature: _______________________________________ 
 
 
DOCTOR WHO PRESENTED THE INFORMATION TO THE PATIENT 
Doctor's First and Last Name (in block letters): _______________________________________ 
Place and Date: _______________________________________ 
Doctor’s Signature: _______________________________________