A Platelet-Rich Plasma-Derived Biologic Clears Staphylococcus aureus Biofilms While Mitigating Cartilage Degeneration and Joint Inflammation in a Clinically Relevant Large Animal Infectious Arthritis Model.
Abstract: The leading cause of treatment failure in Staphylococcus aureus infections is the development of biofilms. Biofilms are highly tolerant to conventional antibiotics which were developed against planktonic cells. Consequently, there is a lack of antibiofilm agents in the antibiotic development pipeline. To address this problem, we developed a platelet-rich plasma (PRP)-derived biologic, termed BIO-PLY (for the BIOactive fraction of Platelet-rich plasma LYsate) which has potent in vitro bactericidal activity against S. aureus synovial fluid free-floating biofilm aggregates. Additional in vitro studies using equine synoviocytes and chondrocytes showed that BIO-PLY protected these cells of the joint from inflammation. The goal of this study was to test BIO-PLY for in vivo efficacy using an equine model of infectious arthritis. We found that horses experimentally infected with S. aureus and subsequently treated with BIO-PLY combined with the antibiotic amikacin (AMK) had decreased bacterial concentrations within both synovial fluid and synovial tissue and exhibited lower systemic and local inflammatory scores compared to horses treated with AMK alone. Most importantly, AMK+BIO-PLY treatment reduced the loss of infection-associated cartilage proteoglycan content in articular cartilage and decreased synovial tissue fibrosis and inflammation. Our results demonstrate the in vivo efficacy of AMK+BIO-PLY and represents a new approach to restore and potentiate antimicrobial activity against synovial fluid biofilms.
Copyright © 2022 Gilbertie, Schaer, Engiles, Seiler, Deddens, Schubert, Jacob, Stefanovski, Ruthel, Hickok, Stowe, Frink and Schnabel.
Publication Date: 2022-05-30 PubMed ID: 35711655PubMed Central: PMC9195519DOI: 10.3389/fcimb.2022.895022Google Scholar: Lookup
The Equine Research Bank provides access to a large database of publicly available scientific literature. Inclusion in the Research Bank does not imply endorsement of study methods or findings by Mad Barn.
- Journal Article
- Research Support
- N.I.H.
- Extramural
- Research Support
- Non-U.S. Gov't
Summary
This research summary has been generated with artificial intelligence and may contain errors and omissions. Refer to the original study to confirm details provided. Submit correction.
This research study presents a solution to combat bacterial biofilms, which are a common reason for the failure of treating infections. The study introduces a platelet-rich plasma-derived biologic, called BIO-PLY, which effectively kills bacterias found in biofilms and protect joint cells from inflammation. In trials using horses, combining BIO-PLY with an antibiotic called amikacin resulted in significantly lower bacterial concentrations and a decrease in infection-related damage to cartilage.
Development and Rationale of BIO-PLY
- The researchers developed a platelet-rich plasma (PRP)-derived biologic, known as BIO-PLY, to address the problems caused by biofilms. Biofilms are a collection of bacteria that are highly resistant to conventional antibiotics because these medications were designed to target free-floating (or “planktonic”) bacterial cells rather than grouped ones.
- BIO-PLY has been found to effectively kill free-floating biofilm aggregates in synovial fluid, a lubricating fluid found in the joints.
- Additionally, BIO-PLY was shown to protect joint cells, specifically equine synoviocytes and chondrocytes, from inflammation.
BIO-PLY and Antibiotic Effectiveness
- The researchers then set out to test the efficacy of BIO-PLY in a real-world model, hence they used an equine model of infectious arthritis. Horses were infected experimentally and then treated with a combination of BIO-PLY and an antibiotic called amikacin.
- Compared to horses treated only with amikacin, those that received both BIO-PLY and amikacin had lower bacterial concentrations in both synovial fluid and synovial tissue, which implies a rapid and stronger antibacterial effect.
- The combined treatment also resulted in significantly lower scores for both systemic and local inflammation.
Cartilage Protection and Restoration
- Besides the effective antibacterial and anti-inflammatory results, the combined treatment of BIO-PLY and amikacin also showed positive effects on the structural elements of joints.
- Treatment with both BIO-PLY and amikacin reduced the loss of infection-related cartilage proteoglycan content in articular cartilage, a critical structural and functional component of cartilage. Therefore, it not only intercepted the infection but also protected the joint against potential structural damage.
- The treatment also decreased fibrosis and inflammation in the synovial tissue, further indicating its potential joint-protective qualities.
Conclusion and Implications
- The results of the study demonstrate a potential new approach to treating infections, particularly those where biofilms are involved. The researchers assert that the partnership of BIO-PLY and amikacin can potentially restore and bolster antimicrobial activity against these biofilms.
- Not only does this combination treatment address the bacterial infection effectively, but it also actively counters inflammation and protects the structural integrity of joints. Thus, it could be a potential solution for treating infection-related conditions such as infectious arthritis.
Cite This Article
APA
Gilbertie JM, Schaer TP, Engiles JB, Seiler GS, Deddens BL, Schubert AG, Jacob ME, Stefanovski D, Ruthel G, Hickok NJ, Stowe DM, Frink A, Schnabel LV.
(2022).
A Platelet-Rich Plasma-Derived Biologic Clears Staphylococcus aureus Biofilms While Mitigating Cartilage Degeneration and Joint Inflammation in a Clinically Relevant Large Animal Infectious Arthritis Model.
Front Cell Infect Microbiol, 12, 895022.
https://doi.org/10.3389/fcimb.2022.895022 Publication
Researcher Affiliations
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States.
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States.
- Department of Pathobiology New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States.
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States.
- Department of Pathobiology New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States.
- Department of Orthopedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States.
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.
MeSH Terms
- Amikacin
- Animals
- Anti-Bacterial Agents / pharmacology
- Anti-Bacterial Agents / therapeutic use
- Arthritis, Infectious / drug therapy
- Biofilms
- Biological Products
- Disease Models, Animal
- Horses
- Inflammation
- Platelet-Rich Plasma
- Staphylococcal Infections / drug therapy
- Staphylococcal Infections / veterinary
- Staphylococcus aureus
Grant Funding
- R01 AR072513 / NIAMS NIH HHS
Conflict of Interest Statement
The contents of this manuscript are the subject of a patent filed by NC State University and the University of Pennsylvania by the authors (JG, TS, and LS). The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
This article includes 74 references
- Attili A. R., Iacoucci C., Serri E., Cuteri V., Cantalamessa A., Linardi M.. Antibacterial Properties of Canine Platelet-Rich Plasma and Other Non-Transfusional Hemo-Components: An In Vitro Study. Front. Vet. Sci. 8.
- Baillet A., Trocmé C., Romand X., Nguyen C. M. V., Courtier A., Toussaint B.. Calprotectin Discriminates Septic Arthritis From Pseudogout and Rheumatoid Arthritis. Rheumatology 58, 1644–1648.
- Bankhead P., Loughrey M. B., Fernández J. A., Dombrowski Y., McArt D. G., Dunne P. D.. QuPath: Open Source Software for Digital Pathology Image Analysis. Sci. Rep. 7.
- Beccati F., Gialletti R., Passamonti F., Nannarone S., Di Meo A., Pepe M.. Ultrasonographic Findings in 38 Horses With Septic Arthritis/Tenosynovitis. Vet. Radiol. Ultrasound 56, 68–76.
- Bidossi A., Bottagisio M., Savadori P., de Vecchi E.. Identification and Characterization of Planktonic Biofilm-Like Aggregates in Infected Synovial Fluids From Joint Infections. Front. Microbiol. 11.
- Boff D., Crijns H., Teixeira M. M., Amaral F. A., Proost P.. Neutrophils: Beneficial and Harmful Cells in Septic Arthritis. Int. J. Mol. Sci. 19.
- Brackman G., Coenye T.. Quorum Sensing Inhibitors as Anti-Biofilm Agents. Curr. Pharm. Des. 21, 5–11.
- Byren I., Bejon P., Atkins B. L., Angus B., Masters S., McLardy-Smith P.. One Hundred and Twelve Infected Arthroplasties Treated With “DAIR” (Debridement, Antibiotics and Implant Retention): Antibiotic Duration and Outcome. J. Antimicrob. Chemother. 63, 1264–1271.
- Ciofu O., Moser C., Jensen P. Ø., Høiby N.. Tolerance and Resistance of Microbial Biofilms. Nat. Rev. Microbiol. .
- Cobo J., Miguel L. G. S., Euba G., Rodríguez D., García-Lechuz J. M., Riera M.. Early Prosthetic Joint Infection: Outcomes With Debridement and Implant Retention Followed by Antibiotic Therapy. Clin. Microbiol. Infect. 17, 1632–1637.
- Corrado A., Donato P., MacCari S., Cecchi R., Spadafina T., Arcidiacono L.. Staphylococcus Aureus-Dependent Septic Arthritis in Murine Knee Joints: Local Immune Response and Beneficial Effects of Vaccination. Sci. Rep. 6, 38043.
- Cox D., Kerrigan S. W., Watson S. P.. Platelets and the Innate Immune System: Mechanisms of Bacterial-Induced Platelet Activation. J. Thromb. Haemostasis 9, 1097–1107.
- Crosby H. A., Kwiecinski J., Horswill A. R.. Staphylococcus Aureus Aggregation and Coagulation Mechanisms, and Their Function in Host–Pathogen Interactions. Adv. Appl. Microbiol. 96, 1–41.
- Dastgheyb S. S., Hammoud S., Ketonis C., Liu A. Y., Fitzgerald K., Parvizi J.. Staphylococcal Persistence Due to Biofilm Formation in Synovial Fluid Containing Prophylactic Cefazolin. Antimicrob. Agents Chemother. 59, 2122–2128.
- Davis J. S.. Management of Bone and Joint Infections Due to Staphylococcus Aureus. Inter. Med. J. 35, S79–S96.
- Della Valle C. J., Bogner E., Desai P., Lonner J. H., Adler E., Zuckerman J. D.. Analysis of Frozen Sections of Intraoperative Specimens Obtained at the Time of Reoperation After Hip or Knee Resection Arthroplasty for the Treatment of Infection. J. Bone Joint Surg. Am. 81, 684–689.
- Drago L., Bortolin M., Vassena C., Romanò C. L., Taschieri S., del Fabbro M.. Plasma Components and Platelet Activation are Essential for the Antimicrobial Properties of Autologous Platelet-Rich Plasma: An In Vitro Study. PloS One 9.
- Farghali H. A., AbdElKader N. A., AbuBakr H. O., Aljuaydi S. H., Khattab M. S., Elhelw R.. Antimicrobial Action of Autologous Platelet-Rich Plasma on MRSA-Infected Skin Wounds in Dogs. Sci. Rep. 9, 1 9, 1–1 9,15.
- Fischer B. L., Ludders J. W., Asakawa M., Fortier L. A., Fubini S. L., Nixon A. J.. A Comparison of Epidural Buprenorphine Plus Detomidine With Morphine Plus Detomidine in Horses Undergoing Bilateral Stifle Arthroscopy. Vet. Anaesth. Analg. 36, 67–76.
- Flick M. J., LaJeunesse C. M., Talmage K. E., Witte D. P., Palumbo J. S., Pinkerton M. D.. Fibrin(ogen) Exacerbates Inflammatory Joint Disease Through a Mechanism Linked to the Integrin Alphambeta2 Binding Motif. J. Clin. Invest. 117, 3224–3235.
- Frisbie D. D. D., McIlwraith C. W. W., Kawcak C. E. E., Werpy N. M. M.. Evaluation of Intra-Articular Hyaluronan, Sodium Chondroitin Sulfate and N-Acetyl-D-Glucosamine Combination Versus Saline (0.9% NaCl) for Osteoarthritis Using an Equine Model. Vet. J. 197, 824–829.
- Gaigneux E., Cormier G., Varin S., Mérot O., Maugars Y., Le Goff B.. Ultrasound Abnormalities in Septic Arthritis are Associated With Functional Outcomes. Joint Bone Spine 84, 599–604.
- Gallo J., Kolar M., Dendis M., Loveckova Y., Sauer P., Zapletalova J.. Culture and PCR Analysis of Joint Fluid in the Diagnosis of Prosthetic Joint Infection. New Microbiologica 31, 97–104.
- Gato-Calvo L., Magalhaes J., Ruiz-Romero C., Blanco F. J., Burguera E. F.. Platelet-Rich Plasma in Osteoarthritis Treatment: Review of Current Evidence. Ther. Adv. Chronic Dis. 10, 1–18.
- Gilbertie J. M., Long J. M., Schubert A. G., Berglund A. K., Schaer T. P., Schnabel L. V.. Pooled Platelet-Rich Plasma Lysate Therapy Increases Synoviocyte Proliferation and Hyaluronic Acid Production While Protecting Chondrocytes From Synoviocyte-Derived Inflammatory Mediators. Front. Vet. Sci. 5.
- Gilbertie J. M., Schaer T. P., Schubert A. G., Jacob M. E., Menegatti S., Ashton Lavoie R.. Platelet-Rich Plasma Lysate Displays Antibiofilm Properties and Restores Antimicrobial Activity Against Synovial Fluid Biofilms In Vitro. J. Orthopaedic Res. .
- Gilbertie J. M., Schnabel L., Hickok N. J., Jacob M. E., Conlon B. P., Shapiro I. M.. Equine or Porcine Synovial Fluid as a Novel Ex Vivo Model for the Study of Bacterial Free-Floating Biofilms That Form in Human Joint Infections. PLoS One. .
- Giraldo C. E., López C., Álvarez M. E., Samudio I. J., Prades M., Carmona J. U.. Effects of the Breed, Sex and Age on Cellular Content and Growth Factor Release From Equine Pure-Platelet Rich Plasma and Pure-Platelet Rich Gel. BMC Vet. Res. 9, 29.
- Høiby N., Bjarnsholt T., Givskov M., Molin S., Ciofu O.. Antibiotic Resistance of Bacterial Biofilms. Int. J. Antimicrobial Agents 35, 322–332.
- Hanke M. L., Heim C. E., Angle A., Sanderson S. D., Kielian T.. Targeting Macrophage Activation for the Prevention and Treatment of Staphylococcus Aureus Biofilm Infections. J. Immunol. 190, 2159–2168.
- Hanke M. L., Kielian T.. Deciphering Mechanisms of Staphylococcal Biofilm Evasion of Host Immunity. Front. Cell. Infect. Microbiol. 2.
- Heusinkveld M., van der Burg S. H.. Identification and Manipulation of Tumor Associated Macrophages in Human Cancers. J. Trans. Med. 9.
- Horohov D. W.. The Equine Immune Responses to Infectious and Allergic Disease: A Model for Humans?. Mol. Immunol. 66, 89–96.
- Hsueh M. F., Zhang X., Wellman S. S., Bolognesi M. P., Kraus V. B.. Synergistic Roles of Macrophages and Neutrophils in Osteoarthritis Progression. Arthritis Rheumatol. 73, 89–99.
- Jacobsen S., Thomsen M. H., Nanni S.. Concentrations of Serum Amyloid A in Serum and Synovial Fluid From Healthy Horses and Horses With Joint Disease. Am. J. Vet. Res. 67, 1738–1742.
- Klim S. M., Amerstorfer F., Gruber G., Bernhardt G. A., Radl R., Leitner L.. Fibrinogen - A Practical and Cost Efficient Biomarker for Detecting Periprosthetic Joint Infection. Sci. Rep. 8, 8802.
- Knott S., Curry D., Zhao N., Metgud P., Dastgheyb S., Purtill C.. Staphylococcus Aureus Floating Biofilm Formation and Phenotype in Synovial Fluid Depends on Albumin, Fibrinogen, and Hyaluronic Acid. Front. Microbiol. 12.
- Lee Y. S., Lee Y.-K., Han S. B., Nam C. H., Parvizi J., Koo K.-H.. Natural Progress of D-Dimer Following Total Joint Arthroplasty: A Baseline for the Diagnosis of the Early Postoperative Infection. J. Orthop. Surg. Res. 13, 36.
- Leid J. G., Shirtliff M. E., Costerton J. W., Stoodley P.. Human Leukocytes Adhere to, Penetrate, and Respond to Staphylococcus Aureus Biofilms. Infect. Immun. 70, 6339–6345.
- Li G. Y., Yin J. M., Ding H., Jia W. T., Zhang C. Q.. Efficacy of Leukocyte- and Platelet-Rich Plasma Gel (L-PRP Gel) in Treating Osteomyelitis in a Rabbit Model. J. Orthop. Res. 31, 949–956.
- López C., Carmona J. U., Giraldo C. E., Álvarez M. E.. Bacteriostatic Effect of Equine Pure Platelet-Rich Plasma and Other Blood Products Against Methicillin-Sensitive Staphylococcus Aureus. An In Vitro Study. Vet. Comp. Orthop. Traumatol. 27, 372–378.
- Maher M. C., Schnabel L. V., Cross J. A., Papich M. G., Divers T. J., Fortier L. A.. Plasma and Synovial Fluid Concentration of Doxycycline Following Low-Dose, Low-Frequency Administration, and Resultant Inhibition of Matrix Metalloproteinase-13 From Interleukin-Stimulated Equine Synoviocytes. Equine Vet. J. 46, 198–202.
- McConoughey S. J., Howlin R., Granger J. F., Manring M. M., Calhoun J. H., Shirtliff M.. Biofilms in Periprosthetic Orthopedic Infections. Future Microbiol. 9, 987–1007.
- McCoy A. M.. Animal Models of Osteoarthritis: Comparisons and Key Considerations. Vet. Pathol. 52, 803–818.
- McIlwraith C. W., Frisbie D. D., Kawcak C. E.. The Horse as a Model of Naturally Occurring Osteoarthritis. Bone Joint Res. 1, 297–309.
- McIlwraith C. W., Frisbie D. D., Kawcak C. E., Fuller C. J., Hurtig M., Cruz A.. The OARSI Histopathology Initiative – Recommendations for Histological Assessments of Osteoarthritis in the Horse. Osteoarthritis Cartilage 18, S93–S105.
- McIlwraith C. W., Vachon A.. Review of Pathogenesis and Treatment of Degenerative Joint Disease. Equine Vet. J. l, 3–11.
- Moser C., Pedersen H. T., Lerche C. J., Kolpen M., Line L., Thomsen K.. Biofilms and Host Response - Helpful or Harmful. APMIS 125, 320–338.
- Pourkarim R., Farahpour M. R., Rezaei S. A.. Comparison Effects of Platelet-Rich Plasma on Healing of Infected and Non-Infected Excision Wounds by the Modulation of the Expression of Inflammatory Mediators: Experimental Research. Eur. J. Trauma Emerg. Surg. .
- Qu W., Wang Z., Hunt C., Morrow A. S., Urtecho M., Amin M.. The Effectiveness and Safety of Platelet-Rich Plasma for Chronic Wounds: A Systematic Review and Meta-Analysis. Mayo Clin. Proc. 96, 2407–2417.
- Raghu H., Flick M. J.. Targeting the Coagulation Factor Fibrinogen for Arthritis Therapy. Curr. Pharm. Biotechnol. 12, 1497–1506.
- Robertson S. E., Young J. D., Kitson S., Pitt A., Evans J., Roes J.. Expression and Alternative Processing of IL-18 in Human Neutrophils. Eur. J. Immunol. 36, 722–731.
- Sanchez-Pernaute O., López-Armada M. J., Calvo E., Díez-Ortego I., Largo R., Egido J.. Fibrin Generated in the Synovial Fluid Activates Intimal Cells From Their Apical Surface: A Sequential Morphological Study in Antigen-Induced Arthritis. Rheumatology 42, 19–25.
- Shahi A., Kheir M. M., Tarabichi M., Hosseinzadeh H. R. S., Tan T. L., Parvizi J.. Serum D-Dimer Test Is Promising for the Diagnosis of Periprosthetic Joint Infection and Timing of Reimplantation. J. Bone Joint Surg. - Am. Volume 99, 1419–1427.
- Sharff K. A., Richards E. P., Townes J. M.. Clinical Management of Septic Arthritis. Curr. Rheumatol. Rep. 15, 332.
- Shirtliff M. E., Mader J. T.. Acute Septic Arthritis. Clin. Microbiol. Rev. 15, 527–544.
- Soulas C., Conerly C., Kim W. K., Burdo T. H., Alvarez X., Lackner A. A.. Recently Infiltrating MAC387+ Monocytes/ Macrophages: A Third Macrophage Population Involved in SIV and HIV Encephalitic Lesion Formation. Am. J. Pathol. 178, 2121–2135.
- So A. K., Varisco P.-A., Kemkes-Matthes B., Herkenne-Morard C., Chobaz-Peclat V., Gerster J.-C.. Arthritis is Linked to Local and Systemic Activation of Coagulation and Fibrinolysis Pathways. J. Thromb. Haemostasis 1, 2510–2515.
- Stoodley P., Ehrlich G. D., Sedghizadeh P. P., Hall-Stoodley L., Baratz M. E., Altman D. T.. Orthopaedic Biofilm Infections. Curr. Orthop. Pract. 22, 558–563.
- Tang R., Wang S., Yang J., Wu T., Fei J.. Application of Platelet-Rich Plasma in Traumatic Bone Infections. Expert Rev. Anti Infect. Ther. 19, 867–875.
- Taylor A. H., Mair T. S., Smith L. J., Perkins J. D.. Bacterial Culture of Septic Synovial Structures of Horses: Does a Positive Bacterial Culture Influence Prognosis?. Equine Vet. J. 42, 213–218.
- Tecchio C., Micheletti A., Cassatella M. A.. Neutrophil-Derived Cytokines: Facts Beyond Expression. Front. Immunol. 5.
- Tong S. Y. C. C., Davis J. S., Eichenberger E., Holland T. L., Fowler V. G.. Staphylococcus Aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management. Clin. Microbiol. Rev. 28, 603–661.
- van Lent P. L. E. M., Blom A. B., Schelbergen R. F. P., Slöetjes A., Lafeber F. P. J. G., Lems W. F.. Active Involvement of Alarmins S100A8 and S100A9 in the Regulation of Synovial Activation and Joint Destruction During Mouse and Human Osteoarthritis. Arthritis Rheum. 64, 1466–1476.
- Villiers E., Baines S., Law A. M., Mallows V.. Identification of Acute Myeloid Leukemia in Dogs Using Flow Cytometry With Myeloperoxidase, MAC387, and a Canine Neutrophil-Specific Antibody. Vet. Clin. Pathol. 35, 55–71.
- Wang Q., Qian Z., Liu B., Liu J., Zhang L., Xu J.. In Vitro and In Vivo Evaluation of New PRP Antibacterial Moisturizing Dressings for Infectious Wound Repair. J. Biomater. Sci. Polym. Ed. 30, 462–485.
- Wang S., Song R., Wang Z., Jing Z., Wang S., Ma J.. S100A8/A9 in Inflammation. Front. Immunol. 9.
- Wayne Mcilwraith C., Fortier L. A., Frisbie D. D., Nixon A. J.. Equine Models of Articular Cartilage Repair. Cartilage 2, 317–326.
- Wei S., Xu P., Yao Z., Cui X., Lei X., Li L.. A Composite Hydrogel With Co-Delivery of Antimicrobial Peptides and Platelet-Rich Plasma to Enhance Healing of Infected Wounds in Diabetes. Acta Biomater. 124, 205–218.
- Whiteside L. A., Roy M. E.. One-Stage Revision With Catheter Infusion of Intraarticular Antibiotics Successfully Treats Infected THA. Clin. Orthop. Relat. Res. 475, 419–429.
- Xiong G., Lingampalli N., Koltsov J. C. B., Leung L. L., Bhutani N., Robinson W. H.. Men and Women Differ in the Biochemical Composition of Platelet-Rich Plasma. Am. J. Sports Med. 46, 409–419.
- Xu D., Trajkovic V., Hunter D., Leung B. P., Schulz K., Gracie J. A.. IL-18 Induces the Differentiation of Th1 or Th2 Cells Depending Upon Cytokine Milieu and Genetic Background. Eur. J. Immunol. 30, 3147–3156.
- Zhang W., Guo Y., Kuss M., Shi W., Aldrich A. L., Untrauer J.. Platelet-Rich Plasma for the Treatment of Tissue Infection: Preparation and Clinical Evaluation. Tissue Eng. - Part B: Rev. 25, 225–236.
- Zimmerli W., Moser C.. Pathogenesis and Treatment Concepts of Orthopaedic Biofilm Infections. FEMS Immunol. Med. Microbiol. 65, 158–168.
Use Nutrition Calculator
Check if your horse's diet meets their nutrition requirements with our easy-to-use tool Check your horse's diet with our easy-to-use tool
Talk to a Nutritionist
Discuss your horse's feeding plan with our experts over a free phone consultation Discuss your horse's diet over a phone consultation
Submit Diet Evaluation
Get a customized feeding plan for your horse formulated by our equine nutritionists Get a custom feeding plan formulated by our nutritionists