International Journal of Medical Laboratory

Loss or destruction of tissues and organs due to aging or pathological conditions is crucial in human health. Although the body itself can usually repair most injuries at an early age, some parts of the body have limited repair capacity. Cartilage has a limited ability to repair the damage because it has no blood vessels and nerves [1, 2]. The limited self-healing capacity of cartilage has encouraged researchers to develop new and biometric technologies to improve tissue integrity. Recently, tissue engineering has emerged as a new method of treating damaged or disabled tissue such as cartilage, bone, and skin [3]. Creating an optimal tissue engineering structure requires three basic components: a suitable cell source, growth and differentiation factors, and a suitable scaffold to support cell regeneration based on cell type.
To design scaffold for cartilage repair, materials should be used that have biochemical and physical properties for better engineering of cartilage tissue structures. Biochemical design is related to the chemical composition and biological properties of scaffolding, affecting cell behavior and activity. The physical design is associated with the scaffold's interior and exterior architecture, mechanical properties, and destruction. Designing an ideal scaffold with a proper physical structure, the possibility of adhesion, migration, and differentiation of cells is important. Scaffolds can be made of natural, synthetic, or hybrid materials [4, 5].
Natural materials often have physiological activities such as cell adhesion, adaptability, and proper degradation. There are two kinds of naturally derived polymers. Carbohydrate-based polymers such as agarose, alginate, hyaluronic acid, and protein matrices such as fibrin and collagen are in this category [6].
Composition, structure, and properties of fibrin
Fibrin is a natural biodegradable material used as an efficient scaffold engineering of many tissues. A fibrin scaffold is a protein network formed by the polymerization of fibrin monomers and protects a variety of living tissues. Fibrin is a biomaterial that naturally consists of a network with transverse connections that has led to its widespread use in medical applications. Fibrin has a high potential for use in tissue engineering. It can be isolated from the patient's blood and used as a potentially safe autologous scaffold for a foreign body interaction or infection [7-9]. Fibrin acts as an active matrix due to its numerous interaction sites for cells and other proteins and is suitable for cell delivery systems and biomedical drugs and molecules [10].
Fibrin is proinflammatory and induces its degradation and substitution by cellular components of the extravascular tissue spaces, and its degradation products are nontoxic physiological substances. Fibrin has been extensively used as scaffold material by incorporating chondrocytes into the fibrin clot, both in-vitro [11] and in-vivo [12]. Peretti et al. reviewed the studies of fibrin hydrogels in articular cartilage repair in laboratory animals. They suggested that the mixture of autologous chondrocytes and allogeneic decellularised cartilage matrices suspended in fibrin glue led to the generation of cartilage-resembling constructs [13].
Microfracture is the most common restorative method used to treat articular cartilage in the clinic. During the microfracture procedure, articular cartilage defects are created by small holes within the subchondral bone. These holes permit the constitution of the clot at the defect site. Progenitor cells and growth factors can incorporate into the defect site and inchoate the tissue's repair by creating a fibrocartilage-like tissue [14, 15]. One study found that using fibrin scaffolds to cultivate human mesenchyme stem cells under laboratory conditions and living organisms increased cell proliferation and survival [16]. The fibrin scaffold increases vertebral disc cells' proliferation compared to the alginate scaffold and reduces cell apoptosis [17]. Fibrin has been used successfully as a scaffold to repair fibrocartilage, elastic cartilage, cranial and facial cartilage, and articular cartilage. Collagen fibrin hydrogels permit the organization of an enduring bond in a cartilage repair chicken model [18]. Fibrin encapsulated chondrocytes in articular cartilage tissue engineering have been widely used in practical studies [19-21].
Biological properties of fibrin
Fibrin is a biopolymer of fibrinogen monomers. The fibrinogen molecule is composed of two sets of three polypeptide chains called Aa, B, and y, joined together by six disulfide bonds [22]. Fibrin mediates blood platelets' formation and the expansion of endothelial cells, the proliferation of fibroblasts in the tissue, and the angiogenic process's strengthening, thereby accelerating the wound healing process [23]. Fibrin prevents further blood loss and also provides a temporary scaffold to support tissue repair and regeneration [24].
Although standard quality fibrin glue is produced, autologous fibrin glue has two significant advantages: the reduced possibility of viral transmission and infection and the lower cost [25, 26]. Fibrin glue for tissue engineering serves as a delivery carrier and as a scaffolding matrix [27]. Fibrin glue can be modified in mechanical properties by applying other polymers such as gelatin, hyaluronic acid, and chondroitin sulfate [21].
Mechanical properties of fibrin
The configuration of the scaffold is serious about supporting cartilage regeneration. With the improvement in the manufacture and shape of the scaffold, a three-dimensional (3D) structure is precedent to two-dimensional (2D) due to further maintenance of cell structure, differentiation, and resemblance of morphology and growth of cells [28]. Fibrin stiffness behavior is subordinated by the phenomenon called "strain hardening": at low pressures, the stress is directly proportional to the pressure. However, in large strains, the fibrin stiffness increases with rising pressure up to 20-fold [29]. However, fibrin scaffolds have poor mechanical properties and fast degradation, limiting the time needed for the formation of neocartilage [30, 31]. The mechanical reactions of fibrin gels to shear, tensile, and compressive forces are known to represent a completely nonlinear reaction known as strain hardening [32]. The composition of polylactic acid with glycolic acid with fibrin increases the elastic modulus of scaffolding, while it has no side effects on cell proliferation and secretion of glycosaminoglycan [33]. By culturing stem cells in a fibrin scaffold as a three-dimensional scaffold, researchers stated that cell survival and proliferation increased and could induce osteogenic, chondrogenic, and adipogenic dynasties [34]. Natural scaffolds such as fibrin could be a proper environment for differentiating mesenchyme stem cells in the presence of transforming growth factor beta (TGF-β) [1]. In cartilage defect treatment, scaffolds are often fixed with fibrin glue to stay in place to inject and localize cells in the defect sites. Fibrin hydrogels could be an attractive carrier for mesenchymal stroma cells (MSC)-based tissue engineering approaches [35]. Fibrin hydrogels permit the high efficiency of cell seeding, better adhesion of cells, and uniform distribution [36]. This study reviewed and summarized the specifications of fibrin scaffold and composite/hybrid scaffolds based on fibrin, along with growth factors and cells in cartilage tissue engineering (Tables 1, 2).

Table 1. Overview of investigated fibrin scaffolds in cartilage tissue engineering

outcome	Method of study	Growth factor	Scaffold type	Year	Author
Fibrin preparations increased cellular proliferation and DNA content. increased GAG accumulation	In-vitro/ human septal cartilage chips chondrocytes	Collagenase-treated medium	Fibrin	2009	Liu Y [36]
Transplanting autologous BM-MSC in PR-FG as a cell scaffold is an effective procedure for better repairing articular cartilage defects in human patients.	In-vivo/ human BMSCs	CM	PRF	2010	Haleem AM [37]
Increased expression of aggrecan cartilage genes, type II collagen, and SOX-9 was observed and showed that mesenchymal stem cells of cartilage differentiation from human adipose tissue with fibrin adhesive could proliferate and subcutaneously form new cartilage in the back of nude mice	In-vivo/ hADSCs in subcutaneously in nude mouse	CM	Fibrin	2010	Jung SN [38]
The results of both in vitro and in vivo studies showed that cultured or transplanted hMSC cells are mixed with TGF-β3 in fibrin hydrogel differentiate into chondrocytes.	In-vitro/ human BMSCs- amniotic fluid In-vivo/ nude mice	CM+  TGF-β3	Fibrin	2011	Park JS [39]
BMSCs in FG demonstrated an increase in Aggrecan gene expression and accumulation of ECM.	In-vitro/ human BMSCs	CM+ TGF-β2	Fibrin	2011	Ahmed TA [40]
The In-vivo culture showed further tissue maturation compared to in the In-vitro condition.	In-vitro- In-vivo/ swine chondrocytes	CM	Fibrin	2012	Deponti D [41]
Cartilage-related genes and proteins were up-regulated, and deposition of collagen type II and GAGs in the neo-cartilage demonstrated.	In-vivo/ Rabbit BMSCs	CM	Fibrin	2016	Dai Y [42]
More proliferation and differentiation into cartilage was demonstrated in mucopolysaccharide in the matrix of cells marked with the toluidine blue.	In-vitro/ hADSCs	CM	PRF	2017	Souza FG [43]
Expression of the chondrogenesis gene marker, SOX9, Aggrecan, and type II collagen, was observed in the Kartogenin and TGFβ3 groups compared with the control group. The expression of type X collagen as a marker of hypertrophy in ketogenic exposed cartilage was also decreased.	In-vitro/ hADSCs	CM+ Kartogenin / CM+ TGF-β3	Fibrin	2017	Izadi MA [44]
ASU in fibrin scaffold raised the expression of COL II and AGG.	In-vitro/ hADSCs	CM+ Kartogenin/ CM+ Avocado soybean	Fibrin	2018	Izadi MA [45]
Applying dynamic compressive force enhanced chondrogenesis and maturation in a simulated In-vitro model of fracture.	In-vitro/  BMSCs	CM	Fibrin	2019	Iseki T [46]
Fibrin scaffold had a high expression in chondrogenic gens. A new strategy for tissue regeneration utilization of inherent scaffolds such as fibrin can act as a protector for MSCs.	In-vitro/   hADSCs	CM+TGF-β	Fibrin	2019	Ghiasi M [47]
PRF promotes the survival and expression of GAG. PRF conditioning media persuade notable migration and growth of cartilage cells from grafts.	In-vitro/ porcine chondrocytes	CM	PRF	2020	Wong CC [48]
Extension of the concentrations of fibrinogen and thrombin caused stiffness. Besides, hADSCs within high-concentration fibrinogen formulation maintained a morphology near to natural chondrocytes.	In-vitro/ hADSCs	CM	Fibrin	2020	Kim JS [49]

     

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