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Hexter AT, Karali A, Kao A, Tozzi G, Heidari N, Petrie A, Boyd A, Kalaskar DM, Pendegrass C, Rodeo S, Haddad F, Blunn G. Effect of Demineralized Bone Matrix, Bone Marrow Mesenchymal Stromal Cells, and Platelet-Rich Plasma on Bone Tunnel Healing After Anterior Cruciate Ligament Reconstruction: A Comparative Micro-Computed Tomography Study in a Tendon Allograft Sheep Model. Orthop J Sports Med 2021; 9:23259671211034166. [PMID: 34568508 PMCID: PMC8461134 DOI: 10.1177/23259671211034166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background: The effect of demineralized bone matrix (DBM), bone marrow–derived mesenchymal stromal cells (BMSCs), and platelet-rich plasma (PRP) on bone tunnel healing in anterior cruciate ligament reconstruction (ACLR) has not been comparatively assessed. Hypothesis: These orthobiologics would reduce tunnel widening, and the effects on tunnel diameter would be correlated with tunnel wall sclerosis. Study Design: Controlled laboratory study. Methods: A total of 20 sheep underwent unilateral ACLR using tendon allograft and outside-in interference screw fixation. The animals were randomized into 4 groups (n = 5 per group): Group 1 received 4mL of DBM paste, group 2 received 10 million BMSCs in fibrin sealant, group 3 received 12 mL of activated leukocyte-poor platelet-rich plasma, and group 4 (control) received no treatment. The sheep were euthanized after 12 weeks, and micro-computed tomography scans were performed. The femoral and tibial tunnels were divided into thirds (aperture, midportion, and exit), and the trabecular bone structure, bone mineral density (BMD), and tunnel diameter were measured. Tunnel sclerosis was defined by a higher bone volume in a 250-µm volume of interest compared with a 4-mm volume of interest surrounding the tunnel. Results: Compared with the controls, the DBM group had a significantly higher bone volume fraction (bone volume/total volume [BV/TV]) (52.7% vs 31.8%; P = .020) and BMD (0.55 vs 0.47 g/cm3; P = .008) at the femoral aperture and significantly higher BV/TV at femoral midportion (44.2% vs 32.9%; P = .038). There were no significant differences between the PRP and BMSC groups versus controls in terms of trabecular bone analysis or BMD. In the controls, widening at the femoral tunnel aperture was significantly greater than at the midportion (46.7 vs 41.7 mm2; P = .034). Sclerosis of the tunnel was common and most often seen at the femoral aperture. In the midportion of the femoral tunnel, BV/TV (r = 0.52; P = .019) and trabecular number (rS = 0.50; P = .024) were positively correlated with tunnel widening. Conclusion: Only DBM led to a significant increase in bone volume, which was seen in the femoral tunnel aperture and midportion. No treatment significantly reduced bone tunnel widening. Tunnel sclerosis in the femoral tunnel midportion was correlated significantly with tunnel widening. Clinical Relevance: DBM might have potential clinical use to enhance healing in the femoral tunnel after ACLR.
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Affiliation(s)
- Adam T Hexter
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Aikaterina Karali
- Zeiss Global Centre, School of Mechanical and Design Engineering, University of Portsmouth, Portsmouth, UK
| | - Alex Kao
- Zeiss Global Centre, School of Mechanical and Design Engineering, University of Portsmouth, Portsmouth, UK
| | - Gianluca Tozzi
- Zeiss Global Centre, School of Mechanical and Design Engineering, University of Portsmouth, Portsmouth, UK
| | - Nima Heidari
- Royal London Hospital and Orthopaedic Specialists (OS), London, UK
| | - Aviva Petrie
- Eastman Dental Institute, University College London, London, UK
| | - Ashleigh Boyd
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Deepak M Kalaskar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Catherine Pendegrass
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Scott Rodeo
- Hospital of Special Surgery, New York, New York, USA
| | | | - Gordon Blunn
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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Hexter AT, Sanghani-Kerai A, Heidari N, Kalaskar DM, Boyd A, Pendegrass C, Rodeo SA, Haddad FS, Blunn GW. Mesenchymal stromal cells and platelet-rich plasma promote tendon allograft healing in ovine anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:3678-3688. [PMID: 33331973 PMCID: PMC8514355 DOI: 10.1007/s00167-020-06392-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The effect of bone marrow mesenchymal stromal cells (BMSCs) and platelet-rich plasma (PRP) on tendon allograft maturation in a large animal anterior cruciate ligament (ACL) reconstruction model was reported for the first time. It was hypothesised that compared with non-augmented ACL reconstruction, BMSCs and PRP would enhance graft maturation after 12 weeks and this would be detected using magnetic resonance imaging (MRI). METHODS Fifteen sheep underwent unilateral tendon allograft ACL reconstruction using aperture fixation and were randomised into three groups (n = 5). Group 1 received 10 million allogeneic BMSCs in 2 ml fibrin sealant; Group 2 received 12 ml PRP in a plasma clot injected into the graft and bone tunnels; and Group 3 (control) received no adjunctive treatment. At autopsy at 12 weeks, a graft maturation score was determined by the sum for graft integrity, synovial coverage and vascularisation, graft thickness and apparent tension, and synovial sealing at tunnel apertures. MRI analysis (n = 2 animals per group) of the signal-noise quotient (SNQ) and fibrous interzone (FIZ) was used to evaluate intra-articular graft maturation and tendon-bone healing, respectively. Spearman's rank correlation coefficient (r) of SNQ, autopsy graft maturation score and bone tunnel diameter were analysed. RESULTS The BMSC group (p = 0.01) and PRP group (p = 0.03) had a significantly higher graft maturation score compared with the control group. The BMSC group scored significantly higher for synovial sealing at tunnel apertures (p = 0.03) compared with the control group. The graft maturation score at autopsy significantly correlated with the SNQ (r = - 0.83, p < 0.01). The tunnel diameter of the femoral tunnel at the aperture (r = 0.883, p = 0.03) and mid-portion (r = 0.941, p = 0.02) positively correlated with the SNQ. CONCLUSIONS BMSCs and PRP significantly enhanced graft maturation, which indicates that orthobiologics can accelerate the biologic events in tendon allograft incorporation. Femoral tunnel expansion significantly correlated with inferior maturation of the intra-articular graft. The clinical relevance of this study is that BMSCs and PRP enhance allograft healing in a translational model, and biological modulation of graft healing can be evaluated non-invasively using MRI.
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Affiliation(s)
- Adam T Hexter
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.
- Institute of Orthopaedics and Musculoskeletal Sciences, Division of Surgery and Interventional Science, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, HA7 4LP, UK.
| | - Anita Sanghani-Kerai
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Nima Heidari
- Royal London Hospital and Orthopaedic Specialists (OS), London, UK
| | - Deepak M Kalaskar
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Ashleigh Boyd
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Catherine Pendegrass
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
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Hexter AT, Shahbazi S, Thangarajah T, Kalaskar D, Haddad FS, Blunn G. Characterisation of the tensile properties of Demineralised Cortical Bone when used as an anterior cruciate ligament allograft. J Mech Behav Biomed Mater 2020; 110:103981. [PMID: 32823143 DOI: 10.1016/j.jmbbm.2020.103981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/21/2020] [Accepted: 07/08/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Graft choice in anterior cruciate ligament (ACL) reconstruction remains controversial and some grafts fail due to inadequate osteointegration. Demineralised cortical bone (DCB) is an osteoinductive collagen-based scaffold. The aim of this study was to measure the tensile properties of DCB from different locations and from different ages, and determine its compatibility with current ACL fixation systems. METHODS The tensile properties of DCB manufactured from femur and tibia of young (9 month) and old (2-3 years) sheep was measured to determine the most appropriate graft choice. The ultimate load and stiffness of DCB allograft using two fixation systems, interference screws and sutures tied around screw posts, was measured ex vivo in an ovine ACL reconstruction model. Comparison was made with superficial digital flexor tendon (SDFT) and ovine ACL. RESULTS DCB derived from young tibia had the highest ultimate load and stiffness of 67.7 ± 10.6 N and 130.2 ± 64.3 N/mm respectively. No DCB fixation system reached the published peak in vivo force through the ovine ACL of 150 N. SDFT fixation with interference screws (308.2 ± 87.3 N) did reach the in vivo threshold but was significantly weaker than ovine ACL (871.0 ± 64.2 N). CONCLUSION The tensile properties of DCB were influenced by the donor age and bone. Owing to inferior tensile properties and incompatibility with suspensory fixation devices, this study indicates DCB is inferior to current tendon grafts options for ACL reconstruction.
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Affiliation(s)
- Adam T Hexter
- Institute of Orthopaedics and Musculoskelatal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK.
| | - Shirin Shahbazi
- Institute of Orthopaedics and Musculoskelatal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - Tanujan Thangarajah
- Institute of Orthopaedics and Musculoskelatal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - Deepak Kalaskar
- Institute of Orthopaedics and Musculoskelatal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - Fares S Haddad
- University College Hospital, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK
| | - Gordon Blunn
- University of Portsmouth, School of Pharmacy and Biomedical Sciences, Portsmouth, PO1 2DT, UK
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Hexter AT, Hing KA, Haddad FS, Blunn G. Decellularized porcine xenograft for anterior cruciate ligament reconstruction: A histological study in sheep comparing cross-pin and cortical suspensory femoral fixation. Bone Joint Res 2020; 9:293-301. [PMID: 32728430 PMCID: PMC7376309 DOI: 10.1302/2046-3758.96.bjr-2020-0030.r2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Aims To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements. Methods A total of 12 sheep underwent unilateral single-bundle ACL reconstruction using pSFT. Two femoral fixation devices were investigated: Group 1 (n = 6) used cortical suspensory fixation (Endobutton CL) and Group 2 (n = 6) used cross-pin fixation (Stratis ST). A soft screw was used for tibial fixation. Functional recovery was quantified using force plate analysis at weeks 5, 8, and 11. The sheep were euthanized after 12 weeks and comprehensive histological analysis characterized graft healing at the graft-bone interface and the intra-articular graft (ligamentization). Results The pSFT remodelled into a ligament-like structure and no adverse inflammatory reaction was seen. The ground reaction force in the operated leg of the Endobutton group was higher at 11 weeks (p < 0.05). An indirect insertion was seen at the graft-bone interface characterized by Sharpey-like fibres. Qualitative differences in tendon remodelling were seen between the two groups, with greater crimp-like organization and more aligned collagen fibres seen with Endobutton fixation. One graft rupture occurred in the cross-pin group, which histologically showed low collagen organization. Conclusion Decellularized pSFT xenograft remodels into a ligament-like structure after 12 weeks and regenerates an indirect-type insertion with Sharpey-like fibres. No adverse inflammatory reaction was observed. Cortical suspensory femoral fixation was associated with more enhanced graft remodelling and earlier functional recovery when compared with the stiffer cross-pin fixation.
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Affiliation(s)
- Adam T Hexter
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, London, UK; NIHR Academic Clinical Fellow, Royal National Orthopaedic Hospital, London, UK
| | - Karin A Hing
- Institute of Bioengineering and School of Engineering and Materials, Queen Mary University of London, London, UK
| | | | - Gordon Blunn
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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Abstract
Introduction: The operating room (OR) is a dynamic, high-pressure clinical setting that offers a unique workplace-based learning environment for students. We undertook a narrative synthesis of the literature to identify factors that influence medical student learning in the OR, and we recommend educational strategies that maximize "theater-based learning". Methods: Key words were searched across three databases PubMed, EMBASE and ERIC (Education Resource Information Center). Eligible studies included original articles published after 1997 presenting empirical research on factors that influence medical students learning in the OR. Methodological quality was measured using the Newcastle-Ottawa Score for education. Results: We identified 764 studies on the topic of student learning in the OR, of which 16 studies fulfilled inclusion criteria. The quality assessments demonstrated a mean value of 2.1 out of a maximum of 6. Conclusions: We identified five key domains that influence student learning in the OR: emotional factors, socio-environmental factors, organizational factors, factors related to educational relevance and factors related to the educator. Educational strategies to enhance theater-based learning include: an induction and physical orientation, clear learning objectives, educator feedback, and simulation.
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Affiliation(s)
- Adam T Hexter
- a Orthopaedic Specialist Registrar and NIHR Academic Clinical Fellow, Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery & Interventional Science , University College London , London , UK
| | | | - Alistair Hunter
- c Consultant Orthopaedic Surgeon University College Hospital , London , UK
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Abstract
Aims The success of anterior cruciate ligament reconstruction (ACLR) depends on osseointegration at the graft-tunnel interface and intra-articular ligamentization. Our aim was to conduct a systematic review of clinical and preclinical studies that evaluated biological augmentation of graft healing in ACLR. Materials and Methods In all, 1879 studies were identified across three databases. Following assessment against strict criteria, 112 studies were included (20 clinical studies; 92 animal studies). Results Seven categories of biological interventions were identified: growth factors, biomaterials, stem cells, gene therapy, autologous tissue, biophysical/environmental, and pharmaceuticals. The methodological quality of animal studies was moderate in 97%, but only 10% used clinically relevant outcome measures. The most interventions in clinical trials target the graft-tunnel interface and are applied intraoperatively. Platelet-rich plasma is the most studied intervention, but the clinical outcomes are mixed, and the methodological quality of studies was suboptimal. Other biological therapies investigated in clinical trials include: remnant-augmented ACLR; bone substitutes; calcium phosphate-hybridized grafts; extracorporeal shockwave therapy; and adult autologus non-cultivated stem cells. Conclusion There is extensive preclinical research supporting the use of biological therapies to augment ACLR. Further clinical studies that meet the minimum standards of reporting are required to determine whether emerging biological strategies will provide tangible benefits in patients undergoing ACLR. Cite this article: Bone Joint J 2018;100-B:271-84.
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Affiliation(s)
- A T Hexter
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - T Thangarajah
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - G Blunn
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK and NIHR University College London Hospitals Biomedical Research Centre, UK
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Abstract
AIMS Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Different bearing surface materials have different surface properties and it has been suggested that the choice of bearing surface may influence the risk of PJI after THA. The objective of this meta-analysis was to compare the rate of PJI between metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC) bearings. PATIENTS AND METHODS Electronic databases (Medline, Embase, Cochrane library, Web of Science, and Cumulative Index of Nursing and Allied Health Literature) were searched for comparative randomized and observational studies that reported the incidence of PJI for different bearing surfaces. Two investigators independently reviewed studies for eligibility, evaluated risk of bias, and performed data extraction. Meta-analysis was performed using the Mantel-Haenzel method and random-effects model in accordance with methods of the Cochrane group. RESULTS Our search strategy revealed 2272 studies, of which 17 met the inclusion criteria and were analyzed. These comprised 11 randomized controlled trials and six observational studies. The overall quality of included studies was high but the observational studies were at high risk of bias due to inadequate adjustment for confounding factors. The overall cumulative incidence of PJI across all studies was 0.78% (1514/193 378). For each bearing combination, the overall incidence was as follows: MoP 0.85% (1353/158 430); CoP 0.38% (67/17 489); and CoC 0.53% (94/17 459). The meta-analysis showed no significant difference between the three bearing combinations in terms of risk of PJI. CONCLUSION On the basis of the clinical studies available, there is no evidence that bearing choice influences the risk of PJI. Future research, including basic science studies and large, adequately controlled registry studies, may be helpful in determining whether implant materials play a role in determining the risk of PJI following arthroplasty surgery. Cite this article: Bone Joint J 2018;100-B:134-42.
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Affiliation(s)
- A T Hexter
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - S M Hislop
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - G W Blunn
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - A D Liddle
- Institute of Orthopaedics and Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
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Abstract
Background: Following injury to the rotator cuff and anterior cruciate ligament, a direct enthesis is not regenerated, and healing occurs with biomechanically inferior fibrous tissue. Demineralized bone matrix (DBM) is a collagen scaffold that contains growth factors and is a promising biological material for tendon and ligament repair because it can regenerate a direct fibrocartilaginous insertion via endochondral ossification. Purpose: To provide a comprehensive review of the literature investigating the use of DBM to augment tendon-bone healing in tendon repair and anterior cruciate ligament reconstruction (ACLR). Study Design: Systematic review. Methods: Electronic databases (MEDLINE and EMBASE) were searched for preclinical and clinical studies that evaluated the use of DBM in tendon repair and ACLR. Search terms included the following: (“demineralized bone matrix” OR “demineralized cortical bone”) AND (“tissue scaffold” OR “tissue engineering” OR “ligament” OR “tendon” OR “anterior cruciate ligament” OR “rotator cuff”). Peer-reviewed articles written in English were included, and no date restriction was applied (searches performed February 10, 2017). Methodological quality was assessed with peer-reviewed scoring criteria. Results: The search strategy identified 339 articles. After removal of duplicates and screening according to inclusion criteria, 8 studies were included for full review (tendon repair, n = 4; ACLR, n = 4). No human clinical studies were identified. All 8 studies were preclinical animal studies with good methodological quality. Five studies compared DBM augmentation with non-DBM controls, of which 4 (80%) reported positive findings in terms of histological and biomechanical outcomes. Conclusion: Preclinical evidence indicates that DBM can improve tendon-bone healing, although clinical studies are lacking. A range of animal models of tendon repair and ACLR showed that DBM can re-create a direct fibrocartilaginous enthesis, although the animal models are not without limitations. Before clinical trials are justified, research is required that determines the best source of DBM (allogenic vs xenogenic) and the best form of DBM (demineralized cortical bone vs DBM paste) to be used in them.
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Affiliation(s)
- Adam T Hexter
- Institute of Orthopaedic and Musculoskeletal Sciences, University College London, Royal National Orthopaedic Hospital, Middlesex, UK
| | - Catherine Pendegrass
- Institute of Orthopaedic and Musculoskeletal Sciences, University College London, Royal National Orthopaedic Hospital, Middlesex, UK
| | | | - Gordon Blunn
- Institute of Orthopaedic and Musculoskeletal Sciences, University College London, Royal National Orthopaedic Hospital, Middlesex, UK
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Abstract
Glenohumeral synovitis is a rare complication of vaccination that can lead to shoulder dysfunction and prolonged pain. We report a case of florid glenohumeral synovitis after routine influenza vaccination, which we consider to have occurred because of the unintentional injection of antigenic material into synovial tissues, resulting in an immune-mediated inflammatory reaction. We provide a review of the literature for this condition and describe an invasive management approach, providing, for the first time, an arthroscopic evaluation and histopathological analysis.
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Affiliation(s)
- Adam T Hexter
- Dr Adam T Hexter, Apartment 15, 37 Chapeltown
Street, Manchester M1 2AT, UK. E-mails: ;
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Hexter AT, Shepherd M, Heppner P. Severe Acute Subdural Hematoma in a Child following a Minor Head Trauma in the Context of a Recent Antecedent Head Injury: A Case Report. Pediatr Neurosurg 2015; 50:157-60. [PMID: 25997477 DOI: 10.1159/000381031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 02/14/2015] [Indexed: 11/19/2022]
Abstract
Knowledge of the force required to generate a subdural hematoma is important when considering the veracity of histories given by family members of young children. Traditional wisdom is that a substantial impact is required to cause an acute subdural hematoma. We present a case of acute subdural hematoma following a low-level fall in a 3-year-old patient. An antecedent head injury associated with normal CT scan might have had some bearing on this outcome.
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Affiliation(s)
- Adam T Hexter
- Manchester Royal Infirmary, Central Manchester Foundation Trust, Manchester, UK
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