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Additionally, a vari- progression of OA in the knee.11 Similar associa- ety of operative techniques such as valgus os- tions have been found between obesity and teotomy, hemiepiphyseodesis, hemiepiphseal stapling,7 and guided growth pin systems are al- Figure 3. More severe injuries, tion and splinting.6 Patients can expect mild im- like the one presented here, have very low proba- provement. If the blood help lower the risk of contamination with mater-sample does not agglutinate with either, the nal blood as well as bacterial contamination.blood is type O. 162 AMSRJ 2015 Volume 1, Number 2Botulinum Toxin Injections for the Management BRIEF REPORTS of Acquired Abducens-Oculomotor Synkinesis Following Abducens Nerve Palsy Ryan Shields, BS1; S. Erzurum, MD, FACS1,2 1Northeast Ohio Medical University, Rootstown, OH 2Eye Care Associates, Youngstown, OHABSTRACT CASE PRESENTATIONAcquired abducens-oculomotor synkinesis re- The patient is a 17-year-old male with neurofi-sults in paradoxical eyelid, pupillary, and/or ex- bromatosis type 1 with remote history of es-tra-ocular movements on attempted lateral gaze. A novel approach to the management of pyoderma gangrenosum complicating reduction mammaplasty. Postoperative AP and lateral knee radiographs so used.8 A valgus osteotomy requires a removal A) Right B) Left of a portion of the tibial joint surface, allowing the femur and tibia to bend away from the affect- ed area. [The Pediatric Orthopaedic Soci- ety of North America Web site]. A literature search performed in bility of recovery and require surgery as the ulti- November 2014 reveals no cases of symptom mate treatment. Protocols for cord blood collection are in place to avoid interfering with the delivery of the baby There is a commonly used second step in blood while preserving sterility. otropia managed surgically with bilateral medi-To the best of our knowledge, there are only two al rectus recession and superior oblique ex-documented cases of abducens-oculomotor panders thirteen years earlier. Hemiepiphyseodesis, hemiepihyseal stapling, and guided growth pin systems all in- volve insertion of hardware across the epiphysis in order to halt growth across a portion of the 146 AMSRJ 2015 Volume 1, Number 2OSTEOCHONDRITIS DISSECANS knee and is thought to possibly arise from repeti- BRIEF REPORTS tive trauma. Direct repair of the nerve is un- resolution using splinting and therapy alone. Most importantly,typing called back typing, also known as reverse cord blood collection should never compromisetyping. His history wassynkinesis of the medial rectus following ab- complicated by multiple neurogenic tumors in-ducens nerve palsy. This micro trauma can be a result of normal activity, but adolescents with sports in- juries or lack of coordination may be at an in- creased risk. common; one group’s experience showed only Pharmacological treatment can be used to treat 44 surgical radial nerve repairs in 22 years at a neuropathic pain from a lesion but cannot repair large tertiary care center.4 Because most radial functional loss. In this step, only the plasma from the the well-being of the mother or the neonate. The previous cases were cluding a stable left optic nerve glioma and amanaged with muscle recession surgery to pro- pilocytic astrocytoma of his brainstem develop-duce orthotropia without a decrease in the synki- ing several years after his strabismus surgery.netic behavior. imaging confirmed bilateral genu varum due to proximal tibial physeal alterations consistent The patient underwent uneventful bilateral with Blount’s disease, Langenskiöld stage III, proximal tibial lateral growth modulation and bilateral medial femoral condyle OCD. Theunion of an A, B, or AB mother and an A, B, or current standard of care in the United States is to AB father; neither parent can have an O blood administer a single dose of 300 µg of Rho(D)type. A and B alleles to be inherited from the same parent. alleles encode a single enzyme with bifunctional Laboratory Medicine. The most common- tion of the oculomotor nerve end organs (eyelid,ly recognized clinical synkineses are of facial pupil, and/or muscles) upon abducens nervenerve origin. MRI through hemi-epiphysiodesis using a plate and staging of his OCD lesions was consistent with screw construct and bilateral knee arthroscopy stage 4, based on Hefti classification.14 Preoper- with arthroscopic OCD transchondral mi- ative radiographic images are shown in Figure 1. The goal of the hemi-epiphysiode- The metaphyseal-diaphyseal angles were 6 de- sis is to arrest growth of the patient’s lateral tibial grees on the left and 5 degrees on the right with physis while allowing continued growth through the medial tibial physis, correcting the deformity and the axis of the lower limb. The neonate has to inherit the A allele and immunoglobulin early in the third trimester.14B allele from each parent (see Table 1).9 The A The 28 weeks recommendation comes from evi-and B alleles cannot be inherited together from dence that 92% of women who develop anti-Dthe same parent. An example of facial nerve synki- stimulation, which normally functions in abduc-nesis can be seen in crocodile tears syndrome, in tion by lateral rectus activation. The moval, radiographs demonstrated completepatient recovered uneventfully from surgery and healing of the OCDs and the patient was painwas discharged home in stable condition. Most recent standing hips to ankles radiograph at 18 month The patient was allowed to bear weight for daily post-operative visit showed correction of theactivities, although impact activities were re- right varus to 7 degrees of valgus and correctionstricted for 3 months postoperatively. AB blood types can potentially accept O,26-28 weeks gestation. Henry’s Clinical Diagnosis and Manage- ment by Laboratory Methods. ples are mixed with known anti-A and anti-B antibody serum, and are then monitored for ag- 5. ticular ABO antigen(s) on the red blood cell sur- Bone Marrow Transplantation. face have reacted with the antibodies present in the serum. vious cases synkinesis.7 A botulinum toxin trial was attempted to para- Unfortunately, it is extremely difficult to deter- lyze the aberrant medial rectus because the pa- mine the mechanism behind this specific synki- tient wanted to avoid surgery given his extensive nesis. treatment in patients up to 3 years of age who have esotropic Duane retraction syndrome. Recent advances in supportive care and pharma- cologic neurostimulation raise new hopes for re- INTRODUCTION habilitating patients with disorders of con- sciousness. After further inspection, a rhage into the gland versus a tumor or other malignant epithelioid neoplasm with necrosis mass. Three of the left to 6 degree of valgus, based onmonths after surgery, the patient had no knee anatomic axis (Figure 8). Subsequent pregnancies A, B, or AB blood type transfusions since AB are affected due to Ig G antibodies against Rh blood types do not have any antibodies to ABO(D), which are formed during the first pregnan- blood group antigens in their plasma. Obviously, this case involves some com- surgical history. Central reorganization as a pathologic trophic regulation of acetylcholine receptors. 1976;264mechanism in ocular synkinesis is less com- (5588):787-9than aberrant regeneration, but it is animportant alternative mechanism to be 10. This case describes the comprehen- The minimally conscious state (MCS) is a disor- sive rehabilitation care of a patient in a chronic der of consciousness in which the patient minimally conscious state. A follow up MRI with contrast and dedi- was suspected, pending immunostains.

We are unaware of any reports of this finding in the literature. Arthroscopic probing of OCD lesions B) OCD lesions posttranschondral microfractureseverity of meniscal tears and cartilage defects, CASE PRESENTATIONillustrating the effects of increased weight on the CASE PRESENTATIONknee joint. Recurrence of varus deformity after proximal tibial osteotomy in Blount disease: long-5. Tendon transfer surgery clinical functionality, after the onset of nerve should also be considered. The syringe method in-anti-A and anti-B antibodies in the plasma of volves clamping the cord prior to delivery of thetype O blood. By using the syringeit becomes clear that certain substances could method, the exposure to air is minimized andcatalyze the false agglutination reaction, thus sterility is maintained.5distorting the blood type result. The patient was managed with botulinum managed by sub-occipital craniotomy in 2012toxin injections into the left medial rectus mus- due to sudden neurologic compromise (Figurecle with promising results. Corresponding Author: Ryan Shields, BS, Northeast Ohio After his surgical resection, he developed left Medical University, 4209 Ohio 44, Rootstown, OH 44272. He had se- vere left esotropia of 50 prism diopters (PD) Email: [email protected] complete paralysis on abduction. Grillo MA, Cavalheiro TT, da Silva Mulazani M, Rocha JL, gangrenosum on the breast: a case presentation and review of the Semchechen D, da Cunha CA.

When there is an un- stable fracture or loose body, then open reduc- tion with internal fixation and occasionally bone grafting is undertaken. She was immediately given 300 µg whenfrequency of cis-AB was 1.1 x 10-5. Black arrows are normal pathways while red arrows er pathologic mechanisms are at play in con- indicate hypothesized pathology. Costa J, Monteiro D, Valenca-Filipe R, Reis J, Silva A.

Post-operative images of the bilateral hemi-epiphysiodesis are shown in 148 AMSRJ 2015 Volume 1, Number 2OSTEOCHONDRITIS DISSECANS BRIEF REPORTSFigure 7. the neonate was suspected to be Rh(D) because the earlier that Rho(D) is given, the lower the This case highlights the risks of cord blood con- risk of isoimmunization. 300 µg of Rho(D) immunoglobulin should cord blood collection for transplantation: a comparison of three meth- be administered at 28 weeks gestation to all Rh ods. A: (left) illustrates the possible junction to the proposed central reorganization. AMSRJ 2015 Volume 1, Number 2 179PRIMARY EPITHELIOID ANGIOSARCOMABRIEF REPORTS shaft.

Additionally, untreated Blount’s dis-ease often leads to growth suppression, knee An obese twelve-year-old African-Americanjoint laxity as a result of mechanical strain, and boy, 161 cm in height and 84.3 kg in weight within severe cases, compensatory ankle valgus.11 a BMI of 32.5 kg/m2, presented with complaints of bilateral knee pain exacerbated by activity for Osteochondritis dissecans (OCD), a term used the past several months. This is a reliable op- palsy but before treatment, will be essential in eration for functional improvement. It is the re- generally excellent and, in contrast to non-oper- sponsibility of the physician to ensure accurate, ative treatment, multiple studies have shown current physical exam information. In fact, there aresubstances within the umbilical cord that can The second cord blood collection technique, thecause this reaction. Best-cor- rected vision of the right eye was 20/20, and the The authors claim no conflicts of interest or disclosures. Pupils were equal and reac AMSRJ 2015; 1(2):163—167 AMSRJ 2015 Volume 1, Number 2 163BOTULINUM TOXIN INJECTIONSBRIEF REPORTS Figure 1.

He was found to haveto describe lesions in articular cartilage and sub- bilateral genu varum on exam and standing hipschondral bone, is most typically found in the to ankles radiographic evaluation revealed the deformity existing through the proximal tibia Figure 5. This be- successful outcomes.8,9 comes even more crucial in cases of invasive treatment when the threat of overtreatment be- Surgery must be carefully discussed with the pa- comes more likely. In cases of iatrogenic radial nerve palsy, the patient may not be entirely enthusiastic about the prospects of another surgery. Wharton’s jelly is a gelati- gravity and glass tube method, allows blood tonous component within the umbilical cord that drain from the incised end of the umbilical cordsupports and protects the umbilical blood ves- into a glass tube. This viscous material is composed of cells ed via the gravity and glass tube method it isthat originate from extraembryonic mesoderm important to wash the red blood cells 3-4 timesand is made up of hyaluronic acid and chon- in saline before determining the blood type ofdroitin sulfate. It is also important not to squeezeological clamping of the umbilical cord shortly the umbilical cord while collecting the cordafter birth and can coat the neonate’s red blood blood because the increased pressure on the cordcells and make them polyagglutinable, causing a could expel Wharton’s jelly into the collection AMSRJ 2015 Volume 1, Number 2 159FALSE NEONATAL BLOOD TYPINGBRIEF REPORTS tube. American College of Obstetricians and Gynecologists. MRI of the brain showing post-surgical changes of the sub-occipital craniotomy and resection of a dorsal pons lesion.

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His family said that he to be found as they most commonly present with was first noted to have this deformity as an in- a defect on the posterolateral surface of the me- fant, suggestive of early onset Blount’s disease, dial femoral condyle.13,14 The radiographs gen- and corrective surgery was recommended on erally show radiolucency in the subchondral initial consultation with a pediatric orthopaedic bone with depression or non-displaced frag- surgeon. Infantile tibia vara: factors affecting outcome (7):1758-76. J Surg Or-recovery was observed and the finding was thop Adv. Flexibility on the part ofthe surgeon is required for translating real-timeclinical progress into real-time surgical plans. However, when contamina- therefore, is not accepted for testing.”6 Addi- tion is not a causal factor, false paternity must be tionally, the American Association of Blood investigated as the inciting factor that would Banks requests that cord blood be collected us- cause a different ABO result based upon the ing a needle and syringe which avoids contami- mother’s known blood type. Maternal Alloimmunization and Fetal Hemolytic Disease. Because of his severe esotropia, he was rectus under anesthesia approximately 2 months 164 AMSRJ 2015 Volume 1, Number 2BOTULINUM TOXIN INJECTIONSlater. The family requested another botulinum injec-tion approximately four months after the previ-ous injection, and 10 units of botulinum toxinwere injected into the left medial rectus underanesthesia. Duval A, Boissel N, Servant JM, Santini C, Petit A, Vignon- 25.

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