Publications by authors named "Leo Donnan"

23 Publications

  • Page 1 of 1

Pedicled fibular transfer for biologic knee extensor tendon reinsertion following proximal tibial resection in pediatric osteosarcoma: Long-term outcomes.

Microsurgery 2021 Aug 25. Epub 2021 Aug 25.

Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Australia.

Introduction: Proximal tibial sarcoma resections result in a reconstructive challenge, necessitating joint and extensor mechanism reconstruction. The gait and functional outcomes for children reconstructed with a combination of megaprosthesis and pedicled fibular flap for extensor mechanism reconstruction, are presented.

Methods: Four patients, aged 11-18 years old, were available for comprehensive analysis. The proximal tibial osteosarcoma was resected, and the reconstructive technique involved a megaprosthesis for the knee joint, used in combination with a pedicled fibula flap as a biologic structure for reinsertion of the knee extensor mechanism. Outcomes were measured with three-dimensional gait analysis and patient questionnaires.

Results: Minor postoperative wound issues occurred in some patients, requiring debridement with skin grafting. One patient fractured their transferred fibula, requiring fixation. The follow up period ranged from 1.7 to 24 years postoperatively. The longevity and quality of reconstructions were strong, measured by both objective and patient-reported outcomes. All patients reported independent walking >500 m in the Functional Mobility Scale and rated their walking as a nine or 10 (out of 10) on the Functional Assessment Questionnaire. Knee society scoring revealed overall satisfaction rate of 75-80%. No patients required gait aids. The gait profile analysis revealed effective gait patterns, with patterns deviating 5.4-7° from "typical gait." Deviations >6.5° are considered abnormal.

Conclusion: The long-term results of combining a megaprosthesis with a pedicled fibula flap for extensor reinsertion, revealed a high level of independent function. The patients performed well, without the need for aids, and gait study evidence of minimal gait deviations.
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http://dx.doi.org/10.1002/micr.30802DOI Listing
August 2021

The Gait Outcomes Assessment List for Children With Lower Limb Difference (GOAL-LD): Assessment of Reliability and Validity.

J Pediatr Orthop 2021 Jun 3. Epub 2021 Jun 3.

Departments of Physiotherapy Orthopaedics, The Royal Children's Hospital The Murdoch Children's Research Institute, Melbourne School of Allied Health, Australian Catholic University, Ballarat, Australia Department of Orthopedics, Nationwide Children's Hospital, Columbus, OH Division of Orthopedics, The Hospital for Sick Children & Department of Surgery, University of Toronto Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada.

Background: The Gait Outcomes Assessment List for children with Lower Limb Difference (GOAL-LD) is a patient and parent-reported outcome measure that incorporates the framework of the International Classification of Functioning, Disability, and Health. This prospective multicenter cohort study evaluates the validity and reliability of the GOAL-LD and the differences between parent and adolescent report.

Method: One hundred thirty-seven pediatric patients aged over 5 years attending limb reconstruction clinics at the participating sites were assessed at baseline, and a self-selected cohort also completed an assessment 2 to 6 weeks later. Construct and criterion validity were assessed by comparing GOAL-LD scores with a measure of limb deformity complexity (LLRS-AIM) and the Pediatric Outcomes Data Collection Instrument, using Spearman correlation coefficients. Face and content validity were determined through ratings of item importance. Test-retest reliability was reported as an intraclass correlation coefficient and internal consistency using Cronbach α. Adolescent reports were compared with their parents using paired t tests.

Results: The GOAL-LD demonstrated a moderate negative correlation with the LLRS-AIM (r=-0.40, P<0.001) and was able to discriminate between deformity complexity groups as defined by the LLRS-AIM (χ2=11.43, P=0.022). Internal consistency was high across all domains (α≥0.68 to 0.97). Like domains of the Pediatric Outcomes Data Collection Instrument and the GOAL-LD were well correlated. Parents reported a lower total GOAL-LD score when compared with adolescents (mean difference 3.04; SE 1.06; 95% confidence interval, 0.92-5.16; P<0.01); however this difference was only significant for body image and self-esteem (Domain F) and gait appearance (Domain D). Test-retest reliability remained high over the study period (intraclass correlation coefficient 0.85; SE 0.03; 95% confidence interval, 0.77-0.91).

Conclusions: The GOAL-LD is a valid and reliable self and parent-reported outcome measure for children with lower limb difference. Parents report a lower level of function and attribute a higher importance to items when compared with their children. The GOAL-LD helps to communicate parent and child perspectives on their function and priorities and therefore has the capacity to facilitate family centered treatment planning and care.

Level Of Evidence: Level II-diagnostic. Prospective cross-sectional and a longitudinal cohort design.
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http://dx.doi.org/10.1097/BPO.0000000000001866DOI Listing
June 2021

Enhancing Value and Uptake for Whole-Population Cohorts of Children and Parents: Methods to Integrate Registries into the Generation Victoria Cohort.

Children (Basel) 2021 Apr 7;8(4). Epub 2021 Apr 7.

Murdoch Children's Research Institute, Melbourne 3052, Australia.

Health registries are critical to understanding, benchmarking and improving quality of care for specific diseases and conditions, but face hurdles including funding, bias towards clinical rather than population samples, lack of pre-morbid and outcomes data, and absent cross-registry harmonisation and coordination. Children are particularly under-represented in registry research. This paper lays out novel principles, methods and governance to integrate diverse registries within or alongside a planned children's mega-cohort to rapidly generate translatable evidence. GenV (Generation Victoria) will approach for recruitment parents of all newborns (estimated 150,000) over two years from mid-2021 in the state of Victoria (population 6.5 million), Australia. Its sample size and population denominator mean it will contain almost all children with uncommon or co-morbid conditions as they emerge over time. By design, it will include linked datasets, biosamples (including from pregnancy), phenotypes and participant-reported measures, all of which will span pre-morbid to long-term outcomes. We provide a vignette of a planned new registry for high-risk pregnancies to illustrate the possibilities. To our knowledge, this is the first paper to describe such a methodology designed prospectively to enhance both the clinical relevance of a large multipurpose cohort and the value and inclusivity of registries in a population.
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http://dx.doi.org/10.3390/children8040285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8067795PMC
April 2021

Syme Amputation: Function, Satisfaction, and Prostheses.

J Pediatr Orthop 2020 Jul;40(6):e532-e536

Departments of Orthopaedics.

Background: Syme amputation (SA) is a term used to describe an amputation at the level of the ankle joint in which the heel pad is preserved. It is performed for a number of indications in a pediatric population. SA is purported to hold the advantage of allowing weight bearing without a prosthesis. A limb length discrepancy (LLD) is useful for ambulation without a prosthesis but can be restrictive with regards to the fitting of modern prostheses.

Methods: A voluntary survey was distributed to persons living with SA. Recruitment occurred through hospital electronic database and electronic advertising. Data collected included baseline demographic information, data pertaining to weight bearing in different environments, as well as 2 validated outcome measures: the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R activity restriction scale) and the Locomotor Capabilities Index-5 (LCI-5). An illustration was designed to allow participants to classify their LLD by zone in relation to their nonamputated limb.

Results: At total of 47 persons living with SA participated. The average age at amputation was 3.7 years (range, 0.5 to 14.1 y), and at survey completion 15.8 years (1.7 to 60.3). Five of the described "zones" of LLD were represented. Average LCI-5 score was 52.6. Mean TAPES-R activity restriction scale was 0.59, the lowest mean being achieved by zone E participants, indicating the least restriction. Ability to walk without a prosthesis was lower in those participants over 11 years, when compared with those under, as well as being dependent on the walking environment.

Conclusions: Our study found no trend indicating that a very low LLD was functionally optimal, and indeed found participants with a moderate LLD (zone E) to have the least mean restriction with regard to their prosthesis. Our study demonstrates that ambulation without a prosthesis depends on the environment (ie, flooring), and rates decrease significantly into adulthood. Optimal care should not focus simply "preserving length," but rather functional optimization and length modulation in parallel with a nuanced understanding of actual daily activities and prosthetic options.

Level Of Evidence: Level III-retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0000000000001430DOI Listing
July 2020

Osteosarcoma in a Child Below 2 Years of Age: Case Report and Review of the Literature.

J Pediatr Hematol Oncol 2019 Jul;41(5):410-412

Paediatric Oncology, Royal Hobart Hospital, Tas, Hobart.

Background: Osteosarcoma in children below the age of 5 is extremely rare.

Observation: We report on a previously well 14-month-old male infant, who presented with a reluctance to weight-bear on his right leg and had an associated limp. Plain imaging and a magnetic resonance imaging scan demonstrated a lytic lesion in the right distal femur. An open surgical biopsy confirmed the diagnosis of osteosarcoma. There was no significant family history of cancer and genetic screening for Li-Fraumeni syndrome was negative.

Conclusions: This case highlights the importance of timely consideration of osteosarcoma in an infant, when the clinical presentation and medical imaging are consistent with that diagnosis.
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http://dx.doi.org/10.1097/MPH.0000000000001315DOI Listing
July 2019

Impact of web-based clinical practice guidelines on paediatric fracture clinics.

ANZ J Surg 2018 Mar 12;88(3):232-235. Epub 2017 Nov 12.

Department of Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.

Background: In an effort to standardize management and reduce over-treatment of uncomplicated paediatric fractures, the Victorian Pediatric Orthopaedic Network and the Royal Children's Hospital, Melbourne, created publically available web-based paediatric fracture pathways. The aim of this study was to determine the impact of web-based fracture pathways on the clinic volume at a tertiary-care paediatric fracture clinic.

Methods: A comparative retrospective review was performed at a large, urban, tertiary-care children's hospital. Fracture clinic data from two 12-week periods before and after implementation of the fracture pathways were compared. For each study period, data collected included: total number of emergency department visits, number of fracture clinic visits, number of fracture clinic visits for patients that presented with upper extremity fractures for which web-based fracture pathways were available, number of radiology department visits for X-rays, and number of fracture clinic visits for patients requiring orthopaedic intervention in the operating room (closed or open reductions).

Results: The number of fracture clinic visits for patients with upper extremity fractures decreased 12% post-pathway implementation, from 954 visits to 842 visits. The number of radiology department visits for patients with upper extremity fractures decreased 24% post-pathway implementation, from 714 to 544 visits.

Conclusion: The implementation of web-based fracture pathways for upper extremity paediatric fractures was associated with a decrease in clinic resource utilization at a tertiary-care children's hospital.
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http://dx.doi.org/10.1111/ans.14260DOI Listing
March 2018

Preoperative Assessment for Complex Lower Limb Deformity.

Authors:
Leo Donnan

J Pediatr Orthop 2017 Sep;37 Suppl 2:S12-S17

Royal Children's Hospital, Parkville, Melbourne, Vic., Australia.

Successful limb reconstruction surgery not only relies on surgical skill but probably more on assessment and planning before intervention. A clear appreciation of the child as a whole, an understanding of natural history and the ability to carefully evaluate the patient clinically are key to successful treatment. The appropriate use of investigations and the ability to analyze, plan and execute a treatment plan is challenging and requires experience and training. This paper outlines some of the steps required to assess the patient with a complex limb deformity.
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http://dx.doi.org/10.1097/BPO.0000000000001023DOI Listing
September 2017

Assessment of the Pediatric Foot Mass.

J Am Acad Orthop Surg 2017 Jan;25(1):32-41

From the Department of Orthopedics, Seattle Children's Hospital, Seattle, WA (Dr. Bouchard), I-MED Radiology Network and the University of Melbourne, Australia (Dr. Bartlett), and the Department of Orthopaedics, Royal Children's Hospital, Melbourne, Australia (Dr. Donnan).

Masses in the pediatric foot are relatively uncommon and can present a diagnostic challenge. The literature lacks a comprehensive overview of these types of lesions. Most are benign soft-tissue lesions that can be diagnosed on the basis of history and physical examination. However, some rare malignant neoplasms can mimic benign masses. It is imperative to recognize these lesions because the consequences of a delayed or missed diagnosis can be substantial. A thorough history and physical examination of all pediatric patients with foot lesions are crucial to ensure that any lesion not readily identified as benign is appropriately managed.
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http://dx.doi.org/10.5435/JAAOS-D-15-00397DOI Listing
January 2017

Blackheads, whiteheads, femoral head.

J Paediatr Child Health 2016 Jul;52(7):781

Infectious Diseases Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/jpc.13082DOI Listing
July 2016

Obituary: Ian Torode.

J Orthop Surg (Hong Kong) 2015 Dec;23(3):408-11

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http://dx.doi.org/10.1177/230949901502300337DOI Listing
December 2015

Septic arthritis in children.

Aust Fam Physician 2015 Apr;44(4):213-5

MBBS, BMedSc, Orthopaedic Registrar, Department of Orthopaedics, The Royal Children's Hospital Melbourne, Parkville, VIC.

Background: Septic arthritis in children is an orthopaedic emergency that has serious consequences if not diagnosed promptly and treated effectively. The presenting symptoms include pain, non-weight bearing and fever. Inflammatory markers are raised and ultra-sonography demonstrates a joint effusion.

Objective: The purpose of this article is to provide an overview of septic arthritis in children.

Discussion: Definitive treatment involves surgical drainage and lavage of the joint, followed by high-dose, empirical, intravenous (IV) antibiotics. Treatment is tailored to the causative organism, if this is identified. For an uncomplicated case of septic arthritis, 2 days of IV antibiotics followed by a 3-week course of oral antibiotics is usually sufficient. Long-term follow-up is necessary to monitor for sequelae of septic arthritis, including cartilage damage, growth disturbance and avascular necrosis of the femoral head.
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April 2015

Rupture of the extensor pollicis longus tendon following dorsal entry flexible nailing of radial shaft fractures in children.

J Child Orthop 2014 Aug 7;8(4):353-7. Epub 2014 Aug 7.

Orthopaedic Department, The Royal Children's Hospital, Flemington Road, Parkville, Melbourne, VIC, 3052, Australia.

Introduction: Diaphyseal forearm fractures are common in children and adolescents. Intramedullary fixation with flexible nails has a high success rate. Complications related to the insertion of the radial nail include injury to the superficial branch of the radial nerve and rupture of the extensor pollicis longus (EPL) tendon.

Materials And Methods: We report a series of nine patients who sustained an EPL injury related to the insertion of an elastic intramedullary nail into the radius.

Results: All nine patients underwent operative management, consisting of either EPL release, EPL direct repair, or tendon transfer (using extensor indicis proprius). In all cases, the nail entry site was directly related to the location of EPL. In many of the cases the EPL dysfunction occurred early on but it's recognition was often delayed.

Conclusion: Based on our findings, we recommend the use of a radial entry point. For surgeons who prefer the dorsal entry point, we recommend that they use an incision which allows visualisation of the extensor tendons and that any post-operative EPL dysfunction is addressed promptly.
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http://dx.doi.org/10.1007/s11832-014-0605-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4128948PMC
August 2014

Multimedia patient education to assist the informed consent process for knee arthroscopy.

ANZ J Surg 2011 Mar 1;81(3):176-80. Epub 2010 Oct 1.

Department of Orthopaedics, Royal Melbourne Hospital, Parkville, Melbourne, Australia.

Background: In contemporary clinical practice, the ability for orthopaedic surgeons to obtain true 'informed consent' is becoming increasingly difficult. This problem has been driven by factors including increased expectations of surgical outcome by patients and increasing complexity of surgical procedures. Surgical pamphlets and computer presentations have been advocated as ways of improving patient education, but evidence of their efficacy is limited. The aim of this study was to compare the efficacy of a computer-based multimedia (MM) presentation against standardized verbal consent and information pamphlets for patients considering knee arthroscopy surgery.

Methods: A randomized, controlled prospective trial was conducted, comparing the efficacy of three methods of providing preoperative informed consent information to patients. Sixty-one patients were randomly allocated into MM, verbal consent or pamphlet groups 3-6 weeks prior to knee arthroscopy surgery. Information recall after the initial consent process was assessed by questionnaire. Retention of this information was again assessed by questionnaire at the time of surgery and 6 weeks after surgery.

Results: The MM group demonstrated a significantly greater proportion of correct responses, 98%, in the questionnaire at the time of consent, in comparison with 88% for verbal and 76% for pamphlet groups, with no difference in anxiety levels. Information was also better retained by the MM group up to 6 weeks after surgery. Patient satisfaction with information delivery was higher in the MM group.

Conclusion: MM is an effective tool for aiding in the provision and retention of information during the informed consent process.
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http://dx.doi.org/10.1111/j.1445-2197.2010.05487.xDOI Listing
March 2011

Ligamentum teres tenodesis in medial approach open reduction for developmental dislocation of the hip.

J Pediatr Orthop 2008 Sep;28(6):607-13

Birmingham Childrens Hospital, Birmingham, United Kingdom.

Background: When closed reduction of a developmental dislocation of the hip fails, some form of open reduction is required. In recent years, the many advantages of the medial approach open reduction have been emphasized. However, there have been suggestions that the rate of growth disturbance in the proximal femur and the requirement for secondary surgical procedures may be higher with this route than with others. The purpose of this study was to investigate the efficacy and safety of a modified medial approach open reduction, in which the stability of the reduction is enhanced by resection of the redundant ligamentum teres and suturing of the stump of the tendon to the anteromedial capsule.

Methods: The hospital records and radiographs of 92 infants and children with 109 dislocated hips were reviewed retrospectively. Key demographic and pretreatment data were collected by the first author and compared with the outcome at the most recent follow-up. In addition, 69 children returned for a clinical evaluation by the first author. The outcome at the most recent follow-up was graded according to Severin, and associations were sought between pretreatment grade of dislocation according to Tonnis, the presence of ossific nucleus, changes in the acetabular index, the requirements for secondary surgery, associations with previous treatment, and the position of abduction in the postoperative cast.

Results: At a mean follow-up of 9 years, 89% of hips were classified as Severin grade 1 or 2. Avascular necrosis (AVN) was classified according to the system of Kalamchi and MacEwen. The incidence of AVN was 41%, but two thirds of these were grade 1 (temporary irregular ossification), and the Severin grading in these hips was not compromised. The presence of ossification in the capital epiphysis and a range of abduction of less than 60 degrees in the hip spica were noted to be protective against the development of AVN. Three hips redislocated and required additional treatment. Thirty-eight hips required a total of 44 additional surgical procedures.

Conclusions: We have demonstrated that it is possible to use a medial approach for open reduction of the congenitally dislocated hip in combination with tenodesis of the ligamentum teres to the anteromedial joint capsule. The incidence of growth disturbance in the proximal femur is high and cumulative with long-term follow-up. However, in this large series, the rate of hip stability, growth disturbance, and need for secondary surgery are comparable to other series. We conclude that the many advantages of open reduction by the medial approach outweigh the disadvantages.
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http://dx.doi.org/10.1097/BPO.0b013e318184202cDOI Listing
September 2008

Peri-acetabular external fixation for hip disease: an anatomical study.

Strategies Trauma Limb Reconstr 2007 Dec 9;2(2-3):69-75. Epub 2007 Nov 9.

Department of Orthopaedic Surgery, Royal Children’s Hospital, Flemington Road, Parkville, Melbourne, VIC, 3052, Australia.

Hip distraction using cross joint articulated external fixation has been used by a number of orthopaedic centres for the treatment of osteoarthritis, chrondrolysis, and osteonecrosis, as an alternative to hip arthroplasty or arthrodesis in the adolescent and young adults . The hip, however, is problematic with respect to external fixation, as it lies deep, surrounded by powerful muscles and in intimate contact with major neurovascular structures and intrapelvic organs. The numbers of patients treated by this technique to date remains small and the technical detail and potential complications, with respect to the application of the external fixation, unclear. In this study we used anatomical information from CT scans combined with computer modelling of the hip and pelvis to identify safe screw positions in the periacetabular region. The surgical insertion of the pins was then performed on five cadavers and anatomical dissections undertaken to confirm the structures at risk. This study indicated that whilst there are a number of anatomic constraints, it is still possible to insert three pins with good divergence into the limited bony corridor of the peri-acetabular region recognising that the more posterior of the laterally inserted pins poses a potential risk to the sciatic nerve if not inclined away from the sciatic notch.
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http://dx.doi.org/10.1007/s11751-007-0019-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2322838PMC
December 2007

The practical application of multimedia technology to facilitate the education and treatment of patients with plantar fasciitis: a pilot study.

Foot Ankle Spec 2008 Feb;1(1):30-8

Victorian Orthopaedic Foot & Ankle Clinic, Epworth Private Hospital, Richmond, Victoria, Australia.

This study was designed to evaluate the efficacy of a multimedia patient education module when incorporated into the standard treatment protocol for patients diagnosed with plantar fasciitis. A thorough, standardized surgeon-patient education discourse took place following diagnosis. At the conclusion of the consultation, patients viewed the multimedia module. Questionnaires designed to assess understanding and satisfaction with information delivery were completed by patients following the consultation and again after viewing the module. Forty-one patients participated in the study. After viewing the module, patients achieved an average of 87% correct responses on the knowledge questionnaire, a significant improvement (P < .0001) over the 64% achieved following the surgeon-patient discourse. Ease of understanding of the information delivered by the module was rated significantly better (P < .0001) than the surgeon-patient discourse. Ninety-eight percent of patients indicated they felt well informed about plantar fasciitis following viewing the module compared with 68% following the surgeon-patient discourse. Sixty-three percent of patients indicated that the module best answered their questions, 7% preferred the surgeon, and 30% rated both equally. Multimedia plantar fasciitis educational material improved patient understanding of the standard treatment protocol and satisfaction with the information delivery in an orthopedic private practice.
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http://dx.doi.org/10.1177/1938640007312299.DOI Listing
February 2008

Metatropic dysplasia: clinical and radiographic findings in 11 patients demonstrating long-term natural history.

Am J Med Genet A 2007 Nov;143A(21):2512-22

Genetic Health Services Victoria, 10th Floor Royal Children's Hospital, Melbourne, Australia.

We report on the largest long-term follow-up study in metatropic dysplasia incorporating data collected over a 37-year period. Case summaries from 11 patients are presented, ranging from 20 weeks of gestation to age 70 years, characterizing the natural history. All patients were seen through the Victorian Clinical Genetics Service and the Southern Cross Bone Dysplasia Centre. Our data lend little support for the current clinical classification of metatropic dysplasia and highlight a spectrum of severity in this rare condition, which we propose has an autosomal dominant inheritance pattern. Complications such as upper respiratory obstruction secondary to laryngo-tracheal dysfunction need to be carefully monitored for in infancy because this is a preventable cause of mortality. The progression of a thoracic kyphoscoliosis in this condition is often relentless and resistant to surgical treatment. Other causes of morbidity include cervical instability, hearing loss, and functional impairments resulting from degenerative joint deformity. Intellectual outcome in all surviving cases has been normal. Final adult heights ranged from 107 to 135 cm.
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http://dx.doi.org/10.1002/ajmg.a.31941DOI Listing
November 2007

The radiographic classification of the bone-screw interface in paediatric tibial lengthening.

J Pediatr Orthop B 2007 Sep;16(5):305-11

Portsmouth Hospitals NHS Trust, UK.

Bone-screw loosening in monolateral external fixators is a significant problem. This study classifies the radiographic appearance of the bone-screw interface and predicts which screws will become loose and those that will remain solidly fixed to bone. Five radiographic features were identified at the bone-screw interface. The classification of these features was validated using interobserver and intraobserver studies. The reliability of the classification was improved by image enhancement with simple filters. Some radiographic features predicted which screws would eventually become loose, allowing the clinician to make earlier management decisions regarding the adjustment of screws.
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http://dx.doi.org/10.1097/BPB.0b013e3282ef4e4aDOI Listing
September 2007

High recurrence after calf lengthening with the Ilizarov apparatus for treatment of spastic equinus foot deformity.

J Pediatr Orthop B 2007 Mar;16(2):125-8

Department of Orthopaedics, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria.

Both gastrocnemius recession and Achilles tendon lengthening lead to scarring in the calf and have high reported recurrence rates when performed under the age of 8 years. Triceps surae lengthening by external fixation seemed to be a valuable alternative. Twelve calf lengthenings have been performed with an Ilizarov device with a mean correction of 27 degrees. No calcaneal gait was observed, but there was a slow continuous loss of dorsiflexion over the observation period. The Ilizarov technique has a higher recurrence rate than most operative procedures for calf lengthening, but carries virtually no risk in producing calcaneus. The technique cannot be recommended for routine clinical use and may only be an alternative for selected cases.
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http://dx.doi.org/10.1097/BPB.0b013e32801092d9DOI Listing
March 2007

Medial temporal lobe dysgenesis in hypochondroplasia.

Am J Med Genet A 2005 Nov;138(4):389-91

Genetic Health Services, Victoria, Australia.

We describe two patients who have hypochondroplasia with medial temporal lobe dysgenesis. This association has only been reported once before. Both patients had an FGFR3 mutation: 1620C --> A, resulting in Asn540Lys. FGFR3 is expressed in the brain during development and plays a role in hippocampal formation. We suggest FGFR3 mutations might cause cerebral malformations in hypochondroplasia as well as in thanatophoric dysplasia. Further neuroimaging studies of patients with hypochondroplasia and epilepsy or developmental delay may clarify the proportion of patients with hypochondroplasia who have this pattern of central nervous system abnormalities.
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http://dx.doi.org/10.1002/ajmg.a.30974DOI Listing
November 2005

Gradual femoral lengthening with the Albizzia intramedullary nail.

J Bone Joint Surg Am 2003 May;85(5):838-48

Children's Hospital, Nancy, France.

Background: Gradual limb lengthening with currently used external fixation techniques can result in less than optimal outcomes, with complications including infection, stiffness of adjacent joints, and secondary axial deviation of the extremity. We describe a totally implantable lengthening device designed to provide results similar to those achieved with external fixation devices, with fewer complications and improved outcomes.

Methods: Between 1993 and 1997, thirty-one patients (forty-one femora) underwent limb lengthening with a new internal fixation technique (Albizzia) to treat a congenitally short extremity (thirteen patients), post-traumatic limb-length inequality (eleven patients), or developmental problems (seven patients). Twenty-one patients (twenty-one femora) underwent unilateral surgery to equalize the limb lengths, and ten (twenty femora) underwent bilateral surgery to correct short stature. The mean age was twenty years and one month (range, twelve to thirty-nine years). After intramedullary corticotomy of the diaphysis of the femur, an intramedullary nail was inserted in an antegrade fashion. Fifteen alternating internal and external rotation maneuvers of the lower limb elongated the nail by 1 mm. The outcomes were assessed clinically and radiographically at a mean of fifty months postoperatively.

Results: The gain in femoral length averaged 3.4 cm (range, 2 to 5.5 cm) after the unilateral lengthening procedures and 6.3 cm (range, 4.6 to 8.4 cm) after the bilateral procedures. Patients underwent an average of three operations on each limb; these procedures included, in addition to the nail insertion and nail removal, ratcheting under general anesthesia in thirteen limbs and eleven procedures to treat complications in nine patients. At the time of follow-up, no patient had axial deviation of the limb secondary to lengthening.

Conclusions: Femoral lengthening with use of the minimally invasive Albizzia technique provides a reasonable alternative to external fixation that is well tolerated by patients and results in excellent function with little or no distortion of body image.
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http://dx.doi.org/10.2106/00004623-200305000-00011DOI Listing
May 2003

Acute correction of lower limb deformity and simultaneous lengthening with a monolateral fixator.

J Bone Joint Surg Br 2003 Mar;85(2):254-60

Sheffield Children's Hospital, England, UK.

We have reviewed, retrospectively, all children with a lower limb deformity who underwent an acute correction and lengthening with a monolateral fixator between 1987 and 1996. The patients were all under the age of 19 years and had a minimum follow-up of eight months after removal of the fixator. A total of 41 children had 57 corrections and lengthening. Their mean age was 11.3 years (3.2 to 18.7) and there were 23 girls and 18 boys. The mean maximum correction in any one plane was 23 degrees (7 to 45). In 41 bony segments (either femur or tibia) a uniplanar correction was made while various combinations were carried out in 16. The site of the osteotomy was predominantly diaphyseal, at a mean of 47% (17% to 73%) of the total bone length and the mean length gained was 6.4 cm (1.0 to 17.0). Univariate analysis identified a moderately strong relationship between the bone healing index (BHI), length gained, maximum correction and grade-II to grade-III complications. For logistic regression analysis the patients were binary coded into two groups; those with a good outcome (BHI < or = 45 days/cm) and those with a poor outcome (BHI > 45 days/cm). Various factors which may influence the outcome were then analysed by calculating odds ratios with 95% confidence intervals. This analysis suggested a dose response between increasing angular correction and poor BHI which only reached statistical significance for corrections of larger magnitude. Longer lengthenings were associated with a better BHI while age and the actual bone lengthened had little effect. Those patients with a maximum angulatory correction of less than 30 degrees in any one plane had an acceptable consolidation time with few major complications. The technique is suitable for femoral deformity and shortening, but should be used with care in the tibia since the risk of a compartment syndrome or neurapraxia is much greater.
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http://dx.doi.org/10.1302/0301-620x.85b2.12645DOI Listing
March 2003

Radiographic assessment of bone formation in tibia during distraction osteogenesis.

J Pediatr Orthop 2002 Sep-Oct;22(5):645-51

Department of Orthopaedics, Royal Children's Hospital, Melbourne, Australia.

The radiologic appearance of bone formation during limb lengthening is used to judge the competence of the underlying biologic process and predict the likely time to healing. Interpretation is, however, based upon subjective parameters that have never been clearly defined. Thirty anteroposterior radiographs from pediatric tibial lengthenings were classified by four pairs of surgeons using a three-part system. Across the group, interobserver consistency showed considerable variation for all parameters tested. Pairwise analysis indicated that the surgeons directly involved in limb lengthening procedures agreed better than those whose practice was of a different nature. A second series of radiographs contained 12 radiographs with a satisfactory and 12 with a poor bone healing index (BHI). These radiographs were digitized, and an interobserver study showed significantly improved observer concordance if the images were enhanced. No feature was associated with a 100% chance of a satisfactory outcome, but certain appearances in the regenerate were associated with a better BHI than others.
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October 2002
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