It was with great excitement that we arrived in Baltimore. Both Natasha and I had previously attended the Baltimore Limb Deformity Course and so we had great expectations for the upcoming week. Monday began with a workshop by Dr Herzenberg on the Multiplier Method using the Multiplier App.  It was fantastic to be able to work through some of the more complex calculations in limb length discrepancy predictions as well as being introduced to some of the additional features, such as the oblique plane deformity calculator.  The remainder of the day was spent in clinic with Dr Herzenberg and Dr Standard reviewing upcoming cases for the week as well as seeing complex deformity patients and children undergoing treatment for Perthes.  The day was rounded off with a crab feast with our families on the crab deck of Phillips Seafood against the beautiful backdrop of the Baltimore Inner Harbor.


Tuesday began with presentations by the fellows, followed by a day in the operating room observing Dr Herzenberg and Dr Standard.  Highlights of the day included an ankle spanning TSF for lengthening and deformity correction in a child with fibula hemimelia and curettage, bone grafting and IM nailing of a femur in Ollier’s Disease.


One of the key to successful outcomes at the International Center for Limb Lengthening is undoubtedly the physiotherapy program led by Anil Bhave.  We were fortunate to have a very interesting lecture on the principles of physiotherapy and splinting in limb lengthening with both practical advice and the theories behind treatment.  We also took a tour of the physiotherapy department, seeing patients undergoing stretches, heat treatment as well as the hydrotherapy pool. Most impressive of all was the gravity reducing treadmill, designed by NASA to simulate weightlessness, which would allow the therapist to dial in the exact amount of weight bearing allowed.


The evening was spent enjoying an Orioles game at the wonderful Camden Yards stadium, its distinctive retro styling made all the more impressive by the profile of the downtown Baltimore skyline.


On Wednesday morning we were fortunate to be able to observe Dr Herzenberg perform a fixator assisted nailing with the Precise system.  Dr H. imparted many pearls and insights into the intricacies of performing this procedure.   We were also able to witness Dr Standard’s technique for repeat osteoplasty following premature consolidation with a lengthening nail in situ. Following this was a highly educational afternoon spent reviewing power point presentations on limb deformity correction, SUPER hip and SUPER ankle procedures as well as joint distraction and advanced techniques for the treatment of Perthes disease.  At the end of the day we were treated to a fantastic dinner at the Food Market.


Thursday morning began with Pre-op conference where the cases for the week were discussed, as were the decision making processes which went along with each patient.  Later on we had a lecture on pre-operative planning for the Precise and were then able to put the theory into practice as we planned and ordered the nails required for the surgeries scheduled for the next week.  During the day we also had the opportunity to observe Dr Standard in his clinic and witness the impressive support team of graphic designers, fine artists, medical editors, photographers, managers and assistants at the ICLL. We were struck by how this dedicated group work tirelessly to provide the extremely professional standard of publications and course material that Baltimore is famous for.


Friday was a change of focus with a club foot day.  We observed a TAL, plantar fasciotomy, PL to PB transfer and tib ant transfer for a residual club foot deformity.  We then observed serial manipulation and casting in the club foot clinic, before heading to the frame lab.  Here we rounded off the week assembling a sawbones model of a TSF for Blount’s with a high riding fibula, including an additional half ring with fixation pins in the fibula for distal fibula transport to re-tension the LCL.


It is with mixed feelings that we now move on to Philly.  We have been touched by the generosity of Dr Herzenberg and his team this past week.  We are extremely grateful for the opportunity to interact on such a personal level with one of the great leaders in the limb deformity world and leave Baltimore having learnt a great deal.


The Paley Institute



Our week in West Palm Beach began at 6:30 am at the surgical center. By 7:50 am 2 cases had been completed and we were on our way to the Paley Institute at St Mary’s Hospital.  We spent the day in the office with Dr Paley, seeing his pre-op patients for the upcoming week as well as some new and follow-up patients. During the course of the day we lost track of the number of patients we saw, with patients from all over the world coming to seek his expertise.  There were patients with fibula hemimelia, tibial hemimelia, congenital femoral deficiency, Ollier’s disease and multiple epiphyseal dysplasia. We also saw patients with both internal lengthening devices and external fixation devices, including the new rail and hexapod systems designed by Dr Paley.  At the end of a long clinic we had a very enjoyable meal at a Mediterranean restaurant near the hospital.


Tuesday was spent in the OR, observing the insertion of Precise nails in patients with congenital femoral deficiency, bilateral Precise nailing for stature lengthening, hemiepiphysiodesis, derotational osteotomy and femoral osteotomy and triple pelvic osteotomy via the SUPER hip approach in a patient with Multiple Epiphyseal Dysplasia.  After a hard day’s work we were very graciously entertained by Dr Paley.  We took a trip on Dr Paley’s boat around the inlet, followed by a very relaxed and enjoyable barbecue at Dr Paley’s house.


Wednesday morning began with a 35 mile bike ride with Dr Paley around Palm Beach with the southern Florida sun beating down.  Dr Paley cycles 5 days a week and is a force to be reckoned with on 2 wheels!  We went straight from cycling to the OR, where we were able to see a peroneal nerve decompression for a patient undergoing a derotational osteotomy with an IM nail, a proximal femoral osteotomy, a distal femoral extension osteotomy and internal lengthening for Ollier’s disease.


Thursday was again spent in the OR, watching percutaneous application of 8 plates, a distal tibial TSF for lengthening and deformity correction in a patient with fibula hemimelia.  It was very interesting to see the percutaneous distal tibial osteotomy performed via the Gigli saw.  The final case of the day was a patient with congenital femoral deficiency with a knee flexion contracture. He underwent a peroneal nerve decompression, gastrocnemius release, posterior capsular release, distal femoral shortening osteotomy, superknee ligament reconstruction procedure and supra tubercular tibial opening wedge osteotomy.  We were both impressed by the meticulous attention to detail of Dr Paley throughout this long and complicated case.


Friday morning began at 7am with a multidisciplinary case conference where the patients for the next week were discussed with the surgical and anaesthetic teams.  This was followed by rounds of the patients on the floor, and then a tour of the physiotherapy department where we were able to witness many patients undergoing lengthening receiving the treatment that is so imperative to the success of their surgery.  We then had a teaching session with Dr Paley on the SUPER ankle and the SUPER hip, followed by discussion on the TSF and Precise with Dr Robbins.  After this we were straight to the office for another clinic again full of patients with congenital deformity, achondroplasis,congenital pseudarthrosis of the tibia and even upper limb abnormalities.


This week has been a truly invaluable experience.  The sheer volume of patients and the variety of cases is staggering. Dr Paley and his team have been the most gracious hosts, taking the time to teach us and make sure that our every need was been taken care of.  The pace and productivity of Dr Paley and the Paley institute is truly remarkable and both Natasha and I have learnt an immeasurable amount in a short time.

Goodbye Orlando!

Incredibly our first week is over! We spent the remainder of the week observing Dr Iobst in the OR. We were exposed to the whole spectrum of limb reconstruction surgery, varying from monolateral rails, to different types of hexapods, to internal fixation. Highlights for me included the percutaneous proximal femoral valgus osteotomy with concomitant distal femoral lengthening using a monolateral external fixator. I was struck by how a significant deformity with leg length discrepancy could be corrected with such an elegant technique. In addition I was particularly impressed by the fixator assisted fixator technique; a method to accurately achieve acute correction prior to lengthening with a rail.

Both Natasha and I have certainly learnt a great deal from our visit to Dr Iobst in Orlando. It has been a unique experience to spend a whole week with one surgeon, observing clinics, ORs and being able to spend time discussing limb reconstruction strategies in great detail.

We are both incredibly grateful to Dr Iobst and his colleagues at Nemours Children’s Hospital in Orlando for their hospitality. This week has been thoroughly rewarding and we look forward to the next 3 weeks.

Week 1 Orlando

Natasha and I arrived to a wet and windy greeting as tropical storm Colin approached central Florida. The first stop on our fellowship is the Nemours Children’s Hospital in Orlando, a brand new purpose built facility. It is located in the centre of Lake Nona Medical City, a new high tech development just 10 minutes from Orlando airport.

Our host is Dr Christopher Iobst, who has prepared a fantastic program of academic and social activities for the week. Monday morning was spent in clinic with Dr Iobst, where we were exposed to a wide range of clinical problems seen in limb deformity, varying from miserable malalignment to brachydactyly. It was great to see how an experienced limb reconstruction surgeon runs his clinics and we gained many tips and tricks along the way.

Monday afternoon was spent running through a sawbones lab using the Smith and Nephew Modular Rail System for spanning the kneeing during femoral lengthening cases. We were able to spend time gaining hands on experience of the intricacies of the system. Following this we went through the pre-operative planning and software programming for the TSF for a case of cubitus varus schedule for later in the week.

In the evening we were very graciously hosted at Luma Restaurant in Winter Park, where Dr Chad Price presented the Orlando hip procedure for congenital femoral deficiency and Dr Steven Frick provided us with some very enlightening career advice.