88 Chapter 3.2 with trisomy 21. Further research into ISQ variation in the developing temporal bone and within groups of different medical co morbidities would allow stronger conclusions to be drawn in the paediatric population. In addition, although ISQ at the abutment level was demonstrated to increase over time there is no relationship concluded with regards to fixture failures, and although statistically significant, the clinical significance of our RFA finding is uncertain. 4.1 Conclusion Implant survival and adverse skin reactions were found to be in keeping with levels in published literature and much improved compared to previous implant systems placed at this centre. Although abutment level ISQ showed an increase over the review period no correlation between this, and implant loss can be concluded. This study demonstrated a very low morbidity associated with the Ponto BXH implant system, and good clinical outcomes in children with Down Syndrome. 5. Limitations The current study reports on long term outcomes of consecutively implanted children with the Ponto BXH Oticon BAHI who have an underlying diagnosis of DS. The absence of uniform surgery technique was a limitation for the current study with three separate methods being applied to the cohort, two performing minimal/no soft tissue reduction at second stage. However, patient demographics, post-operative protocol and routine follow up were identical between the three groups. Review appointment attendance and compliance of 23.3–60.5% was shown despite all parents and carers completing the research commitment contract. The impact of these missing reviews should be taken into consideration when reading the results of this study. The explanation for this variability is largely due to the exceptionally large geographic area from which many patients are referred. The additional travel time, absence from school/education and cost may have been an influencing factor. It is important to consider the social implications for attending a review hospital appointment for study purposes even though all were made aware of the necessary appointments well in advance of their surgery. Time away from school, organisation of care for siblings and the additional challenges to attend for patients with extensive comorbidities and underlying medical conditions requiring yet more reviews with other medical specialties contributed to
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