Metastatic bone disease is increasing in association with ever improving medical management of osteophylic malignant conditions. The precise timing of surgical intervention for secondary lesions in long bones can be difficult to determine. This paper aims to validate a classic scoring system.

All radiographs were examined twice by 3 orthopaedic oncologists and scored according to the Mirels’ scoring system. The Kappa statistic was used for the purpose of statistical analysis.

The results show agreement between observers (κ=0.35–0.61) for overall scores at the 2 time intervals. Inter-observer agreement was also seen with subset analysis of size (κ=0.27–0.60), site (κ=0.77–1.0) and nature of the lesion (κ=0.55–0.81). Similarly, low levels of intra-observer variability were noted for each of the 3 surgeons (κ=0.34, 0.39, 0.78 respectively).

These results validate the Mirels’ scoring system across a wide spectrum of malignant pathology. We continue to advocate its use in the management of patients with long bone metastases.

Objective: Appendicular soft tissue tumours are rare. They represent less than 1% of all malignancy in Ireland. Consequently they are considered to difficult to diagnose and often require several opinions and investigations before a definitive diagnosis is arrived at. Mistakes in this process have been documented to result in the unnecessary loss of limb and life. The Bone and Soft Tissue Service in Cappagh National Orthopaedic Hospital treats a significant proportion of the tertiary referrals in this field. We looked at the referrals to the service of a newly appointed surgeon with an interest in this field.

Method: We prospectively reviewed the charts of all patients (26) with a soft tissue tumour referred to the senior author in his first year of practice and excluded all patients (1) who had an established and treatment instigated by an Orthopaedic Tumour specialist. Where information was not available in the chart the patients GP was contacted for further information.

Results: The most common presenting complaint was swelling (100%), only 3(12%) of the patients complained of pain. The mean time between observation of symptoms and seeking medical advice was 5.2 months (range 3–12 months). All the patients first sought attention from a GP. The mean number of doctors seen prior to presentation was 2 (range 1–4). 21 (84%) patients presented with MRI imaging.8 out of 20 (40%) secondary referrals had histological diagnosis on presentation however 3 of these were incidental findings from surgery performed without malignancy suspicion. Therefore only 5 out of 17 (29%) referrals for management of suspected malignancy had undergone biopsy at the referring institution. A mosaic of histological diagnoses was found, in proportion to previous epidemiological studies. 21 (84%) of the patients went on to have excisional surgery, one had amputation.

Conclusion: Although 40% of secondary referrals had undergone invasive procedures prior to presentation, only 29% had undergone intentional biopsy with a pre-operative suspicion for neoplasia. A pre biopsy referral rate of 71% compares favourably with published international rates. These tumours are rare and benign masses are 150 times more common however we must remain vigilant and consultation with a Tumour service should precede any invasive procedure whenever there is an element of doubt.

Urinary retention following total hip and knee arthroplasty is a common problem frequently requiring catheterisation in the immediate post-operative period. The direct relationship between urinary tract instrumentation and deep sepsis in total hip replacements is well documented.

Method: This prospective study analysed 164 male patients who underwent primary arthroplasty between September 2004 and March 2005 inclusive. Patients who had previous urological intervention for obstructive symptoms were excluded from the study. Upon admission and prior to surgery, all patients answered an 8-point urinary symptom questionnaire and were tested on their ability to micturate while supine.

Result: 34 patients required urinary catheterisation – 130 did not. The average age of the catheterised group was 69.5+/−10.7 years (range 45–90) and the non catheterised group was 65.2+/−10.5 years (range 33–85). There was no difference between these groups (p=0.134, ANOVA). Similarly, there was not difference (p=0.919, ANOVA) between the blood loss in the 2 groups, 880.6+/−455.5 mls and 895+/−533.7 mls respectively. With regards to the symptom questionnaire, the average score in the catheter group was 3.1+/−2.4 and the non-catheter group was 2.0+/−1.8 (p=0.034, ANOVA). The ability to micturate in a supine position was of no predictive value with 22 patients in the catheter group able to do so.

Conclusion: These results show the value of a urinary symptom questionnaire used pre-operatively in predicting those who may require post-operative urinary catheterisation. By appropriate use of this tool, patients with potential for post-operative retention may be identified before surgery. Consequently, this group should be catheterised pre-operatively thus reducing their risk of infection.

A review of the first two hundred and ten patients undergoing Birmingham hip re-surfacing between January 2003 and June 2005 was performed. All surgeries were performed by a single consultant orthopaedic surgeon. All resurfacings were carried out utilising the antero-lateral approach to the hip.

Mean review post-operatively was at six weeks. The following clinical parameters were evaluated: length of in-hospital patient stay, intra-operative blood loss and post-operative range of joint movement. In addition, the following radiological measurements were made: the acetabular inclination angle, the head-shaft angle and evidence of leg-length discrepancy.

One patient experienced fracture of the femoral neck and two other patients underwent revision surgery. Our results demonstrate that the anterolateral approach represents an alternative approach, with short-term results comaprible to the posterior approach for hip resurfacing.

Introduction: Complete spinal cord injury patients demonstrate an initial rapid lower limb bone mineral density loss.^1,2; Reports suggest an increase incidence of lower limb fractures in such patient.³ Such injuries place an additional burden on patients undergoing rehabilitation.

Aims: This prospective study was established to assess whether disuse osteopenia contributes to increased incidence of lower limb fractures in patients following complete spinal cord injury. We compare this cohort to patients who attained mobility after their spinal cord injury.

Methods: We prospectively reviewed 128 patients (107 male; 21 female) treated in our unit, a Tertiary Referral Spinal Trauma Unit. All patients presented between January 1994 and July 2002. There were 66 patients 958 male; 8 female) who initially presented to this unit and subsequently attained mobility either while in hospital or during rehabilitation. Both groups were comparable in age and sex profiles.

Results: The mean length of follow-up was 58 months for patients with complete neurology and 64 months for those who attained mobility. There were 4 lower limb fractures in the group of patient with complete neurology. Two patients sustained supracondylar femoral fractures with one requiring operative intervention, while 2 patients with mid-shaft tibia/fibula fractures were treated conservatively.

Conclusions: Previous papers have shown that patients with complete neurology after spinal injury undergo disuse osteopenia. We report an increase incidence of lower limb fractures in patients with complete neurology compared to patients initially presenting with neurology but attaining full mobility. This difference is statistically significant, (p< 0.05).

Plantar faciitis is a repetitive microtrauma overload injury of the attachment of the plantar fascia at the inferior aspect of the valvaneus. Several aetiological factors have been implicated in the development of plantar faciitis, however the role of hamstring tightness has not previously been assessed.

Materials and Methods: 15 volunteers (mean age 25 years) were prospectively analysed for the difference in forefoot loading using a don-Joy brace applied to each knee simultaneously. The brace was locked at varying degrees of knee flexion (0°, 20°, 40°). Body weight was measured for each volunteer. 15 patients (mean age 41 years) with a diagnosis of plantar faciitis were similarly analysed on the pedobarograph, however they also had their hamstring tightness assessed by means of measuring the popliteal angle. The mean popliteal angle measured was 28.5°. 15 age and sex matched controls (mean age 42 years) then had their hamstring tightness assessed. The mean popliteal angle was 12.5°.

Increasing the angle of flexion from 0–20° at the knee joint led to statistically significant increase in pressure in the forefoot phase by an average of 0.08K/cm2s (p, 0.05,t-test). An increase from 20 – 40° led to increased forefoot phase pressure of 0.15 kg/cm2s (p0.05, t-test). The percentage time spent in contact phase reduced from 30 to 26.5 to 16 with increasing flexion (P< 0.05). However there was an inverse increase in the time spent in the forefoot phase 51–58–69 with increasing degrees of flexion (P< 0.05). Thus the authors feel that an increase in hamstring tightness may induce prolonged fore foot loading.

Previous reports have indicated that elderly patients suffer more operative complications than younger patients undergoing total hip arthroplasty (THR)

We reviewed 46 consecutive patients over 85 years of age at the time of THR. All patients were at least 3 years post-op at the time of review. Pre and post operative D’Aubigne-Postel Hip Scores were assigned. Length of stay, transfusion rates, intra-operative blood loss and patient satisfaction were also noted. Statistical comparisons were mode with a control group of patients, average age 66.3 years.

The average age at the time of operation was 86.6 (range 85–92) years. The average follow up was 52.8 (range 38–86) months. The average hospital stay was 21.1 (range 12–40, median 18) days. Pre-operative D’Aubigne-Postel Score averaged 8.4 (range 1–14) points, post-operative D’Aubigne-Postel Score averaged 13.1 (range 9–18) points. Subjective satisfaction was high. There were no operative complications and no dislocations during the follow up period. There were no deaths within one year of surgery. Four of the 45 patients died during the 3 year follow up period.

When compared to the control group, patients over the age of 85 years had an increased intra-operative blood loss, p< 0.001, they also had an increased blood transfusion at rate, p=0.0005. Patients over the age of 85 remained in hospital longer, p=0.0002. Comparing D’Aubigne-Postel Score, patients over the age of 85 years benefited as much as the control group, p=0.0001.

We conclude that THR is the over 85 years old patients is a safe procedure and yields good functional results.

In Ireland and the United Kingdom, there were 22 deaths as a direct result of blood transfusion during the period October 1996 to September 1998. Added to this mortality, there were 366 cases of complications directly related to blood transfusion.

With the introduction of a Haemovigilance Nurse, changing surgical personnel and an increased public awareness of the potential hazards of transfusion, we were anxious to review whether transfusion rates have changed in our Regional Orthopaedic Centre for the period January 1999 to July 2000

All patients undergoing primary or revision arthroplasty in our Regional Orthopaedic Unit during the study period were retrospectively reviewed.

459 primary or revision arthroplasties were performed in the study period. Prior to the introduction of a haemovigilance Nurse, from the period January 1999 to October 1999, transfusion rates for primary arthroplasties averaged 1.41 units/patient with 74% of patients being transfused. After the introduction of a haemovigilance Nurse, from November 1999 to July 2000, transfusion rates for primary arthroplasties averaged 0.51 units/patient, with 31% of patients being transfused.

Prior to the introduction of a haemovigilance Nurse revision arthroplasties averaged 2.5 units/patient, with 100% of patients being transfused. After the introduction of the haemovigilance Nurse transfusion averaged 1.2 units/patient, with 62% of patients being transfused.

There was a statistically significant difference between transfusion rates prior to the introduction of a Haemovigilance Nurse and new surgical personnel and the period after their introduction (p< 0.005).

In the current climate post the Finlay Tribunal and the resultant increased public awareness, transfusing a patient without justifiable cause is no longer acceptable.

Patients in this unit are now transfused according to clinical needs and accurate measurement of intra-operative and post-operative blood loss, compared to their calculated maximum allowed blood loss (MABL). The changing transfusion rates seen in our Unit correspond to the introduction of a Haemovigilance Nurse and a change in surgical personnel. Our new transfusion protocol is working well without compromising patient care.