The aim of operative treatment for ankle fractures is to allow early movement after internal fixation. The hypothesis of this study was that early mobilisation facilitated by a removable cast after internal fixation of ankle fractures would improve functional recovery of patients compared with that after conventional immobilisation in a cast.

Sixty-two patients between the age of seventeen and sixty-five with ankle fractures that required operative treatment were randomly allocated to two groups: immobilisation in a non weight bearing below knee cast for six weeks or early movement in a removable cast (at two weeks after removal of sutures) for the following four weeks. The follow-up examinations which consisted of subjective (clinical, Olerud-Molander score, AOFAS score, SF 36) and objective (swelling measurement, x-ray) evaluations were performed at two, six, nine, twelve and twenty four weeks post-operatively. Time of return to work was recorded.

There were two post-operative complications in the group treated with immobilisation in cast; two patients had deep vein thrombosis (DVT). There was one superficial wound infection treated with oral antibiotics and two deep wound infections requiring removal of metal in the group treated with early movement in a removable cast. Patients in group two (early movement) had higher functional scores at nine and twelve weeks follow-up. They also returned to work earlier (63.7 days) compared with the ones treated in cast (94.9 days). There was no statistical difference in Quality of Life (SF-36 Questionnaire) at six months between the two groups.

Early movement with the use of removable cast after removal of sutures in operated ankle fractures decreases swelling, prevents calf muscle wasting, improves functional outcome and facilitates early return to work of patients. Our findings support the use of a removable cast and early exercises in selected, compliant patients after surgery of the ankle.

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.

Background: The aim of operative treatment for ankle fractures is to allow early movement after internal fixation. The hypothesis of this study was that early mobilisation facilitated by a removable cast after internal fixation of ankle fractures would improve functional recovery of patients compared with that after conventional immobilisation in a cast.

Material and Methods: Sixty two patients between the age of seventeen and sixty five with ankle fractures that required operative treatment were randomly allocated to two groups : immobilisation in a non weight bearing below knee cast for six weeks or early movement in a removable cast ( at two weeks after removal of sutures ) for the following four weeks. The follow up examinations which consisted of subjective (clinical, Olerud-Molander score, AOFAS score, SF 36 ) and objective ( swelling measurement, x-ray ) evaluations were performed at two, six, nine, twelve and twenty four weeks postoperatively. Time of return to work was recorded.

Results: There were no postoperative complications in the group treated with immobilisation in cast. There was one superficial wound infection treated with oral antibiotics in a patient with a previous dermatological condition around the fractured ankle in the group treated with early movement in a removable cast. Patients in group two ( early movement ) had higher functional scores at nine and twelve weeks follow up but not of statistical significance. They also return to work earlier ( 55.5 days ) compared with the ones treated in cast ( 98.7 days ). Patients treated in removable cast had higher mean SF-36 scores, but this difference was significant only for two of the eight aspects investigated.

Conclusions: Early movement with the use of removable cast after removal of sutures in operated ankle fractures decrease swelling, prevent calf muscle wasting, improve functional outcome and facilitate early return to work of patients. Our findings support the use of a removable cast and early exercises in selected, compliant patients after surgery of the ankle.

Introduction: The optimal management of ankle fractures in the elderly is controversial, with wide variation in the complication rates reported in the literature. Achieving a satisfactory outcome is essential as reduced mobility exacerbates pre-existing morbidity and diminishes the likelihood of independent living. However, in elderly patients surgery carries increased risks due to osteoporosis, poor skin condition and decreased vascularity.

Methods: We performed a retrospective review of outcome and complications in patients over 70 years of age with ankle fractures. Patients were admitted for manipulation under anaesthetic and application of cast (MUA) or open reduction and internal fixation (ORIF). Data were retrieved from medical and nursing notes relating to pre-operative functioning, type of injury, operative procedure and outcome. All X-rays were also reviewed to confirm fracture grade and union.

Results: A total of 134 patients over the age of 70 were admitted for management of ankle fractures during January 1995 and December 2003 and 117 of these were included in the study. 84 were operatively treated for ankle fractures and a further 27 patients underwent MUA. The mean age in both groups was 76 and there was a female predominance in both groups (89% in MUA, 79% in ORIF). 14.8% of the conservatively managed group were nursing home residents compared to 2.4% of the operatively treated group. The groups were similar with respect to ASA grade and co-morbidities. The median length of stay was shorter for the conservatively managed group (4 vs. 6 days). 7.5% of the MUA group required a second intervention compared to 4.5% of the operatively managed group. There were two below knee amputations in the operatively managed group, both related to open fractures, and one arthrodesis in each group. There were three wound complications in the operatively managed group. The rate of postoperative medical complications was the same in both cohorts. 7.4% of patients treated with MUA and 1.1% of patients treated operatively had reduced mobility at final follow-up.

Conclusion: The decision-making process for treatment of ankle fractures in the geriatric population is challenging. We observed significantly better functional results in the ORIF group than the MUA group. These results indicate that open reduction and internal fixation of ankle fractures in geriatric patients is efficacious and safe in selected patients

As our population ages, the incidence of hip fractures per annum is increasing rapidly. Within this patient group are an increasing number of very elderly (over 90 years old). These patients present many challenges to the clinician, both in terms of medical co-morbidities and orthopaedic complications. While the mortality and morbidity of hip fractures in general are well recognised, this study looked exclusively at the outcome in these very elderly patients following admission.

We reviewed 100 patients admitted between May 2000 and June 2002. The average age of our patient group was 92.5 years, 18% were male and 82% female. 60% were resident in nursing homes prior to admission, 26% lived with their families and 14% lived alone in the community. 56% of the fractures suffered were intertrochanteric, 40% were intra-capsular and 4% sub-trochanteric.

Following admission, these patients waited on average 1.5 days before undergoing surgery, the predominant cause for pre-operative delay being maximisation of pre-operative medical condition. Median pre-operative ASA score was three. The method of anaesthesia used was spinal in 78% and general in 22%. 64% of the group underwent internal fixation and 34% had a hemiarthroplasty. Two patients were deemed unfit to ever undergo surgery. Following surgery, mean in-hospital stay was 9.3 days.

There were 8 in-patient post-operative mortalities. Major post-operative morbidities occurred in 8% and included: 3 myocardial infarctions, 2 acute onset cardiac failure and 1 prosthetic dislocation. 11% of patients required a blood transfusion. 25% of the patients died within forty days of surgery, however, 50% of the patients were still alive 126 days post-op. Overall, the mean survival was 195 days. Post-discharge morbidity included two patients who had failure of internal fixation and 8 patients with severe immobility.

We conclude that hip fracture surgery in the nonagenarian population is as well tolerated as surgery in younger patients. Careful pre-operative assessment and medical maximisation combined with prompt surgical intervention yielded a good outcome and return to pre-injury status for most patients.

Aims: To assess the value of measuring subpopulations of T and B lymphocytes in children with bone tumours as an immunodiagnostic procedure in primary diagnosis of tumours.

Methods: In this prospective study blood samples were obtained from 36 patients aged 04–16 presenting with bone tumours in Cappagh Orthopaedic Hospital. Measurements in Immunology laboratory were based upon the principle of Ortho Cytoron Absolute flowcytometry. Levels of CD3 (Total T cells), CD4 (Helper cells), CD8 (Suppressor cells), Helper/Suppressor ratio and CD19 (B cells) were measured. Histological diagnosis of tumours was obtained by histopathological investigation of biobsy samples and flow cytometry results allocated accordingly.

Results: Of 36 patients, 12 (33.12%) had osteosarcoma, 10 (27.7%) Ewing’s sarcoma, 4 (11.1%) giant cell tumour and 10 (27.7%) osteomyelitis. Median values of lymphocytes were within normal values in patients with tumours other than oseomyelitis. In children with osteomyelitis median values were: CD3 2456, CD4 1479, CD8 929, Help/Sup ratio 1.8 and CD19 560 and all significantly raised. Confidence intervals were: CD3 467, CD4 292, CD8 470, and CD19 148. IN order to confidently outrule or confirm the diagnosis of osteomyelitis we measured the cut off point values of lymphocytes (the highest value in other patients groups). The cut off point values were found to be: CD3 2420, CD4 1400, CD8 873 and CD19 550.

Conclusions: The main use of measuring T and B lymphocytes response is in establishing the correct diagnosis between suspected osteomyelitis and other bone tumours. The CD3, CD4, CD8 and CD19 were significantly raised in children with osteomyelitis in contrast to other causes. Levels of CD3, CD4, CD8 and CD19 above the presented cut off values are an important and accurate confirming factor for the diagnosis of suspected osteomyelitis.

Aims: To assess the value of measuring the subpopulations of T and B lymphocytes in patients with musculoskeletal tumours as an immunodiagnostic procedure in primary diagnosis of tumours. Methods: In this prospective study blood samples were obtained from 145 patients aged 04–98 presenting with musculoskeletal tumours. Measurements of subpopulations of T and B lymphocytes (CD3, CD4, CD8, Helper/Suppressor ratio and CD19) were based upon the principle of Ortho Cytoron Absolute Flow Cytometry. The histological diagnosis of tumours was obtained by the histopathological investigation of the biopsy samples and the ßow cytometry results allocated accordingly. Results: Of the 145 patients, osteomyelitis was diagnosed in 15 (10.34%) patients. Median values of subpopulations of T and B lymphocytes were signiþcantly raised in patients with osteomyelitis, as follows: CD3 2456, CD4 1479, CD8 929, Help/Sup ratio 1.8 and CD19 560. Results were also calculated for osteosarcomas, Ewing sarcomas, giant cell tumours, chondrosarcomas, metastatic carcinomas, synovial cell sarcomas, chondroblastomas and others, with their median values within normal reference levels. To conþdently out rule or conþrm the diagnosis of osteomyelitis the cut off point values of lymphocytes (the highest value in other patients groups) were measured. The cut off point values were found to be: CD3 2420, CD4 1400, CD8 873 and CD19 550. Conclusions: The subpopulattions of T and B lymphocytes were signiþcantly raised in patients with osteomyelitis in contrast to other causes. In this study it is clearly shown that the levels of CD3, CD4, CD8 and CD19 above the presented cut off values are an important and accurate conþrming factor for the diagnosis of suspected osteomyelitis.

Biopsy is a key step in the diagnosis of bone and soft tissue tumours. An inadequately performed biopsy may fail to allow proper diagnosis. An improperly planned biopsy may jeopardise plans for limb salvage surgery.

Aims: To analyse the effectiveness of core-needle biopsy for evaluation of suspected primary musculoskeletal neoplasms.

Methods: Core-needle biopsy was performed at our institution in 130 consecutive patients suspected of having a mesenchymal neoplasm. Details of the biopsy and any additional procedures were recorded including size of sample, method of localisation and any complications. Clinical and histological features of the neoplasm and previous radiological or histological diagnosis were compared. Core-needle biopsy results were correlated with results from specimens subsequently obtained at definitive surgery.

Results: 130 consecutive core biopsies were performed for evaluation of suspected primary musculoskeletal neoplasms. All patients tolerated the procedure well and there were no significant complications. A definitive diagnosis was obtained from a single core biopsy in 107 (82%) patients; an additional biopsy was necessary in 24 (18%) following equivocal histology. Twenty-three (96%) of these repeat biopsies were an open procedure. In 98% of patients, core-needle biopsy results were concordant with results from specimens subsequently obtained at surgery with respect to tumour histological features and grade. The accuracy and rate of performance of open biopsy for soft tissue lesions were not significantly different from those for bone lesions.

Conclusions: Obtaining tissue safely, for diagnosis of bone and soft tissue tumours is the goal of all biopsies The biopsy, however, must be well planned so as to avoid creating inadvertent tumour spread, and take into consideration any subsequent approaches for limb-sparing surgery.

The level of bone resection for osteosarcoma depends on the pre-operative evaluation of the extent of intramedullary tumour. We compared the accuracy of magnetic resonance imaging (MRI), computerised tomography (CT), and isotope bone scanning with the actual extent of the tumour in the resected specimens from 34 patients with primary osteosarcoma of a long bone. The extent of medullary tumour was defined accurately in 23 of 24 MRI scans (96%) and 24 of 32 CT scans (75%). A flexion contracture of a joint close to the tumour was an important cause for inaccurate measurements from both MRI and CT scans. Isotope bone scanning was inaccurate: its role is now confined to detecting skeletal metastases and skip lesions.