Introduction: The National Bone Bank of Ireland was established in June 1996 at Cappagh National Orthopaedic Hospital, Dublin in response to the increased demand of allogenic bone grafts in Ireland. We reviewed the Bone Bank performance since it started with special emphasis on Microbiological monitoring of bone allograft as infection is the main complication of bone allograft (Chapman and Villar 1992).

Material and Methods: The femoral head allograft is harvested from living volunteer donors who are undergoing primary total hip replacement at Cappagh Hospital and have been assessed by the Bone Bank Co-Ordinator.

Harvesting: The bone is retrieved and harvested at the time of total hip replacement according to a strict protocol.

Storage: The bone is stored in the “Quarantine” freezer at −80 degrees C for a minimum period of 180 days. Each specimen is subjected to a full technical review by the Bone Bank Co-Ordinator and Medical Director and only when results of screening confirmed negative, the bone designated suitable for “Issue Stock” freezer.

Issue of Allografts: Bone is supplied for use, only after receiving full details of recipient to allow tracking. The results of the culture swab taken at the time of implantation and details of any post operative infection in recipients are forwarded to the bone bank.

Results: From June 1996 to December 2003, 5089 Primary Total Hip Replacements done at Cappagh Hospital and 1921 (38%) femoral heads were harvested. 109 (5.7%) of grafts had initial positive swabs/chips and 22 of these were discarded because of second positive chips. 1457 femoral head grafts supplied to 876 recipients and were used in Revision Total Hip Replacement (60%), Spine Surgeries (15%), Revision Total Knee (12%), Fractures, Tumours, Foot and Ankle (12%). 6 swabs at the time of grafting in recipients grew Staphylococcus Epidermidis but no clinical infection reported in our follow-up system. To double check, we posted a questioner to all consultants with list and details of their recipient patients and only 2 cases of suspected grafts related infection reported.

Discussion and Conclusion: Microbiological surveillance of bone grafts protect recipients from infection and is useful as a quality control of the process of bone banking (Farrington et al 1998). Our study showed contamination rate of 5.7%. Minimum infection rate post Revision Hip Replacement has been reported by Tomford in 1990, but after massive femoral allograft, infection has been reported 4% – 5% (Tomford 1990) and over 11% by Lord et al in 1988. Our experience showed only 2 cases in spite of strict follow-up protocol. We follow the policy of discarding the heavily contaminated grafts (Chapman 1992).

The quality performance of a Bone Bank depend on a full time bone bank co-ordinator, identification of donors, retrieval and harvesting of grafts, blood and microbiological assessment, medical supervision for decisions about contaminated grafts, a strict follow-up protocol and a regular audit of bone bank (Ivory and Thomas 1993). We also suggest that regular correspondence to the consultant using the bone grafts will improve the accuracy of follow-up.

Background: By the end of the current Bone and Joint Decade (2000–2010) the World Health Organisation predicts that 55% of post-menopausal women will have osteoporosis, as defined by fragility fracture and / or BMD. Volume aside, fragility fractures also represent a significant technical challenge in operative care. Current aggressive medical management is aimed to minimize the resource impact of this pandemic.

Study Design: This prospective study of 3000 consecutive fractures treated in a Level 1 trauma unit identified 977 fragility fractures requiring operative management, 803 of which were in patients over the age of 65 years. In every case the GP was informed of the diagnosis of osteoporosis and appropriate recommendations were made regarding medical management. We present the demographic features of this population and the resource impact of their management. We also examine the outcome of our efforts to improve care of the elderly with osteoporotic fractures, as all GP’s were contacted 6 months following discharge to determine the uptake of medical treatment as recommended.

Materials and Methods: Our computerized operative database was utilized to prospectively collect demographic and operative data on all 977 patients. All medical charts were examined to identify medications on admission, GP contact details and other relevant information. GP’s were contacted by telephone and post to determine patient 6-month mortality and the uptake in the use of recommended medication. Data represents the mean ± SD.

Results: Of the 803 patients over the age of 65 years, the average age was 80.5 ± 7.5 years, with a 75% female preponderance. 14% of these had had a previous wrist or vertebral insufficiency fracture, while 2.2% had a previous contralateral hip fracture. Hip fractures accounted for 70% (566 patients) of fragility fractures with 25% AMP, 24% Bipolar, 51% DHS. There were 121 wrist fractures. On admission 23% of hip fracture patients were resident in a Nursing Home. Despite the relatively large number with previous fracture (16.2%) only 3.4% were taking calcium / vitamin D supplementation while only 2.1% were on anti-resorptive therapy, eg a bisphosphonate. The median interval between admission and operation was 1 calendar day with a range of 1–10 days. 57% of all cases were performed outside of routine trauma lists. The average length of stay for this hip fracture population was 11.5 days with a further 16.5 days spent at a step down facility. Only 14.8% went directly home. Of 240 GP’s contacted, 74% replied resulting in complete follow-up data on 730 patients. The inpatient mortality rate was 5.8% while that at 6 months follow up was 19%. By this time 54% of hip fracture patients were living in Nursing Homes. The number of patients taking only calcium / vitamin D was 4%, a bisphosphonate alone 6%, while the use of both had risen dramatically to 16%.

Conclusions: To our knowledge this is the largest reported study documenting the epidemiology, demography and short-term follow-up of hip fractures in an elderly Irish population. Such data is essential to appropriately plan for the impending national health crisis consequent to the predicted dramatic rise in the elderly population with bone fragility. In a short time, we have achieved significant success in improving awareness and treatment of osteoporosis in the elderly following hip fracture.

Spinal injuries are among the most devastating injuries related to recreational sport. There are few studies specifically on spinal injuries in horseback riding. The purpose of our study was to determine the factors contributing to horse-riding accidents and to assess the usefulness of wearing protectors while horse riding.

All patients with spinal injuries admitted to our unit over a six-year period (1993–1998) were reviewed. Of 957 patients admitted to the National Spinal Injuries Unit from 1993–1998, 25 patients incurred spinal injury while horse riding. Age, sex, occupation and injury details were collected for all patients. All 25 patients were also contacted retrospectively to collect further details in relation to the specifics of the horse-riding event.

There were 16 male and 9 female patients with a mean age of 35 years (range 17–61). There were nine cervical fractures/dislocations, eleven thoracic fractures, and eight lumbar fractures. Four patient sustained injuries at more than one level. In relation to spinal cord injury, two patients had complete neurological deficit, a further ten had incomplete lesions. Thirteen patients had no neurological deficit. Surgical intervention was required in eleven patients.

Only six riders, all of who were either jockeys or horse trainers, wore back protectors. Of the 19 patients without a back protector there were 5 cervical, 10 thoracic and 6 lumbar injuries. Two patients sustained injuries at more than one level. However, of the six riders wearing a protective jacket there was a completely different fracture pattern level with 4 cervical injuries, only one thoracic injury and on e lumber injury.

The variation in injury level between the group wearing protective back supports and those without is noteworthy. While the numbers are too small to draw a significant conclusion it would appear that there is a trend for riders wearing a back protector to suffer less thoracic and lumbar injuries relative to cervical injuries.

Dysphagia is said to occur in 2% of patients immobilized in a Halo-Vest for the treatment of cervical injuries. This has been reported to lead to aspiration pneumonia which has a significant mortality rate in the elderly. In our experience dysphagia is a far greater problem than reported and is proportional to the degree of cervical spine extension.

The aim of our study was to ascertain the effect of cervical spine extension on swallowing in normal volunteers immobilized in a Halo- vest.

A halo vest was used to immobilize the cervical spine and to vary the degree of extension in ten volunteers. Videoflouroscopic studies were performed for each volunteer using three consistencies – liquid, paste and biscuit. The study was performed in neutral, 20° and 40° of extension. A subjective rating scale was completed by each volunteer. Videoflouroscopic study were blindly analysed by a radiologist and a speech and language therapist. Fourteen parameters were measured and recorded for each swallow.

Subjectively there was significantly increasing level of difficulty experienced for each swallow. At both degrees of extension there was a significant difference in oral transit time, piecemeal deglutition, Laryngeal penetration (a highly significant risk factor for aspiration), amount of residue occurring at the level of the valleculae and the number of successive clearance swallows compared to control.

In conclusion this study has clearly demonstrated significant impairment in deglutition following halo vest application. This impairment is directly related to the degree of neck extension. These findings should be taken into careful consideration when managing patients in cervical orthoses.