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Background Calcaneal fractures are common, but are difficult to manage. Immediate concern is soft tissue problems, while long term concern is pain as a sequelae of subtalar arthritis. A consensus has not been reached in the management of calcaneal fractures. Objective This study aims to evaluate clinical and radiological outcomes of the patients managed with open reduction and internal fixation with Calcaneal Locking Plates for the displaced intra-articular calcaneal fractures presenting in Dhulikhel Hospital, Kathmandu University Hospital. Method This was a prospective study, conducted on displaced intra articular calcaneal fractures from January 2014 through December 2016. The patients underwent open reduction and internal fixation with Locking Branched Calcaneal Plates through the extensile lateral approach. Post-operatively, ankle was mobilized after two weeks. Weight bearing was started after 12 weeks. Patients were evaluated clinically with Maryland foot score and radiologically with measurements of Boehler's and Gissane angle. Result Twenty-two cases of calcaneal fractures managed with open reduction and internal fixation with Locking Branched Calcaneal Plates were available for final evaluation. Seventeen of the enrolled patients were males in their third decade of life. On average, calcaneal fractures were operated on seven days after the injury. Sanders Type II were seen in 68.2% of the cases and Sanders Type III were in 31.8%. Mean follow-up duration was 21.5 months. The average Maryland foot score was 77.27. Seventeen cases (77.13%) had good, four cases (18.2%) had fair, and one case (5.5%) had poor outcome score. There was statistically significant improvement in Boehler's and Gissane angle across all enrolled patients. Conclusion Displaced intra-articular calcaneal fractures treated operatively with open reduction and internal fixation with Locking Branched Calcaneal Plates through the extended lateral approach, with proper planning of operation and surgical techniques in soft tissue handling, results in good clinical as well as radiological outcomes.

Nepal is one of the 20 poorest countries in the world. Thus, medical care in Nepal is dependent on significant medical and financial commitment from within and outside the country. Dhulikhel Hospital - Kathmandu University Hospital (DH-KUH) was founded in 1996 by Prof. Dr. Ram and colleagues. Collaboration and support of many people and institutions are, in contrast to the experience in other hospitals of the third world, characterized by an extraordinary sustainability. The reason for this is the spirit lived according to the motto "best service for the poor". The structures in DH-KUH are influenced by a very close cooperation with a number of international (university) hospitals. Most of the DH-KUH departments have an amazingly high technical standard. Assuming this development and progress can be continued, a splendid future for DH-KUH can be predicted.

Nepal is one of the 20 poorest countries in the world. Thus, medical care in Nepal is dependent on significant medical and financial commitment from within and outside the country. Dhulikhel Hospital - Kathmandu University Hospital (DH-KUH) was founded in 1996 by Prof. Dr. Ram and colleagues. Collaboration and support of many people and institutions are, in contrast to the experience in other hospitals of the third world, characterized by an extraordinary sustainability. The reason for this is the spirit lived according to the motto "best service for the poor". The structures in DH-KUH are influenced by a very close cooperation with a number of international (university) hospitals. Most of the DH-KUH departments have an amazingly high technical standard. Assuming this development and progress can be continued, a splendid future for DH-KUH can be predicted.

Background: Fractures of the volar articular margin of the distal part of the radius with volar radiocarpal subluxation (volar shearing, or Barton, fractures) can be accompanied by a fracture of the dorsal metaphyseal cortex. We tested the null hypothesis that there is no difference in wrist function or health status after open reduction and plate-and-screw fixation between volar shearing fractures with a dorsal cortical fracture (complete articular, AO Type C) and those without a dorsal cortical fracture (partial articular, AO Type B). Methods: In a multicenter cohort study, fifty-seven patients with a volar marginal shearing fracture of the distal part of the radius and volar radiocarpal subluxation were followed for at least one year following plate-and-screw fixation. Thirty-seven patients who also had a dorsal metaphyseal cortical fracture (Type-C fracture) were compared with twenty patients who had a partial articular (Type-B) fracture. The two cohorts were analyzed for differences in wrist and forearm motion, grip strength, pain, and the Gartland and Werley, Disabilities of the Arm, Shoulder and Hand (DASH), and Short Form-36 (SF-36) scores at six, twelve, and twenty-four months postoperatively. Differences in mean values and their change over time were determined. Results: There were no significant differences between patients with a Type-B fracture and those with a Type-C fracture with respect to motion, grip strength, or the Gartland and Werley or DASH score at any time point. At six months after the surgery, the patients with a Type-B volar shearing fracture reported a mean score for pain in motion of 0.5 point on a 10-point visual analogue scale compared with 2.2 points for patients with a Type-C fracture (difference in means, 1.7 points [95% confidence interval, 0.7 to 2.6 points]; p < 0.001), but no significant difference was seen at twelve or twenty-four months. Conclusions: Volar shearing fractures are usually complete articular, Type-C injuries. Patients with a Type-C volar shearing fracture experience more pain during early recovery, but ultimately their outcome is comparable with that for patients with a Type-B (partial articular) volar shearing fracture.

BACKGROUND Extremity conserving treatment in hospitals of maximum care involves a combination of soft tissue replacement and segment transfer. In contrast some other countries favour the segment transfer without soft tissue replacement and can demonstrate good results. Thus, we posed the question of the effects of soft tissue defects in callus distraction. MATERIALS AND METHODS In an experimental study with two groups of sheep, a standardized fracture model in one group with bone and soft tissue defects and in the other group without soft tissue defects was compared. At specific dates the animals were euthanized and the bone quality combined with different soft tissue conditions were quantified. RESULTS At the outset of callus maturation, animals without soft tissue defects have a lead over animals with soft tissue defects. At the end of the experimental study both groups show the same bone quality results compared to a healthy comparison group. CONCLUSION At the terminal phase of the animal experiment the results of open segment transfer show no differences between the groups with or without soft tissue defects. This supports the experience of other countries. Because of the experimental set-up we cannot make any prediction regarding the biomechanical stability of the callus.

AIM OF THE STUDY The purpose of this study was to verify the possibility of monitoring the callus maturation biochemically. METHOD In an experimental study on sheep, animals with bone fractures with a length 5 cm each were divided into group A (with concomitant damage of the soft tissue) and group B (without soft tissue damage). During callus traction and maturation, biochemical parameters (osteocalcin, AlP, NTx, calcium, phosphate) were measured. Animals of each group (A+B) were euthanised at fixed points in time (according to protocol) and the callus was prepared histologically. RESULTS Total AlP and NTx values were initially reduced during the callus traction and maturation, but increased significantly at the time of Docking+1 transportation time. At the same time, the histological evaluation showed a definite increase of the bone stabilisation, which approximately resembles the structure of a healthy bone as reference. CONCLUSION With the combination of the AlP and NTx values already determined in the daily clinical routine the monitoring of callus maturation in animal studies becomes possible.

Introduction: Conservative management and operation are treatment options for fractures of the thoraco-lumbar transition with encroachment of the spinal canal. Operative treatment is usually preferred if there is neurological deficit, instability or significant encroachment of the spinal canal. Decompression can be indirect (removal of fragments by distraction and realignment of the vertebral body due to ligamentotaxis or vacuum effects) or direct. Ventral spinal decompression (clearance) is the most effective method for fragment removal, but also the most invasive. Both remodelling (with lysis of remnant bony fragments in the canal) and secondary spinal canal stenosis have been described. Aims: Main objectives of that study were to determine whether ventral spinal clearance is more effective than other methods in decompressing the spinal canal and improving neurological outcome, whether and to what extent postoperative restructuring of the spinal canal takes places (remodelling/spontaneous resorption/stenosis formation) and what method of operation is most effective in reconstructing and maintaining the spinal profile. Design: 105 patients with traumatic fractures between Th10 and L3 and radiological evidence of bony encroachment of the spinal canal were analysed in 4 treatment groups: dorsal operation only (n= 10), dorsal operation with transpedicular spongiosaplastic (n =19), combined dorso-ventral operation (n = 52) and combined dorso-ventral operation with clearance of the canal (n=24). Data concerning accident and operation was gathered retrospectively. Mechanism of injury, fracture type (according to AO), neurological status pre- and postoperatively (Frankel/ASIA), functional parameters, CT scans and X-rays were analysed. Follow-up was 3 years postoperatively with re-assessment of neurological status, functional parameters and CT scanning ofthe affected and neighbouring vertebrae. Results: Average age was 38 (14-74) years. Most common mechanism was fall from a height (43.8%). Most frequently injured vertebra was L1 (41%) und most common fracture type was A3 (48.6%). 54,3% of patients had associated injuries requiring treatment, 19% had polytrauma. Average duration of dorsal operation was 1:48 h, ventral operation without clearance 2:49 h and ventral operation with clearance 4:38 h (p < 0.005). Probability for severe bleeding at the operation site was higher with clearance (p

Fractures of the distal radius are most common in adults. Insufficient results following conservative treatment lead to a change of paradigm: during the mid-nineties of the last century the operative procedures like percutaneous K-wiring, external fixation systems and plating with conventional 3.5 mm plate systems became extended by the invention of plate systems with head locking screws, angular stable plate systems. Meanwhile the results after palmar plating with systems in a dimension of 2.4-3.5 mm of even extension fractures of the distal radius are so encouraging that this treatment has become a standard procedure. Only wide displaced fractures type C2 or C3 sometimes need to be addressed from dorsally. The results of 244 extension fractures of the distal radius using palmar approach in plating with three different plate systems are presented. Fracture type and patients data were comparable in all 3 groups. The functional outcome of regular vs. 3.5 mm plates with headlocking screws (LCP) showed similar results. The best outcome with statistical relevance could be created by the use of the 2.4/2.7 mm plate system (Synthes®). Some technical hints have to be regarded to obtain good radiological and functional results: the head locking screws in the distal fragment have to be placed subchondrally and the tips of these screws may not overtop the dorsal cortex. Thus complications like irritation of extension tendons, additional bone grafting even in osteoporotic bone or loss of reduction postoperatively become very rare. Functional treatment postoperatively reduced the rate of reflex sympathic dystrophy syndrome dramatically.

We developed a new trauma model to examinate the connection between trauma and laboratory findings as trauma response in an animal experiment. A transverse mechanism by impact force produced C2 and C3 fractures with 1° open soft tissue injury in hind leg of sheep. Because there are no invasive preparations necessary the laboratory findings are only responsed to the trauma. Also the injury of bone and soft tissue is constant to examinate the operative treatment of defect fractures.

Goniometrically Stable Palmar Osteosynthesis with Plates in Distal Radius Fractures. Of a total of 398 extension fractures of the distal radius, 322 were surgically treated between January 1996 and December 1999 at the hospital for accident, hand and rehabilitation surgery of the Erfurt clinic. Following good experiences with a palmar implantation of a conventional T plate of 3.5 mm radius in A3 and C1 fractures we conducted a prospective study to find out whether a goniometrically stable implant would be suitable also for stabilising instabilities of a higher degree. We compared the 71 patients with goniometrically stable osteosynthesis operated on between 1/1998 and 12/1999 (group A) with a group B of 98 patients who had been treated with a conventional T plate between 1/1996 and 12/ 1997. According to the AO classification, group A comprised 28 A3 fractures, 16 C1 fractures, 17 C2 fractures and 10 C3 fractures, whereas in group B there were 49 A3 fractures, 26 C1 fractures, 14 C2 fractures and 9 C3 fractures. The age and gender distributions being comparable, group A had a higher percentage of C2 and C3 fractures. Following early functional testing of group A patients (usually after the second postoperative day) and functional training of group B patients after the 14th postoperative day, both patient groups were clinically examined at the earliest 6 months after osteosynthesis. The functional result was assessed at follow-up time, using a scoring system according to Cooney and Bussey (50% subjective, 50% objective). The x-ray results were analysed according to a scoring system of the AO working group distal radius (100% subjective). It was established with high significance (p

Regeneration of damaged nerves limits the outcome of complex injuries of the upper extremities. We report the follow-up results in 7 of 10 patients over 5 years who underwent a transplantation of n. suralis in 6 cases and n. cutaneus antebrachii ulnaris in 4 cases. The average DASH-score of 30 points, no neurinoma and a protective sensibility in 5 cases are comparable with the literature.

Extremity conserving treatment in hospitals of maximum care involves a combination of soft tissue replacement and segment transfer. In contrast some other countries favour the segment transfer without soft tissue replacement and can demonstrate good results. Thus, we posed the question of the effects of soft tissue defects in callus distraction.In an experimental study with two groups of sheep, a standardized fracture model in one group with bone and soft tissue defects and in the other group without soft tissue defects was compared. At specific dates the animals were euthanized and the bone quality combined with different soft tissue conditions were quantified.At the outset of callus maturation, animals without soft tissue defects have a lead over animals with soft tissue defects. At the end of the experimental study both groups show the same bone quality results compared to a healthy comparison group.At the terminal phase of the animal experiment the results of open segment transfer show no differences between the groups with or without soft tissue defects. This supports the experience of other countries. Because of the experimental set-up we cannot make any prediction regarding the biomechanical stability of the callus.

The purpose of this study was to verify the possibility of monitoring the callus maturation biochemically.In an experimental study on sheep, animals with bone fractures with a length 5 cm each were divided into group A (with concomitant damage of the soft tissue) and group B (without soft tissue damage). During callus traction and maturation, biochemical parameters (osteocalcin, AlP, NTx, calcium, phosphate) were measured. Animals of each group (A+B) were euthanised at fixed points in time (according to protocol) and the callus was prepared histologically.Total AlP and NTx values were initially reduced during the callus traction and maturation, but increased significantly at the time of Docking+1 transportation time. At the same time, the histological evaluation showed a definite increase of the bone stabilisation, which approximately resembles the structure of a healthy bone as reference.With the combination of the AlP and NTx values already determined in the daily clinical routine the monitoring of callus maturation in animal studies becomes possible.

Regeneration of damaged nerves limits the outcome of complex injuries of the upper extremities. We report the follow-up results in 7 of 10 patients over 5 years who underwent a transplantation of n. suralis in 6 cases and n. cutaneus antebrachii ulnaris in 4 cases. The average DASH-score of 30 points, no neurinoma and a protective sensibility in 5 cases are comparable with the literature.

Im Rahmen einer Nachuntersuchung distaler Radiusfrakturen war auffallig, das der Einstand des ulnaren Schlusselfragmentes eine bedeutende Rolle bei der Beschwerdesymptomatik im Outcome spielt. Um die Reposition und Spongiosaunterfutterung dieses Fragmentes zu verbessern, wurde die minimalinvasive Spongiosaplastik mit dem MINI-SPONG-System entwickelt. Das follow up dieser Patienten zeigt, das diese Methode eine sichere Reposition, Spongiosaunterfutterung und Defektauffullung bei dieser Art der Fraktur ermoglicht.

"It is common practice to treat shaft fractures of the humerus conservatively" says the relevant literature. The results of 126 humerus shaft fractures in the years 1980 to 1989 are reported: 28 fractures were treated conservatively, 98 fractures underwent surgery using plate fixation, mainly the broad AO/ASIF-4,5-mm-DCP. As complications following operative treatment 4 temporary palsies of the radial nerve (4%), three cases of infection (3%) and one non-union (1%) were observed. The striking advantages of internal fixation are the chance of early functional treatment and the high convenience for the patient. The results reveal correctly performed osteosynthesis as an alternative method to conservative treatment of humerus shaft fractures.

A prospective study of 106 orthopedic patients was performed for the detection of infection in the early postoperative stage using 99mTc-labeled murine Mabs directed against epitopes on granulocytes. Accuracy was 81% in the hips (n = 26), 81% in the thigh (n = 21), 84% in the knee (n = 19), and 100% in the tibia (n = 27). The technique did not work well in the spine where false-negative results were observed in the three patients studied. One patient suffered transient swelling of the eyelids following injection. Optimal imaging results were obtained 2-6 hr postinjection.

A girl of 3 years of age sustained an isolated traumatic dislocation of the radial head. The injury was diagnosed 2 1/2 years later and required open reduction, repair of the annular ligament and temporary transcapitellary Kirschner wire fixation. The operative procedure--the annular ligament still intact--is reported.

In patients with posttraumatic or idiopathic gonarthritis, varus deformity and stable medial collateral ligaments the valgus high tibia correction osteotomy in the open wedge method is performed extraligamentary. An autologous wedge from the iliac crest is used, a bridging plate osteosynthesis brings stability for early movement. 58 patients with 64 osteotomies operated between 1981 and 1986 underwent a follow-up examination. There was an infection rate on the tibial head of 15%. The reason for that was not in the procedure itself but in its application and performance. Respecting the site of osteotomy (less than or equal to 6.5 cm below tibial joint line), the size of the wedge at its basis (less than or equal to 10 mm), a strong indication in cases of repeated interventions and the correct technical performance of the procedure we see in the high tibia valgus osteotomy (open wedge method) a proper way of treatment in unilateral varus gonarthritis or varus deformities compared to other existing methods.

Subsequent to orthopedic surgery 23 patients were studied by leukocyte scintiscanning using 99mTc-HMPAOto detect inflammation. 12 patients had all signs of bacterial infection. In 11 patients infection of the wound area was suspected. There was one false negative and no false positive scintigraphic finding. 2 patients with an unclear postoperative course after internal fracture fixation showed intensive uptake. Several days after the scan both patients developed severe bacterial infection. From that experience we conclude that the method may be of higher sensitivity than clinical symptoms. Further investigations are necessary for an accurate assessment of the method.

70 Patienten mit klinisch gesicherten (23 Patienten) bzw. fraglichen (47 Patienten) bakteriellen Infektionen am Skeletsystem bei unfallchirurgisch/orthopadischen Erkrankungen, Verletzungen oder Operationen wurden mit der Eigenleukocytenszintigrafe untersucht. Hierbei macht man sich das Prinzip der Leukocytenmigration zum Infektionsherd zunutze. Als Markierungssubstanz wurde gegenuber bisher geubten Verfahren das sehr vorteilhafte Tc-99m-HMPAO angewandt. Bei den 23 Patienten mit klinisch gesicherten Infektionen ergaben die szintigrafischen Untersuchungen positive Befunde. Von den 47 Patienten mit klinisch fraglichem Infekt ergab sich bei 14 ein szintigrafsch positiver Befund, was sich operativ als richtig bestatigen lies. 28 Patienten zeigten einen durch klinischen Verlauf und Operation gesicherten richtig-negativen Szintigrafebefund. 5 Patienten mit klinisch fraglichen Infektzeichen und positiven Leukocyten-Szintigrammen wurden nach Ruckgang der Infektsymptomatik nach der LS nicht operativ revidiert und einer Sondergruppe zugeordnet (Infection: Yes-Operation: No [IYON]-Gruppe). Bei der Gesamtbeurteilung des Verfahrens ergab sich eine Sensitivitat von 97,1%, Spezifitat von 82,9% und eine Gesamt-Genauigkeit von 90%. Die Tc-99m-HMPAO-Leukocytenszintigrafe erweist sich als geeignetes Verfahren zur Bestatigung/Ausschlus von bakteriellen Fruh-, Spat- und akuten Schuben von chronischen sowie hamatogenen Infekten am Skeletsystem.

The meaning of instability after elbow dislocation (unstable dislocation) is pointed out. We support the trend to surgical treatment in cases of obvious instability and emphasize a differentiated concept in diagnosis and therapy. 32 patients after elbow dislocation were treated and followed up after an average period of 7.5 months. Good to very good results could be achieved in 24/32 patients (75%).

70 patients with confirmed (23 patients) or suspected (47 patients) bacterial infection in the skeleton following diseases, injuries or operations in orthopedic surgery were investigated using Tc-99m-HMPAO leucocyte scintigraphy in order to evaluate the accuracy of this procedure. Infections could be detected correctly in 37 of 70 patients (right positives) while 28 patients had negative scans corresponding to the clinical course (right negatives). One false negative finding was observed. Five patients with clinically suspected infection had a focal uptake in the WBC-scan and were not operated subsequently. They range as false positive results, although they belong to a special group (Infection: Yes-Operation: No [IYON]-group). In the assessment of the Tc-99m-HMPAO-WBC-scan there was a senstivity of 97.1%, specificity of 82.9% and an overall accuracy of 90%. The method is suitable for detection of early and late infection as well as chronic or hematogenous osteomyelitis in the locomotor system. This means an important contribution in diagnosis of infection determining further operative or conservative treatment.

Subsequent to orthopedic surgery 23 patients were studied by leukocyte scintiscanning using 99mTc-HMPAO to detect inflammation. 12 patients had all signs of bacterial infection. In 11 patients infection of the wound area was suspected. There was one false negative and no false positive scintigraphic finding. 2 patients with an unclear postoperative course after internal fracture fixation showed intensive uptake. Several days after the scan both patients developed severe bacterial infection. From that experience we conclude that the method may be of higher sensitivity than clinical symptoms. Further investigations are necessary for an accurate assessment of the method.