Cerclage performance analysis - a biomechanical comparison of different techniques and materials.

BACKGROUND: Wire cerclages play a fundamental role in fracture fixation. With an increasing variety of designs being commercially available the question arises which cerclage should be used. This study investigates the biomechanical properties of metallic and non-metallic cerclages and their different application-types. Furthermore, potential influence of muscular interposition between bone and cerclage constructs was tested. METHODS: Samples of the following four different cerclage types were tested on 3D printed models of human humeri as well as on human cadaveric humeri with and without muscular interposition: Titanium Cable Cerclage (CC), Steel Wire Cerclage (SWC), Suture Tape (ST), Suture Tape Cerclage (STC) with both single- (sSTC) and double-loop application (dSTC). A preinstalled self-locking mechanism secured by the provided tensioner in the STCs being the main difference to the STs. Cyclic loading was performed to 1 kN and then linearly to a maximum load of 3 kN. Statistical analysis was performed using either one-way ANOVA and post-hoc Tukey or Kruskal-Wallis and post-hoc Dunn test depending on normalization of data (p < 0.05). RESULTS: Whilst all cerclage options could withstand high loads during failure testing, only within the CC and dSTC group, all samples reached the maximal testing load of 3000 N without any failure. The SWC reached 2977.5 ± 63.6 N, the ST 1970.8 ± 145.9 N, and the sSTC 1617.0 ± 341.6 N on average. Neither muscular interposition nor bone quality showed to have a negative influence on the biomechanical properties of the cerclage constructs, presenting no significant differences. CONCLUSION: All tested cerclage constructs produce reliable stability but differ in their resulting compression forces, in a simplified fracture model. Therefore, non-metallic cerclage alternatives can provide similar stability with less compression and stiffness to metallic cable constructs, but they may offer several advantages and could possibly provide future benefits. Especially, by offering more elasticity without losing overall stability, may offer a biologic benefit. Installing any cerclage constructs should be performed carefully, especially if poor bone quality is present, as the tightening process leads to high forces on the construct.

[Radial head prosthesis for acute fractures]. / Radiuskopfprothese bei akuten Frakturen ­ wann und welche?

Non-reconstructible radial head fractures with concomitant injuries and resultant instability of the elbow are often treated by implantation of a radial head prosthesis. Various prosthetic designs and implantation techniques are available. Several pitfalls have to be respected during implantation. This article provides tips and tricks for successful implantation and aftercare and gives an overview of long-term outcomes and revision rates.

Establishment of a reliable in-vivo model of implant-associated infection to investigate innovative treatment options.

The increasing number of implant-associated infections and of multiresistant pathogens is a major problem in the daily routine. In the field of osteomyelitis, it is difficult to manage a valid clinical study because of multiple influencing factors. Therefore, models of osteomyelitis with a simulation of the pathophysiology to evaluate treatment options for implant-associated infections are necessary. The aim of this study is to develop a standardized and reproducible osteomyelitis model in-vivo to improve treatment options. This study analyses the influence of a post-infectious implant exchange one week after infection and the infection progress afterward in combination with a systemic versus a local antibiotic treatment in-vivo. Therefore, the implant exchange, the exchange to a local drug-delivery system with gentamicin, and the implant removal are examined. Furthermore, the influence of an additional systemic antibiotic therapy is evaluated. An in-vivo model concerning the implant exchange is established that analyzes clinic, radiologic, microbiologic, histologic, and immunohistochemical diagnostics to obtain detailed evaluation and clinical reproducibility. Our study shows a clear advantage of the combined local and systemic antibiotic treatment in contrast to the implant removal and to a non-combined antibiotic therapy. Group genta/syst. showed the lowest infection rate with a percentage of 62.5% concerning microbiologic analysis, which is in accordance with the immunohistochemical, cytochemical, histologic, and radiologic analysis. Our in-vivo rat model has shown valid and reproducible results, which will lead to further investigations regarding treatment options and influencing factors concerning the therapy of osteomyelitis and implant-associated infections.

A lateral fracture step-off of 2mm increases intra-articular pressure following tibial plateau fracture.

INTRODUCTION: The aim of this study was to evaluate the effects of increasing posttraumatic step-offs after lateral tibial plateau fracture reduction on the intra-articular pressure. MATERIALS AND METHODS: In eight fresh-frozen human cadaveric knees with intact menisci, a standardized sagittal osteotomy of the lateral tibial condyle was performed as an OTA/AO type 41-B1 fracture-model. The fragment was fixed by a customized sled including an angular stable tibia plate to evaluate step-offs from 0 mm to 8 mm in 1mm increments. In a servo-hydraulic testing machine, an axial force was applied to the tibial plateau in 0° (700N), 15° (700N), 30° (700N), 60° (350N), and 90 ° (350N) of flexion while the joint pressure was recorded by two pressure sensors. RESULTS: A 1mm step-off did not result in an increased joint pressure. At 60° of flexion a 2mm step-off increased the lateral joint pressure by 61.84kPa (P = 0.0027). In 30° of flexion, a 3mm step raised the lateral joint pressure by 66.80kPa (p = 0.0017), whereas in 0°, 15° and 90° of flexion, a 4mm step increased the pressure by >50kPa (P < 0.05). Concomitant medial joint pressure increments were lower than those in the lateral plateau. A significant increase of 19-24kPa in the medial joint pressure was detected in 90° of flexion with a 1mm lateral step (P = 0.0075), in 15° and 60° of flexion with a 2mm step (P < 0.05), in 0° of flexion with a 4mm step (P = 0.0215) and in 30° of flexion with a 7mm step (P = 0.0487). CONCLUSION: Lateral fracture step-offs of 2mm or larger should be reduced intraoperatively to avoid large increases in lateral joint pressure.

Primary stability of single-stage revision reconstruction of the anterior cruciate ligament in case of failure of dynamic intraligamentary stabilization depends on implant position during ACL repair.

INTRODUCTION: The object of this study was to evaluate the primary stability of tibial interference screw (IFS) fixation in single-stage revision surgery of the anterior cruciate ligament (ACL) in the case of recurrent instability after ACL repair with dynamic intraligamentary stabilization (DIS), dependent on the implant position during DIS. MATERIALS AND METHODS: Tibial aperture fixation in ACL reconstruction (ACL-R) was performed in a porcine knee model using an IFS. Native ACL-R was performed in the control group (n = 15). In the intervention groups DIS and subsequent implant removal were performed prior to single-stage revision ACL-R. A distance of 20 mm in group R-DIS1 (n = 15) and 5 mm in group R-DIS2 (n = 15) was left between the joint line and the implant during DIS. Specimens were mounted in a material-testing machine and load-to-failure was applied in a worst-case-scenario. RESULTS: Load to failure was 454 ± 111 N in the R-DIS1 group, 154 ± 71 N in the R-DIS2 group and 405 ± 105 N in the primary ACL-R group. Load-to-failure, stiffness and elongation of the group R-DIS2 were significantly inferior in comparison to R-DIS1 and ACL-R respectively (p < 0.001). No significant difference was found between load-to-failure, stiffness and elongation of R-DIS1 and the control group. CONCLUSION: Primary stability of tibial aperture fixation in single-stage revision ACL-R in case of recurrent instability after DIS depends on monobloc position during ACL repair. Primary stability is comparable to aperture fixation in primary ACL-R, if a bone stock of 20 mm is left between the monobloc and the tibial joint line during the initial procedure.

Union rates and functional outcome of double plating of the femur: systematic review of the literature.

BACKGROUND: The optimal treatment strategy for the surgical management of femur fractures and non-unions remains unknown. The aim of this study is to assess union rates, complications and outcome after femoral double plating. Treatment of shaft, distal, periprosthetic fractures and pathological proximal femur fractures as well as femoral non-unions with double plating were evaluated. METHODS: A systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was conducted. Published literature reporting on the treatment and clinical outcome of femoral fractures and non-unions with double plating was identified. In total, 24 studies with 436 cases of double plating, 64 cases of single plating, 84 cases of intramedullary nailing (IM), and 1 interfragmentary screw treatment met the inclusion criteria of this systematic review. The evaluated literature was published between 1991 and 2020. RESULTS: Double plating of femoral fractures achieved high healing rates and few complications were reported. It displayed significantly less intraoperative haemorrhage, shorter surgery time reduced risk of malunion in polytraumatised patients when compared to IM. Fracture healing rate of double-plating distal femoral fractures was 88.0%. However, there were no significant differences regarding fracture healing, complication or functional outcome when compared to single plating. Treatment of periprosthetic fractures with double plating displayed high healing rates (88.5%). Double plating of non-unions achieved excellent osseous union rates (98.5%). CONCLUSIONS: The literature provides evidence for superior outcomes when using double plating in distal femoral fractures, periprosthetic fractures and femoral non-unions. Some evidence suggests that the use of double plating of femoral fractures in polytraumatised patients may be beneficial over other types of fracture fixation. LEVEL OF EVIDENCE: IV.

Variable Fixation Technology Provides Rigid as Well as Progressive Dynamic Fixation: A Biomechanical Investigation.

BACKGROUND: A new locking-screw technology, the Variable Fixation Locking Screw (VFLS; Biomech Innovations), was developed with the aim of promoting secondary fracture-healing. The VFLS features a resorbable sleeve that progressively decreases its mechanical properties and mass during the fracture-healing time. In this study, we investigated whether the VFLS can provide rigid as well as progressive dynamic fixation. METHODS: The interfragmentary stability provided by the VFLS was tested in a simulated fracture-gap model and compared with that provided by standard locking or by a combination of both technologies under compression and torsional loading. Tests were performed with an intact sleeve (initial condition) and after its chemical dissolution. An optical measurement system was used to characterize interfragmentary movements. RESULTS: The axial stiffness did not differ significantly among groups in the initial condition. Sleeve resorption significantly decreased construct stiffness. The torsional stiffness of the samples instrumented with the VFLS was lower than that of the control group. The degradation of the sleeve resulted in a significant increase in axial displacement recorded at both the cis and trans cortices. In samples featuring combined technologies, this increase was about 12% to 20% at the trans cortex and about 50% to 60% at the cis cortex. In samples featuring VFLS technology only, this increase was about 20% to 37% at the trans cortex and about 70% to 125% at the cis cortex. CONCLUSIONS: The initial stability offered by the VFLS is equivalent to that of standard locking-screw technology. The resorption of the degradable sleeve leads to effective and reproducible fracture-gap dynamization, progressively varying the way the fracture gap is strained and the magnitude of the strain. CLINICAL RELEVANCE: The VFLS provides rigid and progressive dynamic fixation in vitro. Such variable stability might have beneficial effects in terms of triggering and boosting secondary fracture-healing.

[Periprosthetic fractures: basics, classification and treatment principles]. / Periprothetische Frakturen: Grundlagen, Klassifikation und Therapieprinzipien.

Periprosthetic fractures (PPFx) are becoming an increasingly important topic in orthopedics and trauma surgery due to the rising number of endoprosthetic joint replacements. The recently published unified classification system (UCS) has replaced numerous historical classification systems and can be applied to all PPFx regardless of the bone or joint involved. The treatment of PPFx requires individual therapeutic concepts taking patient-dependent and patient-independent factors into consideration. The conservative treatment of PPFx is only justified in exceptional situations. In contrast, the choice between operative treatment and deciding between osteosynthesis or revision arthroplasty is particularly based on the assessment of the implant stability. In order to achieve fracture consolidation and also a good functional outcome, knowledge of the basic biomechanical principles of operative (osteosynthesis or endoprosthesis) treatment of periprosthetic fractures is necessary.

[Periprosthetic fractures of the shoulder girdle]. / Periprothetische Frakturen des Schultergürtels.

Periprosthetic fractures of the shoulder girdle will increasingly become part of routine clinical practice due to rising numbers of joint replacements and the demographic changes. Diagnostically, the status of the rotator cuff, bed of the implant (stable or loose), type of shoulder arthroplasty as well as exclusion of joint infections are crucial for therapeutic decision-making. Novel imaging tools, such as dual-energy computed tomography provide improved preoperative planning options. The unified classification system describes the fracture location, stability of the prosthesis and quality of the bone. While nonoperative treatment is reserved for patients with severe pre-existing conditions and nondisplaced fractures, the standard treatment of fractures with a stable bed include fixation with cerclage wiring and angular stable plates. Modern implant systems with variable angle screw holes, attachment plates and hinges enable secure fixation around the stem. In cases of a loose stem revision arthroplasty is necessary. There are currently only a limited number of clinical studies with only few patients that analyzed clinical and radiological results. Thus, increased research efforts are indispensable in order to compare treatment options and improve treatment quality.

[Stimulation of fracture healing by growth factors and cell-based technologies]. / Stimulation der Frakturheilung durch Wachstumsfaktoren und zellbasierte Technologien.

Bone has the special capability to completely regenerate after trauma and to re-establish its original geometry and biomechanical stability corresponding to the pretrauma conditions. Nevertheless, in daily clinical practice impaired fracture healing and nonunions are regular complications as a result of inadequate mechanical stability and/or insufficient biological processes around the fracture region. Since the beginning of the millennium, intensive research on the physiological processes in bone healing as well as the production and clinical administration of growth factors have enabled the possibility to improve the local biological processes during fracture healing by osteoinduction. Although the initial clinical results, particularly of bone morphogenetic proteins, in fracture healing were promising, growth factors did not become established for unrestricted use in the clinical application. Currently, additional growth factors are being investigated with respect to the potential supportive and osteoinductive characteristics for enhancement of fracture healing and possible clinical applications. Furthermore, the development of cell-based technologies is another promising approach to positively stimulate fracture healing. In addition to the gold standard of autologous bone grafting, harvesting of mesenchymal stroma cells by aspiration has gained in importance in recent years. Allogeneic bone cell transplantation procedures and in particular gene therapy are promising new strategies for the treatment of disorders of fracture healing. This review gives an overview of present and future possibilities for modulation of fracture healing by growth factors and cell-based technologies.

[Bilateral well-leg compartment syndrome in a child after abdominal trauma : A review of the literature and treatment recommendations illustrated by a case study]. / Bilaterales Kompartmentsyndrom der Unterschenkel des Kindes nach Abdominaltrauma : Eine Literaturübersicht und Handlungsempfehlungen, veranschaulicht an einem Fallbeispiel.

This article reports a case of a bilateral well leg compartment syndrome (WLCS) in a 9-year-old girl who presented to the emergency room 24 h after blunt abdominal trauma and liver laceration. The abdomen was already packed on presentation. The patient presented a manifest compartment syndrome of both lower legs 48 h after the second look surgery and removal of the packing. Both tibial anterior and peroneal compartments had to be partially resected. In an analysis of literature only five cases of WLCS after surgery in a supine position were found. The young age of the patient and the intra-abdominal packing were identified as risk factors for increased intra-abdominal pressure and reperfusion was suspected to be the cause of the lower leg compartment syndrome.

[Outcome after surgical treatment of calcaneal fractures]. / Outcome nach operativer Therapie von Kalkaneusfrakturen.

BACKGROUND: After controversial discussions in the literature about therapy regimens for calcaneal fractures, a retrospective study of patients operatively treated in a maximum care trauma center was conducted. OBJECTIVE: Investigation of the influencing factors on the treatment quality of operatively treated patients with calcaneal fractures. MATERIAL AND METHODS: Between 2005 and 2013 a total of 90 patients with calcaneal fractures were surgically treated in this hospital with locking plate osteosynthesis. A total of 48 patients with 55 fractures were retrospectively investigated. The assessment with respect to posttraumatic arthrosis was made radiologically and Böhler's and Gissane's angles were also determined. Clinically AOFAS and SF-36 scores were documented. The results were statistically tested with respect to possible risk factors. RESULTS: A total of 9 patients (18.8%) were found with complications necessitating operative revision, with 8 patients requiring subtalar arthrodesis and 1 patient with a deep wound infection. Nicotine abuse and a long interval between trauma and reconstructive surgery were identified as factors that influenced the development of wound healing problems. The average AOFAS score was 68 points and the SF-36 was 58.86 points. A poor result in the scores was caused by the development of symptomatic arthritis and the type of insurance. In this cohort factors, such as age and complexity of fractures were not correlated with a poor result. CONCLUSION: In this patient collective nicotine abuse and a long interval between trauma and surgery were risk factors for development of wound infections. Other factors with an influence on the outcome were the postoperative development of arthritis and the type of health insurance; however, patient age had no impact on the outcome.

Adjustable buttons for ACL graft cortical fixation partially fail with cyclic loading and unloading.

PURPOSE: Despite good initial pullout strength, it is unclear whether adjustable button (AB) devices for anterior cruciate ligament (ACL) soft-tissue graft fixation, which are based on the Chinese finger trap technique, resist cyclic loading. Furthermore, they have never been tested in a cyclic protocol including complete unloading. It was hypothesized, that the displacement of AB devices with the Chinese finger trap technique would be greater than that of continuous suture loop devices and other available AB mechanisms in a cyclic loading with complete unloading protocol. METHODS: ACL reconstruction was performed in a porcine knee model using three different types of cortical fixation devices: two different AB devices that use the Chinese finger trap design, one AB device that uses a locked suture loop mechanism and two different continuous loop devices as control groups (n = 40). Specimens were mounted in a material-testing machine (Instron Inc.) that permitted 2500 loading and complete unloading cycles to a maximum of 250 N, as well as continuous elongation recording. A one-way ANOVA was performed for statistical analysis. RESULTS: The displacement of ABs with a Chinese finger trap loop (mean 8.1; SD 1.5 mm and mean 6.1; SD 1.4 mm) was significantly greater than that of AB with a locked suture loop (mean 4.7; SD 1.0 mm; p < 0.05) and devices with a continuous loop (mean 4.1; SD 0.5 mm and mean 4.4, SD 0.3 mm; p < 0.01). No significant differences were detected between the ABs with a locked suture loop and the continuous loops. CONCLUSION: Cyclic loading and unloading of AB using the Chinese finger trap technique leads to significantly greater construct lengthening compared with other devices. Complete unloading of the ACL is very likely to occur during rehabilitation after ACL reconstruction. Lengthening of the AB device due to cyclic loading might be a potential mode of failure of the ACL graft fixation. Therefore, when using an AB femoral fixation technique, a locked suture loop design or a careful rehabilitation protocol should be considered.

The role of a small posterior malleolar fragment in trimalleolar fractures: a biomechanical study.

AIMS: The aim of this study was to investigate the effect of a posterior malleolar fragment (PMF), with < 25% ankle joint surface, on pressure distribution and joint-stability. There is still little scientific evidence available to advise on the size of PMF, which is essential to provide treatment. To date, studies show inconsistent results and recommendations for surgical treatment date from 1940. MATERIALS AND METHODS: A total of 12 cadaveric ankles were assigned to two study groups. A trimalleolar fracture was created, followed by open reduction and internal fixation. PMF was fixed in Group I, but not in Group II. Intra-articular pressure was measured and cyclic loading was performed. RESULTS: Contact area decreased following each fracture, while anatomical fixation restored it nearly to its intact level. Contact pressure decreased significantly with fixation of the PMF. In plantarflexion, the centre of force shifted significantly posteriorly in Group II and anteriorly in Group I. Load to failure testing showed no difference between the groups. CONCLUSION: Surgical reduction of a small PMF with less than 25% ankle joint surface improves pressure distribution but does not affect ankle joint stability. Cite this article: Bone Joint J 2018;100-B:95-100.

[Operative treatment in orthopedics and trauma surgery : Are more operations carried out in Germany?] / Operative Versorgung in Orthopädie und Unfallchirurgie : Wird in Deutschland immer mehr operiert?

BACKGROUND: Since 2005, when the Diagnosis-Related Group (DRG) system was introduced, an increasing number of surgical procedures have been reported in Germany. In particular, the numbers of elective arthroplasty and spinal surgery procedures have been controversial. OBJECTIVES: The focus of this study was analyzing the development of spinal surgery, arthroplasty, and fracture management. MATERIALS AND METHODS: We analyzed the database for all musculoskeletal operating procedure codes (OPS codes 5­78 to 5­86) from 2005 to 2013 collected by the German Federal Statistical Office. RESULTS: With an increase in total patient numbers of 12.8%, there was a rise in in-patient musculoskeletal procedures of 43.5%; the highest increase in procedures was found in spinal surgery (130%). Despite an ageing population, the numbers of hip- and knee arthroplasty procedures initially decreased after 2011 and after 2009 respectively. The number of osteosyntheses showed a slight increase (16%), whereas the number of (elective) implant removals declined (-7%). An increase in novel techniques was noticeable, such as locked plate osteosynthesis (251%), shoulder arthroplasty (402%) or the use of bone substitutes in spinal surgery (+2,011%). CONCLUSIONS: Despite generally increasing volume growth, the numbers of hip and knee arthroplasty cases decreased. In addition to an ageing population and potential economic incentives, technical innovations and new implant systems should be considered when discussing increasing case numbers.

[Pseudarthroses of the long bones]. / Pseudarthrosen der langen Röhrenknochen.

Pseudarthrosis development is dependent on the presence of individual risk factors in approximately 10% as a result of fractures and are more frequently located in the region of the long bones. The development of non-union regularly results in prolonged pain and reduced functionality of the affected limb. The resulting clearly increased socioeconomic costs are caused by the complex operative treatment strategies and increased indirect costs, which include lost wages, social benefits and compensation. Altogether, non-unions require a differentiated therapeutic treatment strategy. The analysis of the non-union based on the diamond concept is the key for a successful planning and therapy. In this context, the use of focused, high-energy extracorporeal shock waves may be possible under specific circumstances; however, in most cases an operative revision is necessary to optimize the biomechanical stability and/or improve the local biology.

The impact of different peripheral suture techniques on the biomechanical stability in flexor tendon repair.

PURPOSE: Flexor tendon repair consists of circumferential peripheral sutures in combination with core sutures to avoid fraying and reduces the exposure of suture material on tendon surface. The peripheral suture adds up to a tenfold increase of the biomechanical stability compared to the core suture alone. The purpose of our study was to determine the most favourable peripheral repair technique for tendon repair. METHODS: Seventy-two porcine flexor tendons underwent standardized tenotomy and repair using one of the following six methods (n = 12): simple-running (SR), simple-locking (SL), Halsted-mattress (HM), lin-locking (LL), Lembert-mattress (LM), and Silfverskiöld cross-stich (SCS) suture technique. The SL- suture was placed 2 mm; the HM, LM, SC, and LL suture were placed 5 mm from the tendon gap. The SR suture was placed 1, 2, and 3 mm from tendon ends; no additional core suture was applied. For cyclic testing (1000 cycles), elongation was calculated; for load to failure construct stiffness, yield load and maximum load were determined. RESULTS: The mean cyclic elongation for all tested suture techniques was less than 2 mm; there was no significant difference between the groups regarding elongation as well as yield load. The HM, LM, SCS, and LL suture techniques presented significantly higher maximum loads compared to the SR- and SL-sutures. The 3 mm SR showed significantly higher maximum loads compared to the 2 and 1 mm SR. CONCLUSIONS: Beside the distance from tendon gap, the type of linkage of the suture material across and beneath the epitendineum is important for biomechanical stability. Simple-running suture is easy to use, even with a slight increase of the distance from tendon gap significantly increases biomechanical strength. For future repairs of flexor tendon injuries, 3 mm stitch length is highly recommended for simple peripheral suture, while the Halsted-mattress suture unites the most important qualities: biomechanically strong, most part of suture material placed epitendinous, and not too complicated to perform.

High-resolution MRI (3T-MRI) in diagnosis of wrist pain: is diagnostic arthroscopy still necessary?

INTRODUCTION: 3T MRI has become increasingly available for better imaging of interosseous ligaments, TFCC, and avascular necrosis compared with 1.5T MRI. This study assesses the sensitivity and specificity of 3T MRI compared with arthroscopy as the gold standard. PATIENTS AND METHODS: Eighteen patients were examined with 3T MRI using coronal T1-TSE; PD-FS; and coronal, sagittal, and axial contrast-enhanced T1-FFE-FS sequences. Two musculoskeletal radiologists evaluated the images independently. Patients underwent diagnostic arthroscopy. RESULTS: The classifications of the cartilage lesions showed good correlations with the arthroscopy findings (κ = 0.8-0.9). In contrast to the arthroscopy, cartilage of the distal carpal row was very good and could be evaluated in all patients on MRI. The sensitivity for the TFCC lesion was 83%, and the specificity was 42% (radiologist 1) and 63% (radiologist 2). For the ligament lesions, the sensitivity and specificity were 75 and 100%, respectively, with a high interobserver agreement (κ = 0.8-0.9). DISCUSSION: 3T MRI proved to be of good value in diagnosing cartilage lesions, especially in the distal carpal row, whereas wrist arthroscopy provided therapeutic options. When evaluating the surgical therapeutical options, 3T MRI is a good diagnostic tool for pre-operatively evaluating the cartilage of the distal carpal row.

[Traumatology in the elderly : Multimodal prevention of delirium and use of augmentation techniques]. / Alterstraumatologie : Multimodale Delirprävention und Verwendung von Augmentationstechniken.

Recent data show that 20-80% of surgery patients are affected by delirium during inpatient clinical treatment. The medical consequences are often dramatic and include a 20 times higher mortality and treatment expenses of the medical unit increase considerably. At the University Hospital of Münster a multimodal and interdisciplinary concept for prevention and management of delirium was developed: all patients older than 65 years admitted for surgery are screened by a specialized team for the risk of developing delirium and treated by members of the team if there is a risk of delirium. Studies proved that by this multimodal approach the incidence of delirium was lowered and therefore the quality of medical care improved.When surgical treatment of fractures in the elderly is required, limited bone quality as well as pre-existing implants can complicate the procedure. Secondary loss of reduction after osteosynthesis and avulsion of the implant in particular must be prevented. Augmentation of the osteosynthetic implant with bone cement can increase the bone-implant interface and therefore stability can be improved. Additional intraoperative 3D imaging can be necessary depending on the localization of the fracture. In biomechanical studies we could prove greater stability in the osteosynthesis of osteoporotic fractures of the distal femur when using additional bone cement; therefore, the use of bone cement is an important tool, which helps to prevent complications in the surgical treatment of fractures in the elderly. Nevertheless, special implants and technical skills are required and some safety aspects should be considered.