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Alterstraumatologie

Multimodale Delirprävention und Verwendung von Augmentationstechniken

Traumatology in the elderly

Multimodal prevention of delirium and use of augmentation techniques

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Zusammenfassung

Laut aktueller Datenlage sind unfallchirurgische Patienten ab einem Alter von 65 Jahren im Rahmen der stationären Behandlung in 20–80 % vom Krankheitsbild Delir betroffen. Die medizinischen Folgen sind oftmals dramatisch und beinhalten eine bis zu 20-fach erhöhte Letalität. Gleichzeitig entsteht ein erheblicher ökonomischer Aufwand.

Am Universitätsklinikum Münster wurde ein multimodales und interdisziplinäres Konzept zu Delirprävention und -management entwickelt: Alle Patienten über 65 Jahre werden von einem Delirpräventionsteam gescreent und bei bestehendem Delirrisiko durch die Mitarbeiter des Teams betreut. Zudem wurde ein interdisziplinäres Management beim Auftreten deliranter Symptome entwickelt. Im Rahmen von Studien konnte die Delirrate durch diese multimodalen Konzepte deutlich gesenkt und somit die Qualität der medizinischen Versorgung erhöht werden.

Die eingeschränkte Knochenqualität sowie einliegende Implantate erschweren zusätzlich das operative Vorgehen bei Frakturen im hohen Alter. Verhindert werden müssen insbesondere ein Ausbrechen des verwendeten Implantats sowie ein sekundärer Repositionsverlust nach Osteosynthese. Durch das Ummanteln der Implantate mit Knochenzement kann die Kontaktfläche zwischen Knochen und Implantat vergrößert und somit die Stabilität verbessert werden. Je nach Lokalisation der Fraktur kann eine zusätzliche intraoperative 3‑D-Bildgebung erforderlich sein.

In biomechanischen Untersuchungen konnten wir auch für die osteoporotische, distale Femurfraktur eine Überlegenheit der Osteosynthese mit Zementaugmentation nachweisen.

Die Implantataugmentation mittels Knochenzement hilft Komplikationen bei Frakturen im hohen Alter zu verhindern, erfordert jedoch besondere Implantate und technische Fertigkeiten sowie die Beachtung einiger Sicherheitsaspekte.

Abstract

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.

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Authors and Affiliations

  1. Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland

    D. Wähnert, J. Glasbrenner &  M. J. Raschke

  2. Stabstelle Demenzsensibles Krankenhaus, Universitätsklinikum Münster, Münster, Deutschland

    A. Roos, K. Ilting-Reuke & T. Duning

  3. Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Münster, Münster, Deutschland

    P. Ohrmann

  4. Institut für Pharmazeutische und Medizinische Chemie, Westfälische Wilhelms-Universität Münster, Münster, Deutschland

    G. Hempel

  5. Universitätsklinikum Münster, Münster, Deutschland

    N. Roeder

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  1. D. Wähnert
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  2. A. Roos
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  3. J. Glasbrenner
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  4. K. Ilting-Reuke
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  9. M. J. Raschke
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Correspondence to M. J. Raschke.

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D. Wähnert, A. Roos, J. Glasbrenner, K. Ilting-Reuke, P. Ohrmann, G. Hempel, T. Duning, N. Roeder und M.J. Raschke geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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D. Wähnert und A. Roos haben zu gleichen Teilen zu der Arbeit beigetragen.

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Wähnert, D., Roos, A., Glasbrenner, J. et al. Alterstraumatologie. Chirurg 88, 95–104 (2017). https://doi.org/10.1007/s00104-016-0339-2

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