DCS

PREPARACION PARA LA INSERCION

CORRECTA
LATERA MEDIAL
L
3.- INSERCION Plano frontal:
paralelo a 1.
Plano axial:
paralelo a 2

2.- SUPERFICIE ANTERIOR DE LA

RODILLA

1.- LINEA ARTICULACION

FEMOROTIBIAL
Insercion de la aguja
guia/dcs con intensificador
PROFUNDIDAD CORRECTA
DE LA AGUJA GUIA
La profundidad de la
insercion de la aguja guia no
debe de llegar a la cortical
medial.
La verificacion con el
intensificador de imgenes
se realiza con una toma AP
en 30 de rotacion interna
MEDICION DEL LARGO DEL
TORNILLO
Obtener la medida de la aguja
guia, restando el excedente de
aguja con la longitud total de
la misma
RIMADO
Ensamblar el rimador,
adecuarlo a la profundidad
deseada y rimar sobre la
aguja guia
INSERCION DEL DCS
El tarrajeo no es necesario
en huesos osteoporoticos.
UBICACIN DE LA PLACA
Desconectar el mango en T
y colocar la placa.
IMPACTACION DE LA
PLACA
Utilizar un impactor y aplicar
un tornillo de compresin.
No utilizar tonillos de
compresin en huesos
osteoporoticos.
APLICACIN DEL
TORNILLO DISTAL
Aplicar un tornillo de
esponjosa en el agujero ms
distal de la placa para evitar
la rotacin sobre el eje
 II. Nonoperative versus operative methods

A. Open reduction and internal fixation (ORIF) versus cast brace/splint

Five studies were identified which compared operative with nonoperative methods. One of these was a randomized controlled trial 8 and
three of these studies were retrospective cohort studies 2, 9, 10. Thomas et al 7 (nonoperative, above) also contributed information to this
comparison.
High rates of union were achieved in each group (89% in ORIF group, 90% in the nonoperative group).
Similar frequencies of complications were seen in each group. Infection and delayed union were each observed in 4% of patients in either
group. Deep vein thrombosis was observed in 16% of patients treated nonoperatively but only 6% of those treated operatively, RR, 2.7
(95% CI, 0.323.0).
Malunion, as examined in CoE II studies, showed a statistically nonsignificant difference favoring ORIF. Malunion was significantly higher
in the nonoperative group than the ORIF group (18% versus 4%) in CoE III studies with a relative risk of 4.4 (95% CI, 1.019.0).
Range of motion was better in the ORIF group (100 degrees) versus the nonoperative group (95 degrees).
B. Open versus closed reduction
Two retrospective cohort studies (CoE III) were identified 11, 12.
Open reduction was consistently preferred, with excellent/good clinical results (ASIF classification) found twice as often (81% open versus
42% closed, RR 0.5, 95% CI, 0.30.9) and reduced malunion (3% open versus 37% closed, RR 11.8, 95% CI, 1.688.0).
 II. Operative versus operative methods

A.Nails versus plates

One randomized trial (CoE II) and one prospective cohort study (CoE II) made the desired comparison 13, 14.
Union was high in both the plate group (84.6%) and the nail group (90.0%) and the difference was not statistically significant.
Complications appeared to be higher in the plate group, 21.5% compared with 12.0% in the nail group, but this was not statistically
significant, RR, 1.7 (0.74.5).
Similarly, plates may be associated with worse outcomes with regard to deep infections 13, 14, knee range of motion (ROM) 13, and time to
union 13, but there was no statistically significant difference between groups.
B.LISS versus femoral nail
One study identified as a randomized clinical trial but which did not actually adhere to the randomization to determine treatment received
was identified (CoE III) 5.
LISS and the femoral nail appeared to yield similar results. Both achieved identically high rates of union (100%) and excellent clinical
results (88%), based on the Lysholm score.
C.Percutaneous versus ORIF supracondylar intramedullary nail
Only one retrospective cohort study was identified (CoE III) 15.
Union was high in both groups (percutaneous 97% versus 95% in the ORIF group).
Bone grafts were later required by 40% of those who underwent ORIF with the supracondylar intramedullary nail whereas only 8% were
required by those undergoing percutaneous treatment, RR 0.2, (95% CI, 0.10.6).
Knee ROM was slightly higher in the percutaneous group (mean 105 degrees, (84120) than the ORIF group (mean 93 degrees (62120))

D. Mini open dynamic condylar screw versus supracondylar intramedullary nail

One prospective cohort study (CoE II) made the desired comparison 16.
Estimated blood loss, mean operative time, and length of stay were less in the IM nail group compared with the dynamic screw group and
the differences were statistically significant in all instances, P < .001.
Union was high in both the dynamic screw group (95%) and the IM nail group (94%), and excellent results (Schatzker scale) were
achieved in 51% of patients in both groups.
Complication rates appeared higher in the dynamic screw group (22%) than in the IM nail group (17%), but this was not statistically
significant, RR 1.3, (0.53.3).
 PRONOSTICO

Prognosis After treatment for distal femoral fractures, AO fracture type 33A-33C, prognosis is generally good. Prognosis is better for
patients without multiple concurrent trauma as might occur in high-energy events such as motor vehicle accidents. Excellent results have
been identified when the fracture is not very displaced and the fracture does not extend very far into the shaft 17. The potential involvement
of the articular surface of the knee may affect stability, knee flexion, and overall patient satisfaction. More favorable prognosis has been
found for fractures without a gap, with mechanical stability, with less soft tissue damage, and with sufficient nutrition 13. Long-term outcome
appears to differ between younger patients and elderly patients with osteoporosis-related concerns 9.
Las complicaciones
derivadas de la estancia
hospitalaria prolongada y de
la inmobilizacion son
mayores en el manejo
conservador
Execelentes resultados clinico-
radiologicos. No se hizo el
analisis.
Estancia hospitalaria media 33
dias menos que el manejo
conservador
El intervalo de confianzade las
variables cruz la linea de no
efecto y vari en su direccion
de efecto.
Execelentes resultados clinico-
radiologicos para ambas
tecnicas. No se hizo el analisis.

El seguimiento a los 20 meses

no muestra diferencia clinica o
estadistica entre ambas
tecnicas.
 No Union: (6-9 meses), sin
diferencias estadisticas
significativas
Mal-Union: (6-9 meses), sin
diferencias estadisticas
significativas

Execelentes resultados clinico-

radiologicos para ambas
tecnicas. No se hizo el analisis.
En ambos grupois al La estancia hospitalaria media
seguimiento a los 12 meses o fue menor para el RIMN por ser
mas se observo similar numero un metodo menos invasivo.
de pacientes que recobraron la
motilidad completay/o pudieron
caminar sin apoyo.
Se presento un caso de
infeccion tardia del RIMN. No
se describio el manejo.

En ambos grupos no hubo

diferencia en el resultado
funcional respecto del retardo
de consolidacion
Reoperaciones:
Grupo LISS: pseudoartrosis, perdida de la
reduccion y artrofibrosis de rodilla
Grupo FA: pseudoartrosis
Segn e Autor no hubo diferencia
estadisticamente significativa.
Cirugia de Revision: 6% RIMN vs 8% LP
Remocion de Implante: 8/54 RIMN vs 6/60
LP
El resultado favorece al RIMN tanto
clinica como estadisticamente
No hubo diferencias clinica o
estadisticamente significativas entre
ambos grupos