Preoperative planning—rationale and how to do it Published: August 2013 Rodrigo Pesantez, CO AOT Basic Principles Course

Learning outcomes Highlight the importance of preoperative planning Describe various techniques for preoperative planning Formulate and draw an operative plan Describe a surgical tactic step by step p (eg, positioning, choice of surgical approach, instruments, reduction technique, implants) Incorporate patient safety protocols (mark site, time-out check list) in the preoperative plan Teaching points: Utilizing a management concept for each patient and planning each surgical procedure avoids complications and gives the orthopedic surgeon security in contemplating each step of treatment for which he or she is totally responsible.

Ask audience how many would plan each one of this surgeries.

Span, scan, and plan 42-year-old male who sustained this injury after falling from a rooftop. A spanning external fixator was applied until the soft tissues settled down. The fracture was then scanned with the external fixator still on to get more information about the fracture pattern. However, the surgeon neglected to plan the next steps and the results are as follows (next slide).

What is the value of planning? This is Jeff Mast, the master of preoperative planning and all of these are his plans for surgery. And in one of his lectures he said: next slide. Photos courtesy of Matt Graves.

If you cannot draw it on a preoperative plan, you cannot fix it

Atul Gawande, a general surgeon from Boston, talks about surgeons’ performance and surgery as an imperfect science in this book. References: Gawande A. Complications: A Surgeon’s Notes on an Imperfect Science. New York: Picador; 2002.

Why some people have better results than others? “Paying attention to small details as well as having clear goals produce excellent results in almost all professions.” Gawande, A. Excellence is recognizing details, failures. Harvard Magazine, Oct 2012 Gawande published this in a Harvard magazine and said that if we pay attention to small details (plan) we can achieve better results, so we must have a checklist for our surgical activities.

His third book talks about checklists and how they can help you to get things right. The ultimate checklist for orthopedic trauma surgeons is the preoperative planning checklist. References: Gawande A. The Checklist Manifesto: How to Get Things Right. Metropolitan Books; New York; 2009.

“Failing to plan is planning to fail” Planning encourages the surgeon to focus on: Fracture pattern Reduction technique Fixation technique Surgical approach Equipment required Surgeons can mentally rehearse surgery: Anticipate problems Alternative plans

Information required Patient general history and condition Imaging Analyze it Normal side imaging Soft tissues Operating room set up Instruments and implants available

Components of preoperative planning A thorough plan includes: A drawing of the desired end result A step-by-step surgical tactic Details of operation logistics References: Hak DJ, Rose J, Stahel PF. Preoperative planning in orthopedic trauma: benefits and contemporary uses. Orthopedics. 2010 Aug;33(8):581-4

How to create a preoperative plan?

Direct overlay

Normal side silhouette

Use of joint axis

Preoperative planning checklist Radiolucent table Lateral decubitus Image intensifier from opposite side: lateral view from top and AP rolling the C-arm Femoral distractor for reduction Piriformis entry nail (CFN) and conventional locking screws Percutaneous incision proximal to greater trochanter Schanz pin in lesser trochanter (posterior) perpendicular to shaft Schanz pin in distal femur parallel to knee joint and perpendicular to shaft Femoral distractor on pins and traction for shortening and correction of rotation and angulation Piriformis entry point Guide wire Reaming sequentially 12 Insert a 12mm CFN 360mm long Locking distally (32 and 40 mm) Locking proximally (50 and 38 mm) End cap Remove femoral distractor Close wounds

32 YO male, MVA, 6 months before, schedule for THA

32 YO male, MVA, 6 months before, schedule for THA

Surgical tactic Supine on a radiolucent table Image intensifier coming from right side Watson Jones approach to proximal femur Large fragment set Angle blade plate set Hohmann retractors and Verbrugge clamps Mark surgical site Time out checklist

Preoperative planning checklist Kw1 anterior femoral neck (control anteversion) Kw2 90° to femoral shaft (lesser troch) Kw3 2cm from top of greater troch parallel to Kw2 (frontal plane) and parallel to Kw1(transverse plane) Mark the level of osteotomy (saw) Portal of entry for seating chisel Seating chisel inserted parallel to Kw3 Remove seating chisel Insert blade plate 120° 75 mm / 4 holes Kw4 proximal to osteotomy (rotation) Kw5 proximal to osteotomy (rotation) Transverse intertrochanteric osteotomy Resection proximal wedge 20° Resection distal wedge 30° Leg adbuction towards plate Verbrugge on shaft Review length, alignment and rotation Cortical screw in proximal fragment 4.5 mm x 70 mm Articulated tension device in distal fragment (load) 2 cortical screws distal fragment 4.5mm x 40mm

Preoperative planning checklist Kw1 anterior femoral neck (control anteversion) Kw2 90° to femoral shaft (lesser troch) Kw3 2cm from top of greater troch parallel to Kw2 (frontal plane) and parallel to Kw1(transverse plane) Mark the level of osteotomy (saw) Portal of entry for seating chisel Seating chisel inserted parallel to Kw3 Remove seating chisel Insert blade plate 120° 75 mm / 4 holes Kw4 proximal to osteotomy (rotation) Kw5 proximal to osteotomy (rotation) Transverse intertrochanteric osteotomy Resection proximal wedge 20° Resection distal wedge 30° Leg adbuction towards plate Verbrugge on shaft Review length, alignment and rotation Cortical screw in proximal fragment 4.5 mm x 70 mm Articulated tension device in distal fragment (load) 4 cortical screws distal fragment 4.5mm x 56, 44, 42, 42 mm

Postoperative

1 year FU

1 year FU

1 year FU

Take-home messages Preoperative planning is the ultimate checklist for orthopedic trauma surgery You need information to create a plan Clinical Imaging Environment

Take-home messages Three different techniques: Direct overlay Normal side silhouette Joint axis Components of a preoperative plan: Drawing of the desired end result Surgical tactic (step-by-step) Details of operation logistics