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

2. 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.

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

4. 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).

6. 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.

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

8. 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.

9. 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.

10. 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.

11. “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

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

13. 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 Aug;33(8):581-4

14. How to create a preoperative plan?

15. Direct overlay

16. Normal side silhouette

17. Use of joint axis

19. 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

33. 32 YO male, MVA, 6 months before, schedule for THA

34. 32 YO male, MVA, 6 months before, schedule for THA

35. 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

36. 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

37. 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

40. Postoperative

43. 1 year FU

44. 1 year FU

45. 1 year FU

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

47. 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