Preoperative planning—key to success Published: August 2013 Damian McClelland, UK AOT Basic Principles Course

Learning outcomes Appraise the importance of preoperative planning Describe how preoperative planning will improve surgical outcomes Formulate and draw an operative plan Recognize that with preoperative planning a precise and more accurate reconstruction of the fracture is possible, and an improved surgical outcome expected Recognize the potential pitfalls of not planning Teaching points: Compare the surgeon to the pilot or SCUBA diver: “plan your flight – fly your plan”.

“The time which a surgeon devotes to a careful preoperative plan often determines the success or failure of that procedure.” - Joseph Schatzker

What is preoperative planning? It is a strategy to get from A to B

Make an operative plan Decide what you want to achieve Decide how you are going to achieve it Get as much information as you can Want to achieve: articular fractures- anatomical reduction early motion restoration of function diaphyseal fractures – length alignment and rotation How to achieve direct/indirect reduction absolute relative stability Should be thinking not so much about what implant to use but Rather about what techniques are you going to use to produce a particular type of healing

Planning—parts Patient—presurgery Surgery—surgical tactic Post-surgery

Patient—presurgery Type of anesthesia Tourniquet Positioning Operating table Antibiotics Imaging

Surgery—surgical tactic Procedure Equipment Problems Sketch

Surgery—surgical tactic Approach Reduction method Stabilization? Temporary

Surgery—surgical tactic Approach Reduction method Stabilization? Temporary Definitive fixation Closure PLAN ‘B’

Postoperative instructions

Preoperative planning is the key to becoming a good surgeon Summary Preoperative planning is the key to becoming a good surgeon

Preoperative planning

Full plan and surgical tactic Planning set X-rays/drawings Implant templates Pens Small fragment (+ locking) set

Points to consider Which bone to fix first? Which approach to the radius? Lag through the plate or separately? Which surface for the radial plate? Absolute or relative stability? Respect the soft tissues

Ulnar plate—mode? Neutralization Buttress Compression Bridging Tension band

Step 1—make tracing of normal x-rays

Step 2—trace fracture fragments onto the normal bones

Step 2—trace fracture fragments onto the normal bones

Step 2—trace fracture fragments onto the normal bones

Step 2—trace fracture fragments onto the normal bones

Result—tracing of the reduced fracture

Step 3—plan implants (rotate to get contour on plates)

Result—EXAMPLE

Step 4—add detailed plan Patient position Tourniquet Antibiotics Imaging Approach Reduction technique Fracture healing mode Implants needed Sequence of insertion Problems expected Closure Splints / plaster Post op instructions Rehabilitation Equipment Small fragment set Locking screw set Reduction clamps Compact air drive

Take-home messages Formulate a preoperative plan Identify and assess benefits of preoperative planning Develop a surgical tactic Describe steps involved