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

2. 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”.

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

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

5. 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

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

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

8. Surgery—surgical tactic
Procedure
Equipment
Problems
Sketch

9. Surgery—surgical tactic
Approach
Reduction method
Stabilization? Temporary

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

12. Postoperative instructions

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

14. Preoperative planning

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

16. 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

17. Ulnar plate—mode? Neutralization Buttress Compression Bridging
Tension band

18. Step 1—make tracing of normal x-rays

19. Step 2—trace fracture fragments onto the normal bones

20. Step 2—trace fracture fragments onto the normal bones

21. Step 2—trace fracture fragments onto the normal bones

22. Step 2—trace fracture fragments onto the normal bones

23. Result—tracing of the reduced fracture

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

25. Result—EXAMPLE

26. 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

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