Preoperative Planning for Fracture Management
Most orthopedic residents are introduced to preoperative planning at an AO (Arbeitsgemeinschaft für Osteosynthesefragen-Association for the study of the internal fixation) fracture management course, where formal planning is emphasized and attendees are taught the principle 'failing to plan is planning to fail.'(1) Nevertheless, a survey of preoperative planning practices in the United Kingdom, in 1998 found that 94% of consultants and 100% of residents thought that planning was important; however, only half of those routinely planned fracture surgery.(2) I am not aware of any published studies that address current preoperative planning attitudes, but based on discussions fellow residents, it seems that routine formal planning is still not commonplace. Formal preoperative planning should be recognized as an essential prerequisite to fracture management because of the potential to improve surgical efficiency,(3) and advance orthopedic surgical training.
Value of Preoperative Planning to the Surgeon and Trainee
Preoperative planning fracture surgery provides numerous benefits to a surgeon. Disciplined formal planning increases surgical efficiency and decreases stress in the operating room.(3) Moreover, having a plan and conveying it preoperatively provides an excellent opportunity to communicate with and educate those involved in a case, including residents, medical students and operating room personnel. Preoperative planning improves with routine practice. Patients also benefit from preoperative planning because of improved outcomes and increased safety.(3) In addition to the value offered to the surgeon and patient, planning has tremendous medical educational benefits: it forces careful analysis. As orthopedic residents become more proficient in interpreting images, they learn that fractures tend to follow predictable patterns. However, I am certain we all have experienced a time when a subtle variation was overlooked. With careful review of images during preoperative planning, such variations are more likely to be noticed and potential intra-operative difficulties can be avoided. Furthermore, formal planning facilitates mental rehearsal of operative plans. This can prevent unanticipated problems. Formal planning forces residents to make decisions, it stimulates discussion and makes for a more efficient and cohesive approach during surgery. A concrete, drawn-out plan stimulates discussion with an attending surgeon prior to entering the operating room, for instance, and results in an increase in resident engagement with cases, operative understanding, and improves confidence.
Planning Tactics Versus Logistics
As a resident progresses and gains experience, different elements of planning become more meaningful. A mentor of mine stressed that planning fracture surgery should be subdivided into tactics and logistics. AO coined the term surgical tactic to represent the discrete surgical steps taken to achieve an operative goal.(1) Conversely, logistics represents the management of resources for an operation such as the type of operating room table, patient positioning, use of intra-operative imaging, required implants, etc. A polytraumatized patient is a great example of the importance of differentiating these elements. Junior residents often concentrate on surgical tactics and focus on memorizing surgical steps. For a polytraumatized patient with multiple fractures, formulating a management plan that prioritizes certain treatments and facilitates a smooth surgical transition between different fractures can become overwhelming to the resident who thinks in terms of tactics. As tactics become more second nature to an experienced surgeon, thought is transitioned to logistics. “Amateurs talk tactics, professionals talk logistics.” Thinking in terms of logistics makes operations smoother and faster, saving valuable operative time. However, complex cases still require even experienced surgeons to think of both tactics and logistics.
Contemporary Planning
In addition to transitioning from thinking tactics to logistics, I found that as my training progressed, I changed my method of preoperative planning. As my comfort with planning grew, I became more adept at digitally planning. Most residents are introduced to preoperative planning by using the ‘jigsaw method’ that involves hand-tracing images from film.(1,3) However, planning using digital radiographs is now possible using computer based preoperative planning software programs.(4) Accessible standard imaging software such as Adobe® Photoshop® can also facilitate digital planning when more expensive planning software is not available.(5) Digital planning also facilitates the ability to save plans for future reference. Advances in cross-sectional imaging have reduced some of the difficulties of planning that existed when plain radiographs alone were relied upon. Computer tomography (CT) with three-dimensional reconstructions, provide more preoperative information and improved fracture characterization. More recently, some institutions have even converted CT scan data into three-dimensional physical models using a rapid prototyping (RP) process.(6) Models can then be used as adjuncts for pre-operative planning. Despite these advances issues with radiographic magnification, calibration and variability in fracture behavior continue to exist with digital radiographs, as they did with film. Consequently, there is enormous potential for growth in the ability to preoperative plan fracture surgery. Planning should help orthopedic surgeons and residents prepare for cases, stimulate educational discussions and decrease operating room confusion. The benefits of formal preoperative planning should be consistently echoed so it continues outside of AO fracture management courses. Fostering an early belief that planning is an indispensable tool to successful fracture management could ensure that planning skills carry through to surgical practice.
Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.
References
1. Thomas P. Ruedi, Richard E. Buckley and Christopher G. Moran. AO principles of fracture management. Switzerland; AO Publishing, 2007.
2. Wade RH, Kevu J, Doyle J. Pre-operative planning in orthopaedics: a study of surgeons’ opinions. Injury. 1998;29(10):785-786.
3. Hak DJ, Rose J. Preoperative planning in orthopedic trauma: benefits and contemporary uses. Orthopedics. 2010;33(8):581-584.
4. Pilson HTP, Reddix Jr RN, Mutty CE, Webb, LX. The long lost art of pre-operative planning - resurrected? Orthopedics. 2008;31(12). Pii: orthosupersite.com/view.asp?rID=32932.
5. Jamali AA. Digital templating and preoperative deformity analysis with standard imaging software. Clin Orthop Rela Res. 2009;467(10):2695-2704.
6. Hurson C, Tansey A, O’Donnchadha B, Nicholson P, Rice J, McElwain J. Rapid prototyping in the assessment, classification and preoperative planning of acetabular fracturesInjury. Injury. 2007;38(10):1158-1162.
