pre operation plan ao basic surgery.pptx

pre op plan orthopaedic surgery

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

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

3. Span, scan, and plan

4. What is the value of planning?

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

6. 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

7. “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

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

9. 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

10. How to create a preoperative plan?

11. Direct overlay

12. Normal side silhouette

13. Use of joint axis

14. 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 Preoperative planning checklist

15. 32 YO male, MVA, 6 months before, schedule for THA

16. 32 YO male, MVA, 6 months before, schedule for THA

17. 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

18. 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

19. 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 Preoperative planning checklist

20. Postoperative

21. 1 year FU

22. 1 year FU

23. 1 year FU

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

25. 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