Decision making and preoperative planning
1 Introduction 103
2 Planning in MIPO 103
3 Patient evaluation 103
4 Fracture evaluation 103
5 Graphic preoperative plan 104
5.1 Direct overlay of fractured fragments 104
5.2 Overlay using the normal side as a template 104
5.3 Use of physiological axes for articular fractures 104
6 Implants 105
6.1 Type of plates 105
6.2 Plate function 105
6.3 Plate length 105
6.4 Number of screws 105
6.5 Type of screw 105
6.6 Order of screw insertion 106
6.7 Plate position 106
6.8 Plate contouring 106
7 Reduction techniques 106
8 Timing of surgery 106
9 Control of axes, rotation, and length during MIPO 107
10 Preparing the operating room 107
11 Alternative surgical tactic 107
12 Time-out check 107
13 Final assessment 107
14 Examples of cases with preoperative planning and results 108
14.1 Tibia and fibula, proximal: 36-year-old man, complete articular fracture, articular multifragmentary—41-C3 108
14.2 Tibia and fibula, distal: 39-year-old woman, complete articular fracture, articular simple, metaphyseal, multifragmentary—43-C2 110
Introduction
Preoperative planning has always been an important component of the overall strategy of operative fracture care in the AO philosophy. Preoperative planning allows the surgeon to perform the operation in his/her mind before the actual surgical procedure. It provides an opportunity to prepare the equipment that might be required, and enables the surgeon to plan the steps of the operation, including the location of the incisions, reduction technique, choice of implants, and techniques of application. With preoperative planning the surgeon is better prepared for surgery, thus ensuring a higher chance of success and the opportunity to avoid possible complications. Another advantage is that the surgeon can provide the patient with a detailed explanation of the operation in order to obtain informed consent and ensure a good patient–surgeon relationship. In addition, preoperative planning is best considered a team activity that allows the operating room team to prepare for the case.
Planning in MIPO
In minimally invasive plate osteosynthesis (MIPO), preoperative planning plays an even more significant role. Since the fracture sites are not exposed or visualized, the surgeon must plan each step of the reduction and procedure to ensure that the operation proceeds smoothly, precious time is not wasted, and that unnecessary exposure to irradiation is avoided. The following guidelines may be helpful in the decision-making process and preparation of a preoperative plan for MIPO.
Patient evaluation
Proper assessment of the patient and the injury is necessary for correct decision making. This includes a detailed history, a careful physical examination, relevant laboratory tests, x-rays, and other ancillary imaging studies if indicated.
Patient factors that need to be considered in the decision-making process include:
Age
Occupation
General medical status and comorbidities
Posttrauma status, including hemodynamic stability
Bone quality
Preinjury functional status
Patient compliance
Future expectations
This evaluation helps surgeons decide whether the patient is a suitable candidate for surgery and is optimized for anesthesia.
Fracture evaluation
For proper assessment of the fracture, good quality x-rays are required. Traction films are useful in some instances. Other imaging studies that may be helpful include CT scans, 3-D reconstructions, MRI, and vascular studies.
The injury factors that should be taken into consideration include:
Duration after injury
Closed or open fracture
Location—articular, metaphyseal, or diaphyseal
Simple, wedge, or complex
Condition of the skin and soft tissues
Neurovascular injuries
Associated fractures
Associated injuries
Good indications for MIPO include complex or multifragmentary fractures of the diaphysis and metaphysis and intraarticular fractures with extension into the diaphysis.
Relative indications include simple diaphyseal fractures and certain open fractures.
Graphic preoperative plan
In MIPO, preoperative planning is critically important to maximize outcomes. One of the requirements of a good preoperative plan is to prepare a graphic representation of the fracture fragments: manipulating the fragments on paper to produce a reduction, selecting the appropriate type and size of implants and superimposing them on the reduced fracture using templates, and reviewing the plan to see whether the desired end result can be achieved. There are several different ways to prepare a graphic preoperative plan. Compare preoperative planning examples in chapter 16 Femur, proximal with those presented in chapter 18 Femur, distal, for example.
The most common method of presentation is explained here. To prepare a graphic preoperative plan, the following are essential:
Good quality x-rays, including views of the normal side, if possible
Additional imaging, such as CT scans (especially for intraarticular fractures)
Tracing paper (or transparencies)
Relevant implant templates of the correct scale
A goniometer
Colored felt-tipped pens and pencils
The following planning techniques are commonly used:
Direct overlay
Overlay using the normal side
Use of the physiological axes for articular fractures
Digital planning
There are three possible templating techniques that can be used, depending on the bone and position of the fracture fragments.
Direct overlay of fractured fragments
This technique is commonly used for diaphyseal fractures with a straight access. Each fragment is individually traced onto a separate sheet of tracing paper. The bone fragments are then realigned by positioning the fragments in a straight line, using the central axis of the bone as the reference. Then the appropriate implant template is overlaid on the realigned bone to determine the optimal position and the length of the implant.
Overlay using the normal side as a template
First, a tracing of the bone on the intact side is made and inverted to match the injured side. Then the fracture fragments are drawn separately and reassembled over the drawing of the intact side. A template of the planned implant is then superimposed on the reconstructed bone to determine its correct location and size. This method is commonly used for curved bones that do not have a straight axis (see Fig 7-2 , Fig 7-3 , Fig 7-4 ).
Use of physiological axes for articular fractures
A predrawn template, the x-rays of the opposite side, or an outline of a physiological axis of the extremity is drawn. Next the articular fragments are drawn, realigning the joint block to the correct physiological axis. Additional metaphyseal or diaphyseal fragments are also reassembled around the axis.
Preoperative planning for articular fractures differs somewhat from diaphyseal fractures.
For articular fractures, anatomical reduction of each fragment and stable fixation with lag screws are vital to achieve a congruent joint surface. In this respect, CT scans are very useful to decide on the surgical approach and direction of access to depressed fragments, the direction of the lag screws and position of implants, and to facilitate their insertion during the operation (see Fig 7-8 ).
In the case of multifragmentary diaphyseal fractures, the aim of surgery is to restore the correct length, alignment, and rotation of the limb rather than anatomical reduction of the fracture fragments. Nevertheless, drawing in the anatomically reduced fragments in the preoperative plan helps in selecting the appropriate plate and screws.
Implants
The following factors should be considered when selecting the appropriate implant to be used in the MIPO procedure.
Type of plates
The types of plate used in MIPO include:
Conventional plates: dynamic compression, or limited-contact dynamic compression plates, or locking compression plates (LCP)
Fixed angle implants
Special anatomically contoured plates (now more common and advantageous)
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