Keywords
preoperative care - orthopedics - trauma - surgery - education
Introduction
Preoperative planning (PP) is an essential step in orthopedic trauma surgery.[1]
[2]
[3] It enables the surgeon to reflect on the case in an environment free of pressure.[4] It also helps to select the materials and implants needed for fracture reduction
and fixation, and can therefore help anticipate problems, providing the opportunity
to design alternative plans. To summarize, PP saves time and minimises complications,
which translates into better patient outcomes.[1]
[5]
The original preoperative planning (OPP) technique[6] includes four sequential stages:
-
Reconstruction involves identifying and reassembling the fracture fragments, which are drawn on
tracing paper using the uninjured side as a template.
-
Decision-making involves defining the surgical indication and addressing issues such as approach
and fixation methods to minimise the damage to soft tissue.
-
Fixation. Implants are selected and templated physically on the previous drawing to enable
the surgeon to determine their function, length and size, and whether they need to
undergo modifications.
-
Surgical tactic: It is developed in four stages: listing the required equipment, preparation (surgical team, anesthesia, antibiotics, tourniquet, expected blood loss, estimated
surgical time), a stepwise list of the whole procedure, and a postoperative regime.
The OPP yields three documents: the surgical tactic, the annotated drawing, and the
equipment list.
This simple and reproducible method, which remains valid today, established the principles
of PP in orthopedic trauma. We believe that this process can be updated and enhanced
by the use of a ubiquitous digital tool such as a presentation software (PS).
Technique for PPPS
Preoperative planning with a presentation software (PPPS) follows the same principles
as the OPP. We would encourage the reader to refer to the complementary videos to
better understand the following processes.
Materials required for the PPPS:
-
Hardware: either PC (Windows or Linux), Mac, IOS and/or Android devices.
-
Software: PSs, such as PowerPoint, Keynote etc. The authors used Microsoft PowerPoint
(Microsoft Corp., Redmond, WA, US), version 16.27 for Mac.
Basic Settings ([Video 1])
Once the program is open, change the Design and select the black slide background with a white font, as this increases the contrast
of the radiographs. Add the slides corresponding to the proposed PPPS layout ([Table 1]) and operating theater layout ([Fig. 1]).
Table 1
|
- Title slide Keywords and date identifying the case
|
|
- Medical history Patient information and mechanism of injury
|
|
- Soft-tissue status Pictures of the involved area
|
|
- Layout of the operating theater Single slide showing staff and theater layout ([Fig. 1])
|
|
- Imaging
|
|
- Reconstruction
|
|
- Decision-making
|
|
- Fixation
|
|
- Surgical tactic
|
|
○ Equipment
|
|
○ Preparation
|
|
○ Stepwise plan
|
Fig. 1 Slide representing the layout of the operating theater. As it can be seen by the
operating room personnel, it improves team communication and saves time. S = surgeon;
A = assistant; N = nurse; AN = anesthesiologist; II screen = image intensifier screen.
Imaging
Preoperative relevant radiographs, computed tomography (CT) and/or magnetic resonance
imaging (MRI) frames are added to the presentation. Most picture archiving and communication
system (PACS) viewers enable the user to export and save the images in generic format
(.jpeg, .png, .tiff). This is our preferred method because the quality of the image
is much higher. The alternative is to paste a screenshot of the images onto a slide
and crop them (Picture format > Crop). We display orthogonal views of the fracture in one slide, which will then be used
as a model to reconstruct and fix the fracture ([Fig. 2A]). The quality of the images can be enhanced if needed using Picture Format > Corrections > Sharpen 50%.
Fig. 2 Orthogonal views of a distal humerus fracture (A). The same images after applying the following commands: Picture Format > Artistic Effects > Glow Edges (B).
Reconstruction ([Video 1])
To identify fracture fragments, the presentation software offers two options. The
first is to select each image and go to Picture Format > Artistic Effects > Glow Edges. This effect simulates hand-drawing ([Fig. 2B]). The second option is to use the Draw tool, which enables the surgeon to draw directly onto the image.
Fracture fragments can then be individually isolated by selecting the image and clicking
on Picture Format > Remove Background. This enables the surgeon to delineate each fragment separately using both Mark Areas to Keep and Mark Areas to Remove ([Fig. 3 A, B, C, D]). After all main fracture fragments are isolated images, they can be pasted onto
a new slide and manipulated by dragging and rotating them, so the fracture can be
reduced and reconstructed ([Fig. 3E]). Alternatively, if contralateral radiographs are available, these can be mirrored,
and the fracture can be reconstructed over them.
Fig. 3 An anteroposterior view of the fracture is cropped and pasted as a separate image
(A). Using Background Removal, the distal (B, C) and proximal fragments (D) are delimited. Both images are fitted in together to reconstruct the fracture (E).
To design the fixation construct, the surgeon must have access to the implant surgical
operative technique manual. Most can be downloaded in pdf format. These manuals contain
both dimensions of the implants and pictures of them in various planes. These pictures
are captured with screenshots ([Fig. 4A]), pasted on a separate slide ([Fig. 4B]), and modified to remove their background (Picture Format > Remove Background, [Fig. 4C]). Following the OPP guidelines, the color of the implant can be changed to blue
(Picture Format > Color, [Fig. 4D]). For a more accurate prediction of the size, an image of a ruler is downloaded,
and the implant is superimposed over the ruler until it matches its actual size ([Figs. 4E] and [5C]). Note that preoperative radiographs must be taken with a radiologic marker to accurately
scale the image. Finally, the implant image can be adjusted to fit the preoperative
radiograph in Format Picture > 3D rotation ([Figs. 4F] and [5]). If many implants will be used, the
Transparency
tool (
Format Picture > Transparency
) enables the visualization of many implants in different layers (
[
Fig. 5D
]
). Alternatively, fixation can be quickly schematized using the Draw tool.
Fig. 4 A screenshot of the implant (medial distal humerus plate) from the operative technique
is taken (A). The image is pasted onto a slide (B) and edited to have its background removed (C) and its color changed (D). The edited image is superimposed on the ruler to be accurately scaled, according
to the implant's size chart (E). The final image is adjusted to fit the reconstructed
fracture (F).
Fig. 5
Fixation stage of a 3.5-mm cortical screw in the preoperative planning with a presentation
software. A screenshot from the surgical technique manual is cropped (A) and pasted on a slide to have its background removed (B). The color of the image is changed to blue and placed over a ruler to scale its
diameter (C). The one-third tubular plate and the screws are shown over the reconstruction after
applying the Transparency tool (D).
Surgical Tactic ([Video 2])
Add slides describing how the proposed fixation is going to be achieved, the list
of materials, tools and implants needed, and the postoperative plan given the proposed
construct stability.
The final product of the PPPS is a presentation containing the preoperative status,
the desired postoperative reduction and reconstruction of the fracture, the fixation
strategies, and a rehabilitation plan ([Fig. 6]).
Fig. 6 Key slides from the final result of the PPPS.
Discussion
Because the OPP was initially designed to be done on paper, it requires physical materials,
such as radiographs, implant templates, tracing paper, and colored pens. These are
cheap, and, in theory, are available throughout the world. However, most hospitals
currently use PACS to store radiological imaging, so acetate radiographs are rarely
available. In practice therefore, the OPP requires the surgeon to print the radiographs,
which affects the accuracy of the PP. Printed templates are also often unavailable.
All four authors of the present study had trouble finding these in different countries.
The OPP also requires artistic skills and can be quite time consuming, especially
when the surgeon needs to create many hand-drawn copies.
The PS is widely available in most hospitals and surgeons' own devices, being familiar
to most orthopedic surgeons. The PPPS can be performed on nearly any device with a
PS. The presentations can be kept online, making them easy to access and share. This
is a significant advantage over the OPP. Furthermore, there is no image degradation
when the surgeon experiments with the digital radiological images in the PS. The “duplicate
slide” tool also eliminates the need to make many hand-drawn copies. We are aware,
however, that the process of copying, pasting and cropping images can be quite repetitive.
Nevertheless, we have found two important reasons for its use. Firstly, especially
true when CT scans are available, the exercise of selecting the best cuts and capturing
them enables ample image visualization, providing the surgeon with a good mental three-dimensional
image of the fracture. Secondly, the process becomes “automatic” after a few attempts
at the PPPS, and much faster as a result. In our experience, it takes 5 to 15 minutes
to prepare a presentation, depending on the case. Most operating theaters now have
a computer in which the PPPS can be displayed before the case starts. Staff can access
and browse both the theater layout and equipment list, which saves time and improves
team communication.
Specialized software (TraumaCad [Brainlab AG, Munich, Germany], PeekMed [PeekMed,
Braga, Portugal] etc.) has also been developed for the PP. These are wonderful and
accurate tools, but they are not as easily accessible and widely used as a simple
PPPS. Based on the authors' experience, they are largely unavailable in Central and South
America, Asia, Africa, and southern Europe. They also require in-hospital PACS integration
and specialized hardware to function properly.
In our opinion, the main advantage of the PPPS is the educational opportunity it provides.
It enables the surgeon to include pictures or videos of the patient's clinical assessment
(such as, wounds, unusual physical examination findings etc.). Its format makes discussion
with the colleagues easier. In addition, the PPPS goes beyond the PP. Once the case
has ended, intraoperative fluoroscopy can also be added to the PPPS. The surgeon can
identify pitfalls a posteriori by reviewing the case. Old plans can also be useful when planning new cases with
a similar injury. Finally, it is helpful for the follow-up of the patient in the clinic
and for monitoring purposes (such as the status of the soft tissues). All of these
features make the PPPS particularly useful for teaching and self-guided learning.
Reviewing the literature,[1]
[2]
[3]
[7] we have found that there is a significant gap between the OPP and three-dimensional
PP (3D-PP), which has established a new paradigm in PP, by enabling the surgeon to
touch the fracture fragments, apply reduction techniques in advance, and preoperatively
measure and fit implants. Although the 3D-PP is rapidly evolving,[8] its availability and practical application are still restricted. It requires advanced
imaging techniques (CT, MRI), so its applicability to diaphyseal fractures or simple
articular fractures is limited. The environmental costs of producing a significant
amount of thermoplastic fibers, the material used by 3D printers, should also be kept
in mind. On the other hand, the PPPS can be used for every fracture with simple imaging,
and could complement both PP using specialized software and 3D-PP.
Conclusion
To conclude, the PPPS enhances and updates known methods of PP. It is an inexpensive,
straightforward, and widely accessible technique, providing the surgeon with a comprehensive
summary case in a digital presentation, with an incalculable educational and documental
value.
