Tips for Preoperative Planning

There are a variety of ways orthopedic surgeons prepare for cases. Dr. Keith Berend, Dr. Mike Berend, and Dr. Christopher Peters shared some tips in how they practice preoperative planning.

According to Dr. Mike Berend, preoperative planning sets the stage for achieving the best possible outcome for a patient. Even a small amount of preoperative planning can make a difference in identifying and addressing potential complications that could arise. While there will be times when you have to switch from plan A to plan B during surgery, if you’ve identified that possibility beforehand and planned for it, then switching plans feels like a natural thing.

Preoperative planning is more involved than simply templating a case; it begins with the first office visit. During this phase, the patient is evaluated as to whether or not surgery is an appropriate treatment. The plan for an 85 year old woman in a wheel chair will differ from a younger, more active patient. Getting a glimpse of who the patient is, and what their expectations are, will aid in the development of their surgical plan.

After confirming the patient’s characteristics qualify them as a surgical candidate, an X-ray can be used to establish if there is sufficient wear on the joint to warrant surgery. Dr. Keith Berend commented that, for surgery to be effective in relieving pain, the patient needs to have severe enough disease that surgery will make it better. A patient who presents with light wear might not be a good surgical candidate at that time.

It’s also worth considering whether the patient has already failed various conservative measures. Have they tried non-narcotic pain and anti-inflammatory medicines? Have they attended physical therapy or adjusted their diet and exercise regimen?  If they have, then it’s another indicator that surgery may help.

Looking at a patient’s overall health and medical stability is important during preoperative planning. Through this, you can identify factors that increase the risk of complication during surgery. A high BMI, diabetes, and smoking all indicate a higher risk. A history of alcoholism, dementia, kinetic diseases, and metal sensitivities are all good to know at this point as well, as they will require attention in the surgical plan.

All three doctors agree that the most obvious part of preoperative planning is templating. While templating is fairly straightforward, Dr. Christopher Peters offers a few other elements he considers during this step:

  • Watch the patient walk and study their gait
  • Note the joint’s range of motion
  • Look for any leg-length differences
  • Assess for limp or muscle attachment that might influence the surgical approach
  • Identify the type of implants you want to use based on the templates, bone quality, activity level, age, and anatomical differences. It’s also good during this step to identify plan B and note any additional implants necessary should the need arise mid-surgery.

These are simply a few tips that can help aide in preoperative planning. Following a good preoperative planning routine can help optimize your schedule and plan for complications that could arise during surgery. According to all three doctors, surgeons spend most of the week worrying about the 10% to 15% of cases that involve a more complex deformity. Planning ahead of time can help you prepare for these complex cases and provide a contingency plan prior to surgery.

Interview with Dr. Keith Berend, Dr. Mike Berend, and Dr. Christopher Peters on file at Zimmer Biomet.

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