Journal of Orthopaedics Trauma Surgery and Related Research

Journal of Orthopaedics Trauma Surgery and Related Research

An Official Journal of Polish Society of Orthopaedics and Traumatology

e-ISSN: 2449-9145

Rajeev Shukla, Pranav Mahajan* and Ravi Kant Jain
Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India
*Correspondence: Pranav Mahajan, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India, Email: [email protected]

Received Date: Jun 18, 2018 / Accepted Date: Jan 22, 2019 / Published Date: Feb 01, 2019

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Introduction: Pre-operative planning is one of the most important aspects in surgical treatment of patients in modern day surgery. It helps in reducing the common errors before and during surgery and hence saves time, labour and benefits the patient. Materials and Methods: In this study, we analyzed the role of pre-operative checklist in planned orthopaedic surgical procedures. We included adult trauma patients who had closed fracture of upper or lower limb and were planned for surgery. One group of patients were monitored and worked up pre operatively as per routine protocols. The second group of patients was strictly monitored according to the points given in the pre-operative check list applied in their case file. Results: The mean age of the patients was 43.46 years. Majority of patients were males (68.44%). 518 patients were operated by closed techniques. Open techniques were used in 588 patients. The average time taken for surgery in patients in Group A was 59.94 min. (SD 17.66) while that in Group B was 87.72 min. (SD 19.47) Average hospital stay for patients in Group A was 4.34 days (SD 1.77) and for those in Group B was 6.10 days (SD 3.10). There was also variation in the expenditure occurred in the OT in both the groups with an average of Rs. 7146.85 (SD-1869.50) in the Group A and Rs. 8608. 85 (SD-1543.02) in Group B. We also evaluated the individual outcome of different types of fractures in both the groups. Conclusion Pre-operative planning in treatment of fracture is an important professional discipline, and familiarity with the process makes it very quick for treatment of fractures. We highly recommend the use of this pre-operative check list criterion to be used in all the surgeries of orthopaedics, especially in elective cases.


Pre-Operative check list, surgical planning, templating, orthopaedics


CC: Cannulated Cancellous; DHS: Dynamic Hip Screw; ICU: Intensive Care Unit; OPD: Out Patient Department; OT: Operation Theatre; RR: Relative Risk; SD: Standard Deviation


Pre-operative planning is one of the most important aspects in surgical treatment of patients in modern day surgery. The practice of pre-operative planning is very old and it is usually carried out by surgeons prior to treatment/surgery. It ensures that the patient and his/her attendants are fully informed regarding the condition of the patient, disease condition of the patient, about the procedure planned during surgery, possibility of any complications intra and post-operatively and the post-operative recovery. Pre-operative planning also ensures that patient is in optimum health to undergo surgical procedure and has made arrangements for admission, discharge and post-operative care at home as and when required.

Most orthopedic residents are introduced to pre-operative planning during their residency days. AO (Arbeitsgemeinschaft für Osteosynthesefragen- Association for the study of internal fixation) fracture management course emphasizes formal planning prior to surgery and teaches the principle ‘failing to plan is planning to fail [1].

The basic training of residents begins with the ward work which includes preparation of daily orders, developing interaction skills with patients and their attendants, understanding the basic medications which are routinely used for the patients, their practical usage, side effects, interactions, complications related to the disease condition, etc. The next step to observe and learn is to observe patients coming in outpatient department, examination of patients, diagnosing the disease condition, etc. The next step in the learning process is pre-operative planning in patients who are having some disease/orthopaedic condition which will require surgery. Pre-operative planning is important in each and every patient whether planned for a major or a minor surgical procedure.

Since our main interest of the study is trauma cases, we will be talking more commonly about trauma cases coming in the OPD of an Orthopaedic surgeon and how the treatment follows. All the major trauma patients coming in OPD at a tertiary care centre and requiring surgery should be taken care of from many perspectives.

First of all, the patients should be managed primarily depending on the fracture. The fracture site should be immobilized with a splint or slab or traction depending on the injury. Patients should be investigated for ruling any other associated comorbidity. As most of the trauma patients require surgery, they should be investigated to see if they are fit for surgery.

The next important step is pre-operative planning. This is important to ensure less possibility of complications and better results.

A survey of pre-operative 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]. Formal pre-operative planning should be recognized as an essential prerequisite to fracture management because of the potential to improve surgical efficiency, and advance orthopedic surgical training [3].

Value Of Pre-Operative Planning To The Surgeon And Trainee

Pre-operative 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 pre-operatively provides an excellent opportunity to communicate with and educate those involved in a case, including residents, medical students and operating room personnel. Pre-operative planning improves with routine practice. Patients also benefit from pre-operative 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 orthopaedic residents become more proficient in interpreting images, they learn that fractures tend to follow predictable patterns. All orthopaedic surgeons experience a time when a subtle variation was overlooked. With careful review of images during pre-operative 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, drawnout 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. As a resident progresses and gains experience, different elements of planning become more meaningful.

There have been a few studies considering the importance of pre op planning in our day to day practice. One should start learning the concepts of pre-operative planning during their residency days itself so that by the end of their curriculum, the residents have a complete idea of how to evaluate the patient pre operatively and also what things should be given stress upon while looking after the patient.

We have designed a basic pre-operative check list for the residents working at any institute in order to evaluate the details of the patient prior to surgery. This would help the surgeon and residents in better dealing with the surgery. The check list has to be applied in the case file of the patient so that the resident doctor knows exactly what all things need to be done prior to surgery.

Materials and Methods

This study includes 1106 patients who were admitted at our hospital and suffered from fracture in upper or lower limb. These patients were planned for some surgical procedure.

As soon as the patient came to us in OPD/Emergency after a history of trauma, he/she was taken in the emergency room. Detailed history of all patients was taken. All patients were assessed clinically and functionally to determine the type of fracture. The pre-operative medical evaluation of all patients was done to prevent potential complications that can be life threatening or limb threatening. Standard guidelines were utilized to get radiographs-standing antero-posterior view and lateral view of the involved bone is done. Any associated ligament laxity, subluxation of surrounding joint, presence of any bony defects or pathological condition in the bone and the quality of bone was assessed.

All of these patients who had a long bone fracture were primarily managed with i.v. fluids, analgesics, immobilization of the fracture site.

Patient and attendants are explained regarding the condition of the patient. They are explained regarding the type of fracture and the proposed treatment plans.

All the patients who are more than 18 years of age and suffering from upper limb or lower limb closed fracture of long bone were included in the study. Patients in the age group <18 years, open fractures, multiple fractures, any other associated co-morbidity which can lead to delay in surgery or post op monitoring in ICU care, patients having deranged blood investigations are excluded from the study. Patients were randomly divided into two groups after their inclusion in the study.

In one group, no pre op check list was applied. All the patients were planned for surgery following the routine pre-operative protocols. These patients were evaluated for total surgical expenses, surgical time, and surgical complications during and after surgery, total duration of stay after surgery.

In the second group of patients, pre op check list is applied after the patient is admitted. All the points given in the checklist are checked and done prior to surgery (Table 1).

Table 1. Pre op check list proforma.



All patients after thorough pre-op evaluation were taken up for surgery by the same surgical team under general or regional anesthesia. Tourniquet was applied whenever required and sterile preparation done from thighs to toes and draped.

In the second group of patients where Pre-operative check list is applied in case file are monitored for Pre Anesthetic Checkup, all relevant clearances, investigations, consent, pre op medical and OT charges, blood arrangement, implants check for plan A or B, tentative size of implant required, case planning including surgical approach, procedure, plan to be mentioned on white board prior to start of surgery.

Patient is monitored intra-operatively and post-operatively for total surgical time, total surgical cost (intraoperative), any intra op or post op complications, and total duration of stay after surgery. All the patients were operated by the same surgical team. Patients of both the groups are analyzed using MedCalc software.


The study was done in a total of 1106 patients who had a history of trauma and sustained fractures in the bones of upper and lower limbs. All the patients considered for the study had unilateral injuries with single bone involvement.

Out of the total patients, 546 patients had pre op check list attached to their files before surgical workup (Group A) whereas 560 patients were planned for surgery as per the routine protocols (Group B) (Tables 1 and 2).

Bone Fracture Number of Patients
  Group A Group B Percentage
Clavicle 19 21 3.61%
Humerus 106   9.58%
  • Proximal Humerus
12 14  
  • Neck Humerus
4 2  
  • Shaft Humerus
28 31  
  • Distal Humerus
7 8  
Radius/Ulna 223   20.16%
  • Olecranon
7 10  
  • Proximal Radius/ Ulna
4 2  
  • Shaft Radius
27 19  
  • Shaft Ulna
9 10  
  • Shaft Radius and Ulna
28 28  
  • Distal Radius
36 43  
Femur 381   34.44%
  • Neck Femur
44 40  
  • Inter trochanteric Femur
57 58  
  • Sub Trochanteric Femur
24 25  
  • Proximal Femur
11 7  
  • Shaft Femur
21 29  
  • Distal Femur
33 32  
Patella 12 17 2.62%
Tibia/Fibula 271   24.50%
  • Proximal Tibia
32 31  
  • Shaft Tibia/Fibula
50 54  
  • Distal Tibia
32 32  
  • Medial Malleolus
12 16  
  • Bimalleolar
7 5  
Talus 3 4 0.63%
Calcaneum 27 22 4.43%

Table. 2. Distribution of patients according to fracture

The fracture pattern was similar in both the groups with 176 upper limb patients and 369 lower limb patients in Group A while there were 188 upper limb patients and 372 lower limb patients in Group B (Table 3).

Criteria Group A Group B
Age 43.60 years 43.32 years
Sex M 397: F 163 M 373:F 187
Fracture Pattern    
  • Upper Limb
176 188
  • Lower Limb
369 372
Procedure Done    
  • Open
298 291
  • Closed
249 269
Type of Implant    
  • Pinning/TBW
27 39
  • Screw/DHS
60 49
  • Nail
166 187
  • Plate
220 217
  • Fixator
52 48
  • Hemi Arthroplasty
21 19
Time of Surgery 59.94 min. 87.72 min.
Cost of Surgery Rs. 7146.84 Rs. 8608.85
Duration of Stay 4.34 6.10 days
Complications 2.38 % 3.03%

Table. 3. Distribution of patients according to procedure

The mean age of the patients was 43.46 years (Range-18-90 years) (Fig. 1). Majority of patients (757) were males (68.44 %) (Fig. 2).

Fig. 1. Age wise distribution

Fig. 2. Sex distribution

In group A, out of 546 patients, 249 patients were operated by closed reduction internal fixation techniques and 297 patients were operated upon by open reduction internal fixation techniques (Fig. 3).

Fig. 3. Type of surgery done

518 patients were operated by closed techniques (22 patients with CC Screws, 11 DHS, 109 external fixator, 347 nailing, 26 pinning. Open techniques were used in 588 patients out of which 40 were Hemi Arthroplasty, 29 Dynamic Hip Screw, 35 CC Screws, 6 Nailing, 436 plating, 40 Tension Band Wiring (Fig. 4).

Fig. 4. Procedure done

The average time taken for surgery in patients in Group A was 59.94 min. (with SD 17.66) while that in Group B was 87.72 min. (SD 19.47) and was found to be significant (p<0.0001) (Fig. 5).

Fig. 5. Duration of surgery (in minutes)

Average hospital stay for patients in Group A was 4.34 days (SD 1.77) and for those in Group B was 6.10 days. (SD 3.10) was found to be significant (p<0.0001) (Fig. 6).

Fig. 6. Duration of stay

There was also variation in the expenditure occurred in the OT in both the groups with an average of Rs. 7146.85(SD-1869.50) in the Group A and Rs. 8608. 85 (SD-1543.02) in Group B and this was also found to be significant (p<0.0001) (Fig. 7).

Fig. 7. Cost of surgery

We also evaluated the individual outcome of different types of fractures in both the groups, the details of which are shown in Table 4.

  Group A Group B
Bone Fracture No. of Pts. Time
Duration of Stay(days)   No. of Pts Time Cost Duration   Percentage
Clavicle 19 67.10 8308.42 4.05   21 96.19 9135.23 6.71   3.61%
Humerus 106                   9.58%
  • Proximal Humerus
12 68.75 8451.66 5.16   14 108.21 10115.71 7    
  • Neck Humerus
4 41.25 4452.5 3.25   2 87.5 8895 3.5    
  • Shaft Humerus
28 58.39 6712.5 4.25   31 83.22 7898.71 5.35    
  • Distal Humerus
7 98.57 8285.71 6.71   8 125 11908.75 9.87    
Radius/Ulna 223                   20.16%
  • Olecranon
7 55.71 4440 4.42   10 91.5 7715 5.8    
  • Proximal Radius/ Ulna
4 47.5 6277.5 3.75   2 75 7945 8    
  • Shaft Radius
27 47.03 5308.88 4.40   19 81.05 6868.42 5.36    
  • Shaft Ulna
9 38.33 5118.88 3.33   10 70.5 6568 6.5    
  • Shaft Radius and Ulna
28 85.35 6214.64 4.60   28 89.82 7932.5 5.78    
  • Distal Radius
36 46.38 5310.83 4.05   43 73.60 7810.93 5.02    
Femur 381                   34.44%
  • Neck Femur
44 62.38 9015 4.34   40 91.25 9336.25 6.2    
  • Inter trochanteric Femur
57 56.66 8548.77 4.29   58 83.27 9265.69 5.87    
  • Sub Trochanteric Femur
24 65.83 8078.33 4.62   25 93.4 9304.8 6.08    
  • Proximal Femur
11 72.27 8494.54 5   7 111.42 9207.14 6.71    
  • Shaft Femur
21 55.95 7472.85 3.80   29 79.37 8730.34 5.72    
  • Distal Femur
33 74.24 8761.51 4.84   32 99.68 10536.25 7.62    
Patella 12 64.16 4460.83 4.66   17 92.94 7482.35 6.11   2.62%
Tibia/Fibula 271                   24.50%
  • Proximal Tibia
32 60.00 7491.56 4.12   31 95.64 9120 6.58    
  • Shaft Tibia/Fibula
50 52.7 6816.2 4.2   54 79.44 7468.33 5.75    
  • Distal Tibia
32 65.62 7613.12 4.59   32 96.09 9158.43 6.37    
  • Medial Malleolus
12 36.66 3527.5 3.5   16 72.81 7530 3.93    
  • Bimalleolar
7 62.85 5970 3.71   5 88 8014 6.4    
Talus 3 55 6903.33 3   4 71.25 6872.5 4   0.63%
Calcaneum 27 53.33 6240.74 4.44   22 89.09 8626.81 8.13   4.43%

Table. 4. Categorical distribution of patients according to fracture


The importance of planning before performing an operation is wellunderstood and documented. Planning helps the surgeon anticipates the correct implant size and can also help to anticipate possible intra-operative difficulties (more than 80% of intra-operative difficulties were anticipated in the study performed in study by S Eggli et al.) [4].

Our study shows the importance of pre-operative checklist at a tertiary centre which is very much helpful for residents during their learning days. We have determined that there is a definite advantage of applying a pre-operative check list prior to surgery. We found that there was a significant difference (around 30%-40%) in time of surgery in the two groups with lesser time in group in which pre-operative check list was used. Similarly, there was reduction in cost of surgery by around 10%-20% in group A patients. Also, there was partly reduced stay in hospital in patients of group A (Table 4).

The systematic analysis of a problem requires discipline. It requires a review of the information that we do have, a search for information that we do not have, and consistent and correct application of that combined knowledge to each situation. When the full body of experience does not provide an answer, mistakes are easier to accept. When an answer is present but we fail to see it, failure is both more frustrating and less acceptable [5].

According to one of the studies done by Paul O Connor et al. [6], surgical check lists has been shown to improve patient safety and team work in the operating theatre. Responses were obtained from 107 theatre staff. The overall attitudes towards the effect of the checklist on safety and team working were positive. However, there was a lack of rigour with which the checklist was being applied (46% response rate).

Mathew Sewell et al. [7], in their study determined the role of WHO surgical safety checklist in orthopaedics and trauma patients.

The aim of this study was to prospectively audit checklist use in orthopaedic patients before and after implementation of an educational program designed to increase use and correlate this with early complications, mortality and staff perceptions. Data was collected on 480 patients before the educational program and 485 patients after. Pre-training checklist use was 7.9%. The rates of early complications and mortality were 8.5% and 1.9%, respectively. Forty-seven percent thought the checklist improved team communication. Following an educational program, checklist use significantly increased to 96.9% (RR12.2; 95% CI 9.0–16.6). The rate of early complications and mortality was 7.6% (RR 0.89; 95% CI 0.58-1.37) and 1.6% (RR 0.88; 95% CI 0.34-2.26), respectively. Seventy-seven percent thought the checklist improved team communication.

Avish L Jain et al. [8], performed a study on impact of a daily pre-operative surgical huddle on interruptions, delays, and surgeon satisfaction in an orthopedic operating room. 19 baseline observations and 19 huddle-implemented observations of surgeon’s days were assessed. Overall, surgeon satisfaction increased and fewer delays occurred after introduction of huddles. Interruptions decreased in all categories including equipment, antibiotics, planned procedure and side. Time required for a huddle was less than one minute per case.

Alex B Haynes et al. [9], did a study determining the role of Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. They collected and enrolled patients from 8 different cities all over the world representing a variety of economic circumstances and diverse populations of patients who participated in the World Health Organization’s Safe Surgery Saves Lives program. They subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation. The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). They concluded that implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

William Murzic et. al. presented a study with the aim of evaluating the accuracy of a specific templating software (with an emphasis on femoral component fit) and comparing it to the traditional technique using standard radiographs [10].

Digital pre-operative planning enables the surgeon to select from a library of templates and electronically overlay them over the image. Therefore, the surgeon can perform the necessary measurements critical to the templating and pre-operative planning process in a digital environment. The pre-operative planning process is fast, precise, and cost-efficient, and it provides a permanent, archived record of the templating process [11].

Successful surgery requires the precise placement of implants in order that the function of the joint is optimized both biomechanically and biologically. Pre-operative planning is helpful in achieving a successful result in total joint replacement. Pre-operative templating in total hip replacement helps familiarize the surgeon with the bone anatomy prior to surgery, reducing surgical time as well as complications [11].


Fracture planning can seem time consuming and labor intensive. However, it is an important professional discipline, and familiarity with the process makes it very quick for simple fractures, though more complex fractures take longer. Just as important as the process of drawing the plan and determining the tactic is the task of considering surgical management in detail. The whole process makes it far less likely that X-rays will be misinterpreted, surgical pitfalls overlooked, and the correct size implant found to be unavailable after the operation has started. The benefits to the surgeon and residents of a planned approach far outweigh the time necessary for the planning itself. A good plan frequently results in a shorter operating time and a better outcome for the patient.


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