Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam history past history of cancer or radiation prior treatments pre-existing pain smoking or chemical exposure constitutional symptoms fever physical exam notes lymph node involvement, lumps/nodules 2 Interprets basic imaging studies describe the radiographic appearance osteolytic osteoblastic 3 Prescribes and manages nonoperative treatment understand when to have the patient back to clinic for follow-up understand when to order new radiographic imaging studies 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check check radiographs start formal physical therapy at 4 weeks gentle range of motion exercises diagnose and management of early complications infection DVT/PE wound breakdown neurovascular compromise hardware failure postop: 4-6 week postoperative visit check radiographs diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies/lab studies 3D radiographic studies to include CT evaluates cortical bone changes MRI identifies the extent of intraosseus bone tumor angiography determines the vascularity of the tumor lab studies SPEP/UPEP PSA other tumor markers 2 Recommends complex non-operative treatment RFA or cryoablation Bisphosphonates Kyphoplasty or vertebroplasty 3 Nonoperative treatment infection wound breakdown DVT/PE) 4 Pre-operative preparation and consultation onc rad onc counseling C Preoperative H & P 1 Obtains history and performs basic physical exam history pain and function past medical/surgical/social/family history review of systems physical exam heart lungs extremity exam range of motion strength sensation skin changes tenderness screen medical studies to identify and contraindications for surgery 2 Orders basic imaging studies radiographs AP/lateral of the lesion Joint above and below the lesion 3 Prescribe non-operative treatment protected weightbearing bracing no intervention 4 Perform operative consent describe complications of surgery including Infection nonunion Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia Operative Techniques G Anterior Portion of Utilitarian Approach 1 Mark the incision Incision extends from the middle third of the clavicle and passes 1 cm medial to the coracoid process,across the axillary fold and distally along the anteromedial aspect of the arm. 2 Make the skin incision Follow the course of the neurovascular bundle Raise medial and lateral fascia cutaneous flaps 3 Release musculature Release the pectoralis major from its humeral insertion Release the strap muscles from their insertion on the coracoid 4 Expose neurovascular structures Dissect out the musculocutaneous nerve at the point where it enters the coracobrachialis and short head of the biceps this is usually 2-7 cm inferior to the coracoid Release the pectoralis minor from the coracoid identify the axillary nerve and surround with vessel loops Isolate and ligate the anterior and posterior humeral circumflex arteries Identify the radial nerve and preserve H Tumor Exposure 1 Transect deep structures separate the long and short heads of the biceps to expose the humerus determine the site for the osteotomy this is typically 3-4 cm distal to the tumor transect the long head of the biceps and brachialis identify the inferior border of the latissimus dorsi make a fascial incision that allows one finger to pass behind the latissimus and teres major muscles several centimeters from there insertion on the humerus or scapula transect these muscles using electrocautery externally rotate the arm to expose the subscapularis transect at the level of the coracoid process I Proximal Humerus Resection 1 Expose the glenohumeral joint expose the joint circumferentially 2 Perform osteotomy osteotomize the scapula medial to the coracoid along with the distal portion of the scapula En Bloc the resected specimen should contain the proximal half of the humerus, the glenohumeral joint and the distal clavicle J Endoprosthetic Replacement of the Proximal Humerus 1 Use replacement to reconstruct the skeletal defect K Dual Suspension Technique 1 Stabilize the prosthesis make drill holes in distal portion of the osteotomized clavicle and scapula at the level of the spine secure the head of the prosthesis to the remaining portion of the scapula with 3-mm dacron tape suspend the prosthesis mediolaterally during this part of the procedure use more dynamic tape at the end of the clavicle while the the extremity os suspended in a craniocaudal direction tenodese the short head of the biceps to the stump of the clavicle L Soft Tissue Reconstruction 1 Perform tenodesis tenodese the remaining muscles to the pectoralis major and osteotomized border of the scapula with dacron tape N Wound Closure 1 Perform deep closure use 0-vicryl for deep closure 2 Perform superficial closure use 3- vicryl for subcutaneous closure use 3-0 monocryl for skin 3 Place dressings place in abduction orthosis Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids IV antibiotics until drain is discontinued DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 remove drain in 3-5 days appropriately orders and interprets basic imaging studies check radiographs of the humerus in post op appropriate medical management and medical consultation Inpatient physical therapy keep in abduction brace at all times 2 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks wound care R Complex Patient Care 1 Recommends appropriate biopsy including biopsy alternatives and appropriate techniques understand role of open biopsy vs needle biopsy 2 Develops unique, complex post-operative management plans 3 Discusses prognosis and end of life care with patient and family
A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam history past history of cancer or radiation prior treatments pre-existing pain smoking or chemical exposure constitutional symptoms fever physical exam notes lymph node involvement, lumps/nodules 2 Interprets basic imaging studies describe the radiographic appearance osteolytic osteoblastic 3 Prescribes and manages nonoperative treatment understand when to have the patient back to clinic for follow-up understand when to order new radiographic imaging studies 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check check radiographs start formal physical therapy at 4 weeks gentle range of motion exercises diagnose and management of early complications infection DVT/PE wound breakdown neurovascular compromise hardware failure postop: 4-6 week postoperative visit check radiographs diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies/lab studies 3D radiographic studies to include CT evaluates cortical bone changes MRI identifies the extent of intraosseus bone tumor angiography determines the vascularity of the tumor lab studies SPEP/UPEP PSA other tumor markers 2 Recommends complex non-operative treatment RFA or cryoablation Bisphosphonates Kyphoplasty or vertebroplasty 3 Nonoperative treatment infection wound breakdown DVT/PE) 4 Pre-operative preparation and consultation onc rad onc counseling C Preoperative H & P 1 Obtains history and performs basic physical exam history pain and function past medical/surgical/social/family history review of systems physical exam heart lungs extremity exam range of motion strength sensation skin changes tenderness screen medical studies to identify and contraindications for surgery 2 Orders basic imaging studies radiographs AP/lateral of the lesion Joint above and below the lesion 3 Prescribe non-operative treatment protected weightbearing bracing no intervention 4 Perform operative consent describe complications of surgery including Infection nonunion Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia
G Anterior Portion of Utilitarian Approach 1 Mark the incision Incision extends from the middle third of the clavicle and passes 1 cm medial to the coracoid process,across the axillary fold and distally along the anteromedial aspect of the arm. 2 Make the skin incision Follow the course of the neurovascular bundle Raise medial and lateral fascia cutaneous flaps 3 Release musculature Release the pectoralis major from its humeral insertion Release the strap muscles from their insertion on the coracoid 4 Expose neurovascular structures Dissect out the musculocutaneous nerve at the point where it enters the coracobrachialis and short head of the biceps this is usually 2-7 cm inferior to the coracoid Release the pectoralis minor from the coracoid identify the axillary nerve and surround with vessel loops Isolate and ligate the anterior and posterior humeral circumflex arteries Identify the radial nerve and preserve H Tumor Exposure 1 Transect deep structures separate the long and short heads of the biceps to expose the humerus determine the site for the osteotomy this is typically 3-4 cm distal to the tumor transect the long head of the biceps and brachialis identify the inferior border of the latissimus dorsi make a fascial incision that allows one finger to pass behind the latissimus and teres major muscles several centimeters from there insertion on the humerus or scapula transect these muscles using electrocautery externally rotate the arm to expose the subscapularis transect at the level of the coracoid process I Proximal Humerus Resection 1 Expose the glenohumeral joint expose the joint circumferentially 2 Perform osteotomy osteotomize the scapula medial to the coracoid along with the distal portion of the scapula En Bloc the resected specimen should contain the proximal half of the humerus, the glenohumeral joint and the distal clavicle J Endoprosthetic Replacement of the Proximal Humerus 1 Use replacement to reconstruct the skeletal defect K Dual Suspension Technique 1 Stabilize the prosthesis make drill holes in distal portion of the osteotomized clavicle and scapula at the level of the spine secure the head of the prosthesis to the remaining portion of the scapula with 3-mm dacron tape suspend the prosthesis mediolaterally during this part of the procedure use more dynamic tape at the end of the clavicle while the the extremity os suspended in a craniocaudal direction tenodese the short head of the biceps to the stump of the clavicle L Soft Tissue Reconstruction 1 Perform tenodesis tenodese the remaining muscles to the pectoralis major and osteotomized border of the scapula with dacron tape N Wound Closure 1 Perform deep closure use 0-vicryl for deep closure 2 Perform superficial closure use 3- vicryl for subcutaneous closure use 3-0 monocryl for skin 3 Place dressings place in abduction orthosis
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids IV antibiotics until drain is discontinued DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 remove drain in 3-5 days appropriately orders and interprets basic imaging studies check radiographs of the humerus in post op appropriate medical management and medical consultation Inpatient physical therapy keep in abduction brace at all times 2 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks wound care R Complex Patient Care 1 Recommends appropriate biopsy including biopsy alternatives and appropriate techniques understand role of open biopsy vs needle biopsy 2 Develops unique, complex post-operative management plans 3 Discusses prognosis and end of life care with patient and family