Preoperative Patient Care A Intermediate 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 discuss result of the biopsy plan definitive surgery diagnose and management of early complications infection DVT/PE wound breakdown neurovascular compromise postop: 4-6 week postoperative visit start intensive muscle strengthening exercises at 4 weeks if muscle transfer occurred in surgery 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 MRI 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 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies radiographs AP/lateral of the lesion Joint above and below the lesion 4 Prescribe non-operative treatment protected weightbearing bracing no intervention 5 Perform operative consent describe complications of surgery including Infection knee stiffness Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia Operative Techniques E Preoperative Plan 1 Radiographic templating use MRI and CT scan to determine the location and extent of the lesion 2 Execute surgical walkthrough describe the steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation nothing special needed 2 Room setup and Equipment Standard OR table 3 Patient Positioning supine position with bolster under ipsilateral buttock G Thigh Incision 1 Mark incision over lesion make a long incision that extends from the AIIS to the patella the incision should be elliptical and be centered around the biopsy site 2 Create skin flaps make skin and subcutaneous flaps that extend down to the fascia lata they should extend medially to the adductor muscle group and laterally to the greater trochanter and flexor muscles H Deep Dissection 1 Identify and transect deep structures divide the saphenous vein as it enters the fossa ovalis uncover the inguinal ligament and femoral triangle expose the common femoral artery, vein and nerve place lateral traction on the quadriceps this exposes the muscular branches coming from the superficial femoral artery and vein into the quadriceps muscle work from cranial to caudal and clamp divide and ligate the the vessels place lateral traction and identify the muscular insertions from the adductor magnus divide these branches as they cross the superficial femoral artery identify the plane between the tensor fascia lata and the gluteus medius and minimus use cautery to release the tensor from its origin off of the wing of the ilium 2 Identify and divide the musculature identify and divide the sartorius off of the ASIS identify and divide the rectus femoris off of the AIIS identify the origins of the vastus lateralis, intermedius and the medialis on the femur transect from the bone using cautery I Tumor Removal 1 Release the specimen use strong upward and medial traction on the specimen divide the insertions of the vastus medialis, lateralis and the rectus femoris muscle on the patella transect the prepatellar and quadriceps bursae divide the insertion of the vastus medialis into the MCL 2 Prepare the wound for closure copiously irrigate the dissection sit and perform meticulous hemostasis J Biceps Femoris Transfer (optional) 1 Release the biceps femoris transect the long head of the biceps from the fibula 2 Perform transfer transfer the muscle anteriorly to the midline so that it will be in direct line of pull use heavy nonabsorbable suture and suture the muscle to the patella and the remains of the quadriceps and rectus femoris K Sartorius and Semitendinosus Muscle Transfer (optional) 1 Release the sartorius release but not transect the muscle from its distal insertion on the medial aspect of the proximal tibia ligate the distal 2 or 3 vessels the aim is to transfer the muscle anteriorly to the midline to achieve straight line pull suture to the patella tendon the patella and the remains of the quadriceps 2 Release the semitendinosus transect the muscle as far distal as possible from its insertion to the proximal tibia transfer anteriorly suture the muscle and its tendinous parts to the patella and the remains of the quadriceps L 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 knee immobilizer if muscle transfer is performed Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive post operative orders pain control IV antibiotics until all drains removed advance diet as tolerated check appropriate labs wound care remove dressings POD 2 remove drain in 3 to 5 days 2 Appropriately orders and interprets basic imaging studies 3 Appropriate medical management and medical consultation follow up with pathology for findings of biopsy 4 Inpatient physical therapy no muscle transfer in surgery weight bear as tolerated muscle transfer in surgery place in knee immobilizer 5 Discharges patient appropriately pain meds outpatient pt schedule follow up appointment in 2 weeks 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
A Intermediate 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 discuss result of the biopsy plan definitive surgery diagnose and management of early complications infection DVT/PE wound breakdown neurovascular compromise postop: 4-6 week postoperative visit start intensive muscle strengthening exercises at 4 weeks if muscle transfer occurred in surgery 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 MRI 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 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies radiographs AP/lateral of the lesion Joint above and below the lesion 4 Prescribe non-operative treatment protected weightbearing bracing no intervention 5 Perform operative consent describe complications of surgery including Infection knee stiffness Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia
E Preoperative Plan 1 Radiographic templating use MRI and CT scan to determine the location and extent of the lesion 2 Execute surgical walkthrough describe the steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation nothing special needed 2 Room setup and Equipment Standard OR table 3 Patient Positioning supine position with bolster under ipsilateral buttock G Thigh Incision 1 Mark incision over lesion make a long incision that extends from the AIIS to the patella the incision should be elliptical and be centered around the biopsy site 2 Create skin flaps make skin and subcutaneous flaps that extend down to the fascia lata they should extend medially to the adductor muscle group and laterally to the greater trochanter and flexor muscles H Deep Dissection 1 Identify and transect deep structures divide the saphenous vein as it enters the fossa ovalis uncover the inguinal ligament and femoral triangle expose the common femoral artery, vein and nerve place lateral traction on the quadriceps this exposes the muscular branches coming from the superficial femoral artery and vein into the quadriceps muscle work from cranial to caudal and clamp divide and ligate the the vessels place lateral traction and identify the muscular insertions from the adductor magnus divide these branches as they cross the superficial femoral artery identify the plane between the tensor fascia lata and the gluteus medius and minimus use cautery to release the tensor from its origin off of the wing of the ilium 2 Identify and divide the musculature identify and divide the sartorius off of the ASIS identify and divide the rectus femoris off of the AIIS identify the origins of the vastus lateralis, intermedius and the medialis on the femur transect from the bone using cautery I Tumor Removal 1 Release the specimen use strong upward and medial traction on the specimen divide the insertions of the vastus medialis, lateralis and the rectus femoris muscle on the patella transect the prepatellar and quadriceps bursae divide the insertion of the vastus medialis into the MCL 2 Prepare the wound for closure copiously irrigate the dissection sit and perform meticulous hemostasis J Biceps Femoris Transfer (optional) 1 Release the biceps femoris transect the long head of the biceps from the fibula 2 Perform transfer transfer the muscle anteriorly to the midline so that it will be in direct line of pull use heavy nonabsorbable suture and suture the muscle to the patella and the remains of the quadriceps and rectus femoris K Sartorius and Semitendinosus Muscle Transfer (optional) 1 Release the sartorius release but not transect the muscle from its distal insertion on the medial aspect of the proximal tibia ligate the distal 2 or 3 vessels the aim is to transfer the muscle anteriorly to the midline to achieve straight line pull suture to the patella tendon the patella and the remains of the quadriceps 2 Release the semitendinosus transect the muscle as far distal as possible from its insertion to the proximal tibia transfer anteriorly suture the muscle and its tendinous parts to the patella and the remains of the quadriceps L 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 knee immobilizer if muscle transfer is performed
O Perioperative Inpatient Management 1 Write comprehensive post operative orders pain control IV antibiotics until all drains removed advance diet as tolerated check appropriate labs wound care remove dressings POD 2 remove drain in 3 to 5 days 2 Appropriately orders and interprets basic imaging studies 3 Appropriate medical management and medical consultation follow up with pathology for findings of biopsy 4 Inpatient physical therapy no muscle transfer in surgery weight bear as tolerated muscle transfer in surgery place in knee immobilizer 5 Discharges patient appropriately pain meds outpatient pt schedule follow up appointment in 2 weeks 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