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 remove sutures check radiographs 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 used to evaluate the extent and level of bony destruction MRI evaluates the medullary and extraosseous components of the tumor intracapsular extension presence of skip metastasis within the femoral canal angiography of the illiofemoral vessels 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 Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia Dislocation Abductor insufficiency and trendelenburg gait Prosthetic loosening Operative Techniques E Preoperative Plan 1 Radiographic templating determine the extent of the resection determine the dimensions of the required prosthesis 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 endoprosthesis system 2 Room setup and equipment standard OR table sterile hoods with circulating fans for surgical team hip positioners or bean bag check back table to make sure correct equipment available 3 Patient positioning lateral decubitus with operative extremity facing up axillary roll, anterior positioner on pubic symphysis, posterior positioner on sacrum, foley in place in obese patients place towel or pad between positioners and skin arms stacked on top of each other with blankets underneath and in between, taped down to arm boards prep and drape entire leg above iliac crest and midline sacrum to make sure adequate working area bovie pad on contralateral thigh or abdomen foot in "candycane holder" and ankle stirrup with extremity externally rotated to prevent knee buckling during prep G Lateral Approach 1 Perform skin incision make incision that starts 3 to 4 cm proximal to the greater trochanter extend the incision to the distal 2/3 of the thigh 2 Expose the gluteus medius and maximus 3 Detach the gluteus medius and maximus open the iliotibial band longitudinally detach the femoral insertion of the gluteus maximus retract the gluteus maximus posteriorly this allows visualization to the retrogluteal area, external rotators, sciatic nerve, abductors and the posterior capsule identify and mobilize the sciatic nerve identify the abductors transect the abductors through there tendinous attachments when there is no tumor involvement 4 Reflect the vastus lateralis transect the vastus lateralis from its origin at the vastus ridge and reflect distally ligate the posterior perforating vessels identify the femoral nerve below the fascia identify the superficial and profundus femoral artery and vein in the sartorial canal if they have been invaded by tumor then they can be ligated just distal to there takeoff from there common femoral vessel H Detachment of the Posterior Hip Musculature and Capsule 1 Detach the posterior hip musculature and capsule detach the rotator muscles en bloc 1 cm from their insertion on the proximal femur 2 Open the the hip capsule if there is no tumor involvement the hip capsule should remain intact because of its role in stability of the prosthesis open the capsule longitudinally along its anterolateral aspect and detach it circumferentially from the femoral neck 3 Dislocate the femur anterolaterally I Distal Femoral Osteotomy and Release of Medial Structures 1 Determine the level of the osteotomy typically this is 3-4 cm distal to the farthest point for primary sarcomas and 1-2 cm distal for metastatic lesions 2 Perform resection place a malleable retractor medial to the femoral shaft to protect the soft tissues use an oscillating saw to make a right angle cut to the shaft of the femur 3 Remove the femur remove the femur laterally do not distract the femur because of the possibility of placing tension on the sciatic nerve 4 Identify the medial structures identify and tag the psoas and the adductors J Reaming and Trial Articulation 1 Ream the intramedullary canal use serial reaming to ream 2 mm above the chosen stem diameter a 1 mm cement mantle is required around the stem 2 Perform trial articulation match the length of the resected specimen to the length of the trial component check pulses if the pulses are diminished, they prosthesis should be shortened pull the joint capsule over the femoral component 3 Check stability test the prosthesis in flexion, adduction and internal rotation K Prosthetic Assembly and Implantation 1 Assemble the modular prosthesis 2 Cement the prosthesis into the medullary canal use pulsatile lavage to irrigate the canal use 2 bags of cement place an intramedullary cement restrictor reduce the cement by centrifugation pressurize the cement then use a cement gun precoat the proximal portion of the femoral stem with bone cement 3 Check the orientation of the prosthesis use the linea aspera as a guideline place the femoral neck 5 to 10 degrees anteverted with respect to the imaginary perpendicular line from the prosthesis and a line is drawn from the linea aspera through the body of the prosthesis 4 Cover tip of stem with extra cement L Soft Tissue Reconstruction 1 Secure the hip capsule tightly suture the remaining hip capsule with a 3 mm dacron tape around the neck of the prosthesis 2 Reattach the external rotators rotate the external rotators proximally and suture them to the posterolateral aspect of the capsule 3 Reattach the psoas rotate the psoas anteriorly and tenodese to the anterior capsule 4 Reattach the abductor tendon to the prosthesis use Dacron tape to attach the abductor tendon to the the lateral aspect of the prosthesis through a metal loop use the vastus lateralis and tenodese to overlie the abductor muscle fixation suture the remaining muscles to the vastus lateralis anteriorly and the hamstrings posteriorly N Wound Closure 1 Irrigation, hemostasis, and drain close wound over a 28 gauge chest tube under continuous suction cauterize peripheral bleeding vessels 2 Deep closure use 0-vicryl for deep fascia 3 Superficial closure use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressing and immediate immobilization place in balanced suspension with the hip elelvated and flexed 20 degrees Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids IV antibiotics continue until all drainage tubes are removed DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 continuous suction of drain for 3 to 5 days appropriately orders and interprets basic imaging studies post-op xrays of hip to evaluate implant position appropriate medical management and medical consultation inpatient physical therapy keep extremity in balanced extension for 5 days order a customized abduction brace mobilize in abduction brace for 6 weeks weight bear as tolerated active hip abduction is required before the abduction brace can be removed 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 remove sutures check radiographs 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 used to evaluate the extent and level of bony destruction MRI evaluates the medullary and extraosseous components of the tumor intracapsular extension presence of skip metastasis within the femoral canal angiography of the illiofemoral vessels 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 Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia Dislocation Abductor insufficiency and trendelenburg gait Prosthetic loosening
E Preoperative Plan 1 Radiographic templating determine the extent of the resection determine the dimensions of the required prosthesis 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 endoprosthesis system 2 Room setup and equipment standard OR table sterile hoods with circulating fans for surgical team hip positioners or bean bag check back table to make sure correct equipment available 3 Patient positioning lateral decubitus with operative extremity facing up axillary roll, anterior positioner on pubic symphysis, posterior positioner on sacrum, foley in place in obese patients place towel or pad between positioners and skin arms stacked on top of each other with blankets underneath and in between, taped down to arm boards prep and drape entire leg above iliac crest and midline sacrum to make sure adequate working area bovie pad on contralateral thigh or abdomen foot in "candycane holder" and ankle stirrup with extremity externally rotated to prevent knee buckling during prep G Lateral Approach 1 Perform skin incision make incision that starts 3 to 4 cm proximal to the greater trochanter extend the incision to the distal 2/3 of the thigh 2 Expose the gluteus medius and maximus 3 Detach the gluteus medius and maximus open the iliotibial band longitudinally detach the femoral insertion of the gluteus maximus retract the gluteus maximus posteriorly this allows visualization to the retrogluteal area, external rotators, sciatic nerve, abductors and the posterior capsule identify and mobilize the sciatic nerve identify the abductors transect the abductors through there tendinous attachments when there is no tumor involvement 4 Reflect the vastus lateralis transect the vastus lateralis from its origin at the vastus ridge and reflect distally ligate the posterior perforating vessels identify the femoral nerve below the fascia identify the superficial and profundus femoral artery and vein in the sartorial canal if they have been invaded by tumor then they can be ligated just distal to there takeoff from there common femoral vessel H Detachment of the Posterior Hip Musculature and Capsule 1 Detach the posterior hip musculature and capsule detach the rotator muscles en bloc 1 cm from their insertion on the proximal femur 2 Open the the hip capsule if there is no tumor involvement the hip capsule should remain intact because of its role in stability of the prosthesis open the capsule longitudinally along its anterolateral aspect and detach it circumferentially from the femoral neck 3 Dislocate the femur anterolaterally I Distal Femoral Osteotomy and Release of Medial Structures 1 Determine the level of the osteotomy typically this is 3-4 cm distal to the farthest point for primary sarcomas and 1-2 cm distal for metastatic lesions 2 Perform resection place a malleable retractor medial to the femoral shaft to protect the soft tissues use an oscillating saw to make a right angle cut to the shaft of the femur 3 Remove the femur remove the femur laterally do not distract the femur because of the possibility of placing tension on the sciatic nerve 4 Identify the medial structures identify and tag the psoas and the adductors J Reaming and Trial Articulation 1 Ream the intramedullary canal use serial reaming to ream 2 mm above the chosen stem diameter a 1 mm cement mantle is required around the stem 2 Perform trial articulation match the length of the resected specimen to the length of the trial component check pulses if the pulses are diminished, they prosthesis should be shortened pull the joint capsule over the femoral component 3 Check stability test the prosthesis in flexion, adduction and internal rotation K Prosthetic Assembly and Implantation 1 Assemble the modular prosthesis 2 Cement the prosthesis into the medullary canal use pulsatile lavage to irrigate the canal use 2 bags of cement place an intramedullary cement restrictor reduce the cement by centrifugation pressurize the cement then use a cement gun precoat the proximal portion of the femoral stem with bone cement 3 Check the orientation of the prosthesis use the linea aspera as a guideline place the femoral neck 5 to 10 degrees anteverted with respect to the imaginary perpendicular line from the prosthesis and a line is drawn from the linea aspera through the body of the prosthesis 4 Cover tip of stem with extra cement L Soft Tissue Reconstruction 1 Secure the hip capsule tightly suture the remaining hip capsule with a 3 mm dacron tape around the neck of the prosthesis 2 Reattach the external rotators rotate the external rotators proximally and suture them to the posterolateral aspect of the capsule 3 Reattach the psoas rotate the psoas anteriorly and tenodese to the anterior capsule 4 Reattach the abductor tendon to the prosthesis use Dacron tape to attach the abductor tendon to the the lateral aspect of the prosthesis through a metal loop use the vastus lateralis and tenodese to overlie the abductor muscle fixation suture the remaining muscles to the vastus lateralis anteriorly and the hamstrings posteriorly N Wound Closure 1 Irrigation, hemostasis, and drain close wound over a 28 gauge chest tube under continuous suction cauterize peripheral bleeding vessels 2 Deep closure use 0-vicryl for deep fascia 3 Superficial closure use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressing and immediate immobilization place in balanced suspension with the hip elelvated and flexed 20 degrees
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids IV antibiotics continue until all drainage tubes are removed DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 continuous suction of drain for 3 to 5 days appropriately orders and interprets basic imaging studies post-op xrays of hip to evaluate implant position appropriate medical management and medical consultation inpatient physical therapy keep extremity in balanced extension for 5 days order a customized abduction brace mobilize in abduction brace for 6 weeks weight bear as tolerated active hip abduction is required before the abduction brace can be removed 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