Updated: 10/4/2016

Endoprosthetic Reconstruction of Proximal Femur Malignant Lesion

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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

 

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