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 discuss result of the biopsy plan definitive surgery diagnose and management of early complications<br /> infection DVT/PE wound breakdown neurovascular compromise postop: 4-6 week postoperative visit check radiographs diagnosis and management of late complications<br /> 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 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 Inadequate specimen Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia
E Preoperative Plan 1 Radiographic templating template part of the lesion to be biopsied plan the biopsy tract 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 guiding needle 2 Room setup and equipment Standard OR table fluoroscopy 3 Patient positioning depends on the area of the lesion G Biopsy Tract 1 Mark incision over lesion define what part of the lesion needs to be biopsied plan the safest anatomic route to the lesion 2 Make a longitudinal incision transverse incisions are contraindicated because of the need for a wider resection at the time of surgery H Entry Hole to Bone 1 Create cortical window oblong holes with rounded edges have the greatest residual strength I Remove Tissue 1 Use a knife or curette to remove the tissue care must be taken not to crush the sample 2 Send frozen section ensure that the obtained tissue is adequate J Hemostasis 1 Seal the cortical window plug the window with methacrylate to limit hematoma formation K Wound Closure 1 Perform layered closure use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 2 Place dressings place soft dressings over incision
O Perioperative Inpatient Management 1 Write comprehensive post operative orders pain control advance diet as tolerated check appropriate labs wound care remove dressings POD 2 IV fluids nutrition appropriate medical management and medical consultation follow up with pathology for findings of biopsy inpatient physical therapy weight bear as tolerated 2 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 3 Discusses prognosis and end of life care with patient and family