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Distal Femur Resection

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 or radiolucent
  • osteoblastic or radiodense
  • mixed

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
  • identifies characteristics of the tumor on T1 and T2 sequences
  • angiography
  • determines the vascularity of the tumor
  • lab studies
  • SPEP/UPEP
  • PSA
  • TSH
  • LDH/ALP
  • 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

E

Preoperative Plan

1

Radiographic templating

  • template implant size

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

  • endoprosthetic system of the distal femur

2

Room setup and Equipment

  • Standard radiolucent OR table
  • fluoroscopy (optional)

3

Patient Positioning

  • supine position with bump underneath the hip
G

Extensile Longitudinal Medial Approach

1

Mark the incision

  • make a longitudinal incision proximally along the sartious border and follow it distally towards the medial aspect of the tibial tubercle
  • Any previous biopsy tract should be kept in line with the incision and should be ellipsed

2

Identify the saphenous nerve

  • identify and protect the saphenous nerve

3

Create interval

  • open the interval between the sartorius and vastus medialis
  • expose the superficial femoral artery and vein along the saphenous nerve
H

Tumor Margins and Neurovascular Mobilization

1

Mobilize structures

  • dissect the vessels and the saphenous nerve from proximal to distal
  • reflect the structures posterior and medial with the sartorious

2

Tie off vessels

  • tie off all geniculate vessels with 2-0 or 3-0 silk ties as they course from the vessels towards the distal femur and tumor
  • be careful to not tie off the medial or lateral sural vessels that are found posteriorly and are the main blood supply to the respective gastrocnemius muscles
  • these vessels will be the base of the gastroc flap if needed
  • be careful at the canal of Hunter because these vessels are just deep to the adductor tendon

3

Dissect out the popliteal vessels

  • distal to the canal of Hunter, dissect the popliteal vessels and reflect posterior and medial
  • visualize the short head of the biceps proximal to distal joining the long head laterally

4

Identify and protect the sciatic nerve

5

Expose the tumor

  • reflect the quadriceps laterally off the femur by separating the junction between the adductors and the vastus medialis proximal and medial to the tumor

6

Ligate the appropriate vessels

  • ligate the terminal profunda artery and vein just deep the medial intermuscular septum

7

Dissect out neurovascular structures

  • dissect the superficial femoral vessels, saphenous nerve and popliteal vessels from the tumor throughout its length to below the joint line

8

Incise the medial gastrocneumius

  • be sure not to ligate the medial sural vessels

9

Expose the distal aspect of the tumor

  • with the femoral vessels dissected and reflected, reflect a portion of or entire quadriceps along with the patella and patellar tendon over the tumor
  • this leaves the vastus intermedialis as an oncologic margin

10

Open the joint capsule

  • cut the ACL, PCL, popliteus tendon and the collateral ligaments
  • cut the posterior capsule while the popliteal vessels are kept in direct view or under your finger to prevent injury

11

Reflect the quadriceps over the tumor

  • leave a cuff of muscle on top of the tumor as the tumor margin

12

Make cortical marks

  • before dislocating the knee, place marks proximally on the femur and tibia
  • mark the distance between the points
  • this distance should be the same after the prosthesis is implanted
  • the anterior cortex is marked on the proximal femur to help with rotary alignment during the femoral stem insertion
  • the linea aspera is also used to approximate rotary position

13

Dislocate the knee

  • cut the short head of the biceps and the rest of the posterior capsule
I

Femoral Resection

1

Cut the femur

  • cut the femur with a saw at the predetermined level
  • remove one centimeter more than the assembled length of the femur

2

Identify pathology

  • send a sample of proximal marrow to pathology for fresh frozen analysis and tumor margin

3

Prepare the femur

  • ream the femur to accept the largest stem possible
  • chamfer the cut end
  • clean the cut end with an irrigating brush
J

Tibia Cuts

1

Prepare the tibia

  • remove 7 mm of proximal tibia
  • osteotomize the tibia with an oscillating saw with a slightly posterior slope
K

Confirm Length, Rotation, And Trial Components

1

Place trial components

  • remove half of the undersurface of the patellar fat pad
  • remove and prepare the undersurface of the patella with a burr to receive the patellar component
  • resurfacing the patella is optional as some surgeons opt not to resurface for pediatric patients

2

Perform trial reduction

  • measure to make sure that the post-construction distance is the same as the pre-resection difference
  • passively range the knee to assess for rotation, length, and patellar traction
  • check the tension of the neurovascular structures
L

Final Implant Placement and Hinge Assembly

1

Cement in the appropriate order

  • cement the tibia component and the patella first

2

Insert the femoral component

  • insert the femoral component slowly

3

Confirm measurements

  • make a final measurement with the components in place
N

Wound Closure

1

Perform deep closure

  • close the joint capsular tissue to the remaining capsule around the proximal tibia
  • use 0-Vicryl for deep closure
  • suture the sartorius to the vastus medialis over a 10 mm flat drain with an 0-Vicryl suture

2

Perform superficial closure

  • place a 10 mm flat drain
  • use 2-0 vicryl for subcutaneous closure
  • use 3-0 monocryl or staples for skin

3

Place dressings

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 or when output is less than 30cc/24hr
  • appropriately orders and interprets basic imaging studies
  • check radiographs of the humerus in post op
  • appropriate medical management and medical consultation including medial oncology
  • appropriate evaluation by radiation oncology if deemed appropriate
  • Inpatient physical therapy

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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