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<br /> infection DVT/PE wound breakdown neurovascular compromise hardware failure 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 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
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
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