OT notes · Orthopaedics

Tumour resection with endoprosthetic (custom prosthesis) reconstruction

Usual anaesthesia
General anaesthesia
Position
Supine on a radiolucent table, whole limb prepared and draped free (and the opposite thigh if a skin graft may be needed)
Setting
elective

Operative note template for wide resection of a bone tumour around the knee with modular or custom endoprosthetic reconstruction (distal femur or proximal tibia with gastrocnemius flap), with a filled example for distal femoral osteosarcoma after neoadjuvant chemotherapy reconstructed with a modular distal femoral prosthesis.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • infection of the prosthesis (the commonest cause of failure), which may need further surgery or amputation
  • wound breakdown and skin flap necrosis
  • local tumour recurrence
  • injury to the femoral / popliteal vessels needing vascular repair
  • peroneal nerve palsy, especially if the limb is lengthened
  • heavy bleeding and blood transfusion
  • aseptic loosening, stem fracture or bushing failure
  • extensor mechanism failure and knee stiffness or instability
  • limb-length difference
  • amputation if limb salvage is not possible at surgery

Pre-operative details for this operation

  1. Diagnosis and biopsytumour type and grade, biopsy method, date and site of biopsy tract
  2. StagingMRI of the whole bone (skip lesions, intramedullary extent, soft-tissue mass, relation to vessels), CT chest, bone scan or PET-CT
  3. Neoadjuvant chemotherapyregimen, cycles, date of last cycle; blood counts on the day
  4. Resection planbone and site; planned osteotomy level measured from the joint line (cm); intra- or extra-articular; approach (medial / lateral / anteromedial / anterolateral)
  5. ProsthesisModularCustom-madeExpandable (growing child)system, sizes available, cemented or uncemented stem, rotating or fixed hinge
  6. Support arrangedblood units cross-matched; vascular surgeon and plastic surgeon on call; ICU bed

Anaesthesia and position

  1. AnaesthesiaGeneralcentral line / arterial line if planned
  2. PositionSupine on radiolucent table
  3. TourniquetNot used (distal femur)Used during cementation (proximal tibia)
  4. Drapingwhole limb free; ipsilateral thigh prepared for skin graft if needed

Operative findings

  1. Tumour extent seensoft-tissue mass size and direction, relation to vessels and nerves, joint involvement
  2. Neurovascular bundlefree of tumour / adherent; vessels ligated (e.g. anterior tibial artery)
  3. Biopsy tractexcised en bloc with the specimen
  4. Frozen section of marrow at osteotomy levelFree of tumourTumour present: further resection done
  5. Distal pulses after trial reductionpresent / reduced; change with knee flexion

Procedure (steps)

  1. Incisionsingle longitudinal incision including the biopsy tract in an ellipse; approach side
  2. Neurovascular dissectionfemoral / popliteal vessels and branches to the notch ligated; peroneal nerve neurolysis (tibia)
  3. Soft-tissue cuff and muscles releasednormal muscle cuff kept on the tumour; which muscles resected with specimen; quadriceps preserved as much as possible
  4. Joint opened and ligaments dividedcapsule, collateral and cruciate ligaments; patellar tendon detached (tibia)
  5. Rotation marked and osteotomyanterior midline mark; osteotomy level in cm from joint line; resected length
  6. Specimen removed and marrow sampledfrozen section sent; specimen oriented and labelled
  7. Re-preparationhaemostasis, saline wash, gloves, instruments and top drapes changed
  8. Bone preparationcanal reamed to stem size; tibial plateau cut (thickness) and canal reamed / distal femur prepared
  9. Trial reductionlength, rotation, joint line, range of motion, varus-valgus stability, patellar tracking; distal pulses checked
  10. Final implantPress-fit stemCemented stemcomponents and sizes; if cemented, femoral and tibial sides cemented separately
  11. Extensor mechanism and soft-tissue reconstructionquadriceps myoplasty; patellar retinaculum repair; patellar tendon to prosthesis with non-absorbable sutures or mesh; medial gastrocnemius rotational flap

Closure, drains and dressing

  1. Drainsnumber and size, deep to fascia, exiting in line with the incision
  2. Patellar repair checked at 90 degrees knee flexion
  3. Skin coverPrimary tension-free closureSplit skin graft on gastrocnemius flapNegative pressure dressing
  4. Dressing and orthosisKnee immobiliser in extensionCylinder cast
  5. Distal circulation and foot movements at end

Specimens and implants

  1. Resected specimensent for HPE with requisition: bone, side, length, orientation sutures, margins marked, chemotherapy response to be reported; X-ray of specimen
  2. Frozen section of marrowsent at time; result
  3. Prosthesis componentseach component: make, size, batch/lot, serial number, sticker pasted
  4. Cement, mesh, sutures for tendon attachmenttype and batch

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Distal circulation and peroneal nervefoot pulses, capillary refill, ankle and toe dorsiflexion; check closely, most often in the first 24 hours
  2. Drainsrecord output; plan for removal
  3. Hb and electrolytesHb and haematocrit closely; calcium and magnesium; blood kept ready
  4. Antibioticsdrug, dose and duration as per unit protocol
  5. DVT prophylaxisLMWH and compression stockings; drug and dose
  6. Wound and flapflap colour, skin edges; negative pressure dressing for 5 days if skin graft
  7. Rehabilitationdistal femur: quadriceps isometrics from POD 2, partial weight bearing 4 weeks; proximal tibia: extension orthosis 6 weeks, then flexion to 20, 60 and 90 degrees in 2-weekly steps
  8. OncologyHPE with margins and necrosis percentage; restart adjuvant treatment once the wound heals

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Miss S.P., 17 years, high-grade conventional osteosarcoma of the left distal femur, diagnosed on trocar biopsy through an anteromedial tract. MRI: tumour extends 11 cm from the joint line with a posteromedial soft-tissue mass close to but not involving the femoral vessels. CT chest clear. Three cycles of neoadjuvant chemotherapy completed.

Case details

Date: 03/08/2026. Elective left distal femoral resection and modular endoprosthetic reconstruction. OT 1.

In OT 08:30. Incision 09:30. Closure completed 13:40.

Surgeon: Dr A. (consultant, orthopaedic oncology). Assistants: Dr B. (3rd-year resident), Dr C. (2nd-year resident). Anaesthetist: Dr D. Scrub nurses: Sr E., Sr F. Vascular surgeon Dr G. on call.

Indication and pre-op

Indication: localised high-grade osteosarcoma of left distal femur, suitable for limb salvage (vessels not involved), after neoadjuvant chemotherapy.

Planned femoral osteotomy 14 cm from the knee joint line (about 3 cm above the tumour on MRI). Resection intra-articular.

Hb 10.4 g/dl, platelets 2.1 lakh, ANC 2800 per cumm. Blood group B positive, 4 units PRBC cross-matched.

Consent: general, procedure-specific, blood transfusion and anaesthesia consent in Hindi from patient and both parents. Infection, recurrence, vessel and nerve injury, loosening and possible amputation explained.

Left limb marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:10.

Anaesthesia and position

General anaesthesia with arterial line.

Supine on radiolucent table. Whole left lower limb painted with povidone-iodine and draped free. No tourniquet.

Procedure

Anteromedial longitudinal incision from mid-thigh to the tibial tubercle, taking the biopsy tract in an ellipse.

Findings: posteromedial soft-tissue mass about 6 by 5 cm, covered by a cuff of vastus medialis and adductors. Femoral vessels free of tumour. Biopsy tract excised with the specimen.

Femoral and popliteal vessels dissected and protected; branches to the notch ligated. Vastus medialis cuff and medial gastrocnemius origin kept on the tumour. Rest of the quadriceps preserved as far as the margin allowed.

Knee capsule, collateral and cruciate ligaments divided. Anterior midline of the femur marked for rotation. Femur osteotomised 14 cm from the joint line.

Specimen removed. Marrow from the proximal femoral canal sent for frozen section: no tumour.

Haemostasis secured. Wound washed with saline. Gloves, instruments and top drapes changed.

Femoral canal reamed for a press-fit stem. Tibial plateau cut freehand, 17 mm, horizontal, and tibial canal reamed.

Trial rotating-hinge prosthesis of 14 cm resection length inserted. Full flexion and extension with the patella relocated. Stable to varus and valgus. Patella tracks centrally. Femoral pulse good, popliteal and dorsalis pedis pulses present.

Final components: uncemented press-fit femoral stem, distal femoral body for 14 cm resection, rotating-hinge knee, cemented tibial component. Patella not resurfaced.

Closure

Remaining quadriceps reattached by myoplasty. Patellar retinaculum and fascia repaired; repair checked at 90 degrees of knee flexion.

Two suction drains deep to the fascia, exiting in line with the incision. Subcutaneous tissue and skin closed without tension.

Compression dressing and knee immobiliser in extension. Foot warm, dorsalis pedis pulse present.

Specimens and implants

Specimen: left distal femur, 14 cm, with vastus medialis cuff and biopsy tract, orientation suture at the proximal medial corner, sent for HPE in formalin with requisition asking for margins and chemotherapy necrosis. Specimen X-ray taken.

Frozen section of proximal femoral marrow: negative.

Modular distal femoral prosthesis: femoral stem, body, rotating-hinge knee and tibial component, one packet of bone cement. Make, sizes, batch and serial numbers recorded; stickers pasted.

End of procedure

Estimated blood loss 1200 ml. 2 units PRBC transfused, no reaction.

Inj cefazolin 2 g IV repeated at 13:10, 4 hours after the first dose.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to ICU in stable condition. Pulse 104/min, BP 112/70 mmHg.

Post-op orders

Left foot pulses, capillary refill, ankle and toe dorsiflexion checked closely, most often in the first 24 hours. Inform at once if foot drop or cold foot.

Drain output charting. Hb, haematocrit, calcium and magnesium tonight and on POD 1. 2 units PRBC kept ready.

Antibiotics as per unit oncology protocol. LMWH as per unit protocol and compression stocking on the right leg.

Quadriceps isometrics from POD 2. Partial weight bearing with walker for 4 weeks, then full.

Follow HPE report for margins and necrosis. Oncology review for adjuvant chemotherapy once wound heals.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 03/08/2026, 14:00.

Must document for this operation

  • That the biopsy tract was excised en bloc with the specimen. A tract left behind is a source of local recurrence, and the tumour board will ask about it.
  • Osteotomy level, resected length and the frozen section result. Margins decide recurrence risk, and the resected length is needed for revision and for matching the prosthesis.
  • Which muscles and vessels were resected or ligated. This explains weakness after surgery and guides flap planning if the wound fails.
  • Distal pulses and peroneal nerve status before closure and at the end. Vessel stretch and peroneal palsy are known risks, especially after lengthening.
  • Every prosthesis component with size, batch and serial number. Modular parts are revised separately, and each needs to be identified for recall or revision.
  • Specimen orientation and the questions asked of the pathologist. The pathologist can report margins and chemotherapy necrosis only if the specimen is oriented.

Common mistakes in these notes

  • Not stating whether the biopsy tract was removed.
  • Specimen sent without orientation or margin marks.
  • Resection length and component sizes missing.
  • Leaving out the soft-tissue reconstruction (myoplasty, flap, tendon attachment).
  • No post-op neurovascular order for the peroneal nerve.

Indian practice and paperwork

  • Record the batch and serial number of every component in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • Consent before transfusion of blood and blood components is a separate NABH requirement, apart from the surgical and anaesthesia consent. (NABH 5th ed., PRE.2(g))
  • Discarded formalin from specimen jars is chemical waste in the yellow (f) category; tissue not sent for HPE is human anatomical waste in the yellow bag. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Özger H, Sim FH, Puri A, Eralp L, eds. Orthopedic Surgical Oncology for Bone Tumors: A Case Study Atlas. Springer Nature; 2022, Ch 22, Implant reconstruction of the distal femur: I, modular prosthesis (Trovarelli G, Georgoulis J, Pala E, Mavrogenis AF, Ruggieri P); Ch 29, Implant reconstruction of the proximal tibia: modular prosthesis and rotational gastrocnemius flap (Funovics PT), pp. 225-233; 299-310.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; redose after 4 h (relevant for long resections). academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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