Orthopaedics Assessment:

Oncology Division

dr. Reza Devianto Hambali

dr. Bugi Priandika
dr. A.S. Marsahala Lumbantobing

Consultants :
Prof. Dr. dr. Darmadji Ismono, Sp.B., Sp.OT(K).
dr. M. Naseh Sajadi Budi Irawan, Sp.OT(K).
dr. Herry Herman, Sp.OT., Ph.D.
dr. Bangkit Primayudha, Sp.OT.
Preoperative Assessment
Mrs.R.,57 y.o.
 Mrs. R, 57 y.o.
History Taking:
Chief complain: lump and wound at right thigh
2 year prior hospital admission, the patient
complained of swelling that came suddenly at her
right thigh
• Then there was lump with the size of a egg, but
grew bigger as an tennis ball
• Patient feels pain in her thigh
• There is no decrease sensibility on the leg
• History of fever was denied.
• History of lumps elsewhere was denied.
• History of night pain was denied
• 10 months before came to Hasan Sadikin Hospital,
patient seek medical treatment in Subang General
Hospital, got X ray, CT scan and biopsy
examination

Past Medical History:

Physical Examination • There is no past medical history
At Right Thigh :
L: Lump +, sixe 12x8x4 cm at posteromedial aspect of thigh, ulcer +, discharge +, shiny skin +, discoloration around lump +, fungating wound
(+) size 1x1x0.5cm, scar +, venectation (-), peau d'orange (-), distal swelling (-)
F: Tenderness +, warmth +, immobile, semi solid, ill defined margin, irreguler surface, distal neurovascular was normal compared to other side,
CRT <2“
M: ROM hip and knee joint within normal limit
X Ray (July 2021)
X Ray (July 2021)
MRI (August 2021)
MRI (August 2021)
MRI (August 2021)
MRI (August 2021)
MRI (August 2021)
MRI (August 2021)
MRI (August 2021)
PA (November 2020)
 Pathological Finding
(Illustration)

Özer, E. Pleomorphic rhabdomyosarcoma. PathologyOutlines.com website.

https://www.pathologyoutlines.com/topic/softtissuepleomorphicrhabdo.html.
Accessed September 27th, 2021.
 Working Diagnosis:

Malignant soft tissue tumor at right thigh posteromedial

aspect suspect rhabdomyosarcoma Enneking
classification stage IB

Plan to:

• Wide excision
• Radiotherapy
SURGICAL
PLANNING
SURGICAL
PLANNING
 SURGICAL
PLANNING

Exposure.
• Large anterior and posterior fasciocutaneous flaps are elevated and retracted anteriorly to expose the vastus medialis and the
sartorial canal and posteriorly to the lower edge of the adductor muscle group.
• The sartorius muscle is the key to the dissection of the entire muscle group.
• The sartorial canal is opened proximally to identify the common femoral artery and vein prior to ligation of the profundus
vessels
• The obturator vessels are ligated and transected. The dissection continues from proximal to
distal.
• The profundus femoral vessels are usually ligated and transected.
 SURGICAL
PLANNING

Exploration:
• The sartorial canal is mobilized along the sartorius muscle.
• The common femoral artery and vein and
profunda femoral artery and vein are identified, as well as the popliteal artery and vein as they exit the adductor hiatus by the knee joint.
• Care must be taken to identify the profundus and common femoral artery and vein prior to ligation of the profundus
vessels.
• The dissection continues from proximal to distal.
• The profundus femoral vessels are usually ligated and transected.
 SURGICAL
PLANNING

• Release of adductor muscles from insertion.

• The adductor magnus and longus are detached from their insertions on the femur throughout its
length to the adductor hiatus.
• The adductor magnus tendon is then transected distally.
SURGICAL
PLANNING
 SURGICAL
PLANNING

The lateral (biceps femoris long head and short head) muscles are exposed.
 SURGICAL
PLANNING

• Resection generally involves the long head of the biceps femoris, semimembranosus, and semitendinosus.
• It is possible for a portion of the lateral quadriceps mechanism to be included with the specimen.
• The three muscles mentioned are superficial to the sciatic nerve, and their origin is from the ischial tuberosity. A tumor-free
margin of resection depends on a tumor-free plane superficial to the posterior limits of this compartment.
• It is clear that the next adjacent structure is the sciatic nerve itself.
 SURGICAL
PLANNING

• Dissection of the muscle group from proximal to distal aspects.

• Blood vessels and nerves that enter the hamstring muscle are ligated and divided.
By means of blunt and sharp dissection, the sciatic nerve, the short head of the biceps laterally, and the adductor
muscles medially are elevated from the base of the dissection.
 SURGICAL
PLANNING

• The long head of the biceps femoris muscle is transected through its tendinous portion
on the lateral aspect of the thigh.
• One must take care to avoid injury to the common peroneal nerve.
Thank You