Orthopaedic Oncology Surgical Prep

Simple cases do not require blood transfusions. Larger cases may require a blood transfusion, so before surgery, a blood sample may be taken to determine your blood type. Many patients ask about blood donation before their surgery. For patients with cancer, it is not advised to donate blood to oneself. For patients that do not have cancer, if you want to donate blood, you should go through your local Red Cross. Patients who do require transfusions should feel comfortable with the blood from Mass General's blood bank. For more information about Mass General's blood bank, visit their website.

All patients receive a dose of antibiotics in surgery, and then if they remain in the hospital will receive two additional doses of antibiotics. Sometimes complex cases require prolonged use of intravenous antibiotics, such as those involving malignant tumors, plastic reconstructive surgery or a diagnosis involving infection (such as a prosthetic joint infection, post-operative wound infection, etc).

These risks involve the formation of a blood clot inside a vessel, usually in the legs but can occur in the arms (DVT) and sometimes in the lungs (PE). Symptoms of a DVT can include pain and swelling in an extremity and fever. Symptoms of a PE vary but can include chest pain, shortness of breath, pain in the shoulders, pain with deep breathing and fever.

During most operative procedures and post-operatively, SCDs are placed on the lower extremities to prevent blood clots and maintain adequate circulation. (picture of SCDs) Post-operatively, for simple surgeries, medication to prevent blood clots (anticoagulation) is not necessary unless mobility will be affected. In those cases, a daily aspirin may be prescribed. For more complex procedures involving benign and malignant tumors of the pelvis, hips and lower extremities, an anticoagulation medication will be prescribed; most often Lovenox, a subcutaneous injection. 

Patients already taking one of the many oral anticoagulant medications for other medical issues such as placement of a cardiac stent, prior stroke or atrial fibrillation, will resume their home medication post-operatively and not receive additional anticoagulant medication from their physician.

Depending upon the anatomical location of your surgical incision, there are always underlying nerves and vessels that can be injured during surgery. Usually, the injury is temporary and with time, symptoms lessen. Because nerves and vessels control motor and sensory function, symptoms are often numbness (sensory) and weakness (motor).

Some patients have a slower healing process than others, maybe due to medical issues (i.e. diabetes) or sometimes post-operative swelling and redness occur, which can represent a skin infection (superficial cellulitis) or a deeper infection. Other patients develop a fluid collection (seroma) or blood collection in the operative area (hematoma) or even extra drainage coming from their incision. All of these situations require a visit to your surgeon, where you may or may not need an antibiotic or wash-out (surgical cleaning of the incision).

With any surgery, even the smallest procedure, there are inherit risks related to our body systems: cardiac, respiratory, gastrointestinal, genitourinal, neurological.

While in the prone position (face-down), patients are at risk for pressure sores on their forehead, under their eyes and on their chin. Anesthesia works diligently to protect a patient’s skin using an assortment of facial pads. It is extremely rare to develop blindness. One of the reasons we stage these procedures is to decrease the amount of time a patient remains in a prone position.

In addition to the information on infections listed above, for these complex procedures, antibiotics usually are continued throughout the patient’s hospital stay.

In addition to the information on blood clots listed above, in between the stages of complex procedures, an Inferior Vena Cava (IVC) filter is placed to prevent blood clots from entering the lungs, causing pulmonary emboli. These filters are retrievable and stay in place for an average of 3-6 months after these major surgeries. They eventually will be removed. Some form of anticoagulation medication usually is prescribed (aspirin, Lovenox) after all stages of the procedure are complete.

atients may have bowel, bladder and sexual dysfunction with pelvic and sacral surgeries, even lower level lumbar spine surgeries. Surgeries involving the spine run the risk for paralysis, foot drop, bilateral lower extremity edema and weakness.

Removing tumors in the spine may damage the dura, which is the covering of the spinal cord. This is common with these complex surgeries. Treatment for a dural tear involves lying flat for 24+ hours with the hope of spontaneous healing of the leak. Some patients experience headaches or sensitivity to light from the dural tear. Caffeine and medication are prescribed for the headache and dimming the lights for comfort. Sometimes with a persistent leak, the patient returns to the operating room where your surgeon will “patch” the leak.

Sutures or staples are not removed for a minimum of four weeks usually longer, to allow adequate tissue healing.

When a tumor is removed in the pelvis or spine, a dead space is left behind. This space tends to fill-up with fluid, which is a normal occurrence. However, if the fluid becomes infected, or the patient is experiencing significant pain/other symptoms, the patient will return to surgery for a washout. This procedure involves opening the incision and draining the fluid, washing the operative site and/or any involved instrumentation. Unfortunately, this is a common recurrence due to the preoperative radiation and complexity of the procedure. Many times this will lead to a prolonged intravenous or oral antibiotic course or a consultation with our plastic surgery team to fill the dead space with muscle/skin graft.

Patients with extensive pelvic or spinal instrumentation (hardware), run the risk of loosening or fracture of the instrumentation. Some patients continue to function well with fractured hardware, but when pain worsens and mobility decreases, the patient will return to surgery for hardware revision.

Patients usually receive pre-and-post operative radiation therapy to prevent recurrent tumor. Unfortunately, radiation weakens the bone and can cause tiny stress fractures to occur in the radiation field where the bone received the treatment. These fractures cause pain and most are treated non-operatively with pain medication and limiting physical activity.

Patients who have complex past medical history including atrial fibrillation, history of heart attack, stroke, cardiac stents, emphysema, diabetes and obesity, run the risk of having post-operative problems associated to their medical history. In addition, many patients develop issues that were unforeseen, like deep vein thrombosis, pulmonary emboli, pneumonia, gastrointestinal bleed due to medication or even acute renal failure and/or allergic reaction due to medication. If these problems occur, physicians in all specialists are consulted to address these problems.

Patients with cervical and thoracic spine tumors sometimes endure prolonged intubation (breathing tube placed during surgery). Because of the removal of tumor and reconstruction of the spine in these areas, it is normal for patients to have a prolonged intubation. However, the surgeon and intensive care unit staff monitor how long the tube is in. If the tube is in place too long, a tracheostomy is placed after a lengthy discussion with the patient’s family. This tracheostomy usually is temporary until the patient can breathe on his/her own.

Patients who are unable to eat solid food, such as those with a tracheostomy or signification swelling that occurs after cervical procedures, will be fed by a Nasal Gastric Tube (NG Tube) or a Gastric Tube (G Tube). Tissue healing requires a high caloric intake. Patients will have a consult with our nutritionist.

Some patients will have permanent dysfunction, while others have a temporary pause with bowel and bladder function associated with most pelvic and lower lumbar spine surgeries. If the nerves that provide this function are not removed with the tumor, then normal function or semi-normal function should return. In the meantime, for bladder function, both male and female are taught how to self-catheterize. The same principles hold true for bowel function. Patients with permanent bowel dysfunction, sometimes decide to have a colostomy. Many patients through trial-and-error, find a bowel regimen that suits their lifestyle, meaning some patients use chronic laxative, suppositories, time their bowel movements (planned visit to the bathroom), even digital evacuation.

Most pelvic and spine surgeries require a stay in the intensive care unit. Normal sleep/wake cycles are disrupted due to the intensive nursing care required around-the-clock. In addition to interrupted sleep, anesthetic and narcotics contribute to confusion. The surgical team relies heavily on family members to inform us if patients are acting confused. Infection or reaction to medications can cause confusion, even something as simple as a urinary tract infection.

During the informed consent process, most complex surgical procedures mention the risk of death due to those unforeseen medical complications.

Drug (Generic)	Common Trade Names	When to Stop
ASA	Aspirin	No significant risk when taken alone.
Apixaban	Eliquis	3 days (CrCl>50) 4 days (CrCl<50)
Clopidogrel	Plavix (75mg)	5-7 days
Dalteparin (therapeutic)	Fragmin (5000 units BID or 120 units/kg BID or 175 units/kg QD)	24 hours
Dalteparin (prophylactic)	Fragmin (</= 5000 units QD)	12 hours
Enoxaparin (therapeutic)	Lovenox (>60mg QD or 1mg/kg BID or 1.5mg/kg QD)	24 hours
Enoxaparin (prophylactic)	Lovenox (</=60mg QD)	12 hours
Fondaparinux	Arixtra (2.5mg)	4 days
Fondaparinux	Arixtra (5mg, 7.5mg, 10mg)	7 days
Rivaroxaban	Xarelto	2 days (CrCL > 50); 3 days (CrCl < 50)
Warfarin	Coumadin	3-5 days, INR </= 1.5

• Use Hibiclens® soap instead of your regular soap. Do not use both. If you do, the Hibiclens will not work correctly.
• Do not use Hibiclens® if you have an allergy to chlorhexidine-containing products. If you do, you may use an antibacterial soap instead (like Dial antibacterial soap).
• Do not use Hibiclens® on your head or face. If you get this soap in your eyes, flush with water right away.
• Do not use Hibiclens® on the vaginal area.

Do not follow the directions on the Hibiclens package. They are meant for surgeons. Follow the instructions below:

• First, rinse your body very well with water.
• Turn the water off.
• Wash with the Hibiclens® from the neck downwards. Wash the part of your body (hip, knee, etc.) where you are having the surgery very well.
• Wash your body gently for five minutes. Do not scrub your skin too hard. You can use a sponge to help with lathering. Hibiclens® does not lather as well as regular soap.
• Turn the water back on and rinse well. Pat dry with a clean towel.

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• 5 days before my surgery: apply one dose in evening
• 4 days before my surgery: apply one dose in morning and evening
• 3 days before my surgery: apply one dose in morning and evening
• 2 days before my surgery: apply one dose in morning and evening
• 1 day before my surgery: apply one dose in morning and evening
• My surgery day: apply one dose in morning

• Wash your hands very well.
• Put a pea-size amount of ointment onto a cotton swab. Insert the cotton swab about 1/4 inches into the nostril and apply the ointment.
• Remove the cotton swab. Close the nostril by pressing the sides of the nose together and releasing. Massage the nostril in this way for one minute to spread the medicine evenly throughout the nostril.
• Use a new cotton swab and do the same thing to the other nostril.
• Wash the skin below your nose to remove any remaining medicine. Wash your hands.
• Do not touch your eyes. If the medication gets into your eyes, it may cause burning and tearing. If this happens, rinse your eyes well and call your doctor.
• If your surgery is postponed, stop your medication schedule above.
• If your new surgery date is more than 2 weeks away, start the whole schedule again 5 days before your new surgery date.
• If your new surgery date is less than 2 weeks away, continue your medication schedule where you left off. For example, if you took medication for 2 days before stopping, restart the medicine 3 days before your new surgery date.

You need to call the office (617-724-3700) the day before your surgery about 1-2 pm. If your surgery is on Monday, please call the office on the Friday before your surgery because the office is closed for the weekend.

YES. There will also be a surgical assistant, either the fellow or resident to assist your doctor. Your surgical team involves your surgeon, the fellow or resident, the anesthesiologist, and a scrub nurse who all remain sterile and at your side at all times. A circulating nurse is also pre-sent to circulate around the operating.room and help with the needs of the team.

Patients who are having major abdominal, pelvic, sacral or complicated pelvic and hip surgery need a 'bowel prep.' When the bowel is empty of stool, it is more manageable during the surgical procedure and the area being worked on is more visible. Severe infection and complications can arise if stool contaminates the surgical area. A bowel prep consists of a clear liquid diet the entire day before surgery which limits you to broth, black tea or coffee, jello, pop-sides, apple/cranberry/ clear juices and ginger ale. No cream, milk or juice with pulp. No solid food at all which includes gum, candy and crackers. Antibiotics taken by mouth will be ordered for you to take at 12 noon, 4 p.m., 8 p.m. and 10 pm on the day before surgery. 'Golytely' is a drink that you will take between 2 and 6 p.m. on the day before surgery which will cause you to have several bowel movements to empty or 'clean out' your bowel. A more gentle version of the bowel prep for less complicated surgery involves the clear liquid diet, one bottle of Magnesium Citrate (the size of a soda) and about 2 enemas on the afternoon and evening before surgery. Years ago insurance companies would pay for a one day preoperative stay in the hospital for the bowel prep. Now most preps are done at home and the patient arrives at the hospital on the same day as surgery.

Patients who have complex surgery involving the pelvis, abdomen, sacrum or hip usually go to the ICU for closer observation by the medical and nursing staff until all of the major body systems are stable. Many times the endotracheal or 'breathing tube' is left in your throat for a few days. If you wake up with this tube, you will not be able to speak. The nurses will give you medication to relax you and prevent you from pulling at the tube or 'fighting' the tube. Your breathing and amount of circulating oxygen, hematology and chemistry blood values, heart function, and incision are closely monitored. The breathing tube will be removed as soon as the anesthesiologist or intensive care physician feels you can safely breathe on your own. As soon as all of your systems are stable, you will be transferred to the nursing floor. ICU visiting hours are limited, as is the number of visitors allowed per patient due to the severe surgical and medical conditions of all the patients in the ICU.

Most of our patients receive pain medication (narcotics) through the patient controlled analgesia (PCA) pump. The narcotic is morphine or dilaudid. The medication is placed in a syringe and locked into a pump. You are able to push a button to receive your pain medication. You can not overdose because the pump is calculated, set and locked at your correct dosage. If an epidural catheter was placed to administer your anesthesia during surgery, pain medicine will also be delivered through this catheter postoperatively. After a few days, you will be weaned off the intravenous pain medication and given pain medication pills. We usually dis-charge our patients with a small supply of Percocet or Tylenol with Codeine for children and instruct them to wean off this medication within a week or two. Eventually Tylenol Extra Strength or anti-inflammatories such as Advil, Motrin or Aleve can be taken for minor discomfort. Anti-inflammatories should not be taken if you are taking Coumadin.

Patients with pelvic, hip and thigh surgery will have a catheter placed after they are asleep from anesthesia. The catheter remains in place for a few days postoperatively.

Anticoagulation means preventing a blood clot, Deep Vein Thrombosis (DVT/VTE) or Pulmonary Embolism (PE) from forming. These involve the formation of a blood clot inside a vessel, usually in the legs but can occur in the arms (DVT) and sometimes in the lungs (PE).

Many people refer to anticoagulants as 'blood thinners'. They actually do not thin the blood, rather lengthen the time it takes for blood to clot. If you take an anticoagulant, it makes it harder for a clot to form in your blood vessel, or it keeps an existing clot in your vessel from getting bigger.

There are several anticoagulation medications available to prevent a blood clots. You will be prescribed the appropriate medication after surgery for your condition and type of surgery performed. For example:

• Aspirin: once daily
• Lovenox injection: usually once daily
• Eliquis: twice daily
• Xarelto: daily
• Coumdin: daily in the evening
• Or, resume your regular home dose of anticoagulation medication