Biopsy Anatomical Approach

Region specific approaches

 

Theory

- want to traverse one muscle / one compartment

- keep away from NV bundle

- as a rule perform open biopsy through compartment the tumour is in

- this is the compartment that will require surgical removal in wide excision

- direct approach without going through muscle if possible i.e. tibia, distal ulna

 

Lower Limb

 

Thigh

 

1.  Lateral compartment ST tumour

- lateral approach

- through ITB

- through vastus lateralis / anterior to lateral intermuscular septum

 

2.  Medial compartment ST tumour

- medial approach

- through gracilis

- keep away from NV bundle

 

3.  Posterior compartment ST tumour

- posterior approach / transmuscular

 

Femur

 

1.  Femoral head / neck

- depends if lesion benign or malignant

- tdranstrochanteric: for completely contained osseous tumour

- Watson-Jones: however if is malignant will consign patient to extra-articular resection

 

Proximal Femur Tumour

 

Proximal Femur Bony Tumour0001Proximal Femur Bony Tumour0002

 

2.  Subtrochanteric

- remember lesions here in elderly may be chondrosarcoma from enchondroma

- lateral approach

 

Tumour Subtrochanteric Femur

 

3.  Femoral Shaft

- lateral through vastus lateralis

- anterior cortical window

 

Femoral Shaft Bony Lesion

 

4.  Condyles

- medial or lateral approach

- incision through medial or lateral vastus

 

Bony Lesion Lateral Distal Femur

 

Popliteal fossa

 

Popliteal fossa / parosteal OS

- posterior approach

- go through hamstrings or gastrocnemius

- depending on whether lesion medial or lateral

 

Parosteal Osteosarcoma

 

Patella

 

Direct anterior

 

Patella Lytic Lesion

 

Tibial

 

1.  Medial plateau proximal tibial bony tumour

- direct medial approach directly onto bone

 

Proximal Tibial Lytic Epiphyseal Lesion XrayTibial Shaft Lesion

 

2.  Lateral plateau proximal tibial bony tumour

- through biceps femoris

- avoid CPN

 

3.  Tibial shaft

- through tibialis anterior

 

4.  Medial malleolus

- direct medial approach

 

5.  Posterior distal tibia

- posterolateral approach

 

Fibula

 

1.  Fibular head

- incision posterior fibular head

- expose and protect CPN

 

2.  Fibular shaft

A.  Direct lateral

- straight down to bone

- fibula / peroneals and nerve get taken in salvage

B.  Posterolateral approach

 

3.  Lateral malleolus

- direct lateral approach

 

Distal Fibular Lucent Lesion

 

Leg

 

1.  Proximal posterior compartment ST tumour

- medial to tibia

- preserve anterolateral compartment

 

2.  Proximal anterolateral compartment ST tumour

- direct approach through tibialis anterior

- will likely not be able to preserve CPN

 

Talus

 

1.  Head and neck

- medial approach between T anterior and T posterior

- may need medial malleolar osteotomy

 

2.  Body

- Ollier's approach

 

Calcaneum

 

Bony tumour

- direct lateral

- avoid medial NV bundles

 

Calcaneal Bony Lesion CTCalcaneal Bony Lesion MRI

 

Foot

 

1.  Navicular / Medial cuneiform

- direct medial

 

2.  Cuboid

- direct lateral

 

3.  Intermediate cuneiform

- between EHL and EDC but away from dorsalis pedis

 

4.  Lateral cuneiform

- lateral to EDC

 

5.  Metatarsals / phalangeals

- dorsal approach

 

Metatarsal tumour

 

6.  Soft tissue tumour

- medial or lateral as required

 

Soft tissue sarcoma medial foot

 

Pelvis

 

Iliac crest

- definitive surgery via ilioinguinal approach

- best to use iliac crest aspect of this approach

- can go medial or lateral to crest

 

Pelvis Soft Tissue Sarcoma

 

Anterior column

- Watson - Jones through G medius

- avoid femoral NV bundle

 

Posterior column

- Kocher - Lagenbeck through G maximus

 

Pubis

- Pfannenstiel approach

 

Ischium

- lithotomy position

- detach adductor and hamstrings

 

Sacrum

 

Direct posterior approach

 

Upper Limb

 

Humerus

 

1.  Proximal humeral bony tumour

- direct lateral

- through deltoid muscle

- never deltopectoral (condemns patient to forequarter amputation)

 

2.  Shaft

- modified Henry

 

3.  Distal humerus bony tumour

- lateral longitudinal to capitellum

- medial approach to trochlea

 

Radius

 

1.  Proximal bony tumour

- protect radial nerve at all times

 

A.   Radial head: Kocher approach / through anconeus

B.   Proximal third:  Henry approach / take off supinator

C.   Middle third: Henry approach / take off pronator teres

D.   Distal third: Henry approach / take off pronator quadratus

 

2.  Distal radius

- dorsal approach as salvage is always wrist fusion

- through second compartment / sacrificeable

 

Lesion distal radius

 

Wrist / Hand

 

1.  Carpus

- dorsal approach

 

2.  Metacarpal / phalanges

- dorsal approach

- avoid volar to preserve NV bundle

 

Sarcoma Finger

 

Ulna

 

1.  Proximal ulna bony tumour

- direct subcutaneous approach

- away from ulna nerve

 

2.  Coronoid

- posterior approach with window for biopsy

 

3.  Distal ulna bony tumour

- direct lateral approach between FCU and ECU

- down onto subcutaneous surface of ulna

 

Clavicle

 

Clavicle

- direct subcutaneous

 

Scapula

 

Acromion - deltoid split

Spine - transverse approach

Body - Judet posterior approach

Glenoid - posterior approach, through T major

Coracoid - deltopectoral approach

 

Spine

 

C1-2 bony tumour

- anterior retropharyngeal approach

- anterior to SCM

- resect submandibular gland and ligate duct

- CN XII superiorly

- between carotid sheath and larynx

- biopsy through longus colli

 

C3-T1

- Smith-Robinson approach

- vertical incision

- split longus colli

 

T2 - T12

- posterior approach and transpedicular

- open or CT guided

 

L1-L5

- anterior retroperitoneal approach