OT notes · Orthopaedics

Open biopsy of bone / soft-tissue lesion

Usual anaesthesia
General or spinal
Position
Supine for most limb lesions (other positions as the site needs), bony prominences padded, C-arm available
Setting
elective

Operative note template for open (incisional) biopsy of a bone or soft-tissue lesion planned so the tract can be removed at definitive surgery, with a filled example for a proximal tibial lesion with a soft-tissue component.

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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

  • non-diagnostic sample and need for repeat biopsy
  • bleeding and haematoma
  • infection
  • spread of tumour cells along the tract (the tract is removed at the main operation)
  • fracture through the biopsy site
  • nerve or vessel injury
  • wound breakdown

Pre-operative details for this operation

  1. Lesionbone or soft tissue, site, side, size, depth (above / below fascia), compartment
  2. Work-up completed before biopsyX-ray, MRI of whole bone / part, CT chest, bone scan / PET if done, blood tests (myeloma screen if relevant)
  3. Clinical and radiological differential diagnosis
  4. Previous needle biopsyNoneCore biopsy: non-diagnostic / inadequateFNAC
  5. Planned definitive surgery and surgeonlimb salvage incision or amputation flap the biopsy tract must fall in; biopsy done by or with the surgeon who will do the resection
  6. Planned biopsy site and approachmarked on skin in line with the future incision; through one muscle, not an intermuscular plane; away from main neurovascular bundle
  7. Pathologist informedFrozen section bookedNot needed

Anaesthesia and position

  1. AnaesthesiaGeneralSpinalRegional block
  2. Positionposition and padding
  3. TourniquetNot usedLimb elevated then inflated, no Esmarch (to avoid squeezing tumour cells)time up and down
  4. C-armused to localise the lesion and the cortical window

Operative findings

  1. Soft-tissue componentpresent / absent, colour, consistency, bleeding, pseudocapsule
  2. Cortex and periosteumintact / breached / periosteal reaction
  3. Lesion tissuecolour, consistency (fleshy, gritty, cartilaginous, cystic, necrotic), bleeding
  4. Frozen section reportdiagnostic / non-diagnostic; what was said, by whom, time

Procedure (steps)

  1. LocalisationC-arm or landmarks; site marked
  2. Skin incisionlongitudinal, length (usually 3-5 cm), placed so it lies within the definitive resection; never transverse
  3. Deep approachstraight through a single muscle (name it); no flaps raised; no intermuscular plane opened; major neurovascular structures avoided
  4. Site sampledSoft-tissue extension (leading edge), bone not openedCortical window in boneSoft-tissue mass onlysample more than just the pseudocapsule
  5. Cortical window (if made)round or oval, size in mm, made with multiple drill holes and a small osteotome; curettage of lesion
  6. Specimen amount and handlingnumber and size of pieces; fresh for frozen section; formalin for HPE; fresh for culture; any tissue for special studies
  7. Frozen sectionsent at (time); result; further tissue taken if non-diagnostic
  8. Bone hole pluggedNot neededSmall amount of bone cement (PMMA) to plug hole
  9. Haemostasistourniquet released before closure; bleeding controlled (a haematoma carries tumour cells)
  10. Culturetissue sent for aerobic / anaerobic culture; antibiotic given after culture samples

Closure, drains and dressing

  1. DrainNoneSmall suction drain exiting in line with and close to the end of the incision
  2. Layersmuscle / fascia, subcutaneous, skin; suture used; tight layered closure, no wide retention sutures
  3. Dressing and splintsplint or protection if bone opened

Specimens and implants

  1. Frozen sectionnumber of pieces, time sent
  2. HPE (formalin)number of containers, label with site and side, clinical and imaging details on requisition
  3. Cultureaerobic, anaerobic; AFB / fungal if infection is in the differential
  4. Special studiesfresh tissue for cytogenetics / flow cytometry if requested by pathologist
  5. ImplantsNonePMMA plug: brand, lot

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. Limb elevation and neurovascular watch
  2. Weight bearingprotected weight bearing (e.g. 6 weeks) if bone was opened; state crutches / walker
  3. Drainoutput; removal time
  4. Woundwatch for haematoma and infection; dressing plan
  5. Analgesiadrug, dose, frequency
  6. HPE follow-upexpected date; tumour board discussion
  7. Culture follow-up
  8. Stitchesremoval date

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: Mr. A.S., 19 years, pain and swelling below the right knee for 2 months. X-ray: mixed lytic-sclerotic lesion of the proximal tibial metaphysis with periosteal reaction. MRI: lesion with an anteromedial soft-tissue component, no skip lesion. CT chest clear. CT-guided core biopsy non-diagnostic. Open biopsy by the tumour unit that will do the resection.

Case details

Date: 15/09/2026. Elective list. OT 4.

In OT 11:00. GA 11:10. Incision 11:35. Closure 12:20.

Surgeon: Dr A. (consultant, orthopaedic oncology), who will do the definitive resection. Assistant: Dr B. (2nd-year resident, Orthopaedics), who closed the wound.

Anaesthetist: Dr C. Scrub nurse: Sr D. Pathologist Dr E. informed; frozen section booked.

Indication and pre-op

Proximal right tibial lesion with soft-tissue extension, suspected primary bone sarcoma. Core biopsy non-diagnostic (only reactive bone).

Planned definitive incision: anteromedial longitudinal, for limb salvage. Biopsy site marked on this line, over the soft-tissue mass on the anteromedial tibia, 4 cm below the joint line.

Consent in Hindi, including repeat biopsy if non-diagnostic and fracture risk. Right leg marked. WHO checklist done.

Anaesthesia and position

General anaesthesia. Supine, bony points padded. No tourniquet. C-arm used to confirm level.

Painted with povidone-iodine and draped.

Procedure

4 cm longitudinal incision on the anteromedial proximal leg in line with the planned resection incision. No flaps raised.

Deep fascia opened in line. Soft-tissue mass reached directly; no intermuscular plane opened; saphenous vein and pes tendons not disturbed.

Findings: grey-white fleshy tissue with gritty areas under a thin pseudocapsule. Cortex breached by the lesion at this point.

Tissue taken from the soft-tissue extension (leading edge), deeper than the pseudocapsule: 4 pieces of about 1 x 0.5 cm. Bone not opened.

One piece sent fresh for frozen section at 11:45. Report at 12:05 (Dr E.): viable malignant tumour, diagnostic tissue obtained, final typing on paraffin sections.

After culture sample was taken, inj cefazolin 2 g IV given at 12:06.

Haemostasis with bipolar cautery. Wound washed with saline.

Closure

No drain. Deep fascia closed tightly with polyglactin 910 (Vicryl) 0. Subcutaneous tissue Vicryl 2-0. Skin subcuticular poliglecaprone (Monocryl) 4-0. No retention sutures.

Dressing. Distal pulses palpable.

Specimens and implants

Frozen section: 1 piece (fresh). HPE: 2 pieces in formalin, labelled right proximal tibia, soft-tissue extension; requisition with X-ray and MRI summary. Culture: 1 piece (fresh), aerobic and anaerobic.

No implant.

End of procedure

Estimated blood loss 60 ml. Count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 84/min, BP 118/72 mmHg.

Post-op orders

Right leg elevated. Watch for swelling of the wound.

Protected weight bearing with crutches till the definitive plan, because the cortex is breached.

Analgesia as per anaesthesia chart.

HPE report date noted; case to tumour board. Stitches: subcuticular, dressing check on day 3.

Signature

Dr B., JR-2, Orthopaedics, for Dr A. Reg. no. ________. 15/09/2026, 12:40.

Must document for this operation

  • Exact site, direction and length of the incision and the muscle it passed through. The whole biopsy tract has to be excised with the tumour; the resecting surgeon needs to know where it is.
  • Where the tissue was taken from (soft-tissue extension or bone) and the size and shape of any cortical window. A badly placed or irregular bone window can lead to fracture and loss of limb salvage.
  • Frozen section result and who reported it. Shows diagnostic tissue was obtained and prevents an unnecessary second biopsy.
  • Drain exit site, if a drain was used. The drain tract is also contaminated and must be excised en bloc.
  • Tourniquet use and how the limb was exsanguinated. Compression exsanguination can squeeze tumour cells into the circulation.
  • All specimens and their destinations. Missing a culture or special-study sample can delay diagnosis.

Common mistakes in these notes

  • Transverse incision, or no mention of incision direction.
  • Not stating whether tissue came from the soft-tissue extension or from bone.
  • Drain brought out away from the incision without recording where.
  • No frozen section result, so tissue adequacy is not known from the note.
  • No weight-bearing instruction after a cortical window.

Indian practice and paperwork

  • Specimens go in formalin for HPE; discarded formalin is chemical waste, yellow (f), and tissue not sent is human anatomical waste, yellow (a). (Bio-Medical Waste Management Rules 2016, DGHS/CPCB guidelines)
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed. (2020), COP.14(e) and (f))

Sources

  • Saghieh S, et al., eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 107, Incisional biopsy: soft tissue (Huang MJ); Ch 108, Incisional biopsy: bone tumor (Saghieh S), pp. 375-378.
  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 26, General principles of tumors: staging, biopsy, Table 26.4, pp. 873-877.
  • 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). 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.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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