Sport and Exercise Sciences Research Institute
Standard Operating Procedure
QUADRACEPS MUSCLE BIOPSY
(SS/SOP0021)
Procedural Equipment
Disposable razor.
Standard dressing pack (365 Healthcare, Worcs, UK or equivalent).
Biogel® sterile gloves or equivalent.
Inadine® or alternative skin antiseptic.
Foliodrape® surgical drape.
5ml syringe.
Green needle (21gauge).
Blue needle (23 gauge).
5mls of 2% lignocaine/adrenaline (Xylocaine® 2% with adrenaline 1:200,000).
Size 11 disposable surgical scalpel (Swann-Morton, Sheffield, UK).
ACECUT® automatic biopsy system (TSK Laboratory, Japan).
Steri-strips.
Mepore or equivalent wound dressing.
Permanent marker (black) & Measuring tape (1 metre).
Verbal Consent
The patient will have already signed the study consent form.
For good clinical and research practice, please advise the patient regarding certain factors
pertaining to the muscle biopsy process particularly in relation to a stinging effect on
administration of the local anaesthetic and a pressure or pinching sensation on acquisition
of the muscle specimen. Advise the patient that there will be a small wound which will be
closed with paper stitches (steri-strips) and that the dressing will fall off naturally over
the following few days which is to be expected and should not worry the patient. The
wound may be slightly painful on the patient’s second walk in the research clinic and this
is expected. The wound may become slightly painful later in the day and simple analgesia
with paracetamol or co-codomol should be sufficient to minimise this discomfort. There
is a small risk of bruising and infection at the wound site and patients are advised to
minimise strenuous activity for approximately 48-72 hours post-procedure.
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Anatomical Marking
1) Examine the quadriceps muscle on the right lower limb to rule out previous surgery,
trauma or other scars / wounds which would preclude biopsy testing on that limb.
(If any concerns use the contralateral limb – left side).
2) Measure the distance directly from the anterior superior iliac spine to the top of the
patella on the right lower limb.
3) Mark the half way point of this line using a permanent marker.
4) Palpate the quadriceps muscle at this level to ensure adequate bulk of muscle for
biopsy.
5) Triangulate the biopsy site using a permanent marker.
(Do not mark the site of biopsy directly to minimise the risk of skin tattooing).
Anatomical Marking for Week 2 Visit Muscle Biopsy
A different muscle biopsy site is required to avoid tissue sampling from the previous site
which could introduce a sampling error. As described previously assess the plane
between the anterior superior iliac spine and patella. On this imaginary line, select a new
biopsy site 3cm distal to the previous biopsy site.
Procedure
To be performed using an aseptic technique.
1) Open dressing pack.
2) Remove contents from container and empty over onto sterile area of pack.
3) Fill the two smaller compartments with inadine skin antiseptic.
4) Open 5ml syringe, green and blue needles onto dressing pack sterile area.
5) Aspirate 5mls of 2% lignocaine / adrenaline.
6) Prepare the biopsy site over the marked biopsy site.
7) Cut a perforation in the surgical drape and cover the biopsy site.
Advise patient of possible stinging effect of local anaesthetic and ensure blue needle
attached to syringe.
Always aspirate prior to injecting any of the local anaesthetic to reduce risk of
intravascular infiltration.
8) Infiltrate 1-2mls of local anaesthetic over a 2cm transverse plane in the middle of the
triangulated area of the biopsy site.
(Note the small needle infiltration wound which is not the site of maximal infiltration).
9) Leave for 90 seconds.
10) Remove blue needle from syringe and attach the green needle.
11) Insert the green needle through the centre of the previously injected local anaesthetic
at a 90 degree angle and inject 1-2mls gradually.
12) Then repeat a further time with l-2mls at an 80 degree angle.
13) Massage the area gently for 20-30 seconds and wait for a further 90 seconds.
Biopsy Procedure – ACECUT automatic biopsy system
Please read directions for use prior to obtaining biopsy.
1) Open the device sterile packaging and allow the person obtaining the sample to
remove the device aseptically onto the sterile dressing pack area.
2) Examine the device to ensure there are no defects.
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3) Remove the needle sheath cover.
4) Prepare the device for use by locking the trigger safety switch in the LOCK position.
5) Confirm the sampling lever is in the closed position.
6) Pull the cover level slowly upwards until it touches the safety switch where a clicking
sound will occur.
7) Close the cover lever back to the neutral position.
8) Tap the patient’s skin with the scalpel first to ensure adequate anaesthesia.
9) Incise the skin transversely in the middle of the marked triangulated area.
10) Ensure the skin wound is only 0.5cm in diameter.
(A 0.5cm wound roughly equates to a third of the scalpel length inserted into the wound).
11) Insert the prepared biopsy device at 90 degrees to skin edge.
12) Pass the biopsy device deeply until the fascia has been passed. The quadriceps
muscle may twitch when the device has entered the subfascial plane.
The operator should use their other hand to steady the device and minimise the risk of
passing the biopsy device too deeply.
13) Set the biopsy device safety switch to FIRE position.
14) Press the FIRE button.
Advise the patient that they may still feel some pressure and a pinch as the biopsy is
taken. Try to minimise any patient movement as the biopsy gun fires.
15) Capture the specimen by pressing the FIRE button for the second time.
Watch the distance graduations on the ACECUT device to ensure the gun is inserted
between 0.5cm and 1cm into the muscle during the capture of the muscle biopsy specimen.
15) Once the specimen has been captured, rotate the device 180 degrees clockwise and
180 degrees anti-clockwise to further ensure the specimen is captured.
16) Withdraw the biopsy device slowly and apply pressure to the wound for 2 minutes
with gauze.
17) Place steri-strips to approximate the wound edges and apply a mepore dressing to the
wound.
Release of Biopsy Specimen from Device
Take the biopsy device to the sterile dressing area.
1) Place device down onto a piece of gauze.
Ensure the device is pointed away from all staff members to minimise risk of tissue
splatter.
2) Fire the biopsy device into the gauze and place the muscle specimen into the sample
container.
Adverse Events (Common)
As described previously, wound discomfort for 48-72 hours after the biopsy is to be
expected. Light activities and simple analgesia are recommended. Bruising at the biopsy
site or an area distant to the biopsy site may also occur. Patients should be reassured that
the bruising will settle over time but can still take up to 6 weeks to fully settle.
Serious Adverse Events (Rare)
In the event of wound inflammation, erythema, cellulitis or abscess, the patient should be
assessed by a physician. If the patient is in attendance at the research clinic, they can be
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examined by Dr Mark O’Donnell (Vascular Surgeon) or if the patient contacts the
research office at a later stage, they should be advised to contact their General
Practitioner. In the event of wound site bleeding following the biopsy, manual digital
pressure is advised for a period of 15 minutes where most episodes of bleeding should
settle. If this occurs in the research laboratory, the patient will be assessed by Dr Mark
O’Donnell. If the patient is in attendance at the research clinic on an adhoc basis, they
should have a pressure dressing applied and be advised to attend the nearest emergency
unit (Whiteabbey Hospital) for further assessment if the bleeding does not settle.
Please observe laboratory safety and emergency instructions in case of any patient
emergency. Enclosed ACECUT automatic biopsy system directions for use guideline.
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