< Back Short-term contemporary outcomes for staged versus primary lower limb amputation in diabetic foot disease In the setting of infected diabetic foot disease, a staged lower extremity amputation achieves quality outcomes superior to a one-stage amputation, despite the former cohort’s greater illness acuity level. SA should be considered in all diabetic patients presenting with active foot infection. 🧠 Key Points: Staged amputation (SA) was compared with primary amputation (PA) in diabetic foot patients with severe infections. • SA showed lower 30-day readmission (17% vs 27%) and 30-day unplanned reoperation (11% vs 13%). • Length of stay and major adverse cardiovascular events were similar. • SA may provide better short-term quality outcomes in selected patients. Journal of Vascular Surgery (2020) doi.org/10.1016/j.jvs.2019.10.083 Previous Next

< Back Dr. Alper DUNKI University of Health Sciences, Istanbul, Umraniye Research and Education Hospital Dr. Alper Dünki completed his medical education at Yeditepe University Faculty of Medicine and residency training in Orthopaedics and Traumatology at Tekirdağ Namık Kemal University. His primary fields of interest include orthopaedic oncology and trauma. He currently serves as an orthopaedic surgeon at SBÜ Ümraniye Training and Research Hospital. Dr. Dünki is a member of TOTBİD, the Foot and Ankle Surgery Society, and the Young Orthopaedic Surgeons Group (AGUH). Oncologic Orthopaedics alperdunki@gmail.com Previous Next

< Back Hip Fractures B S hip-fractures Previous Next

< Back Hallux Rigidus hallux-rigidus Previous Next

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< Back Dr.Bengül SERARSLAN YAĞCIOĞLU Radiotherapy For Extremity Sarcomas Radiation therapy plays a crucial role in the multidisciplinary management of extremity soft tissue sarcomas, aiming to achieve optimal local control while preserving limb function. For Stage I disease, wide surgical excision with ≥1 cm margins is often curative. Stage II–III tumors require a combination of surgery and radiotherapy—either preoperative (50 Gy) or postoperative (60–66 Gy)—with consideration of chemotherapy for large, deep, or high-grade lesions. In unresectable cases, definitive radiotherapy (70–80 Gy) or concurrent chemo-RT may downstage tumors for resection. Field design and dose planning follow MRI-defined margins, with emphasis on sparing critical structures such as skin, bone, and joints. IMRT is preferred for dose conformity and tissue preservation, while IORT and brachytherapy provide localized dose escalation when indicated. Despite high local control rates (~90%), complications such as wound dehiscence, fibrosis, edema, and fracture remain clinically significant. Long-term surveillance with MRI and chest CT is essential due to recurrence and metastasis risk Timing & Technique · Postoperative EBRT: Start 10–20 days after surgery · Preoperative EBRT: 42,75 Gy in 15 fraction or 50 Gy in 25 fraction, surgery follows ~3 weeks later · Post-op Brachytherapy: ≥6 days post-op · Post-op IORT: During surgery Field Design · Post-op: Tumor bed, scar, drain sites + margins (4 cm longitudinal, 1.5 cm radial) After 50 Gy: Reduce field to surgical bed + smaller margins (+ 2 cm longitudinal, 1.5 cm radial) · Pre-op: Tumor (MRI T1 postcontrast) + 4 cm longitudinal, 1.5 cm radial + suspicious edema (MRI T2) Dose Limitations 20 Gy: Risk of premature epiphyseal closure ≥40 Gy: Bone marrow ablation ≥50 Gy: Bone fracture risk Limit bone V40Gy < 64%, reduce mean bone dose Critical Structures to Spare 1.5–2 cm strip of skin Skin over anterior tibia ½ of weight-bearing bone cross-section Major tendons and joint cavities Avoid treating full extremity circumference >50 Gy Technique Tips IMRT preferred for better tissue sparing Frog-leg position for upper inner thigh Prone position for buttock/posterior thigh No elective nodal radiation; gross nodes should be resected Brachytherapy Catheters placed 1 cm apart in OR. Loaded ≥6 days post-op for healing. Target: tumor bed + 2 cm longitudinal, 1-1.5 cm circumferential margin Special Considerations If using doxorubicin: reduce dose/fraction (1.8 Gy), delay RT >3 days Use gonadal shielding to preserve fertility Early physical therapy improves outcome Complications Wound healing issues: 5–15% post-op RT vs. 25–35% pre-op RT. Bone/soft tissue growth abnormalities. Limb length discrepancy (2–6 cm). Fracture risk within 18 months. Fibrosis, lymphedema, dermatitis, telangiectasia. 5% risk of secondary malignancy. Follow-Up First 2 years: Exams + MRI of primary + CT chest every 3 months Years 3–5: Every 6 months After 5 years: Annually Ultrasound for superficial lesions. Bone scan or PET if clinically indicated Heterotopic Ossification Indications: Used perioperatively for patients with prior heterotopic ossification, diffuse idiopathic skeletal hyperostosis, or hypertrophic osteoarthritis—especially when indomethacin is contraindicated. Timing: Administered <24 hours before surgery or <72 hours after. Include soft tissue around joint space. Blocking surgical hardware is controversial. Dose and fractionation: 7 Gy in single fraction via AP/PA fields. References · Springer International Publishing AG, part of Springer Nature 2018 , Eric K. Hansen and M. Roach III (eds.), Handbook of Evidence-Based Radiation Oncology, https://doi.org/10.1007/978-3-319-62642-0_39 · Demos Medical, Videtic, Gregory M. M., Vassil, Andrew D., Woody, Neil III (eds.),Handbook of treatment planning in radiation oncology , Third edition. New York, NY, [2021] · Springer Nature Switzerland AG 2022 1. N. Y. Lee et al. (eds.), Target Volume Delineation and Field Setup, Practical Guides in Radiation Oncology, https://doi.org/10.1007/978-3-030-99590-4 STAGE TREATMENT 5- YEAR OUTCOMES Extremity Stage I Surgery alone if margins ≥1 cm LC: 90–100%OS: 90% Extremity Stage II–III Pre-op RT → surgery or surgery → post-op RT. Consider neoadjuvant/adjuvant chemo for large, deep, high-grade tumors. For local recurrence (LR): amputation can salvage ~75% LC: ~90%OS: 80% (Stage II), 60% (Stage III) Extremity Stage IV If controlled primary + ≤4 lung mets or long disease-free interval → surgery + metastatectomy Otherwise: best supportive care, chemo, palliative surgery or RT OS: ~25% OS: ~10% Extremity Unresectable Definitive RT (70–80 Gy), chemo (Doxorubicin + Ifosfamide), or chemoRT. Surgery if becomes resectable Retroperitoneal Surgery + IORT (12–15 Gy) → post-op EBRT (45–50 Gy) or pre-op RT ± chemo → resection ± IORT boost LC: ~50% DM: 20–30% OS: ~50% GIST Resectable: surgery → imatinib (or observation if completely resected). Unresectable: imatinib → surgery → imatinib Desmoid Tumors Surgery. R0: observe. R1: re-resect or observe. R2/inoperable: RT (54–58 Gy). Consider chemo/hormonal/targeted therapy Treatment Recommendations Condition DOSE Negative margins 60 Gy Microscopic residual 60 Gy Positive margins 66 Gy Gross disease 70–76 Gy Pre-op EBRT 50 Gy Post boost (EBRT/IORT) 65–75 Gy Post-op brachytherapy (R1) 14–18 HDR / 16–18 LDR Post-op brachytherapy (R2) 18–24 HDR / 20–26 LDR IORT 10–15 Gy Dose Guidelines Previous Next

Hand General Principles Hand Anatomy & Biomechanics Tendon Zones & Repair Principles Nerve Anatomy (Median, Ulnar, Radial) Vascular Supply of the Hand Physical Examination & Special Tests Fractures & Injuries Phalangeal Fractures Metacarpal Fractures Thumb Injuries (UCL, Bennett, Rolando) Scaphoid Fractures Perilunate & Lunate Dislocations Carpal Fractures Distal Radius & Ulna Fractures (Wrist) Tendon, Nerve & Ligament Injuries Flexor Tendon Injuries Extensor Tendon Injuries Mallet Finger, Boutonnière Deformity Nerve Injuries (Median, Ulnar, Radial) Ligament Injuries Special Considerations Complex Regional Pain Syndrome (CRPS) Congenital Hand Problems Dupuytren's Disease Infections Carpal Tunnel Kienböck's Disease

< Back Growth Modulation & Guided Growth growth-modulation-guided-growth Previous Next

< Back Dr. Sefa Giray BATIBAY Metastatic Bone Disease Metastatic bone disease (MBD) is the most common malignant condition of the skeleton, often originating from breast, prostate, lung, kidney, or thyroid cancers. Treatment targets fracture prevention, functional maintenance and pain relief. Overview Metastatic bone disease (MBD) is the most frequent malignant bone condition. It reflects the spread of systemic cancer to the skeletal system, typically in advanced disease stages. Common primary sites include breast, prostate, lung, kidney, and thyroid. Clinical Presentation Persistent bone pain (often worse at night) Pathological fractures Neurologic symptoms (if spine is involved) Hypercalcemia-related symptoms (confusion, nausea) Systemic cancer signs (weight loss, fatigue) Common Primary Tumours Causing Bone Metastases Breast: Most common in ♀, more than >%50 are blastic Prostate: Mostly sclerotic/blastic lesions, spine predilection, most common in ♂ Lung: Lytic, often aggressive Kidney (RCC): Lytic, vascular; surgical bleeding risk Thyroid: Often solitary, lytic, surgical bleeding risk Frequent Skeletal Sites Involved Spine (especially thoracic) Pelvis Proximal femur Humerus Ribs Skull Imaging X-Ray: Lytic/blastic/mixed lesions; cortical breach CT : Useful for bone imaging and thorax-abdominal metastatic screening. MRI: Marrow involvement, spinal cord assessment Bone Scan: Detects most metastases, but misses pure lytic lesions PET-CT: Helps detect unknown primaries and whole-body disease burden Biopsy Strategy Core needle biopsy is preferred Always after imaging Histopathology reflects the primary tumour (e.g., adenocarcinoma in breast CA) Treatment Principles : Depends on survey expectation Non-Surgical Short life expectancy / If the damage caused by surgery is greater than the tumor itself External beam radiotherapy for pain and local control (It can be used alone or after surgery.) Bisphosphonates or Denosumab (reduce skeletal-related events) > complication ; osteonecrosis of the jaw Systemic therapy based on primary tumour (Chemotherapy and hormone therapy depends on receptor posivity ) Embolization ; especially for thyroid and renal cancers for reducing blood loss Pain control, bracing for support Surgical Indications Impending or complete pathological fracture Neurologic compromise (cord compression) Solitary lesion in a patient with long survival Intractable pain Surgical Techniques Plate fixation with curettage + cementation : In areas close to the joint like elbow, wrist and ankle Intramedullary nailing : Diaphyseal long bones Endoprosthetic reconstruction : Proximal femur/humerus : relatively long life expectancy Curettage + cementation : For small, contained lesions; can be combined with implant fixation Spine decompression and fixation : In cord compression Prognosis & Decision-Making Life expectancy is key (although controversial; ideally >3–6 months for surgery) The Mirels criteria are less useful in the upper extremities. A score of 7 or higher is in the upper extremities, and a score of 9 or higher is an indication for fixation for impending fractures in the lower extremities. Some tools like Pathfx 3.0 helps to estimate. (https://www.pathfx.org/) Prognostic scoring systems: Tomita , Tokuhashi Avoid major surgery in patients with short survival Differential Diagnosis Multiple myeloma Lymphoma Primary bone tumours Bone infections Sources: Campbell’s Operative Orthopaedics, 14th Edition WHO Classification of Bone Tumours, 2020 Current Orthopaedic Oncology guideline Mirels' score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation? doi: 10.1016/j.jseint.2022.03.006. eCollection 2022 Jul.. 2022 Apr 25;6(4):675-681.JSES Int.Hoban et al. External validation of the PATHFx decision-support tool on Turkish patients with skeletal metastasis. 2023 Feb 27.Indian J Cancer. Ozkan et al. doi: 10.4103/ijc.IJC_417_20. Previous Next

< Back Alignment Techniques in Total Knee Arthroplasty Wide range of clinical results exist for new alignment techniques in the short term. The safe range of alignment for long-term survivorship remains unknown. Further high-quality studies should be performed to warrant the widespread use of new alignment techniques. 🧠 Key Points: • Mechanical alignment remains standard in TKA but doesn’t consider individual pre-arthritic alignment. • Newer techniques (kinematic, restricted, inverse, modified, functional alignment) aim to restore native joint line and improve satisfaction. • Most RCTs show comparable or better short-term outcomes with novel techniques. • Long-term survivorship data are still lacking; alignment “safe zones” remain debated. • Robotic and navigation systems are key tools in implementing newer alignment methods. Journal of Joint Surgery and Research (2023), Vol 1: 108–116 doi.org/10.1016/j.jjoisr.2023.02.003 Previous Next

< Back Alper DUNKI Coagulopathies Spot Knowledge Coagulation Basics Intrinsic pathway (XII → XIIa): PTT Extrinsic pathway (tissue factor): PT Fibrinolysis: Plasmin breaks down fibrin Tranexamic acid: Antifibrinolytic, reduces blood loss in orthopaedics Coagulopathies and Venous Thromboembolic Diseases Coagulation Mechanisms The coagulation cascade leads to fibrin formation through enzymatic reactions. Fibrin traps platelets, stopping bleeding. Intrinsic pathway: Activated by factor XII upon contact with collagen in endothelial injury. Measured by PTT. Extrinsic pathway: Initiated by tissue thromboplastin released after cell injury. Evaluated by PT. Fibrinolytic system: Plasminogen → plasmin, which degrades fibrin. Tranexamic acid inhibits fibrinolysis, reducing blood loss in orthopedic surgery without increasing thrombosis risk. Hemophilia A hereditary factor deficiency causing bleeding disorders. Recurrent hemarthroses lead to joint destruction. Treatment: Factor replacement, joint aspiration, splinting, physical therapy. Advanced cases: Radioisotope/arthroscopic synovectomy or total knee arthroplasty (TKA) may be required. Issues: Inadequate hemostasis, HIV positivity, and central catheter use increase infection risk. Surgery: Factor levels should be raised to 100% preoperatively; 3–5 days for soft tissue surgery, 3–4 weeks for major joint surgery. Recombinant factors are preferred. Inhibitors: Antibodies neutralizing factor VIII/IX may develop; high-dose therapy can overcome this. Von Willebrand Disease A genetic coagulopathy due to vWF deficiency. Type 1: Mild, frequent epistaxis, gastrointestinal bleeding, menorrhagia. Type 2: Functional defect. Type 3: Severe, very rare. Diagnosis: Bleeding time, factor VIII activity, vWF level, and functional assays. Treatment: Desmopressin increases endothelial vWF release; severe cases require factor VIII + vWF concentrates. Trauma- and Surgery-Related Coagulopathies Can develop in major trauma or prolonged surgeries. Management: Fluid replacement, red blood cell transfusion, platelet and fresh frozen plasma as guided by laboratory monitoring. Venous Thromboembolic Disease (VTE) Pathophysiology and Risk Factors Deep vein thrombosis (DVT) and pulmonary embolism (PE) result from activation of the coagulation cascade and platelet aggregation. Virchow’s triad: Venous stasis, endothelial injury, hypercoagulability. Risk: PE rate up to 7% after hip fracture surgery; TKA has higher DVT risk, lower PE risk compared to THA; prior VTE increases risk. Prophylaxis Mandatory in major orthopedic surgeries (THA, TKA, hip fracture). Guidelines: CHEST 2012: Aspirin acceptable, LMWH preferred. AAOS 2011: No specific agent recommended; pharmacologic and/or mechanical methods can be used; routine ultrasound screening not recommended. Strategy: High bleeding risk → mechanical methods; high VTE risk → pharmacologic + mechanical combination. Pharmacologic Methods Drug Characteristics Heparin(UFH) Low efficacy, high bleeding risk, risk of HIT LMWH Factor Xa inhibitor, high bioavailability, long half-life; first dose 12–24 h post-op Fondaparinux Synthetic pentasaccharide, Xa inhibitor; reduces DVT risk but may increase bleeding Warfarin Vitamin K antagonist; target INR ~2; delayed onset Aspirin Low efficacy alone; reduces PE risk after TKA/THA DOACs (Rivaroxaban, Apixaban, Dabigatran) Oral, convenient; bleeding risk and cost are disadvantages Diagnosis of Thromboembolic Events DVT: Clinical signs nonspecific → lower extremity ultrasound or venography. PE: Dyspnea, tachypnea, tachycardia, fever → CT angiography first choice; V/Q scan, pulmonary angiography, D-dimer as adjuncts. Treatment Acute: IV heparin or LMWH first 5 days → warfarin (INR 2–3 for 3–6 months). Postoperative: Dose adjustment important due to bleeding risk. IVC filter: For patients who cannot receive anticoagulation; recommended short-term use. Isolated calf DVT: Usually not associated with PE; monitored with serial ultrasound. Conclusion Coagulopathies and VTE have high morbidity and mortality in orthopedic practice. Critical for patient safety: Accurate diagnosis Appropriate prophylaxis strategies Individualized treatment planning References 1. Wu B, Yu W, Li D, Deng X, Pei W. NOACs for VTE prevention in patients with lower limb fracture: a systematic review and meta-analysis. J Orthop Surg Res . 2025;20:40. doi:10.1186/s13018-025-06092-5 2. Jones A, McQueenie R, McCowan C, Sutherland AG, Kwaramba T, Tho LM. Venous Thromboembolism Prophylaxis in Major Lower-Extremity Orthopaedic Procedures: A Narrative Review. J Bone Joint Surg Am . 2023;105(13):1184-1192. doi:10.2106/JBJS.22.00824 Previous Next

Proximal Humerus Fracture Proximal Humerus Fracture Proximal Humerus Fracture