< Back Tendons Spot Knowledge Role: Transmit muscle force to bone → joint motion, stability, elasticity, energy storage Composition: Water: 65–80% Collagen: ~86% dry weight (mainly type I) → tensile strength Proteoglycans: ~1% (decorin, biglycan, fibromodulin) → fibril organization, load-bearing Elastin: <2% → elasticity, key in Achilles tendon Cells: Mainly tenocytes (fibroblasts), few tenoblasts; ECM synthesis Structure: Hierarchical collagen arrangement (molecule → fibril → fascicle → tendon) Vascularity: Limited; nutrition via diffusion; low healing capacity Tendon: Structure, Components, and Functions General Features Tendons transmit muscle force to bone, enabling joint motion. Their primary roles include force transmission, energy storage, and providing elasticity. They also contribute to joint stability. Structural Composition Tendons are composed of 65–80% water. Approximately 86% of the dry weight is collagen. Proteoglycans constitute 1%, and elastin fibers account for less than 2%, contributing to elasticity. Cellular Composition Tendons are sparsely cellular tissues. The main cell type is the fibroblast (tenocyte), which synthesizes collagen, proteoglycans, and other ECM components. Tenoblasts are immature, more metabolically active cells. Surrounding the tendon are the epitenon and endotenon, which contain blood vessels, nerves, and lymphatics. Collagen Type I collagen is the predominant fibrillar type. Its molecular structure is rich in glycine (33%), proline (15%), and hydroxyproline (15%). Collagen fibrils are organized hierarchically: molecule → microfibril → subfibril → fibril → fascicle → tendon. This organization provides high tensile strength. Type III collagen increases during repair. Proteoglycans Proteoglycans constitute ~1% of the dry weight. Due to their water-binding capacity, they enhance mechanical strength. Decorin, biglycan, and fibromodulin are the major proteoglycans, playing roles in fibril organization and load-bearing. Elastin Elastin accounts for less than 2% of tendon content. Located between fascicles, it provides elasticity. It is particularly important in energy-storing tendons such as the Achilles tendon. Vascularity Tendons are largely avascular, with nutrition primarily achieved via diffusion. Blood vessels usually enter through the epitenon and endotenon. This limited vascularity contributes to their restricted healing capacity. Functional Properties Force transmission: Transfers muscle contraction forces to bone. Energy storage: Stores and releases energy during movement due to elastic properties. Mechanical strength: Resists tensile and loading forces. Flexibility and adaptation: Supports continuous motion and joint stability. Clinical Relevance Tendon injuries heal slowly. Limited vascularity restricts nutrition and repair. Alterations in collagen and proteoglycan content are associated with degenerative tendon disorders. Repetitive microtrauma can lead to tendinopathy. References 1. Zhang H, Wang Y, Li B, Chen S. Tendon mechanobiology in the context of tendon biofabrication. Front Bioeng Biotechnol . 2025;13:1560025. doi:10.3389/fbioe.2025.1560025 2. Massey JH, Shearer T, Hazel A. A microstructural model of tendon failure. arXiv . 2021;2103.04844. 3. Mackey AL, Kjaer M. Structure-function relationships in tendons: a review. Int J Mol Sci . 2023 Previous Next

< Back Metatarsalgia metatarsalgia Previous Next

< Back Quality of Life and Outcomes After Treatment Failure for Recurrent PJI of TKA Multicenter retrospective study comparing outcomes of above-knee amputation (AKA), permanent spacers, and knee arthrodesis in patients with recurrent periprosthetic joint infection (PJI) of the knee after failed revisions. A total of 86 patients (35 AKA, 43 spacer, 8 arthrodesis) were evaluated for quality of life (SF-36), pain (VAS, DN4), complications, and functional outcomes. 🧠 Key Points AKA patients had better quality of life scores (higher SF-36 general health and role-physical scores) compared to spacers. Pain relief was superior in AKA (lower VAS and DN4) than both spacer and arthrodesis. Complication and reoperation rates were highest with spacers (53% and 42%) vs. lowest with AKA (14% each). Functional mobility: AKA patients more often walked >1 mile (26% vs. 5% with spacer) and were more frequently able to drive (42% vs. 23%). Mortality and reinfection rates were similar across groups at 2 years. Conclusion: AKA should not only be a last resort —it offers better pain control, fewer complications, and improved QoL in selected patients. The Journal of Arthroplasty (2025) doi.org/10.1016/j.arth.2025.08.017 Previous Next

< Back Classification Systems Q D shoulder-elbow-classification Previous Next

< Back Dr. Sefa Giray BATIBAY Chemotherapy For Bone Tumors Chemotherapy plays a central role in the multimodal treatment of primary malignant bone tumors, particularly osteosarcoma and Ewing sarcoma. Its main objectives are to eradicate micrometastatic disease, reduce tumor size before surgery, and improve long-term survival. The effectiveness of chemotherapy has transformed previously fatal conditions into potentially curable diseases. Indications Osteosarcoma: Neoadjuvant and adjuvant chemotherapy are standard components of treatment. Ewing Sarcoma: Highly chemosensitive; systemic therapy is essential for all patients. Chondrosarcoma: Generally resistant to conventional chemotherapy; only the dedifferentiated and mesenchymal subtypes may respond. Other rare tumors (e.g., MFH/UPS, Angiosarcoma): Chemotherapy considered in high-grade or metastatic cases. Chemotherapy Timing Type Purpose Typical Use Neoadjuvant Shrink tumor, facilitate limb-salvage surgery, evaluate histologic response Osteosarcoma, Ewing Sarcoma Adjuvant Eliminate residual micrometastatic disease Osteosarcoma Palliative Control symptoms or progression in unresectable/metastatic disease All high-grade sarcomas Evaluation of Response Histologic response is assessed by percentage of tumor necrosis in resected specimens: 90% necrosis → good responder<90% necrosis → poor responder Imaging: MRI and PET-CT can aid in preoperative assessment but are less reliable than pathology. Prognostic impact: Histologic response remains one of the strongest predictors of overall survival. Toxicities and Supportive Care Acute toxicities: Myelosuppression, mucositis, nausea/vomiting, nephrotoxicity (cisplatin), and cardiotoxicity (doxorubicin). Long-term complications: Ototoxicity, infertility, secondary malignancies, and renal or cardiac dysfunction. Supportive strategies: Adequate hydration and mesna for ifosfamide/cyclophosphamide Dexrazoxane for anthracycline cardioprotection Growth factor support (G-CSF) to reduce neutropenia Emerging Therapies Targeted therapy: IGF-1R inhibitors, mTOR inhibitors, and VEGF-targeted agents show limited but growing promise. Immunotherapy: Research into checkpoint inhibitors and cell-based therapies (e.g., CAR-T) is ongoing, particularly in relapsed Ewing sarcoma. Chemo-sensitivity modulation: Nanocarrier drug delivery and combination regimens are under investigation to improve efficacy while minimizing toxicity. Key Points Chemotherapy is mandatory for osteosarcoma and Ewing sarcoma , but ineffective for most low-grade chondrosarcomas . Histologic necrosis after neoadjuvant therapy remains a critical prognostic factor. Ongoing trials aim to optimize drug combinations and identify predictive biomarkers for response. References Bielack SS et al. Osteosarcoma: ESMO Clinical Practice Guidelines. Ann Oncol. 2022;33(12):1344–1356. Ladenstein R et al. Ewing Sarcoma: Current Management and Future Directions. J Clin Oncol. 2021;39(26):3039–3053. Palmerini E et al. Chemotherapy in Chondrosarcoma: When and Why? Eur J Cancer. 2020;140:74–83. Ferrari S et al. MAP and Beyond: New Horizons in Osteosarcoma Chemotherapy. Cancer Treat Rev. 2023;114:102516. Tumor Type Standard Regimen Key Agents Osteosarcoma MAP protocol Methotrexate, Doxorubicin, Cisplatin ± Ifosfamide Ewing Sarcoma VDC/IE alternating protocol Vincristine, Doxorubicin, Cyclophosphamide / Ifosfamide, Etoposide Mesenchymal Chondrosarcoma Ewing-based regimens VDC/IE or VIDE Recurrent Disease Salvage chemotherapy Gemcitabine + Docetaxel, Ifosfamide + Etoposide, or High-dose Ifosfamide Common Regimens Previous Next

< 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