< Back Soft Tissue Assessment soft-tissue-assessment Previous Next

< Back Dr. Ali Erkan Yenigul Principles of Surgical Resection & Margins Tumour resection aims to achieve oncologic control while preserving function; margin status is critical for local recurrence risk. Historical Background Pre-1940s → Amputation was standard treatment. 1940s sonrası → Tumour resection 1970s → Chemotherapy + Radiotherapy + Limb-sparing surgery standard of care. Basic Principles Wide surgical margin = most important factor for local control. All imaging must be completed before surgery. Surgical planning should be based on imaging close to surgery date . Enneking’s Margin Classification Intralesional Curettage / piecemeal debulking / Macroscopic disease remains Marginal Shelling out via pseudocapsule- reactive zone / May leave satellite or skip lesions Wide En bloc with cuff of normal tissue / Adequate, but skip lesions possible Radical En bloc removal of whole compartment / No residual local disease Natural Barriers Bone: Cortical bone, articular cartilage Joint: Articular cartilage, capsule Soft tissue: Fascial septa, tendon origins/insertions Barrier effect : Fascia, tendon sheath, vascular sheath, cartilage act as protective margins Critical Points in Limb-Sparing Surgery Poor biopsy incision Major vascular involvement Motor nerve sacrifice Preoperative infection Expected poor motor function after resection ➡️ These complicate but do not always contraindicate limb-sparing surgery. Advanced Techniques Microsurgical reconstruction Tendon transfers, nerve/vessel grafts Flap coverage after large resections Role of Adjunctive Therapies Neoadjuvant chemotherapy/radiotherapy → may shrink tumour, improve margin status. Wide margins still required even after neoadjuvant treatment. Practical Margin Rules Bone tumours: ≥ 3 cm bone marrow margin on T1 MRI. Soft tissue tumours: Aim for ≥ 2 cm margin. References Enneking WF. Musculoskeletal Tumor Surgery. New York: Churchill Livingstone; 1983. Simon MA, Springfield DS. Surgery for Bone and Soft-Tissue Tumors. Philadelphia: Lippincott-Raven; 1998. Healey JH, Lane JM. Operative Techniques in Orthopaedic Surgical Oncology. Philadelphia: Lippincott Williams & Wilkins; 1996. (For the figures and the margin classification) Mankin HJ, Hornicek FJ. Diagnosis, classification, and management of soft tissue sarcomas. Cancer Control. 2005;12(1):5–21. O’Donnell RJ, Springfield DS, Motwani HK, et al. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. J Bone Joint Surg Am. 1994;76(12):1827–33. Previous Next

< Back Elbow Dislocations elbow-dislocations Previous Next

< Back Elbow Stiffness stiff-elbow Previous Next

< Back Charcot Arthropathy charcot-arthropathy Previous Next

About About OrthoRico OrthoRico is a non-commercial educational platform created by and for orthopaedic professionals. Our goal is simple: To empower orthopaedic surgeons, residents, and medical professionals with reliable, practical, and structured educational content. 🎯 What We Offer 📚 Structured Core Topics based on clinical relevance 🛠️ Step-by-step Surgical Guides illustrated with high-quality images 👨⚕️ Expert Contributions from dedicated doctors across various subspecialties 🔒 Free and secure access — only for verified medical professionals 🤝 Why OrthoRico? We believe in sharing knowledge without barriers. OrthoRico is not affiliated with any institution or commercial brand. There are no subscriptions, no paid courses — just high-quality, peer-reviewed orthopaedic knowledge. We’re building a collaborative space where education comes first, and doctors grow together. 👩⚕️ Join the Community If you are a medical doctor, specialist, or trainee and wish to contribute or access premium content, you are welcome to Join Us. Together, let’s shape the future of orthopaedic education.

< Back Alper DUNKI Biomaterials Biomaterials are synthetic substances, derived from organic or inorganic components, designed to interact with biological systems. Their properties are determined by their structure (elemental composition, atomic bonding, crystalline configuration) and their processing methods (casting, forging, extrusion, sintering, etc.). Classes of Biomaterials Metals: Strong, durable, conductive materials; may exist as single elements (Cu, Ag) or alloys (e.g., stainless steel). Ceramics: Hard, brittle, corrosion-resistant; typically metal oxides (Al₂O₃, ZrO₂). Polymers: Carbon-based chain structures, flexible, corrosion-resistant (polyethylene, PTFE, silicone, hydrogels). Composites: Mixtures of two or more distinct phases, engineered for specific properties (fiberglass, concrete). Natural biomaterials: Plant/animal-derived tissues, proteins, polysaccharides. Applications and Requirements in Orthopedics Used in fracture fixation, osteotomy, arthrodesis, wound closure, tissue replacement, and prostheses. They must be biocompatible, corrosion/degradation resistant, and possess adequate mechanical strength and wear resistance. Biocompatibility The ability of a material to elicit an appropriate biological response in vivo. Inert: Minimal tissue response (e.g., stainless steel). Bioactive/interactive: Promote favorable responses (e.g., porous titanium allowing bone ingrowth). Living: Contain cells and undergo remodeling. Reseeding constructs: Donor tissues re-implanted following culture. Biologically incompatible: Induce undesirable reactions. Corrosion and Degradation Resistance The physiological environment may induce corrosion. Types of corrosion: Pitting, crevice, fatigue, stress cracking, galvanic, and fretting. Polymer degradation: Depolymerization, oxidation, hydrolysis, additive leaching, cracking. Mechanical Properties Basic concepts: Compression/tension, shear, torsion; stress, strain, strength, toughness. Elastic modulus: Defines stiffness; yield point marks onset of plastic deformation. Material types: Brittle: Fail with minimal deformation (ceramics, glass). Ductile: Sustain significant deformation (steel, titanium alloys). Fatigue fracture: Failure due to repetitive loading; highly relevant in orthopedics. Anisotropy: Direction-dependent properties (bone, tendon). Viscoelastic behavior: Time-dependent deformation (creep, stress relaxation). Specific Biological and Medical Materials a. Bone: Composed of inorganic (calcium phosphate) and organic (type I collagen) phases. Both anisotropic and viscoelastic. Cortical bone density ~1.8 g/cm³; trabecular bone 0.1–1.0 g/cm³. With aging, both mass and elasticity decline. b. Tendon: Rich in type I collagen; transmits muscle forces to bone and redirects force. Anisotropic and viscoelastic. Failure often occurs at the bone- or muscle-tendon junction. c. Ligaments: Composed primarily of type I collagen; connect bone to bone. Insertional regions play a key role in mechanical strength. d. Metals: Crystalline structure with high conductivity; can form alloys. Stainless steel (316L): Low cost, ductile; nickel and chromium may cause allergic reactions. Cobalt alloys: High strength, long service life. Titanium: Lightweight, highly biocompatible; pure titanium suitable for low-load applications, alloys for high-load regions. Tantalum: Corrosion resistant, supports osseointegration. e. Polymers: Properties determined by monomer composition, molecular weight, and crystallinity. PMMA: Bone cement, may be loaded with antibiotics. UHMWPE: High impact resistance, widely used in joint prostheses. Biodegradable polymers: PLA, PGA; provide controlled degradation and drug delivery. Hydrogels: High water content, low friction, promising in tissue engineering. f. Ceramics: Ionic compounds of metals and non-metals; hard, brittle, with high compressive strength. Bearing surfaces: Alumina and zirconia, with low wear rates. Bone substitutes: Hydroxyapatite (slow resorption), tricalcium phosphate (faster resorption, higher biological activity). References: 1. Im, G. I., & Lee, Y. (2020). Biomaterials in orthopaedics: the past and future with immune modulation. Biomaterials Research, 24 , 10. https://doi.org/10.1186/s40824-020-0185-7 2. Zhang, Y., Lu, H., Wang, S., & He, C. (2024). Advancement in biomedical implant materials — a mini review. Frontiers in Bioengineering and Biotechnology, 12 , 1400918. https://doi.org/10.3389/fbioe.2024.1400918 3. Allizond, V., Comini, S., Cuffini, A. M., & Banche, G. (2022). Current knowledge on biomaterials for orthopedic applications modified to reduce bacterial adhesive ability. Antibiotics, 11 (4), 529. https://doi.org/10.3390/antibiotics11040529 Previous Next

< Back Hand Anatomy & Biomechanics hand-anatomy-biomechanics Previous Next

< Back Crush Syndrome Crush syndrome is a systemic condition caused by prolonged muscle compression, leading to rhabdomyolysis, acute kidney injury, and potential multi-organ failure. Crush Syndrome (traumatic rhabdomyolysis) develops after prolonged compression of muscle tissue, commonly seen in disasters, traffic accidents, or entrapment injuries. ⚠️ Pathophysiology: Muscle breakdown → release of myoglobin, potassium, phosphate Leads to hyperkalaemia , metabolic acidosis , hypovolaemia Myoglobinuria causes renal tubular obstruction → acute kidney injury (AKI) 🚑 Clinical Features: Swollen, tense limbs Dark-coloured urine (myoglobinuria) Hypotension, arrhythmias, AKI 💉 Management: Early and aggressive IV fluid resuscitation (isotonic saline) Avoid potassium-containing fluids Consider mannitol & bicarbonate to prevent AKI Monitor and treat hyperkalaemia Dialysis may be required 🧪 Key Labs: Elevated CK , myoglobin Hyperkalaemia, metabolic acidosis Rising creatinine and urea 🩺 Prevention: Fluid resuscitation even before extrication in disaster settings Fasciotomy only if clear compartment syndrome, not prophylactically crush-syndrome Previous Next

< Back Infection in Reconstruction Surgery infection-reconstruction-surgery Previous Next

< Back Dr. Savas CAMUR Dislocation & Instability Despite advances in implant design, surgical technique, and perioperative protocols, instability continues to challenge both surgeons and patients.Hip dislocation remains one of the most feared complications following total hip arthroplasty (THA), associated with higher morbidity, increased healthcare costs, and up to 25% of all revision procedures. Hip Dislocations and Instability after Arthroplasty Incidence and Timing Reported incidence ranges from 0.2% to 10% globally, with large modern registries showing ~2.3% dislocation rate within 2 years after primary THA. Half of dislocations (≈52%) occur in the first 3 months , and >80% within 2 years postoperatively. Recurrent instability is common — 57% of patients with an initial dislocation experience recurrence, and 11% have ≥5 events , often necessitating revision surgery. Etiopathogenesis and Risk Factors Patient Factors Age <65 years and female sex are independent risk factors. Obesity (BMI >30) and high comorbidity burden (Elixhauser index ≥3) correlate with higher dislocation rates. Neuromuscular disorders, cognitive decline , and inflammatory arthropathy increase postoperative instability risk. Surgical Factors Posterior approach historically carried higher risk, yet modern evidence shows no difference in dislocation rates between posterior, lateral, or anterior approaches when soft tissue repair is adequate. Component positioning remains crucial — excessive cup anteversion, inclination >45°, or combined offset malalignment significantly increase instability. Femoral head size: larger diameters (≥36 mm) reduce dislocation risk by improving impingement-free motion arcs. Implant-Related Factors Cemented fixation and metal-on-poly or metal-on-metal bearings are associated with higher instability compared to ceramic-on-poly. Dual-mobility cups have emerged as effective solutions for high-risk patients. Hip Precautions and Rehabilitation Recent systematic reviews found no statistical difference between restricted vs unrestricted postoperative protocols (2.2% vs 2.0% dislocation rates). ➡️ Early mobilization and functional recovery improve patient satisfaction without increasing risk.Traditional precautions — avoiding >90° flexion, adduction, and internal rotation — have not been shown to reduce dislocation risk following posterior-approach THA. Mechanisms of Instability Soft-tissue insufficiency (capsular laxity, abductor deficiency). Component malalignment (excessive anteversion/retroversion). Impingement (bony or prosthetic). Head–neck ratio mismatch or short offset . Neurologic or proprioceptive deficits. Management Algorithm Initial episode: Closed reduction under sedation → radiographic assessment for component positioning and fracture. Activity modification + physiotherapy. Recurrent dislocation: CT-based evaluation of implant orientation. Consider dual-mobility constructs, constrained liners , or component revision when malposition or soft-tissue insufficiency confirmed. Chronic instability: Multidisciplinary approach — surgical correction of malalignment, soft-tissue reconstruction, or revision arthroplasty. Prevention Principles Accurate component positioning is the strongest modifiable factor. Repair posterior capsule and short external rotators when using posterior approach. Assess combined anteversion intraoperatively. Use larger heads (≥36 mm) to increase jump distance. Consider dual mobility or constrained liners in high-risk or revision cases. 💡 Soft-tissue balance and version alignment matter more than approach choice. Postoperative Protocols Traditional restrictions (avoiding >90° flexion, adduction, or internal rotation) do not significantly reduce dislocation rates . Modern rehabilitation emphasizes: Early mobilization Functional independence Education on safe movement patterns Diagnosis and Evaluation Radiographs: confirm reduction, component orientation, or periprosthetic fracture. CT scan: assess anteversion, inclination, and bone coverage. MRI (metal-artifact reduction): evaluate soft-tissue or abductor insufficiency. Clinical Pearls Most dislocations occur early — meticulous soft-tissue repair and orientation are more impactful than postoperative restrictions. Dual mobility or constrained liners should be considered for revision cases or high-risk primary THAs . Dynamic stability testing intraoperatively (flexion, rotation, extension) predicts postoperative behavior better than static visual assessment. . References Gillinov SM et al. Incidence, Timing, and Predictors of Hip Dislocation After Primary THA for OA. J Am Acad Orthop Surg. 2022;30:1047–1053. Crompton J, Osagie-Clouard L, Patel A. Do Hip Precautions After Posterior-Approach THA Affect Dislocation Rates? Acta Orthop. 2020;91:687–692. Dargel J et al. Surgical approach and risk of dislocation. Clin Orthop Relat Res. 2014. Peters RM et al. Effect of reduced hip precautions on dislocation and function after THA. Bone Joint J. 2019. Previous Next