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< Back Lisfranc Injuries lisfranc-injuries Previous Next

< Back Proximal Biceps Tendon Pathology CD DC proximal-biceps-tendon Previous Next

Deformity Correction & Limb Lengthening General Principles Deformity Evaluation Deformity Analysis Gait Analysis Principles of Osteotomy Fixation Methods Lower Limb Reconstruction Femoral Osteotomies Tibial Osteotomies High Tibial Osteotomy (HTO) Distal Femoral Osteotomy (DFO) Ankle & Foot Realignment Procedures Upper Limb Reconstruction Humeral Osteotomies Forearm Malunion & Osteotomy Radial & Ulnar Lengthening/Shortening Elbow Deformity Correction Special Considerations Growth Modulation & Guided Growth Limb Lengthening Bone Transport Techniques Nonunion & Malunion Management Infection in Reconstruction Surgery

< Back Posterior Tibial Tendon Dysfunction (PTTD) posterior-tibial-tendon-dysfunction Previous Next

< Back Alper DUNKI Imaging Principles Plain radiography remains the first-line and often diagnostic in most bone tumors, while CT provides detailed cortical and 3D anatomical evaluation. MRI offers superior soft-tissue and marrow contrast, essential for assessing intramedullary extension and surgical margins. PET/CT assist in detecting metastases and evaluating treatment response. 1. Introduction Imaging plays a central role in the diagnosis, staging, and surgical planning of musculoskeletal (MSK) tumors. Plain radiography , CT , MRI , nuclear medicine scans , and PET/CT remain the core modalities, often complemented by angiography and ultrasound for specific indications. Selection of modality depends on tumor type, location, aggressiveness, and tissue composition 2. Plain Radiography (X-ray) Serves as the first-line imaging tool and remains diagnostic in >80% of bone tumor cases Reveals: Tumor location within the bone (epiphyseal, metaphyseal, diaphyseal). Cortical destruction or thickening , periosteal reactions (e.g., Codman triangle , sunburst pattern ). Matrix type — osteoid, chondroid, or fibrous. Soft-tissue calcification patterns suggesting tumor type. Limitation: early detection in pelvic and spinal lesions is poor due to overlapping structures. 3. Computed Tomography (CT) Preferred modality for assessing extent of cortical destruction and 3D anatomy . Helical CT with ≤1 mm slice thickness allows high-resolution multiplanar and 3D reconstructions Contrast-enhanced CT delineates: Relationship of tumor to vessels and neurovascular bundles . Vascular invasion or distortion aiding surgical planning. 3D reconstruction helps estimate need for en bloc vessel resection or approach modification. 4. Magnetic Resonance Imaging (MRI) Superior to CT for evaluating intramedullary spread and extraosseous soft-tissue extension Advantages: Multiplanar imaging (axial, sagittal, coronal). Excellent contrast resolution for tumor–muscle–fat differentiation. Contrast-enhanced MRI defines vascular involvement , cystic components , and nerve proximity . MRI is essential for surgical margin planning and defining safe resection limits . Characteristic tumor appearances: Lipomas, liposarcomas, PVNS, hemangiomas, and fibromatoses show distinctive patterns. Pitfalls: Hemorrhagic high-grade sarcomas may mimic hematomas — clinical follow-up is vital. 5. Bone Scintigraphy (Bone Scan) Used to detect metastatic spread or multifocal disease Bone tumors imaging Three-phase bone scan reflects tumor biologic activity : “Tumor blush ” pattern — increased uptake during late flow phase in malignant lesions. Also used to monitor chemotherapy response by comparing uptake pre- and post-treatment. 6. Angiography and Venography Angiography: Demonstrates arterial displacement, occlusion, or encasement by tumors CT angiography is increasingly replacing conventional techniques. Preoperative embolization reduces intraoperative bleeding in hypervascular metastases (e.g., renal carcinoma). Venography: Shows venous obstruction or compression by tumor mass. Indirectly suggests neural invasion when adjacent vein occlusion is present. 7. Positron Emission Tomography / CT (PET/CT) Functional imaging using FDG uptake proportional to tumor glucose metabolism Applications: Initial staging, monitoring therapy response, and recurrence detection. PET-CT fusion combines functional and structural data — useful in detecting small metastatic lesions . Standardized Uptake Value (SUV) quantifies uptake, helping to distinguish malignancy from infection or inflammation . 8. Ultrasonography (USG) Recommended initial test for superficial soft-tissue masses (per ACR Appropriateness Criteria ) Benefits: No radiation, real-time vascular evaluation, dynamic movement analysis, cost-effective. Evaluates echogenicity, margins, vascularity, and cystic vs. solid composition . Diagnostic accuracy: 77–93% , though specificity for malignancy is limited. Pitfall: differentiation between lipoma and liposarcoma remains challenging. Suspicious features (pain, rapid growth) → further MRI required. 9. MRI Next-line imaging if diagnosis remains uncertain after USG or radiographs Provides superior soft-tissue contrast and local staging . Diagnostic parameters: Size (>5 cm), deep location, heterogeneous T2 signal, ill-defined margins, perilesional edema. Necrosis, bone or neurovascular invasion → suggest malignancy. Post-contrast MRI enhances diagnostic accuracy: Differentiates cystic vs. solid lesions. Identifies necrotic areas and optimal biopsy sites . Reported sensitivity and specificity for differentiating benign vs. malignant: 64–93% and 82–85% , respectively. 10. CT and PET/CT in Soft-Tissue Tumors CT acts as a second-line modality when MRI is nondiagnostic or contraindicated (e.g., pacemaker, claustrophobia). Contrast-enhanced CT evaluates bone involvement and surgical planning . PET/CT : Not routine for primary diagnosis but valuable for metastatic work-up and treatment response evaluation . Studies suggest PET/CT may help differentiate benign and malignant tumors , but ACR discourages routine use. Key Findings Optimal MSK tumor imaging requires multimodal integration . Radiography and MRI form the diagnostic backbone, with CT and PET/CT for staging and surgical planning. Ultrasound remains useful for superficial masses, while angiography assists in vascular evaluation. Advances in functional imaging (PET/MRI) and 3D reconstruction continue to enhance preoperative accuracy and individualized treatment planning. References 1. Rajakulasingam R, Stediuk K, Teh JJ, et al. Current progress and future trends in imaging of bone tumours. Eur Radiol Exp. 2021;5(1):27. 2. Shu H, Ma Q, Li A, et al. Diagnostic performance of US and MRI in predicting malignancy of soft tissue masses: using a scoring system. Front Oncol. 2022;12:853232. 3. Gitto S, Ippolito D, Bandiera E, et al. CT and MRI radiomics of bone and soft-tissue sarcomas. Insights Imaging. 2024;15(1):16. Modality Main Role Advantages Limitations X-ray Initial screening Identifies matrix, periosteal reaction Poor soft-tissue detail CT Cortical detail, 3D mapping High resolution Radiation exposure MRI Soft-tissue and marrow evaluation Multiplanar, no radiation Costly, motion artifacts Bone Scan Detects metastases High sensitivity Low specificity Angiography Vascular mapping Guides embolization Invasive USG Superficial mass evaluation Real-time, no radiation Operator-dependent PET/CT Functional staging Detects active disease Limited initial utility Summary Table of Modalities Previous Next

< Back Hip Approaches Previous Next

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< Back Dr. Recep DINCER Spinal Cord Injury Management Acute spinal cord injury (SCI) is a devastating condition resulting in high morbidity and long-term disability. Management focuses on rapid diagnosis, spinal immobilization, airway protection, and maintenance of perfusion with a target mean arterial pressure of ≥85–90 mmHg. The pathophysiology involves a primary mechanical insult followed by secondary injury cascades—ischemia, inflammation, and apoptosis—which are key therapeutic targets. High-dose steroids are no longer routinely recommended due to limited benefit and adverse effects. Early surgical decompression, ideally within 24 hours, has been shown to improve neurological outcomes in selected patients (STASCIS trial). Emerging therapies such as neuroprotective agents, stem cell transplantation, and neuroprosthetic technologies are under investigation. A structured multidisciplinary approach combining early stabilization, evidence-based acute care, and long-term rehabilitation remains the cornerstone of SCI management. Introduction Acute spinal cord injury (SCI) is a catastrophic event that results in significant morbidity and long-term disability. The annual incidence ranges from 10 to 80 cases per million worldwide, with motor vehicle accidents, falls, sports injuries, and violence being the most common etiologies. · Pathophysiology of SCI involves two major phases: Primary Injury - Mechanical disruption due to fracture, dislocation, compression, or penetrating trauma. - Immediate axonal disruption and vascular damage. Secondary Injury - Occurs minutes to weeks after trauma. - Mechanisms: ischemia, excitotoxicity, ionic imbalance, oxidative stress, lipid peroxidation, apoptosis, and inflammation. - Secondary injury is the main target of medical and surgical interventions. Initial Evaluation and Assessment Prehospital Care - Immobilization: Rigid cervical collar and spinal board use until spinal injury is excluded. - Airway, Breathing, Circulation (ABC): Prioritize airway control with cervical spine protection. - Rapid transport to a designated trauma center. Emergency Department Assessment - Neurological Examination: American Spinal Injury Association (ASIA) Impairment Scale (AIS) used to grade severity. - Imaging: Plain radiographs, CT scan (gold standard for bony injury), MRI (superior for cord compression, hemorrhage, disc, and ligamentous injury). Acute Medical Management Airway and Breathing - High cervical injuries (C1–C4) may require immediate intubation or tracheostomy. - Mechanical ventilation as indicated. Circulatory Support - Neurogenic shock: Characterized by hypotension and bradycardia. - Target mean arterial pressure (MAP): Maintain ≥85–90 mmHg for the first 7 days (AANS/CNS guidelines). - Vasopressors (e.g., norepinephrine) preferred. Pharmacological Management - Methylprednisolone (NASCIS trials): Historically used but remains controversial due to infection and GI complications. - Riluzole: sodium channel blocker; phase II–III clinical trials ongoing. - GM1 ganglioside: promising in preclinical studies but failed in phase III trials. - Minocycline: anti-inflammatory antibiotic; phase II showed motor improvement, phase III underway. -Granulocyte Colony-Stimulating Factor (G-CSF): early trials suggest improved outcomes. - Other preclinical agents: magnesium, fibroblast growth factor, hepatocyte growth factor. DVT and Ulcer Prophylaxis - Low molecular weight heparin, compression devices, frequent repositioning, specialized mattresses. Neuroregenerative Approaches - Rho-ROCK inhibitors (e.g., Cethrin): early promise, but phase III trial stopped for futility. - Anti-Nogo-A antibody: enhances axonal sprouting in animal models, not yet in clinical trials. - Cell-based therapies: Schwann cells, olfactory ensheathing cells, mesenchymal stem cells under investigation; clinical results remain inconsistent. Surgical Management · Indications for Surgery - Persistent spinal cord compression. - Instability of the vertebral column. - Progressive neurological deficit. - Associated unstable fractures or dislocations. Timing of Surgery - Early decompression (<24 hours): Supported by STASCIS trial, associated with improved neurological recovery. Prognosis - Complete injuries (AIS A): Lower likelihood of neurological recovery. - Incomplete injuries (AIS B–D): Higher potential for improvement, especially if early surgical decompression is performed. - Factors influencing prognosis: age, initial severity, level of injury, timing of intervention. Future Directions - Neuroregeneration and stem cell transplantation. - Neuroprosthetics and brain-computer interfaces. - Biomarkers for prognosis and individualized treatment. - Advanced rehabilitation technologies: robotic-assisted gait training, exoskeletons, virtual reality therapies. Key Points - Acute SCI requires rapid diagnosis and structured management. - Initial management: immobilization, airway protection, hemodynamic stabilization, early imaging. - High-dose steroids are no longer routinely recommended. - Early surgical decompression (<24 hours) improves neurological outcomes in selected patients. - Long-term rehabilitation is critical for maximizing functional recovery and quality of life. References 1. Fehlings MG, et al. Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the STASCIS Trial. PLoS ONE. 2012. 2. Hadley MN, Walters BC, et al. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. Neurosurgery. 2013. 3. AANS/CNS Joint Section. Management of Acute Cervical Spine and Spinal Cord Injuries. J Neurosurg Spine. 2013. 4. Tator CH, Fehlings MG. Review of the Secondary Injury Theory of Acute Spinal Cord Trauma. J Neurosurg. 1991. 5. Wilson JR, et al. Acute Traumatic Spinal Cord Injury: Current Evidence and Future Directions. Spine. 2020. Previous Next

< Back Dr. Serkan BAYRAM Dr. Serkan Bayram is an orthopaedic surgeon specialising in musculoskeletal oncology, extremity reconstruction, and orthopaedic trauma. His clinical and academic interests include limb salvage surgery, modular endoprosthesis, and the management of bone and soft-tissue tumours. He combines surgical expertise with ongoing research in medical sciences and forensic medicine. Education Ph.D. in Medical Sciences (ongoing) – İstanbul University-Cerrahpaşa, Institute of Forensic Medicine and Forensic Sciences (2023–present) Residency in Orthopaedics and Traumatology – İstanbul University, İstanbul Faculty of Medicine (2014–2019) Doctor of Medicine (M.D.) – İstanbul University, İstanbul Faculty of Medicine (2007–2013) Clinical Interests Musculoskeletal oncology, limb salvage surgery, bone and soft-tissue reconstruction, endoprosthesis Oncologic Orthopaedics dr.serkanbayram89@gmail.com Previous Next

< Back Distal Radius/Ulna Distal radius fractures are among the most common upper limb injuries. Management depends on fracture pattern, displacement, articular involvement, and patient factors. Distal radius fractures are common, particularly in older adults following low-energy falls. Classification systems like AO and Frykman are useful for assessment. Treatment options include conservative casting, closed reduction with percutaneous pinning, and open reduction with internal fixation (typically volar plating). Ulnar styloid fractures or distal radioulnar joint (DRUJ) involvement should also be evaluated. distal-radius-ulna Previous Next

< Back Tibial Osteotomies tibial-osteotomies Previous Next