< Back Principles of Surgical Resection & Margins Tumour resection aims to achieve oncologic control while preserving function; margin status is critical for local recurrence risk. The goal of oncologic resection is complete tumour removal with appropriate margins to minimise recurrence.🔸 Surgical Margins (Enneking Classification) : Intralesional : Through the tumour — used in palliative or diagnostic settings. Marginal : Through reactive zone — risk of microscopic disease. Wide : Includes healthy cuff of tissue around tumour — standard for primary malignancies. Radical : Entire compartment removed — used in selected sarcomas.🔸 Key Considerations : Pre-operative planning with imaging is essential. Biopsy tract must be included in resection. Margins should be assessed intraoperatively and histopathologically. Achieving a wide margin is often the best predictor of local control in malignant tumours.Balancing oncologic safety with preservation of function (e.g., limb salvage vs amputation) is central to surgical decision-making. Previous Next

< Back Multiple Myeloma A haematologic malignancy involving clonal proliferation of plasma cells, often affecting multiple skeletal sites. Multiple myeloma is a plasma cell dyscrasia characterised by clonal proliferation of malignant plasma cells within the bone marrow. It commonly presents in patients over 60 with bone pain, fatigue, or pathological fractures. Skeletal involvement is frequent, especially in the spine, ribs, pelvis, and skull, where lytic lesions or diffuse osteopenia are observed on imaging. Laboratory findings may reveal anaemia, hypercalcaemia, renal impairment, and elevated serum/urine monoclonal proteins (M-protein). Diagnosis is confirmed via bone marrow biopsy and serum electrophoresis. Treatment includes systemic therapy (e.g. bortezomib, lenalidomide, dexamethasone), bisphosphonates for bone disease, and supportive care. Radiation may be used for painful lesions or spinal cord compression. Orthopaedic involvement focuses on fracture stabilisation and decompression where indicated. Previous Next

< Back Pathologic Fracture Management Management of pathological fractures requires a tailored approach based on the underlying tumour type, location, prognosis, and functional demands. Main Content : Initial assessment involves distinguishing between benign, metastatic, and primary malignant causes. Imaging (X-ray, MRI, CT) and histopathology (biopsy) are essential.In metastatic disease , stabilisation aims to restore function and relieve pain. Intramedullary nailing , plate fixation , or modular prostheses are selected based on fracture location and bone stock.For primary bone malignancies , management typically involves en bloc resection followed by reconstruction.Prophylactic fixation may be considered in lesions with high risk of fracture (e.g., Mirels score ≥ 9).Decision-making should include oncologic input , especially when adjuvant therapy (e.g., radiotherapy or chemotherapy) is planned. Previous Next

< Back Dr. Ahmet Müçteba Yıldırım Staging Systems (Enneking, AJCC) Staging plays a crucial role in treatment planning and prognosis estimation for primary bone and soft tissue tumours. The two main systems used in orthopaedic oncology are: Enneking Staging System (commonly used in surgical planning) AJCC TNM Staging System (widely used in oncology) 1. Enneking Staging – Bone Sarcomas This system includes: Grade (G): Histological aggressiveness T (Tumour extension): Local vs extracompartmental M (Metastasis): Distant spread 2. Grade Classification (Enneking) G1 (Low Grade): Mild atypia, mitosis <1/10 HPF Examples: ACT, parosteal osteosarcoma G2 (High Grade): Distinct atypia, mitosis 1–2/10 HPF Examples: Classic osteosarcoma, Grade 2 chondrosarcoma G3 (Anaplastic/Dedifferentiated): Marked atypia, mitosis >2/10 HPF Examples: Ewing sarcoma, undifferentiated chondrosarcoma 3. T & M Definitions (Enneking) T1: Tumour within compartment T2: Extension to soft tissue, skip metastasis, or pelvic involvement M1: Presence of distant metastasis 4. Enneking Stage Summary Table Stage IA Grade 1 (low grade) Tumour confined within the bone (T1) No metastasis (M0) Stage IB Grade 1 Tumour has extended beyond the compartment (T2) No metastasis (M0) Stage IIA Grade 2 or 3 (high grade) Tumour confined (T1) No metastasis (M0) Stage IIB Grade 2 or 3 Tumour has spread beyond compartment (T2) No metastasis (M0) Stage III Any grade Any tumour extent Distant metastasis present (M1) 5. AJCC Staging – Bone Tumours (8th Edition) More commonly used by oncologists. Uses: T (Tumour size) N (Lymph node involvement) M (Metastasis site: M1a = lung, M1b = other) Grade (G1–G4) 6. T Category Definitions (AJCC) T1: ≤5 cm T2: >5–10 cm T3: >10–15 cm T4: >15 cm 7. AJCC Bone Staging Table StageTNMGradeIAT1N0M0G1–2IBT2–T3N0M0G1–2IIAT1N0M0G3–4IIBT2N0M0G3–4IIIT3N0M0G3–4IVAny TN1 or M1Any MAny G 8. AJCC – Soft Tissue Sarcomas (Extremity & Trunk) Uses TNM + Grade system. Version 8 no longer considers superficial vs deep location. Grade Definitions: G1: Well-differentiated (e.g., liposarcoma) G2: Moderately differentiated (e.g., leiomyosarcoma) G3: Poorly/undifferentiated (e.g., pleomorphic or synovial sarcoma) References Siegel, G. W., & Biermann, J. S. OKU: Musculoskeletal Tumours 5 Choi, J. H., & Ro, J. Y. 2020 WHO Classification of Bone Tumours Tanaka, K., & Ozaki, T. AJCC 8th Edition – Bone & Soft Tissue Tumours Enneking Staging – Bone Sarcomas AJCC Staging in Primary Bone Malignancies AJCC – Soft Tissue Sarcomas 8th AJCC Staging of Soft Tissue Sarcomas of the Extremities and Trunk Previous Next

< Back Palliative Surgery Palliative surgery in orthopaedic oncology aims to relieve pain, preserve function, and improve quality of life in patients with advanced or incurable musculoskeletal malignancies. Main Content : Indications for palliative surgery include pathological fractures, intractable pain, spinal cord compression, neurovascular compromise, and loss of ambulation or function.Common procedures include intramedullary nailing, modular endoprostheses, or stabilization with bone cement (e.g., PMMA). Vertebroplasty and decompressive laminectomy may be used in spinal metastases.The focus is not on oncological margins , but rather on rapid recovery and symptom relief .Multidisciplinary assessment is crucial to balance surgical risk with expected benefit, considering the patient’s performance status and life expectancy. Previous Next

< Back Anti-inflammatory drugs Anti-inflammatory drugs, particularly NSAIDs, are commonly used in orthopaedics to manage pain and inflammation, but they carry risks related to gastrointestinal, renal, and cardiovascular systems. Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit COX enzymes and reduce prostaglandin synthesis. COX-1 inhibition affects platelet function and gastric mucosa. COX-2 selective inhibitors have fewer GI side effects but may increase cardiovascular risks. Previous Next

< Back Synovium & Synovial Fluid The synovium is a connective tissue that lines the inner surface of synovial joints and produces synovial fluid, which provides lubrication and nourishment to cartilage. The synovial membrane is composed of two layers: an intima and subintima. It is rich in blood vessels, lymphatics, and type A/B synoviocytes. Synoviocytes produce hyaluronic acid and lubricin, key components of synovial fluid. Synovial fluid: Is ultrafiltrate of plasma enriched with hyaluronan. Acts as a lubricant and shock absorber. Supplies oxygen and nutrients to avascular cartilage. In inflammation (e.g. arthritis), synovial thickening and hyperplasia occur, often accompanied by increased fluid and inflammatory cells. Previous Next

< Back Renal Osteodystrophy Renal osteodystrophy is a bone pathology resulting from chronic kidney disease, leading to impaired mineral metabolism and bone remodelling. Renal osteodystrophy encompasses a spectrum of skeletal disorders seen in patients with chronic kidney disease (CKD), especially in those on long-term dialysis. It results from disrupted calcium, phosphate, and vitamin D metabolism, along with secondary hyperparathyroidism. Clinical manifestations include bone pain, fractures, and growth retardation in children. Radiographic features may show subperiosteal bone resorption and osteosclerosis. Management involves phosphate binders, vitamin D analogs, and sometimes parathyroidectomy. Early recognition and treatment are crucial to prevent skeletal deformities and improve quality of life in CKD patients. Previous Next

< Back Hyperparathyroidism Hyperparathyroidism is a condition of excessive parathyroid hormone secretion, leading to increased bone resorption and altered calcium-phosphate balance. Hyperparathyroidism is classified as primary, secondary, or tertiary depending on the cause. In primary hyperparathyroidism, autonomous overproduction of parathyroid hormone (PTH) often results from a parathyroid adenoma. Secondary hyperparathyroidism occurs in response to hypocalcaemia, commonly due to chronic kidney disease. Tertiary hyperparathyroidism represents persistent PTH elevation after long-standing secondary hyperparathyroidism. Bone manifestations include osteitis fibrosa cystica, subperiosteal bone resorption, and pathological fractures. Diagnosis involves elevated serum calcium (in primary) and PTH levels. Treatment ranges from surgical parathyroidectomy to phosphate binders and vitamin D analogs, particularly in CKD patients. Previous Next

< Back Ligaments Structure, biomechanical role, and healing characteristics of ligaments in orthopaedic function. Ligaments are dense bands of fibrous connective tissue that connect bone to bone, contributing to joint stability and guiding joint motion. They are composed primarily of type I collagen, with some type III collagen, organized in a crimped pattern that allows elasticity and load absorption. Ligaments contain fibroblasts (ligamentocytes), extracellular matrix components, and have limited vascular supply. Their biomechanical strength varies based on location and function—e.g., the anterior cruciate ligament (ACL) has high tensile strength but poor intrinsic healing potential. Healing occurs via: Inflammatory phase – clot formation and cell infiltration. Proliferation phase – fibroblast proliferation and matrix deposition. Remodeling phase – collagen alignment and maturation. Extra-articular ligaments (e.g., MCL) heal better than intra-articular ligaments (e.g., ACL). Surgical reconstruction is often needed for the latter. Current research explores biological augmentation, scaffolds, and gene therapy to improve healing outcomes. Previous Next

< Back Vitamin Deficiency Disorders Rickets and scurvy are skeletal disorders caused by deficiencies in essential vitamins—D and C respectively—leading to impaired bone growth, mineralisation, and connective tissue function. Rickets is primarily due to vitamin D deficiency, leading to impaired mineralisation of the growth plate in children. Clinical signs include bowing of the legs, delayed closure of fontanelles, rachitic rosary, and wrist widening. Radiographs show cupping, fraying, and widening of the metaphyses. Causes include inadequate sunlight exposure, poor dietary intake, or malabsorption. Scurvy is a result of prolonged vitamin C deficiency, impairing collagen synthesis. It manifests with musculoskeletal pain, bleeding gums, petechiae, pseudoparalysis in children, and poor wound healing. Radiological signs include the White line of Frankel, Pelkan spurs, and the Trümmerfeld zone. Treatment involves prompt vitamin C supplementation. Both conditions are preventable and reversible with adequate nutritional intervention. Previous Next

< Back Osteoporosis & Osteopenia Osteoporosis is a systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to increased fracture risk. Osteoporosis is commonly seen in postmenopausal women and the elderly but can also result from secondary causes such as glucocorticoid use, endocrine disorders, or chronic inflammatory diseases like rheumatoid arthritis. Diagnosis is typically made using bone mineral density (BMD) testing via DEXA scan (T-score ≤ -2.5). Management includes lifestyle interventions (e.g., weight-bearing exercise, calcium/vitamin D intake), antiresorptive agents (bisphosphonates, denosumab), and anabolic therapies (teriparatide, abaloparatide) in high-risk cases. Fall risk assessment and fracture prevention strategies are key components of care. Previous Next