SHOULDER & ELBOW General Principles Shoulder & Elbow Anatomy Biomechanics Physical Examination Imaging Classification Systems Shoulder AC & SC Joint Injuries Rotator Cuff Tears Shoulder Instability Proximal Biceps Tendon Pathology Glenohumeral Dislocations Elbow Radial Head Fractures Olecranon Fractures Monteggia Fractures Elbow Dislocations Distal Humerus Fractures Coronoid & Terrible Triad Injuries Ligament Injuries (UCL, LCL) Special Considerations Throwing Athlete Injuries Brachial Plexus Injuries Elbow Stiffness Pediatric Growth Plate Injuries Infection & Septic Arthritis

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< Back Dr. Erhan OKAY Fibrous Dysplasia Fibrous dysplasia (FD) is a benign bone disorder characterized by the replacement of normal bone with fibro-osseous tissue, leading to pain, deformity, and fractures. It results from post-zygotic GNAS gene mutations that disrupt osteoblastic differentiation. FD may be monostotic (single bone) or polyostotic, the latter often occurring as part of McCune–Albright syndrome (MAS). Radiologically, it presents with a ground-glass appearance and possible deformities such as the “shepherd’s crook” in the proximal femur. Treatment is primarily symptomatic, involving bisphosphonates for pain control and surgery for deformity or fracture correction. Although benign, the disease may progress during growth and stabilize in adulthood, requiring periodic follow-up for skeletal deformity and functional assessment. Pathophysiology Caused by post-zygotic mutations in the GNAS gene . Leads to defective osteoblastic differentiation and formation of immature woven bone mixed with fibrous tissue. Two clinical forms: Monostotic FD: Involves a single bone. Polyostotic FD: Affects multiple bones and may be associated with McCune–Albright syndrome (endocrine abnormalities + café-au-lait spots). Clinical Presentation & Imaging Symptoms: Bone pain, deformity, limp, or pathological fracture. Typical signs: “Ground-glass” appearance on radiographs, cortical thinning, and possible cystic changes. Characteristic deformity: Shepherd’s crook in proximal femur due to repeated microfractures. CT scan: Useful for evaluating lesion extent and surgical planning. MRI: May show low-to-intermediate T1 and high T2 signal intensities. Differential Diagnosis Monostotic FD: Simple bone cyst, osteofibrous dysplasia, osteoblastoma, hemangioma, Paget’s disease. Polyostotic FD: Hyperparathyroidism, enchondromatosis, neurofibromatosis, eosinophilic granuloma.Fibrous dysplasia Treatment Medical Management Pain control: NSAIDs for symptomatic relief. Bisphosphonates (Pamidronate): 0.5–1 mg/kg/day IV for 2–3 days every 6–12 months. Reduces pain and bone turnover, but does not halt disease progression . Experimental therapies: Calcitonin and other bone-modulating agents under investigation. Surgical Management Indicated for: Structural deformity or pathological fractures. Progressive or symptomatic lesions. Procedures: Curettage, bone grafting, internal fixation (e.g., intramedullary nailing), corrective osteotomies. Risks: Recurrence and infection, though outcomes are generally favorable. Prognosis Usually benign and stabilizes after skeletal maturity. Polyostotic cases may require annual follow-up for deformity monitoring. Disease activity typically declines after adolescence. Functional disability may occur in cases with extensive skeletal involvement. References Hartley I, Zhadina M, Collins MT, Boyce AM. Fibrous Dysplasia of Bone and McCune-Albright Syndrome: A Bench to Bedside Review. Calcif Tissue Int. 2019;104(5):517–529. doi:10.1007/s00223-019-00550-z. Fitzpatrick KA, Taljanovic MS, Speer DP, et al. Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation. AJR Am J Roentgenol. 2004;182(6):1389–1398. doi:10.2214/ajr.182.6.1821389. Riddle ND, Bui MM. Fibrous Dysplasia. Arch Pathol Lab Med. 2013;137(1):134–138. doi:10.5858/arpa.2012.0013-RS. Lala R, Matarazzo P, Bertelloni S, et al. Pamidronate Treatment of Bone Fibrous Dysplasia in Children with McCune-Albright Syndrome. Acta Paediatr. 2000;89(2):188–193. doi:10.1080/080352500750028816. Hart ES, Kelly MH, Brillante B, et al. Onset, Progression, and Plateau of Skeletal Lesions in Fibrous Dysplasia and the Relationship to Functional Outcome. J Bone Miner Res. 2007;22(9):1468–1474. doi:10.1359/jbmr.070511. Plain radiograph and coronal CT image of the leg show a well-circumscribed intramedullary expansile lesion in the proximal fibula with a ground-glass matrix and smooth cortical thinning. No cortical breakthrough or periosteal reaction is present. The imaging features are consistent with monostotic fibrous dysplasia. Radiograph and coronal MRI images of the proximal femur demonstrate a well-defined intramedullary expansile lesion with a ground-glass matrix and cortical thinning without periosteal reaction or soft-tissue extension. On MRI, the lesion shows heterogeneous low-to-intermediate signal on T1-weighted and high signal on fat-suppressed proton-density images, consistent with a fibrous dysplasia involving the proximal femoral shaft. Aspect Details Nature Benign fibro-osseous lesion replacing normal bone with fibrous tissue Genetic Basis GNAS mutation causing defective osteoblastic differentiation Forms Monostotic (single bone) and Polyostotic (multiple bones, often with McCune–Albright syndrome) Common Sites Femur, tibia, ribs, craniofacial bones Characteristic Imaging “Ground-glass” matrix, cortical thinning, shepherd’s crook deformity (proximal femur) Symptoms Bone pain, deformity, limp, or pathologic fracture Treatment Pain control (NSAIDs), bisphosphonates for bone turnover reduction, surgery for deformity/fracture Prognosis Benign course; stabilizes after skeletal maturity; annual follow-up for polyostotic cases 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

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< Back Dr. Kayahan KARAYTUG Robotic Assisted UKA Robotic unicompartmental knee arthroplasty (R-UKA) is an evolution of traditional unicompartmental knee replacement, developed to improve component accuracy, reduce outliers, and enhance short-term recovery. It is indicated for isolated medial or lateral compartment osteoarthritis (Kellgren–Lawrence grade IV) when the remaining compartments are intact. 💡 Approximately 20% of knee OA cases are unicompartmental — most involve the medial side. Robotic Unicompartmental Knee Arthroplasty (R-UKA) Why Robotics? Conventional UKA is highly technique-sensitive ; even 2–3° of malalignment can shorten implant life. Robotic systems minimize this variability by integrating preoperative imaging, 3-D planning, and intra-operative feedback, allowing precise bone preparation and implant positioning. 💡 Accuracy translates to reproducibility and potentially longer survivorship. Robotic Platforms Common systems: MAKO (Stryker, NJ, USA) – most extensively validated Cuvis Joint ( Meril, India) NAVIO / CORI® (Smith & Nephew, MN, USA) ACROBOT (UK) Systems are categorized as passive (navigational), semi-active , or active , depending on the degree of robotic autonomy. Accuracy & Alignment R-UKA achieves superior coronal and sagittal alignment compared to manual UKA. Tibial slope variation and component overhang are significantly reduced. Fewer alignment deviations >2° are reported. Improved restoration of joint line and mechanical axis alignment. 💡 Most alignment-related failures seen in conventional UKA are rare in robotic surgery. Functional & Clinical Outcomes Early postoperative pain and opioid use are reduced . Faster return to daily activities and physiotherapy. Improved early range of motion and hospital discharge time. At 1-year, gait studies show more physiological motion patterns during stance phase. Mid-term outcomes (2–5 years) are comparable to conventional UKA in survivorship. 💡 Robotic precision benefits early recovery, but long-term differences remain under investigation. Implant Survivorship Short- to mid-term survival rates: ≈98–99% at 2–3 years. Failures in robotic series are rarely due to malalignment — mostly aseptic loosening or progression of arthritis in untreated compartments. Long-term (>10 years) data are still limited. 💡 Accuracy may delay mechanical failure but cannot prevent disease progression. Limitations & Considerations Higher cost and longer setup time. Requires specific training and case volume to justify system investment. Outcomes depend on surgeon experience, platform type, and patient selection. Clinical Pearls Ideal candidates: isolated unicompartmental OA, intact cruciate ligaments, correctable deformity, BMI < 35. Avoid in: inflammatory arthritis, tricompartmental OA, fixed deformity > 15°, severe bone loss. Precision ≠ Perfection: robotic systems guide, but do not replace, surgical judgment. Integration with AI-based planning and patient-specific implants will likely define the next generation of R-UKA. Summary Robotic UKA enhances surgical precision, reproducibility, and early functional recovery compared to conventional techniques. While radiographic and short-term clinical outcomes are consistently superior, long-term survivorship equivalence underscores the importance of patient selection, surgical skill, and individualized alignment goals . References Cobb JP et al. J Bone Joint Surg Br. 2006;88-B:188–197. Cool CL et al. J Arthroplasty. 2023;38(4):754–763. Herry Y et al. Bone Joint J. 2022;104-B:325–333. Bell SW et al. Knee Surg Sports Traumatol Arthrosc. 2021;29:1001–1012. Pandit H et al. J Arthroplasty. 2020;35:S15–S22. Previous Next

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