< Back Perilunate & Lunate Dislocations perilunate-dislocations Previous Next

< Back Principles of Flap Surgery flap-surgery-principles Previous Next

< Back Dr. Kayahan KARAYTUG Periprosthetic Joint Infection (PJI) Periprosthetic Joint Infection (PJI) is one of the most devastating complications of arthroplasty. Although uncommon (≈1–2%), it is a leading cause of revision surgery and implant failure. Biofilm formation on implant surfaces makes eradication difficult and often necessitates complex surgical management. Periprosthetic Joint Infection (PJI) Pathophysiology & Risk Factors Biofilm formation protects bacteria from antibiotics and immune response. Common organisms: Staphylococcus aureus , S. epidermidis , and Gram-negatives. Risk factors: prior surgery, obesity, diabetes, immunosuppression, long operative time, wound complications. 💡 Host factors often outweigh surgical technique in determining infection risk. Diagnosis 1.Clinical Persistent pain, drainage, erythema, or early implant loosening. Chronic PJI may lack systemic signs (fever often absent). 2. Laboratory ESR >30 mm/h , CRP >10 mg/L → highly suggestive. Normal ESR + CRP → infection unlikely. 3. Synovial Fluid Aspiration before antibiotics. Evaluate WBC count, %PMN, culture, and novel biomarkers (α-defensin, leukocyte esterase, synovial CRP). ≥2 positive cultures → diagnostic. 4. Imaging X-ray: loosening or osteolysis (nonspecific). MRI (metal-artifact reduction) → soft-tissue assessment. PET-CT / Indium-labeled WBC scan for uncertain cases. 5. Intra-operative ≥5 tissue samples; >5 PMNs/HPF = infection. Ultrasonication of explanted implants enhances microbial yield. Treatment Strategies 1. Antibiotic Suppression Reserved for unfit patients or non-surgical candidates. Combination therapy (e.g., rifampicin + fluoroquinolone) may control low-grade infection. 2. DAIR (Debridement, Antibiotics, and Implant Retention) Indication: acute infection (<3 weeks), stable implant, sensitive organism. Success: 30–70%. 💡 Early (<48 h) intervention improves eradication. 3. Resection Arthroplasty Salvage in non-ambulatory or medically fragile patients. High infection-control rate but poor function. 4. Single-Stage Exchange Removal and reimplantation in one operation. Indicated for known organism, healthy host, good bone stock. Control rate: 80–90% . 5. Two-Stage Exchange (Gold Standard) Step 1: remove all components, debridement, antibiotic spacer + 6 weeks IV therapy. Step 2: reimplant after infection markers normalize. Success: >90–95% . 💡 Most reliable approach for chronic PJI. Antibiotic-Loaded Cement & Spacers Deliver high local antibiotic concentration. Articulating spacers (e.g., PROSTALAC) maintain limb length and mobility while treating infection. Recurrent or Resistant Infections Options: repeat two-stage revision, chronic suppressive therapy, or salvage resection. MRSA/VRE infections → rifampicin-based protocols remain effective. Outcomes & Prognosis Infection eradication: >90% achievable with early multidisciplinary care. Function depends on timing, host status, and bone/soft-tissue preservation. Key Pearls Always rule out infection before any revision. Combine serologic + synovial + intra-operative data for accurate diagnosis. Early, coordinated management (orthopaedics + ID + microbiology) is vital. Prevention: meticulous wound care, peri-op glucose control, skin optimization. References Parvizi J, et al. Clin Orthop Relat Res. 2021; 479: 985-99. Tande AJ, Patel R. N Engl J Med. 2014; 370: 2451-62. Zimmerli W, et al. Lancet. 2004; 364: 1539-54. Osmon DR, et al. Infect Dis Clin North Am. 2020; 34: 57-75. Previous Next

< Back Dr. Abdullah IYIGUN He graduated from Erciyes University Faculty of Medicine in 2009. He received his specialist training in Orthopedics and Traumatology at Ankara Training and Research Hospital in 2015. He is still working in SBU Umraniye Research and Education Hospital as a trauma and spine surgeon. Spine - Trauma Surgery abdullahiyigun@gmail.com Previous Next

< Back Dr. Korhan Ozkan Surgical Reconstruction Options Surgical reconstruction following tumor resection is a cornerstone of musculoskeletal oncology, aiming to restore form, function, and stability after achieving oncologic clearance. Advances in modular prostheses, biological reconstruction, and 3D-printing technologies have allowed surgeons to preserve limb function without compromising oncologic safety. Reconstruction choice depends on patient age, tumor site, expected survival, and remaining bone and soft-tissue stock. Reconstruction Principles Oncologic Safety: Clear margins remain the first priority. Functional Restoration: Maximize joint motion and weight-bearing capacity. Durability: Select reconstruction that matches expected patient lifespan. Simplicity: Avoid over-complex solutions when reliable alternatives exist. Soft-Tissue Coverage: Adequate muscular or flap coverage is vital for wound healing and prosthesis protection. Types of Reconstruction 1. Endoprosthetic Reconstruction Indication: Segmental bone loss in extremity sarcomas, especially around knee, hip, or shoulder. Technique: Modular metallic prostheses anchored with cemented or press-fit stems. Advantages: Immediate stability, early mobilization, predictable outcomes. Limitations: Mechanical failure, aseptic loosening, infection risk. Recent Advances: Silver-coated implants reduce deep infection rates; rotating-hinge designs improve knee kinematics. 2. Biological Reconstruction Includes options that promote osteointegration or use native bone for long-term durability. Autograft (e.g., vascularized fibula): Used for diaphyseal or pediatric reconstructions; allows gradual hypertrophy and remodeling. Allograft: Large segmental grafts restore anatomy; can be combined with prosthesis (allograft–prosthetic composite). Recycled Autografts: Tumor-bearing bone re-implanted after sterilization (liquid nitrogen, autoclaving, or irradiation) in resource-limited settings. Limitations: Nonunion, graft fracture, late resorption, infection. 3. Allograft–Prosthetic Composite (APC) Indication: Periarticular resections where joint surface requires replacement but metaphyseal bone stock remains. Advantages: Combines biological fixation with mechanical stability. Outcomes: Good mid-term function, but risk of nonunion and graft resorption persists. 4. Arthrodesis Indication: In cases of infection, poor soft-tissue coverage, or failed prosthesis. Technique: End-to-end bone fusion using compression plates, intramedullary rods, or vascularized fibula. Outcome: Pain-free but stiff limb; favored in young or high-demand patients. 5. Rotationplasty Indication: Selected femoral or distal thigh sarcomas in children and adolescents. Concept: Distal limb rotated 180°; ankle functions as the new knee joint. Advantages: Excellent durability, no prosthesis-related complications, good energy efficiency. Limitation: Cosmetic concerns; extensive rehabilitation required. 6. Amputation and Disarticulation Indication: When negative margins cannot be achieved or soft-tissue coverage is impossible. Technique: Emphasis on myodesis and optimal stump shaping for prosthetic fitting. Modern Focus: Myoelectric and osseointegrated prosthetic systems improving function and comfort. Soft-Tissue Reconstruction Adequate coverage is critical for wound healing and implant longevity: Local Muscle Flaps: Gastrocnemius (knee), latissimus dorsi (shoulder), rectus abdominis (pelvis). Free Flaps: ALT (anterolateral thigh), free latissimus dorsi for large defects. Vacuum-assisted closure (VAC): Useful for staged closure in contaminated wounds. Complications and Outcomes Complication Typical Cause Management Infection Extensive soft-tissue loss or long surgery Debridement ± prosthesis exchange, antibiotic spacers Mechanical Failure Fatigue fracture, hinge breakage Modular revision, redesign Nonunion (biological grafts) Insufficient fixation, poor vascularity Bone grafting, plate augmentation Aseptic Loosening Stress shielding, bone loss Stem revision, cemented fixation Local Recurrence Inadequate margins Re-resection, possible amputation Key Points Surgical reconstruction after tumor resection must balance oncologic safety and functional restoration . Endoprosthetic replacement remains the gold standard for large periarticular resections. Endoprosthetic replacement provides the best early function but higher long-term complication risk. Biological methods are valuable for younger patients or diaphyseal defects. Multidisciplinary planning with plastic surgeons and rehabilitation teams optimizes outcomes. Rotationplasty remains a highly functional alternative in children with large femoral resections. Arthrodesis and amputation preserve oncologic safety when limb salvage is not feasible. References Jeys LM, Kulkarni A, Grimer RJ. Reconstruction after Resection of Musculoskeletal Tumors: Current Concepts. J Bone Joint Surg Br. 2023;105-B(4):412–422. Abudu A, Grimer RJ, Tillman RM. Endoprosthetic Replacement of the Proximal Tibia: Functional and Oncological Outcomes. J Bone Joint Surg Br. 2019;101-B(3):350–358. Avedian RS, et al. Allograft-Prosthetic Composites in Tumor Reconstruction. Clin Orthop Relat Res. 2020;478(2):238–247. Puri A, Gulia A. Biological Reconstruction for Bone Tumors: Principles and Pitfalls. Indian J Orthop. 2021;55(6):1419–1428. Jeys L, Wafa H, Grimer R. Silver-Coated Endoprostheses in High-Risk Patients: Infection Reduction and Survivorship. Bone Joint J. 2015;97-B(2):252–257. Complication Typical Cause Management Infection Extensive soft-tissue loss or long surgery Debridement ± prosthesis exchange, antibiotic spacers Mechanical Failure Fatigue fracture, hinge breakage Modular revision, redesign Nonunion (biological grafts) Insufficient fixation, poor vascularity Bone grafting, plate augmentation Aseptic Loosening Stress shielding, bone loss Stem revision, cemented fixation Local Recurrence Inadequate margins Re-resection, possible amputation Complications and Outcomes Reconstruction Type Typical Indication Advantages Limitations / Complications Functional Outcome (MSTS%) Endoprosthetic Replacement Periarticular bone loss (knee, hip, shoulder) Immediate stability, early mobilization, modular design Infection, mechanical failure, aseptic loosening 70–85% Allograft–Prosthetic Composite (APC) Partial metaphyseal involvement with joint preservation Biological fixation + mechanical stability Nonunion, graft resorption, fracture 65–80% Biological Reconstruction (Autograft / Allograft) Diaphyseal or intercalary resections, young patients Long-term durability, biological incorporation Nonunion, late fracture, resorption 60–75% Rotationplasty Pediatric femoral / distal thigh tumors Durable, energy-efficient, no implant failure Cosmetic concerns, rehabilitation required 75–90% Arthrodesis (Joint Fusion) Infected prosthesis, poor soft tissue envelope Stable and pain-free limb Loss of motion, gait asymmetry 60–70% Amputation / Disarticulation Unresectable or recurrent tumors, failed salvage Oncologic safety, low reoperation rate Psychosocial impact, prosthetic dependence 50–60% Comparison of Reconstruction Techniques in Musculoskeletal Tumor Surgery Previous Next

< Back Pediatric Growth Plate Injuries pediatric-growth-plate-injuries Previous Next

< Back Patellofemoral Arthroplasty Patellofemoral arthroplasty is a type of partial knee replacement in which surgical option for isolated patellofemoral arthritis. Two different designs include; • İnlay-style designed (previous generation) o Positioning Inset flush with native trochlea o Rotation Determine by native trochlea o Narrower o No further proximal extension than native trochlear surface • Onlay-style designed (newer generation) o Replaces entire trochlea, perpendicular to AP axis o Set by surgeon, perpendicular to AP axis o Wider o Extends further proximal than native trochlea CLINICAL PRESENTATION · Anterior knee pain arise from patellofemoral joint o aggravated by activities such as squatting, ascending or especially descending stairs , getting up from a chair · Patellar crepitus and reproduce pain during retro-patellar palpation RADIOLOGIC ASSESMENT · Standing AP/lateral knee radiographs · Rosenberg view · Patellar skyline (axial or merchant) view · Standing full-leg radiographs o To evaluate; - Femorotibial compartments - Femorotibial malalignment - Stage of PF-OA (Iwano classification) - Trochlear dysplasia - Patellar height - Patellar subluxation · MRI - Meniscal pathology, ligament injury · CT - To evaluate rotational malalignment INDICATIONS · Indications o Isolated symptomatic PF o PF-OA Iwano stage 3–4 o Posttraumatic PF-OA o Trochlear dysplasia with or without instability o Failed prior conservative procedure o Good patellar tracking o Age>40 years · Absolute contraindications o Systemic inflammatory arthropathy o Tibiofemoral OA o Severe uncorrected tibiofemoral malalignment (Valgus deformity > 8 degrees or varus deformity > 5 degrees) o Uncorrected patellofemoral instability or maltracking o Stiffness o Ligamentous tibiofemoral instability o Acute infection or CRPS · Relative contraindications o Quadriceps atrophy o Patella baja o BMI > 30 COMPLICATIONS Showing that the 5-year cumulative revision rate was greater than 20% for inlay prostheses and less than 10% for onlay designs Early complications · Patellar instability · Maltracking (inlay-style implants %17-36, onlay-style implants less than %1) · Arthrofibrosis · Persistant pain · Extensor mechanism failure Late complications · Progression of tibiofemoral arthritis (most common reason for long-term failure, ̴25% of the revision at 15 years of follow-up) · Aseptic loosening (more frequent in cementless PFA) REFERENCES · Batailler C, Libert T, Oussedik S, Zaffagnini S, Lustig S. Patello-femoral arthroplasty- indications and contraindications. J ISAKOS. 2024 Aug;9(4):822-828. doi: 10.1016/j.jisako.2024.01.003. Epub 2024 Jan 5. PMID: 38185247. · Lonner JH, Bloomfield MR. The clinical outcome of patellofemoral arthroplasty. Orthop Clin North Am. 2013 Jul;44(3):271-80, vii. doi: 10.1016/j.ocl.2013.03.002. Epub 2013 May 4. PMID: 23827831. Pisanu G, Rosso F, Bertolo C, Dettoni F, Blonna D, Bonasia DE, Rossi R. Patellofemoral Arthroplasty: Current Concepts and Review of the Literature. Joints. 2017 Oct 4;5(4):237-245. doi: 10.1055/s-0037-1606618. PMID: 29270562; PMCID Previous Next

< Back Bone Transport bone-transport Previous Next

< Back Dr. Mutlu COBANOGLU Professor of Orthopaedics and Traumatology, Aydın Adnan Menderes University Prof. Dr. Mutlu Çobanoğlu, born in Trabzon in 1979, graduated from Karadeniz Technical University Faculty of Medicine in 2003. He completed his orthopaedic residency at Aydın Adnan Menderes University in 2008 and fulfilled his mandatory service at Erzincan State Hospital. He joined the same university as a faculty member in 2011, became Associate Professor in 2017 , and Full Professor in 2023 . He received advanced spine surgery training at the Istanbul Spine Center (2014–2015) and completed a research fellowship at Alfred I. duPont Hospital for Children, Delaware, USA (2016–2017) focusing on paediatric orthopaedics and spine surgery. Prof. Çobanoğlu is an active member of EUROSPINE , Turkish Spine Society , Turkish Orthopaedics and Traumatology Association (TOTBID) , and the Turkish Paediatric Orthopaedics Association . His main interests include spine surgery, deformity correction, trauma, and paediatric orthopaedics . Spine drmutlu79@hotmail.com Previous Next

Surgical Guide Step-by-step surgical approaches, indications, and technique pearls Trauma Spine Shoulder & Elbow Knee & Sports Deformity Correction Pediatrics Arthroplasty Orthoplastic Approach Hand Foot & Ankle Oncologic Orthopaedics

< Back Atlantoaxial Injuries (C1-C2) fenerbahçe Previous Next

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