< Back Damage Control S SS damage-control Previous Next

< Back Hip Fractures B S hip-fractures 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 Dr. Recep DINCER Spinal Cord Monitoring Spinal cord monitoring is an essential intraoperative tool used to prevent neurological injury during spinal surgery. The main modalities include somatosensory evoked potentials (SEP) for dorsal column function, motor evoked potentials (MEP) for corticospinal tracts, and electromyography (EMG) for nerve root integrity. SEPs are reliable and anesthetic-resistant but limited to sensory pathways, while MEPs are highly sensitive to anterior spinal ischemia yet affected by anesthesia. EMG, both spontaneous and triggered, helps identify nerve irritation or pedicle screw breaches in real time. A >50% reduction in signal amplitude or latency prolongation indicates potential cord compromise requiring immediate correction. Combined multimodal monitoring significantly improves intraoperative safety and postoperative neurological outcomes. SPINAL CORD MONITORING Spinal cord monitoring is a method to detect injury to the spinal cord during operative procedures most common forms are EMG (electromyography) SEP (somatosensory evoked potentials) 25% sensitive, 100% specific MEP (motor evoked potentials) 100% sensitive, 100% specific ANATOMY Spinal cord pathways sensory (afferent) dorsal column spinothalamic tract motor (efferent) lateral corticospinal tract ventral corticospinal tract Blood supply anterior spinal artery primary blood supply to anterior 2/3 of spinal cord, including both the lateral corticospinal tract and ventral corticospinal tract posterior spinal artery (right and left) primary blood supply to the dorsal sensory columns SENSORY EVOKED POTENTIALS (SEPS) Function monitor integrity of dorsal column sensory pathways of the spinal cord Technique signal initiation lower extremity usually involves stimulation of posterior tibial nerve behind ankle upper extremity usually involves stimulation of ulnar nerve signal recording transcranial recording of somatosensory cortex Advantages reliable and unaffected by anesthetics administering propofol with ketamine intravenously is recommended neuromuscular blocking agents do not affect the SEP Disadvantages not reliable for monitoring the integrity of the anterior spinal cord pathways reports exist of an ischemic injury leading to paralysis despite normal SEP monitoring during surgery changes in body temperature, blood pressure, circulating blood volume, arterial blood oxygen saturation, and intracranial pressure influence the SEP Intraoperative considerations loss of signals during distraction mandates immediate removal of device and repeated assessment of signals decrease in amplitude of 50% and/or 10% prolongation in latency is considered a significant change changes should be confirmed by at least three recordings. When the wave pattern suddenly changes, the following factors should be checked: · The surgical procedure, accidental lesion to the spinal cord, aggressive distraction, derotation, etc. · Hardware-related issues, electrode dislodgment, cable lesion, and amplifier and stimulator problems. If these issues occur, the artifact pattern is affected. · Changes in the volume of the anesthetic agent and neuromuscular blocking agent. MOTOR EVOKED POTENTIALS (MEP) Function monitor integrity of lateral and ventral corticospinal tracts of the spinal cord Technique signal initiation transcranial stimulation of motor cortex signal recording muscle contraction in extremity (gastroc, soleus, EHL of lower extremity) Advantages effective at detecting a ischemic injury (loss of anterior spinal artery) in anterior 2/3 of spinal cord Disadvantages often unreliable due to effects of anesthesia Intraoperative considerations loss of signals during distraction mandates immediate removal of device and repeated assessment of monitoring signals >100 V increase in threshold is suggestive of an early injury >50% decrease in MEP amplitude is considered significant ELECTROMYOGRAPHY (SPONTANEOUS) Introduction monitor integrity of specific spinal nerve roots Technique concept microtrauma to nerve root during surgery causes depolarization and a resulting action potential in the muscle that can be recorded contact of a surgical instrument with nerve root will lead to "burst activity" and has no clinical significance significant injury or traction to a nerve root will lead to "sustained train" activity, which may be clinically significant signal initiation mechanical stimulation (surgical manipulation) of nerve root signal recording muscle contraction in extremity Advantages allows monitoring of specific nerve roots Disadvantages may be overly sensitive (i.e. sustained train activity does not necessarily reflect a nerve root injury) ELECTRICAL ELECTROMYOGRAPHY (TRIGGERED) Introduction allows detection of a breached pedicle screw Technique concept bone conducts electricity poorly an electrically stimulated pedicle screw that is confined to bone will not stimulate a nerve root if there is a breach in a pedicle, stimulation of the screw will lead to activity of that specific nerve root signal initiation electrical stimulation of placed pedicle screw signal recording muscle contraction in extremity thresholds <8 mA may be indicative of a breach Advantages allows monitoring of specific nerve roots Disadvantages may be overly sensitive (i.e. sustained train activity does not necessarily reflect a nerve root injury) References: Banoub M, Tetzlaff JE, Schubert A. Pharmacologic and physiologic influences affecting sensory evoked potentials: implications for perioperative monitoring. Anesthesiology. 2003;99(3):716–737. Lall RR, Hauptman JS, Munoz C, Cybulski GR, Koski T, Ganju A, Fessler RG, Smith ZA. Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist. Neurosurgical Focus (FOCUS). 2012;33(5):E10. doi:10.3171/2012.9.FOCUS12235 . Abbasi H, Moore DJ, Rajaeirad M, Zhan J. Screw stimulation thresholds for neuromonitoring in minimally invasive oblique lateral lumbar interbody fusion (OLLIF): a correlational study. Cureus. 2024;16(6):e62859. doi:10.7759/cureus.62859. Previous Next

< Back Classification Systems Q D shoulder-elbow-classification Previous Next

< Back Evidence-Based Medicine Spot Knowledge Definition: Integration of best research evidence + clinical expertise + patient values Goal: Maximise quality & duration of life, improve decision-making 🔄 EBM 5 Steps Formulate clinical question Search for evidence Critically appraise evidence Apply to practice Evaluate outcome Evidence-Based Medicine: Definition, Process, and Levels of Evidence Definition and Purpose Evidence-based medicine (EBM) is an approach that integrates clinical expertise with the best available evidence from systematic research. The aim is to maximize both the quality and duration of patients’ lives. This approach emphasizes the integration of empirical evidence, clinical experience, and patient values. Fundamental Steps The EBM process consists of five stages: Formulating an answerable clinical question. Identifying and retrieving the evidence. Critical appraisal of the evidence. Integrating the evidence into clinical practice. Evaluating the effectiveness and efficiency of the application. The appraisal of evidence is not limited to randomized controlled trials and meta-analyses. Other study designs presenting consistent findings may also contribute to clinical practice. Studies are classified according to their quality and reliability. Levels of Evidence and Study Types Therapeutic Studies Level I: High-quality randomized controlled trials (RCTs) or homogeneous systematic reviews. Level II: Lower-quality RCTs, prospective comparative studies. Level III: Case-control studies, retrospective comparative studies. Level IV: Low-quality cohort studies or case series. Level V: Expert opinion. Prognostic Studies Level I: High-quality prospective studies and systematic reviews thereof. Level II: Retrospective studies or lower-quality prospective studies. Level III: Case-control studies. Level IV: Case series. Level V: Expert opinion. Diagnostic Studies Level I: Development of diagnostic criteria tested in consecutive series of patients, validated against an appropriate “gold standard.” Level II–IV: Development of criteria tested in more limited samples or against lower-quality standards. Level V: Expert opinion. Economic and Decision Analyses Level I: Robust data from multiple sources, supported by sensitivity analyses. Level II: Analyses based on limited data and resources. Level III–IV: Analyses based on weak assumptions or limited sensitivity testing. Level V: Expert opinion. Key Concepts in Evidence-Based Medicine Frequently used concepts in EBM include: Absolute Risk Reduction (ARR): The difference in event rates between treatment and control groups. Relative Risk Reduction (RRR): The proportional risk reduction achieved by the intervention. Number Needed to Treat (NNT): The number of patients that must be treated to prevent one adverse outcome. Likelihood ratios, sensitivity, specificity, positive and negative predictive values: Indicators of diagnostic test performance. Randomized Controlled Trial (RCT): A design in which treatment and control groups are assigned randomly, considered the strongest source of evidence. Meta-analysis and Systematic Review: Methods combining results from multiple studies to generate stronger evidence. Type I error (α) and Type II error (β): The probabilities of false-positive and false-negative results, respectively. Clinical Relevance The evidence-based approach provides guidance not only in treatment selection but also in diagnosis, prognosis, and health economics. The reliability of clinical decision-making depends on the level of evidence employed. High-quality studies offer clinicians stronger and more dependable guidance. Conclusion Evidence-based medicine grounds healthcare decision-making on a scientific basis. Its primary goal is to maximize patient benefit. The integration of clinical expertise, patient preferences, and robust scientific evidence constitutes the foundation of modern medical practice. References 1. StatPearls. Evidence-Based Medicine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. PMID: 35412347. 2. Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, et al. The Oxford Levels of Evidence 2. Oxford Centre for Evidence-Based Medicine; 2011. 3. Puljak L. The difference between evidence-based medicine, evidence-informed practice, and evidence generation. J Clin Epidemiol . 2022;145:1–3. doi:10.1016/j.jclinepi.2021.12.002 Previous Next

< Back Elbow Injuries Elbow injuries include a spectrum from dislocations to complex fracture-dislocations and can involve multiple anatomic stabilizers, particularly in adults. Common elbow injuries include radial head fractures, olecranon fractures, and terrible triad injuries (elbow dislocation + radial head + coronoid fracture). Stability assessment after reduction is crucial. Radial head arthroplasty or fixation, ligament repair, and early motion protocols are often employed. Pediatric injuries like lateral condyle fractures or medial epicondyle avulsions also demand careful management. Neurovascular exam is essential due to proximity of the ulnar and median nerves and the brachial artery. elbow-injuries Previous Next

< Back Extensor Mechanism Problems Previous Next

< Back Complex Regional Pain Syndrome (CRPS) crps-hand Previous Next

< Back Pelvic Ring Pelvic ring injuries range from stable, low-energy fractures to life-threatening unstable disruptions. Accurate classification and management are critical due to potential vascular and visceral injuries. Main Text: The pelvic ring is a closed osteoligamentous structure. Disruptions may result from high-energy trauma such as motor vehicle collisions or falls from height. The Young-Burgess and Tile classification systems are commonly used to guide diagnosis and management. Stable fractures are often treated conservatively, while unstable injuries may require surgical fixation with external fixators, plates, or percutaneous screws. Assessment must include vascular, urogenital, and neurologic examination. Early stabilization reduces hemorrhage risk and facilitates mobilization. pelvic-ring Previous Next

< Back Dr. Natig VELI Biopsy Principles Biopsy is a crucial diagnostic step in musculoskeletal oncology that must be carefully planned after full imaging and in coordination with the treating surgical team. The chosen approach should align with the future resection line to prevent tumor seeding and preserve limb-salvage options. Core needle biopsy is preferred for most lesions, while incisional biopsy is reserved for deep or non-diagnostic cases, and excisional biopsy only for small, superficial benign tumors. Proper tract placement, meticulous hemostasis, and clear marking are essential. A well-planned biopsy ensures accurate diagnosis and optimal oncologic outcomes, whereas an unplanned one can compromise definitive treatment. Definition and Purpose Biopsy is a critical diagnostic step in musculoskeletal oncology, providing tissue for histopathological, immunohistochemical, and molecular evaluation. It confirms diagnosis, determines tumor grade and type, and guides the surgical and oncologic treatment plan. A poorly planned biopsy can compromise definitive surgery and negatively affect patient outcomes. Pre-Biopsy Evaluation Imaging first: All biopsies must be performed after complete imaging — plain radiographs, MRI, and CT if necessary — to define the lesion’s anatomy, extent, and relation to neurovascular structures. Multidisciplinary planning: The procedure should be planned collaboratively by the orthopaedic oncologist, radiologist, and pathologist to ensure diagnostic yield and safe resection later. Never biopsy without imaging: This avoids contamination of uninvolved compartments or incorrect approach that may preclude limb salvage. Types of Biopsy Core Needle Biopsy (CNB): Preferred method in most cases; minimally invasive and highly diagnostic (accuracy >90%). Multiple cores should be taken from viable, non-necrotic areas under image guidance (CT or USG) . Especially suitable for deep-seated or pelvic lesions. Incisional Biopsy: Indicated when core biopsy is non-diagnostic or tissue architecture is required. Performed through a small longitudinal incision in line with the planned surgical approach, directly over the lesion. The tract must be placed within the future resection field , as it will be excised en bloc during definitive surgery. Excisional Biopsy: Reserved for small (<3 cm), superficial, easily accessible masses suspected to be benign. Should only be performed when wide excision can be achieved without compromising margins. Technical Principles Approach: Follow the most direct route to the tumor; avoid crossing multiple compartments or uninvolved joints. Hemostasis: Essential to prevent hematoma and tumor seeding. Use minimal cautery and avoid suctioning into clean planes. Contamination control: Avoid biopsy through skin that will not be included in the definitive resection field. Suture placement: Mark the biopsy tract clearly to facilitate complete removal during tumor surgery. Specimen handling: Send fresh tissue in sterile saline for histopathology, microbiology, and molecular studies. Common Pitfalls Inadequate imaging or unplanned approach leading to tumor spread along biopsy tract . Incision placed transversely instead of longitudinally, complicating excision. Sampling necrotic tissue , resulting in non-diagnostic pathology. Performing biopsy before referral to a specialized musculoskeletal oncology center . Key Points Biopsy must be performed by — or in consultation with — the surgeon who will perform definitive tumor resection . Plan the biopsy incision as part of the final surgical approach . The entire biopsy tract must be excised with the tumor during definitive surgery. A well-planned biopsy enables accurate diagnosis and limb salvage; a poorly planned one can convert a resectable lesion into an inoperable case. References Mankin HJ, Lange TA, Spanier SS. The Hazards of Biopsy in Patients with Malignant Primary Bone and Soft-Tissue Tumors. J Bone Joint Surg Am. 1982;64(8):1121–1127. Skrzynski MC, Biermann JS, Montag AG, Simon MA. Diagnostic Accuracy and Complications of Open vs Core Needle Biopsy. J Bone Joint Surg Am. 1996;78(5):644–649. Puri A, Gulia A. Musculoskeletal Tumor Biopsy: Planning, Principles and Techniques. Indian J Orthop. 2022;56(1):21–28. Enneking WF. Surgical Staging of Musculoskeletal Neoplasms. Clin Orthop Relat Res. 1986;(204):9–24. Previous Next

< Back Legg-Calvé-Perthes Disease legg-calve-perthes-disease Previous Next