< Back Dr. Omer POLAT He has been working on spinal diseases and tumors at Umraniye Training and Research Hospital for over 10 years. He also has expertise in trauma. Spine dromer.polat@gmail.com Previous Next

< Back Dr. Erhan OKAY Synovial Sarcoma Synovial sarcoma is a high-grade malignant soft tissue tumor primarily affecting the extremities of young adults. Diagnosis requires MRI, histopathology, and molecular confirmation of the SS18–SSX fusion gene. Treatment is multidisciplinary, centered on complete surgical excision with limb preservation when feasible, combined with perioperative radiotherapy and chemotherapy for large, deep, or high-risk lesions. Prognosis depends on tumor size, depth, margin status, and recurrence, with lung metastasis being the most common pattern of spread. Long-term surveillance is essential due to the potential for late metastatic relapse. Epidemiology Synovial sarcoma is a high-grade soft tissue sarcoma predominantly affecting adolescents and young adults , most commonly arising in the extremities , especially the lower limbs. The median age at diagnosis is in the 30s, with a slight male predominance . Diagnostic delays are common, with up to 35% of cases initially undergoing unplanned excision before referral to specialized centers (Broida 2024). The lungs are the most frequent site of metastasis (≈70%), followed by bone (10–20%) and lymph nodes (17%) (Wu 2017). Diagnosis & Imaging Diagnosis relies on a combination of MRI, histopathology, and molecular testing . Core needle biopsy with immunohistochemistry and fusion testing (SS18–SSX) should be performed at a sarcoma center before any surgery. MRI is the modality of choice for local staging (size, depth, neurovascular or bony involvement). Triple sign (mixed high, intermediate, low signal on T2) is a typical imaging feature. Chest CT is essential for staging due to pulmonary metastasis risk. PET-CT can help assess treatment response or recurrence. Pathology Histologically, synovial sarcoma presents as monophasic, biphasic, or poorly differentiated forms, the latter associated with worse prognosis. Immunoprofile: Bcl-2 , EMA , and TLE1 are commonly positive (Li 2024). Molecular confirmation via SS18–SSX gene fusion testing is diagnostic, particularly when morphology or IHC is inconclusive (Amary 2007). Treatment Overview Optimal management requires multimodal therapy within a specialized multidisciplinary team . Surgery : Complete (R0) resection with limb preservation is the cornerstone of treatment. Limb salvage is feasible in >60% of cases, and negative margin status strongly predicts local control and survival (Sharma 2024). Radiotherapy : Indicated for residual disease or high recurrence risk. Preoperative RT (≈50 Gy) followed by R0/R1 resection improves local control (Gingrich 2020). Surgery is typically scheduled 3–4 weeks post-RT . Chemotherapy : Neoadjuvant anthracycline–ifosfamide regimens are used for large, deep, or borderline-resectable tumors. Adjuvant chemotherapy is considered for high-risk patients and systemic disease. Prognosis Prognosis depends on tumor size, depth, margin status, bone invasion, mitotic count , and recurrence . Adverse factors include tumor >5 cm, deep location, positive margins, axial site, and local relapse (Song 2017, Broida 2024). Late metastases (>5 years) are not uncommon; therefore, long-term surveillance is essential. Early re-excision with negative margins and appropriate perioperative therapy significantly improves metastasis-free and disease-specific survival . References Broida SE, Arguello AM, Sullivan MH, et al. Unplanned Excision of Synovial Sarcoma: Factors Associated with Recurrence and Survival. Cancers (Basel). 2024;16(18):3157. doi:10.3390/cancers16183157 Wu Y, Bi W, Han G, Jia J, Xu M. Influence of Neoadjuvant Chemotherapy on Prognosis of Patients with Synovial Sarcoma. World J Surg Oncol. 2017;15(1):101. doi:10.1186/s12957-017-1165-9 Li C, Krasniqi F, Donners R, et al. Synovial Sarcoma: The Misdiagnosed Sarcoma. EFORT Open Rev. 2024;9(3):190–201. doi:10.1530/EOR-23-0193 Amary MF, Berisha F, Bernardi Fdel C, et al. Detection of SS18–SSX Fusion Transcripts in Formalin-Fixed Paraffin-Embedded Neoplasms: Analysis of Conventional RT-PCR, qRT-PCR, and FISH as Diagnostic Tools. Mod Pathol. 2007;20(4):482–496. doi:10.1038/modpathol.3800761 Sharma J, Deo SVS, Kumar S, et al. Clinicopathological Profile and Survival Outcomes in Patients with Localised Extremity Synovial Sarcomas. Clin Oncol (R Coll Radiol). 2024;36(4):e97–e104. doi:10.1016/j.clon.2024.01.018 Gingrich AA, Marrufo AS, Liu Y, et al. Radiotherapy is Associated With Improved Survival in Patients With Synovial Sarcoma Undergoing Surgery: A National Cancer Database Analysis. J Surg Res. 2020;255:378–387. doi:10.1016/j.jss.2020.05.075 Song S, Park J, Kim HJ, et al. Effects of Adjuvant Radiotherapy in Patients With Synovial Sarcoma. Am J Clin Oncol. 2017;40(3):306–311. doi:10.1097/COC.0000000000000148 Previous Next

< Back Spinal Epidural Abscess Previous Next

< Back Coronoid & Terrible Triad Injuries coronoid-terrible-triad Previous Next

< Back Ankle & Foot Anatomy ankle-foot-anatomy Previous Next

< Back Microsurgery Basics microsurgery-basics Previous Next

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

< Back Alper DUNKI Musculoskeletal Infections and Microbiology Spot Knowledge Staphylococcus aureus is the leading cause of MSK infections. MRSA strains (community vs hospital) differ in virulence. Children 6 mo–4 yrs: Kingella kingae is most common. Sickle cell disease: Salmonella is typical pathogen. Implant infections: Biofilm formation → requires debridement. MRI is nearly 100% sensitive in early osteomyelitis. Epidemiology & Microbiology Main pathogens: S. aureus , S. epidermidis, coagulase-negative staphylococci. Gram-negative: E. coli, Proteus, Klebsiella, Enterobacter . IV drug users: Pseudomonas, Serratia, fungi . Gonococcal arthritis: Neisseria gonorrhoeae in young adults. Post-shoulder surgery: Propionibacterium acnes . Pathogenesis Synovium lacks basement membrane → easy microbial entry. S. aureus virulence factors: Protein A, polysaccharide capsule, biofilm, PVL toxin. Biofilms protect bacteria in prosthetic joint infection → need surgery + antibiotics . Clinical Findings Septic arthritis: monoarticular, knee most common. Kocher criteria (peds): fever, non-weight bearing, ESR >40, WBC >12,000. Osteomyelitis (peds, MRSA risk): fever >38°C, Hct <34%, WBC >12,000, CRP >13. Diagnosis Radiology: joint space narrowing, periosteal reaction, Codman’s triangle. MRI: gold standard, early detection. Lab: CRP, ESR monitoring. Synovial fluid: WBC >50,000, >90% PMN highly suggestive. Treatment Osteomyelitis: 4–6 wks (≥6 for MRSA). Septic arthritis: 3–4 wks. Adults empiric: Vancomycin + Ceftriaxone. Children (MRSA): IV Vancomycin (15 mg/kg q6h). Implant infection: add Rifampin (synergy vs biofilm). C. difficile must be considered in prolonged antibiotic use . Antibiotic Prophylaxis in Orthopaedics Not routine in elective surgery without implants. Give ≤1 h before incision (Vanco: 2 h prior). 1st line: cephalosporins. Clinda/Vanco for β-lactam allergy. Duration: ≤24 h. Prevention of Surgical Site Infection Risk factors: DM, obesity, malnutrition, smoking, RA, MRSA colonization. Measures: chlorhexidine prep, double gloving, monofilament sutures, drains <24h, normothermia, glycemic control. Periprosthetic Joint Infection Knee arthroplasty: Synovial WBC >2,500/mm³ or >90% PMN → chronic infection. Gram stain not useful. Atypical & Rare Infections Necrotizing fasciitis: S. pyogenes, CA-MRSA; urgent surgery. Gas gangrene: Clostridium spp., surgery + high-dose PCN/Clinda. TB: spine most common, 4-drug ≥6 months. NTM: M. marinum (hand infections post-water exposure). Vibrio vulnificus: severe necrotic infection after seawater. Candida albicans: rare prosthetic infection. Lyme (Borrelia): late monoarthritis. HIV/AIDS: optimize immunity pre-surgery . References Masters EA, et al. Nat Rev Microbiol . 2022. Touaitia R, et al. Antibiotics . 2025. Sanpera I, et al. Current Concepts in Septic Arthritis . 2024 . Previous Next

< Back Segmental Defects segmental-defects Previous Next

< Back Physical Examination shoulder-elbow-physical-examination Previous Next

< Back Dr. Krishna A. Reddy Consultant Orthopaedic Oncologist, M.S., FRCS (Trauma & Orthopaedics) Current Institution: Vanderbilt University Medical Center (USA) / Formerly Royal Orthopaedic Hospital, Birmingham (UK) Location: Nashville, Tennessee, USA Professional Summary Dr. Krishna Reddy is an orthopaedic surgeon with extensive international experience in musculoskeletal oncology, sports medicine, and reconstructive orthopaedics . He completed his orthopaedic residency in India and moved to the United Kingdom in 2002, where he became a Fellow of the Royal College of Surgeons (Trauma & Orthopaedics) . He received advanced Orthopaedic Oncology training at the renowned Royal Orthopaedic Hospital in Birmingham and later pursued fellowships at Vanderbilt University (Orthopaedic Oncology) and the University of Cincinnati (Sports Medicine) . Dr. Reddy has contributed to numerous peer-reviewed publications and international presentations , focusing on limb-salvage surgery, sarcoma reconstruction, and long-term functional outcomes. Oncologic Orthopaedics reddykh@ucmail.uc.edu Previous Next

< Back Kienböck’s Disease kienbocks-disease Previous Next