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You can find all the information about UBE Spine Surgery in the treatment of Low Back Pain, Spine Pain and Canal Stenosis (Unilateral Biportal Endoscopic) in this article. (Unilateral Biportal Endoscopic) What is UBE Spine Surgery? Unilateral Biportal Endoscopy (UBE) is an arthroscopic approach to the spine. All operations performed in open surgery performed with a microscope can be performed through two 1 cm holes. Muscle and tissue are not cut, bleeding is less than a teaspoon. The entire surgery is recorded on video like arthroscopy and it is a less invasive surgery that provides 30 times tissue augmentation. In Which Situations Is It Preferred? It is very effective in central canal stenosis, large disc fragments occupying the central canal, facet joint cysts, screw and implant placement with endoscopy. It can be applied to all age groups. How Is It Applied Under Anesthesia? It may be general anesthesia or epidural anesthesia. How Long Does Unilateral Biportal Endoscopy (UBE) Take? (Unilateral Biportal Endoscopy) UBE Spine Surgery takes approximately 1 hour. What is the Recovery Process After the Surgery? Since the muscles and ligaments are not cut in the surgical incision, it is faster than open and microscopic surgery. Does Discomfort Recur After Surgery? The recurrence rate is not different from open surgery. How Much is the Surgery Fee? Pricing is made according to the hospital class determined according to the patient's budget.

Tennis elbow, medically known as “lateral epicondylitis”, is seen in people who work in arm strength jobs. The extreme discomfort of the tissues can be defined as the lateral epicondyle unencrypted strain to which the tendons of the arm muscles adhere. Beam and bone joints are tattooed, healing in tattoos is achieved with beam fibrotic cells and bones are again with periosteal cells with very good differentiation ability. Forcing continued healing tissue is more fibrotic, about creating a scar that does not bleed very well between cartilage and bone at rest. In either case, the tissue does not resemble muscle, bone, or tendon tissue. We call this condition “Entesopathy” beam-bone attachment site disorder. In this respect, tennis player disease is a kind of enthesopathy disorder. Patients complain of not being able to bear weight, sometimes it is even possible to lift a tea glass. Pain can spread to the forearm, and there may be those who wake up with pain at night. This discomfort, which affects daily life, becomes chronic and difficult to treat if it is not treated in a timely and correct manner. The diagnosis can be made supported by examination and simple radiological tests. MRI examination should be performed in resistant and repetitive situations. MRI reveals tears in muscle structures and allows us to examine intra-articular ligament structures. If there is no muscle tear, the treatment is mostly successful with simple bandages, oral and locally used anti-inflammatory drugs. It is possible to continue medical treatment in resistant cases, up to shock therapy (ESWT), cellular therapies and steroid injection as a last resort. If all these treatments do not result in results, surgical treatments should be considered. Timing is very important in surgical treatment. Instead of a resistant epicondylitis treatment, it may be possible to return to daily life in a short time with an intervention before the recovery capacity is lost. If there is a muscle rupture, if it does not respond to plaster determination; It should be repaired without waiting, and after the plaster fixation, rehabilitation should be started immediately and adhesions called contractures should be prevented. Different methods, ranging from soft tissue surgeries such as “loosening” to bone surgeries, may be preferred in the surgical treatment of resistant epicondylitis. During open surgery, intense adhesion may unintentionally cause external connective structures to be damaged. In addition, postoperative wound care and long-lasting plaster fixations are in question. Nowadays, arthroscopic treatment not only minimizes the complications of traditional methods, but also easily eliminates scar tissue that causes pain in the epicondyle area with magnification and non-bleeding imaging. Operations can be recorded and examined during future controls. If intra-articular structures are observed, correction of cartilage problems and control of ligaments are other advantages. If there is no repair after elbow arthroscopy, plaster cast is usually not applied and the next day can be returned to work. Using a bandage, it may even be possible to use a computer. We recommend ten days of rest to our patients, unless more is required.

Riding a motorcycle and enjoying it is a situation that can arise as machine and human harmony increases. While walking to a café after a short drive, I witnessed the distorted facial expressions of limping, holding back his waist, or removing gloves from his numb hand. In my opinion, if we are committed to this business, first of all, driving has to be a part of life and the motorcycle has to be like a part of our body. Although our fit varies according to our motorcycle style, the seat height must necessarily match our leg length, our distance should neither be close to nor far from the handlebar. This situation is much more important for touring or long-distance drivers. Human-machine harmony, that is “ergonomics”, which I briefly mentioned above, is of vital importance in motorcycle riding. Misuse can make our spine vulnerable to direct strain, with joints stretched, muscles ruptured, or even injured. For this reason, ergonomics is indispensable for effortless traveling, especially on long rides. How to Increase Motorcycle Ride Comfort? More or less seat height causes deterioration of posture and pain and fatigue after a while as a result of unbalanced sitting. In racing engines, the handlebars and grips are relatively far away, and reach is required. This situation causes stress on the shoulder joint and strains as a result of excessive bending in the elbow. This type of motor is therefore not used for long rides. It is a very wrong choice to use racing engines for street excursions as well. The opposite of this situation poses a problem in terms of ergonomics. The close distance of the handlebars causes excessive bending of the elbows and the distance (Chopper; monkey sling style handlebars) causes the shoulder to hang, impairing control and causing chronic shoulder disorders. On the ideal handlebar; The wrist angle should be parallel and straight to the ground, the handlebar height should be kept below the shoulder level and the distance to the elbows should be 95-100 degrees. Shoulders should not come forward too much, the spine should be able to reach a relatively upright position and all pedals and grips to be able to control the machine should be easily accessible. At the correct handlebar distance and seat height; Remember that when the maximum turning limits of the handlebars are reached, your elbow should never be in line with the shoulder. Correct adjustment of the handlebar and seat will give you maximum control, as well as fatigue-free and safe driving. Handlebars are tubular in some engine types and can be easily adjusted. Here, a straight wrist will maximize your grip strength. Make sure that the handles are suitable for the size of your hand and that they are thick enough to make a full grip. Do not forget that the throttle, gear and brake synchronization, and therefore the pleasant ride, depends on your grip and full control. If you do not have heated grips for cold weather, you can also use rubber covers that do not transmit cold. Motorcycle Riding Comfort; Although the seat and handlebar body’s participation in upright or reclining driving depends on the type of engine, in some cases, we see that the tour or city motors are leaning forward under the spoiler, especially at high speeds. In addition, lying in a model designed for an upright sitting will overload the spine, making it susceptible to injury during torsion and stress. A windbreaker designed at the right height is also very important in this respect. Vibrations from the Road; The position of the foot steps should be parallel to the ground in order for the driver to counteract the vibrations from the road and reduce the load on the body and spine. Chopper-style pegs, which are unusually arranged, prepared for the feet to balance the body that is tilted back rather than to meet the load, can cause the load to spread directly to the discs between the vertebrae and even cause hernias. In racing type engines, the foot position is designed to direct the vehicle like a crowbar while the driver is lying down, so it is not enough to meet the load on the spine. Using such motors with strong body muscles in an athletic structure, avoiding long rides and non-racing uses will prevent injuries. The position of the aftershock or passenger seat also changes according to the engine type. The engines most suitable for the passenger are enduro, touring style or cruiser engines. In sporty models, the passenger stays quite high and the handles are not suitable and the seating area is very narrow. This type of driving can be quite dangerous for aftershocks, and because it is a light engine, it can create moments that affect stable driving. For long rides, if possible, there should be ergonomic foot rests and handles for the passenger. In addition, in some engine types, precautions have been taken in such a way that the passenger will rest (sissybar). So, as a result, we can say that the rider must determine a motorcycle suitable for his height and weight. Remember, there is always a motorcycle suitable for your height and weight. In the second stage, you have to define your style: long ride, track, city use … Remember that each engine has a different ergonomics according to its area of ​​use. Enjoyable Rides.

Spinal degeneration is the result of primary or secondary spondylo-arthritis and disc degeneration (1). Although there are some who associate the onset of degeneration involving the intervertebral disc and facet joints with facet joint arthritis, the general belief is that it occurs as a result of disc degeneration (1,2). The disc structure begins to degenerate in the third decade, water loss occurs in the nucleus pulposus, the disc height decreases with annular tears, the facet joint distance is prolonged, the spine becomes prone to abnormal movement and instability as a result of ligament laxity and becomes open to trauma. With the addition of inflammatory factors to recurrent traumas, cartilage becomes thinner, annular tears grow, facet joint synovitis occurs, cartilage goes to destruction and osteophytes develop. Posterior movement of the disc structures causes narrowing of the spinal canal, hypertrophy develops in the facet joints, and the ligamentum thickens. Result; It is degenerative stenosis (1-3). Disc degeneration Intervertebral disc, which is one of the main reasons for the onset of spinal degeneration, has an avascular structure. It consists of chondrocyte and fibroblast-like cells within the extracellular matrix. Disk; It includes two main regions: nucleus pulposus (NP) and Annulus Fibrosis (AF). While chondroblasts and type-2 collagen are mostly organized in the gelatinous structure of the NP in the inner region of the disc, the basic structure of AF in the lamellar structure is mostly composed of fibroblasts surrounded by type-1 collagen. It synthesizes the appropriate matrix in which both cell groups are located. In the lower and upper parts of the disc (endplate); There are chondrocyte cells that synthesize hyaline cartilage surrounded by a thin cortical bone (1). Disc degeneration is characterized by NP dehydration along with AF rupture and clefts in the endplate area that can turn into fractures. With annulus degeneration, collagen loses its fibril organization and undergoes myxomatous degeneration. The number of lamellae increases, cell distribution deteriorates, and clusters occur. While NP loses water, it loses its height, cavities form and expand posterolaterally. Endplate degeneration progresses with subchondral sclerosis and calcification in the hyaline cartilage. All this causes the disc to become thinner, to lose its elasticity, and to not be able to distinguish between the nucleus and annular region. Disc hernias with the nucleus remaining in the annular ligament (Contained-NP containing) and material protruding out of the disc (noncontained-NP content) It can be divided into. Annular tears are often very large in an uncontrolled hernia. Degeneration is at an advanced stage (1). At the cellular level, disc degeneration begins with increased cellular mating and groupings in the NP region. The distribution of the basic proteins of the cytoskeleton, Actin and Vimentin, is disturbed. The cell loses its shape. Gap connections are reduced with connexins 43 and 45, which provide intercellular connection. In addition to all these mechanical reasons, nutrient and oxygen diffusion in cells is metabolically reduced (1). Diffusion occurs through the posterior and anterior vertebral vessels. Factors such as enplate calcification, narrowing of the lamina cribrosa pores and decreased local blood flow reduce diffusion. Matrix synthesis is disrupted by increasing the amount of lactate by anaerobic metabolism. Martrix degradation increases and gradient molecules accumulate. With the addition of genetic, systemic factors and smoking, necrosis increases, NP becomes hyalinized, the annulus weakens with disorganization, proteoglycan distribution will change, and water retention decreases (1). Matrix proteins undergo changes in the degenerated disc. Proteoglycans provide the viscoelastic structure by holding water and increase the tensile-compressive strength of the disc. Chondroitin sulfate and keratan sulphate are predominant proteoglycan, they aggregate by binding to hyaluronate molecules. Aggrecan, the largest aggregate molecule, is mostly found in AF. Versican, decorin, biglycan, fibromodulin and lumican, which are more in the fetal disc, are also available. Link proteins stabilize proteogiers as glycoproteins. Chondroitin sulfate synthesis is disrupted by degeneration, leaving its place to keratan sulphate. This leads to a decrease in water retention in the NP structure and deterioration of the gel consistency. In addition, water depletion reduces diffusion at the molecular level. Collagen and matrix connections provide the mechanical strength and stability of the disc. Collagen Type 2 increases resistance to compressive forces. This stability, which is protected by cross-links, is disrupted by the replacement of types 1, 2, 3 and 5 collagen by degeneration, by type 1, 4 and X In advanced levels of degeneration, anaerobic respiratory cross-links are disrupted and stability is removed. Fibronectin osteoarthritis is a glycoprotein containing collagen-glycoprotein-integrin and membrane protein binding points with increased itte release. In recent years, it has been found that while decreasing proteoglycan synthesis in NP in degenerate disc, it increases proteoglycan synthesis with an adverse effect in AF and its release is high in annulus repair. It has been observed that fibronectin fragments inhibit chondrocyte-derived aggrecan production and increase metalloproteinases responsible for cartilage breakdown. A link between polymorphism in the Aggrecan gene and disc degeneration has been determined. Sequence differences in protein chains are held responsible in degenerate discs. Chondromodulin-1 (ChM-I) is thought to have a role in chondroprotective effect by preventing vascularization and fibrosis change in early degeneration of the disc. This molecule is secreted during the gestational period, the growth plate due to cartilage provides the development of chondrocytes. It is thought to be secreted also in mature NP and AF cells. Inflammatory such as nitric oxide (NO), interleukin-1B (IL-1)., Interleukin-6 (IL-6)., Tumor necrosis factor alpha (TNF-oc)., Prostaglandin E2 (PGE2)., Matrix metalloproteinase (MMP) Other tissues are also affected by the spontaneous increase of mediators in disc cells. Proteoglycan synthesis is inhibited in joint cartilage. Cartilage degradation begins with the increase in IL1. While MMP increases this degradation, exogenous NO, IL-6 and PG-E2 increase inflammation. Phospholipase activation by migration of CD68 cells during neovascularization is the main cause of pain and destruction at this stage. This mechanism may explain the inflammatory mechanism of disc-induced facet joint degeneration (1). Mechanical effects in disc degeneration cause endplate damage, increased intra-disc hydrostatic pressure to increase NO amount and decrease proteoglycan synthesis and decrease water retention. Vibration reduces the amount of intracellular aggrecan. The related increase in MMP-1 causes matrix degradation. In addition, vibration disrupts ATP controlled flow in Ca channels. Result; disruption of cell nutrition, reduction of martyx production, degradation and degeneration (1). Externally, the effect of growth factors on degeneration has been demonstrated. These effects are of varying intensity at different stages from apoptosis to matrix organization. The presence of LacZ and Luciferase markings in degenerated discs has shown that genetic transition in degeneration can occur regardless of age and gender. It is claimed that gene transfers with adenoviruses may eliminate the genetic factors, perhaps the main cause, of disc degeneration in the future. Masuda et al, recombinant human osteogenic protein-1 (rHOP-1) increased cell and matrix proteoglycan synthesis on the radar with its mitogenic effect. Because of the similar effects of growth factors, they may be used in treatment (1). In short, disc degeneration develops due to extrinsic, intrinsic and genetic reasons. Deciding the stage of this condition resulting in stenosis in the spinal functional subunit should constitute the main framework in determining treatment options. Pathological anatomy of the lumbar degenerated spine Spinal canal stenosis may develop in the central, lateral dead-end and pedicular regions in the coronal plane (Figure 1). Figure 1: Schematization of the anatomical localizations of degenerative stenosis. While lateral stenosis is classified as subarticular, foraminal and extraforaminal, central stenosis may occur at the pedicular disc and intermediate levels. (Inspired by Kuslich (27)). In the sagittal plane, narrowing may be at pedicular, intermediate and disc levels (3,4). Lateral stenosis; It can occur in three stages, including the entrance of the spinal nerve to the foramen (subarticular), foramen and exit (extraforaminal). The first part described is the most cephalic located, superior articular facet medial and inferior location. It has only anterior and posterior osseous wall. Medial and lateral are normally open. The middle part contains the foramen, under the pars interarticularis of the lamina and the pedicle. The anterior wall forms the vertebral body. Pars interarticularis makes the posterior wall, pedicle lateral wall. The medial wall opens into the spinal canal and is normally open. The exit part is surrounded by the intervertebral foramen. The disc is located in the anterior, and the lower part of the facet joint is located laterally. (3-5). Anatomical classification of the degenerative spine made the therapeutic classification necessary with the growing need for planning treatment. Hansraj stenosis; It handles in two parts as simple or typical and complex. In the typical definition of stenosis, cases without instability or with first-degree spondylolisthesis and scoliosis of less than 20 degrees are understood. These patients often only benefit from decompression therapy. Complicated cases may need to be combined with decompression therapy, as well as fusion and instrumentation (5,6). Clinic It usually becomes symptomatic in older ages. It is more common in women. L3-4, L4-5 levels are the most frequently affected segments. Cervical involvement is detected in 5% of the patients (2). Patients describe hip, thigh, leg, foot pain along with back and waist pain. Bilaterate involvement is common. Neurological claudication, increased pain when walking and standing, decreased pain when lying down and extending the legs, and increased pain with concussion are typical. Posture is slightly flexed. With the increase in pain, functional capacity gradually decreases and walking distance becomes shorter. Daily business starts to disrupt. Pain can be questioned with various scales. Visual analog pain grading system VAPS is one of the most widely accepted scales (7). Work disability can be scored by the work disability score (WL-26). Under the Deyo core set title, he gathered the interrogation suggestions targeting spinal diseases in six groups and created a useful system. In recent years, the numerical expression of the impact on functional capacity in spinal diseases can be made using disability scoring systems such as Oswestry. Scores such as SF-36 that question general health status are useful before surgery (6,7). These applications should be queries that the patient can easily understand. Roland disability questionnaire, which has been translated into Turkish and its validity has been determined statistically, is a specific and sensitive test for low back pain (8). The need for analgesics and response to analgesics should be recorded. This can give an idea about the degree of stenosis. Bladder functions must be questioned. Flattening, paravertebral spasm, increased pain with movement and decreased range of motion in extension can often be detected in lumbar lordosis. Flexion width has decreased but is accompanied by pain. The straight leg raising test is usually negative. Decrease in motor power can be detected in provocative tests. Although sensory impairment can sometimes be selective in the relevant dermatome, it is generally not sensitive because minor sensory changes are expected at these ages (6-9). Diagnosis Radiologically, disc space reduction, osteophytes, facet hypertrophy are pathognomonic. The defect in the pars interarticularis should be noted in terms of spondylolysis and narrowing of the pedicle spaces in terms of congenital stenosis. The borders of the foramina should be examined, the hypertrophy of the facet joints and the relationship of osteophytes on the wing should be evaluated. must. The presence of scoliosis, kyphosis, hyperlordosis, sacralization and lumbalizations that disrupt the spine mechanics should be questioned in flexion-extension and standing dynamic radiographs. It is involved in the etiology of foraminal stenosis of a fibrocartilage-like structure in spondylolysis. Listesis rate should be graded by standard indicators. The psoas shadow and the robustness of the pedicles should be noted (9,10). Tomographic evaluation maintains its importance in understanding osteophyte organization. Lateral dead-end and foraminal structures limited by bony structures can be clearly evaluated. Magnetic resonance imaging (MRI) has greatly reduced tomography and myelographic examinations. With MRI, the channel relationship of disc structures, intradiscal pathologies and fibrous tissues that cause foraminal stenosis can be evaluated better. MRI is the most sensitive evaluation method in disc degeneration. However, CT-myelogram is as valuable as MRI for preoperative planning in cases with metal implants and MRI application is contraindicated (5,9-11). In laboratory tests, neuroflament specific to nerve injury and proteins such as 5-100 have been shown to increase in the cerebrospinal fluid (CSF) and blood. It was found that the amount of total protein, albumin, IgG, IL-8 increased in CSF and the amount of ApoE increased in both CSF and plasma (5). Discography is the most effective diagnostic method that enables a dynamic decision to clarify the disc pathology and to plan the treatment. Discography provides the clinical relationship of the location of the annular tear and point targeting convenience in the treatment of complicated radicular symptoms. Anesthetic agent and steroid injection into the disc can provide therapeutic effect and assist the physician in differential diagnosis. White and Pancabi measured the disc pressure and showed the effects of pathological loads on the disc. Disc pressure dynamic measurement can be used as a reference in elucidating mechanical problems. The objective contribution of the EMG test, which is the most commonly used electrodiagnostic test, is indisputable. It fully reveals the radicular level of the lesion. Working with evoked sensory potentials is more sensitive. Electrodiagnostic tests do not show the decompression or treatment site. However, the surgical intervention area should be decided by comparing it with other diagnostic tests. The perop must be repeated to confirm the diagnostic discography intervention site. Selective root blocks can be used to separate the cause of pain in multi-segment stenosis (5,9-12). The diagnostic algorithm guides in planning treatment. The flow chart should primarily separate low back pain and non-mechanical pain due to medical diseases. Conservative treatment and pain that does not respond to rest necessitate re-initiation of differential diagnostic steps. Differential diagnosis Disc hernias should be evaluated very well in differential diagnosis. Usually in the stenotic degenerated spine the disc shows a slight overflow. Symptoms should not be attributed to disc disease and limited to discectomy or medical therapy. The medical evaluation flow chart that separates medical and non-mechanical low back pain should be followed carefully (9). If cauda equina syndrome develops acutely, extensive disc herniation may be considered. Spinal cord tumors, primary and metastatic bone tumors, infections and fractures should be considered in the differential diagnosis (2). It is the vascular claudication, which is the most clinically involved condition. This type of pain increases with walking, in contrast to stenosis, when lying down, and decreases when standing. A careful vascular examination makes diagnosis easier. EMG is required for differential diagnosis in patients with diabetic neuropathy (2). Treatment Anti-inflammatory therapy is the first step in degenerative lumbago. Treatment for reflex muscle spasm supported by muscle relaxants can be combined with physical therapy. In resistant cases, epidural steroids and anesthetics may facilitate transition to functional therapies (13,14). Combinations of gababentin or amiltriptyline give significant results in cases where epidural injection is applied (13). Successful results of calcitonin use in degenerative luminopia have been reported (10). Cases who do not respond conservatively, have neurological dysfunction (bladder, radicular motor deficit, etc.), and whose functional disability is found to be low, may be referred to surgical treatment. Surgery should reduce pain, increase mobility and prevent neurological deficit. Adequate decompression and preservation of joint and pedicle structures to ensure stability are the basis of treatment. Today's surgery can be summarized as maintaining anatomical integrity, providing decompression and avoiding fusion as much as possible. Minimally invasive procedures meet these needs with increasingly developing techniques. Strictures that can be treated with wide bone resections with percutaneous surgeries and scopic interventions can be easily reached, vital vascular nerve structures Decompression and fusion can be applied through. Open surgical decompression operations were performed under spinal anesthesia, reducing pulmonary complications. However, the occurrence of conditions that will increase the possible CSF pressure (coughing, etc.) may lead to large and difficult dural tears (11). Surgical treatment: 1. The location of the stenosis, 2. the number of involved segments, 3. stability, 4. degenerative spondylolisthesis, 5. previous surgical treatments, recurrence and iatrogenic reasons, and 6. accompanying scoliosis and kyphosis are regulated by evaluating parameters. Surgical treatment flow chart is summarized in Figure 2 (11). Non-fusion techniques and disc surgery Disc degeneration and reduced disc height are the main causes of spinal degeneration. Maintaining the disc height before facet joint involvement occurs can prevent lumbar degeneration. It is possible to reduce disc damage and pain due to injury by repairing the damage. Various treatment methods are used for the annulus and nucleus (15,16). The first attempt to target the nucleus in disc surgery was performed in 1963 by Lyman W. Smith with kimopapain injection. After the injection of chymopapain into the nucleus, it decomposes the proteoglycans contained in the nucleus, decreasing its volume and providing decompression. However, it has a damaging effect on neural tissues. Deaths due to transverse myelitis, paraplegia, and anaphylactic shock have been reported (11,15). Techniques targeting the nucleus in disc herniations containing nuclei can be grouped under the heading Nucleoplasty. In the early 1990s, laser discectomy and nucleotomy, which were popular with local anesthesia, became one of the safe and effective treatments with a short rehabilitation period (17). Using similar equipment and energy in annuloplasty, this time it was aimed to evaporate the nucleus water content. In this way, the pressure in the posterior annulus is reduced. It is necessary to be more selective than annuloplasty in patient selection. Arthrocare Perc-D Coblation device, one of the options in nucleoplasty, vaporizes the nucleus with bipolar radioenergy by mechanically giving localized energy. Approximately six channels are opened to the nucleus to provide decompression. The nucleus turns into plasma form with its water content and is taken out of the cannula (17-20). The use of thermal energy in nucleus decompression has been provided by radiowave Radionics probes. In short, in the treatment referred to as PIRFT, the heat effect of the energy is utilized. Unlike annuloplasty in nucleoplasty, the temperature reaches 70-80 degrees. The contribution of this energy to annular denervation is controversial and the pain reduction mechanism has not been explained yet (17,19). In laser nucleoplasty technique, the evaporation effect of energy and the heat effect are reflected on the nucleus as ° rent. The nucleus is broken down by laser energy. Intradiscal electrothermal therapy (IDET) is a treatment intervention for annulus. It is referred to as "annuloplasty" as it is aimed to treat annulus rupture in this way. In 1997, Saal and Saal treated the tears in annular defects with the help of thermal wire. The basis of treatment should be stabilized collagen fibrils as in arthroscopic capsulography. Thermal effect can be obtained from electrothermal, radio wave or laser energies. Symptoms regress with thermal effect, collagen stabilization and annulus denervation. When 42 ° C is exceeded in heat therapy, neural structures are damaged (17). "The narrowing of the disc space is the beginning of the process in the degenerative spine." his discourse has revealed his materials replacing the disc. Facet instability, foraminal narrowing and subsequent degenerative conditions are secondary to narrowing of the disc space. Artificial nucleus replacements Artificial Nucleus Replacement (ANR) have been tried to regain this distance. Injection of polymethylmethacrylate and silicone materials into the nucleus cavity resulted in disappointment. The metal nucleus results he described Fernstrom in 1966 are still controversial. It has been observed that reactive bone formation and resorption continue in the silicon-dacron composite implant in Urbaniak chimpanzees. The ideal material described by Edeland in 1981 should have vital functions such as water permeability as well as nucleus-like skin-sil responses. A nucleus-like effect was created by using hygroscopic thixotropic gel such as hyaluronic acid with high molecular weight polyethylene fiber encapsulated impregnated with ray and gobbin polymeric material. The cadaver biomechanical studies of the horseshoe shaped lumbar intervertebral disc prosthesis (LIDP) implanted by Hou et al anterior paramedian retroperitoneal intervention have been completed. The elastomer reinforced polyurethane nucleus modified by Sulzer Spine-tech company, the Hydrogel nucleus developed by Rao and Higham in 1991 that can be sent from the 5 mm cannula, and finally the Ray modification (Prosthetic Disc Nucleus PDN), which includes a hydrogel polyethylene sheath. Its main purpose is to provide physiological response of the nucleus to the loads, as well as the disc height. The most important technical problem in disc prostheses is the sizing difficulty. If the disc prosthesis is smaller or larger than normal, it will cause problems (17,19). Decompressive attempts It is planned according to the development area of ​​the stenosis. The aim is to eliminate the pressure without disturbing the stability of the spine. Interventions that will create instability should be determined by fusion applications (Figure-2). Central canal stenosis: The stenotic segment is treated with decompressive lumbar laminectomy. Decompression starting from the maximum constriction zone should be extended caudally and cephalicly. Instability should be prevented by protecting the medial facet joint. Decompression is terminated by making sure that the nerve root is relaxed. If there is any sensation in the dura, superior facet medial can be included in the excision (4,10,11,16,18,20). In lateral canal stenosis, the nerve root can be treated with unilateral laminotomy. Stenosis at the entrance requires medial facetectomy. Facetectomy should be sufficient to provide 1 cm medialization of the nerve. In the stenosis of the middle part, the dorsal root is under pressure. Decompression can be performed by performing total facetectomy to include the pars area. Fusion and instrumentation are required to ensure stability. Hypertrophic facet welding in the exit section! ' There is compression of osteophytes and osteophytic margins around the disc. The Witse paraspinal approach is used for decompression of this area with open techniques. The area is reached with transverse protrusion excision. The success and patient satisfaction of minimally invasive techniques such as foraminoscopy is higher. Mr Knight et al. Provides fusion decompression in minimally invasive foraminoscopic decompression treatments. (4,10,11,16,18,20). Knight et al. It reports successful results by applying annuloplasty and nucleoplasty in the same session as well as decompression with the combined use of laser and radiowave energies (12). Multiple laminotomies can be performed at multiple levels in mild to moderate stenosis, preserving structures such as Spinoz protrusion in the midline. Expansive Lumbar Laminoplasty provides decompression by preserving the technical stability applied for the first time by Tsuji et al. (11). In distraction laminoplasty, the lumbar canal is decompressed by preserving the maximum bone. The medial facet and inner regions of the lamina are removed with the aid of distraction instruments (11). Distraction devices such as spinous protrusion x-stop and PEEK reduce compression in the area of ​​constriction caused by the ligamentum flavum by indirect decompression. It can be applied under local anesthesia (11). Dynamic intervertebral disc prostheses are a developing technique as an alternative to fusion from non-fusion techniques. Since Edeland, there are disc prostheses anchored to the bone, designed either constrained or nonconstrained, such as total joint prostheses that allow movement. The main purpose of these implants, whose validity is discussed with animal and biomechanical experiments such as the caustic design, is to protect the spine motion by preserving the disc height (21). Fusion surgeries These are interventions that maintain stability by providing arthrodesis. It is applied in posterior instrumentation, pedicle screw fixation, wide decompression causing instability and multi-level laminectomies. It is used to provide a corrective effect and prevent progression in the presence of spondylolisthesis and mechanically impaired spine such as scoliosis. Distraction and alignment correction after extensive decompression may contribute to decompression. Arthrodesis reduces pain and prevents progression. Since the fusion will be achieved by rigid fixation, it can be combined between the posterior elements as well as the vertebral bodies. The necessity of the integration is to ensure fusion and maintain the stability until fusion. Various studies comparing pseudoarthrosis rates advocate that pedicle screw fixation should leave its place to selective fusion other than spondylolisthesis, scoliosis and multi-segment decompression (2-4,10,11,22). Interbody fusion It can be applied posteriorly or anteriorly. It provides selective fusion opportunity. Apart from open surgery, it can be applied scocopically (10,11,22). In addition to being popular especially in scopic decompression surgeries that require fusion, it has become one of the indispensable techniques combined with posterior applications with wide decompression. Lumbar interbody fusion (LIF) technique, which has developed rapidly since Cloward (1950), can be applied to the posterior and anterior. Posterior LIF is classified according to the entrance corridor: Paramedian intervention (PLIF), transforaminal intervention (TL1F) (23). Both techniques can be applied as percutaneous, minimally invasive or open (4,22,24,25). Implant; It is a titanium cylinder with a cancellous-like structure like the Bagly and Kuslich design (BAK), which is called cage (4). Transforaminal application with grade 1-2 spondylolisthesis neurolo It is the ideal treatment option in cases without jik deficits (25). Provides disc height in the foraminal area and reduces foraminal stenosis. Anterior LIF can be performed transperitoneally or paramedian retroperitoneally or laparoscopically (26-29). AL1F scope application is advantageous compared to PLIF applications in terms of not causing dural damage. While PLIF allows decompression and fusion together, the dura and nerve damage risk is higher. Like posterior applications, ALIF restores disc height and provides decompression in the formaninal region following discectomy, but it is considered as a disadvantage that facet nipertrophy and osteophyte organizations do not 'eliminate' (27): Result Back pain is resolved despite treatment at the rate of ° / 087. Any treatment that starts without defining the stage of the pathology may increase the symptoms of the patient. Therefore, physiopathological staging should be done very well. Decompressive attempts to cause instability in a stable spine may cause the symptoms to worsen. Fusion surgery can also reduce patient satisfaction when not performed on site. The limits of minimally invasive interventions are clear. In cases that require extensive decompression, traditional surgical methods should not be avoided (30). After making sure that the degenerative spine is responsible for pain and dysfunction, the degree of lumbar degeneration and disc pathology should be established. Degeneration is a progressive process but can be slowed down. Conservatively or surgically recovered healthy disc distance will delay stenotic spine disease. Stenosis surgery has now been demonstrated with its clear benefits and harms. The current approach should be to discuss conservative, genetic, and surgical, especially minimal invasive techniques that preserve disc distance before degeneration begins. Current Medical Journal (April 2004-Volume 9 Issue: 4) Resources Chung SA, Khan SN, Diwan AD. The molecular basis of intervertebral disk degeneration. Orthop Clin N Am 2003;34: 209-19. Whiffen JR, Neuwirth MG. Spinal stenosis in Spinal surgery. Ed Bridwell KH, DeWald RL. Vol 2 (25). Lippincott Co Philadelphia; 1991,S:637-656. White AA, Pamjabi MM. Clinical Biomechanics of the spine. Part 4 349-362 Lippincott Co Philadelphia; 1990 Kuslich SD. Lumbar degenerative disc disease-axial back pain Posterior In Vaccaro AR, Albert T] ed. Master Cases Spine Surgery. Thieme NewYork; 2001, 5:93-99. Brisby H. Nerve root injuries in patients with chronic low back pain. Orthop Clin N Am. 2003;34: 221-30. Boden SD. Outcome assesment after spinal fusion. Orthop Clin N Am. 1998;29(4).: 717-28. Schaufele MK, Boden SD. Outcome research in patients with chronic low back pain. Orthop Clin N Am. 2003;34: 231-7. Küçükdeveci AA, Tennant A, Elhan AH, Niyazoglu H. Validation of the Turkish Version of the Roland-Morris Disability Questionnaire for Use in Low Back Pain. Spine 2001; 26(24)., 2738h- McCowin PR, Borenstein D, Wiesel SW. The Current Approach to the Medical Diagnosis of Low Back Pain. Orthop Clin N Am. 1991;22 (2). 315-25. Spivak MJ. Degerenative Lumbar Spinal Stenosis. (Current Concepts Review).. J Bone Joint Surg . 1998; 80-A Sengupta DK, Herkowitz HN. Lumbar spinal stenosis treatment strate­gies and indications surgery. Orthop Clin N Arn. 2003;34: 281-95. Knight M, Goswami A. Management of isthmic spondylolisthesis with posterolateral endoscopic forarninar decompression. Spine 2003;15; 28(6).: 573-81. Pirbudak L, Karakurum G, Satana T, Karadasli H, Topalhan M, Oner U, Gulec A. Epidural Steroid Injection and Amitriptyline in The Management of Acute Low Back Pain Originating frorn Lumbar Disc Her­niation. Arthroplasty Arthroscopic Surgery 2003;14(2).:89-93. Freedman MK. Axial low back pain. Nonoperative approach. In Vac­caro AR, Albert TJ ed. Master Cases Spine Surgery Thieme NewYork; 2001,5:78-83. Herkowitz Current status of percutaneous discectomy and chemonucleolysis. Orthop Clin N Ara 1991;22(2). 327-32. Hasea RJ. Lumbar spinal stenosis:surgical considerations. J South Ort­hop Assoc 2002 11(3). 127-34. Sagi HC, Bao QB, Yuan HA. Nucrear Repracement Strategies. Orthop Clin N Am 2003;34: 263-67. Kwon BK, Vaccaro AR, Grauer JN, Beiner J. Indications, techniques and outcomes of posterior surgery for chronic low back pain. Orthop N Anı 2003;34:297-308. Davis TT, Sra P, Furier N, Bae H. Lumbar intervertebral thermat ther­ Orthop Clin Am 2003;34:255-62. McCuiloch JA. Lumbar spinal stenosis without instability. in Vaccaro AR, Albert TJ ed. Master Cases Spine Surgery Thieme NewYork; 2001,S:100-8 Kostuik JP. Alternatives to spinal fusion. Orthop Ciin N Am 1998;29(4).: 701-14. Brislin B, Vaccaro AR. Advances in posterior lumbar interbody fusion. Orthop Clin N Am 2002;33: 367-74. Moskowitz A. Transforaminal lumbar interbody fusion. Orthop Clin N Am 2002;33:359-66. Mathews HH. Percutaneous interbody fusions. Orthop Clin N Am 1998;29(4).: 647-63. Moskovitz PA. Minimal invasive posterolateral lumbar arthrodesis. Orthop Clin Am 1998;29(4). 665-78. Burkus (K. Intervertebral Fixation: CIinical results with anterior cages. Orthop Clin N Am 2002; 33: 349-57. Kuslich SD. Lumbar Degenerative disc disease-axial back pain an­terior approach. In Vaccaro AR, Albert T] ed. Master Cases Spine Surgery Thieme NewYork; 2001,85-92 Silcox III HD. Laparoscopic bone dowel fusions of the lumbar spine. Orthop Clin N Am 1998; 29(4).: 665-693. Zdeblick TA. Laparoscopic spinal fusion. Orthop Clin N Am 1998;29 (4). 635-45. Diwan AD, Parvartaneni H, Cammisa F. Faifed degenerative lumbar spine surgery. Orthop Clin N Am 2003;34: 309-324.

Arthroscopy is the visualization of the joint with an optical device scope. While visualizing the intra-articular structures, they are examined and radiologically invisible cartilage problems and tears of intra-articular structures can be revealed. For example, while peripheral separation of the meniscus can be missed during mri, it can be diagnosed on arthroscopy. Mri is proficient in surface injuries of cartilage tissue, and arthroscopy can be performed even for diagnostic purposes, despite normal Mri examination in knee pain that does not heal. The main purpose of arthroscopy is to eliminate the cause revealed during diagnosis, and repair / reconstructive treatments are performed simultaneously. With advanced suture materials, patients with anterior cruciate ligament repair can be pressed the next day. Shoulder dislocations, rotator muscle repairs can return to normal life immediately. Tears in the elbow and wrist joints are repaired, and treatment-resistant conditions such as tennis elbow can be corrected. Compression caused by ankle sprain can be eliminated and joint wear can be prevented by removing stuck in the hip bone. Open surgical techniques have largely been removed from our practice as the gold standard in arthroxopia joint surgery. Scope wound is 5-7 mm, completion of the entire surgical procedure through 2-3 holes, almost no need for surgical wound care, very little bleeding, ensures very rapid healing. It has been with the contribution of arthroscopic methods in the orientation of modern surgery to minimally invasive treatments.

Pain; It is the most common complaint that mankind has referred to for centuries, from healers, shaman priests to practitioners of modern medicine… In fact, the reason for the existence of pain is nothing more than an early warning. It can occur with the contact of a needle to our skin to protect it from it. Sometimes it is too late, for example, when a decaying tooth causes pain, we may be too late. In the musculoskeletal system, pain may indicate a more severe situation, especially in the joints, rather than an early warning. When the cause of joint pain is questioned, we think that cartilage and other intra-articular structures (meniscus and ligaments) are damaged by various diseases or trauma. Our body has the ability to repair damaged structures, but this is very limited for articular cartilage. The improvement in tissues such as joint cartilage and muscle is almost nonexistent compared to the regenerative ability of our skin. Considering that pain is not a cause but a result, we can say that cartilage damage occurs with surface changes and decreased slipperiness as a result of poor healing. Joint attachment, restriction of movement and swelling are perceived as ordinary findings. However, the cause of joint damage is immediately eliminated. should be removed, its recovery should be accelerated and its recurrence should be prevented. If the joint damage is caused by a rheumatism, the primary approach is of course to try to stop or reduce the cartilage damage of the disease. If it occurred as a result of trauma and is above the body’s capacity to heal itself, it should be repaired immediately. Meniscus repair, removal of tears, correction of cartilage surfaces are possible with arthroscopy, which is the gold standard today. However, the issue of replacing cartilage is still fraught with technical difficulties. The joint damaged by arthroscopy is largely ready to repair itself. Advanced arthroscopic surgery not only detects and repairs problems with high resolution cameras, but also enables cellular treatments. For science that succeeded in replicating a sheep with “cloning = gene copying” that has emerged from fantasy novels in the last two decades, it has not yet been possible for every tissue to copy organs and tissues. Cartilage can be used in cellular treatments by being reproduced to a certain extent. In cellular treatments, tissue is obtained in two ways. The first method is to take a sample of the tissue and provide a suitable environment for proliferation. In this method, tissues that do not have the ability to reproduce, such as muscle and brain cells, cannot be produced. At the same time, it is not yet possible to produce some secreting specialized tissues and organs in this way. The second method is to produce cartilage by “differentiation from stem cells”, even in muscle tissues in highly specialized laboratories. started to happen. Promising treatment is the way of using stem cells in treatment by differentiating them into tissues. Human-cloning production of human tissue is ethically prohibited worldwide. The world of science continues to work on the cloning of organs by establishing their ethical foundations. Who can receive cellular therapy in joint diseases? First of all, the person to be transferred should have full body functions that can heal himself. Cellular therapy applications for the elderly are limited compared to young people. In the area to be treated with cellular therapy, the disease must be terminated and sufficient nutrition must be available for the cells to heal to survive. Finally, the alignment and surface relationship of the joint should not be disturbed, cartilage losses should not be common. The second issue is that the tissue to be transferred carries living cells capable of proliferation. The tissue must be undamaged and unaffected by the disease. In this respect, I think the difficulty of finding tissue that preserves vitality with the advancement of age will increase the importance of tissue banks. When tissues to be differentiated in stem cell banks are extremely expensive, it can be an economical solution. The age limit can be considered as the average age of 50 while qualifying recovery capacity. If the loss of cartilage covers the entire surface, cellular therapy cannot be performed because its success decreases considerably. Surgery is much more than the treatment of surface cells in people with active rheumatic disease and deformed joints. treatments are applied. These treatments can range from therapies that change the center of gravity to prosthetic surgeries. If the patients undergoing cellular therapy meet the appropriate conditions during arthroscopy, the tissue sample is immediately taken and sent to the laboratory with a special carrier. The cells, whose suitability is tested in the laboratory, are put into production, made into tissue in a special carrier and made ready for transfer within 15 days. The treatment continues with the placement of the produced cartilage in the area where the cartilage is lost by re-operating the patients. This method, which is gradually spreading around the world, can be applied in selected centers in our country. Cellular therapies, which are currently applicable, are to eliminate the consequences of diseases or traumas with complete cartilage loss on the joint surface. Instead of such treatments in superficial losses, arthroscopic applications are performed to increase the improvement of the existing tissue. Arthroscopic examination is essential to determine the degree of cartilage loss and to determine the type of treatment. Since today’s advanced radiological imaging methods are not yet sufficient to determine the type of treatment, it is very difficult to understand without arthroscopy, even in patients selected for such a treatment option. This situation is a major disadvantage if patients refuse surgery as a treatment option. Today, it is very important to be active for a healthy life. Joint health is the basic condition of being able to move without pain. So we should protect our joints and evaluate the chances of treatment in time.

Surgery is a sub-branch of medical sciences working on the surgery of trauma and deformities of the musculoskeletal system, muscle diseases, joint diseases surgery and medical treatment. It is performed by an orthopedic and traumatology specialist. The fact that physicians who accept patients after a 5-year education in Turkey dominate all sub-branches requires specialization due to the difficulty of following up the developing treatment options. It is common to come across definitions such as joint surgery, shoulder, knee, pediatric orthopedics, spine surgeon. The traumatology unit of the branch, which focuses on two main departments; In addition to working as a part of the trauma team in general body trauma, he performs the correction of fractures due to skeletal trauma and the replacement of dislocations by considering vital functions (head-chest and abdominal injuries). At the end of these procedures, it is aimed for the individual to quickly return to their former quality of life and functions. • Closed treatment and fixation of fractures and dislocations (plaster-splint-orthosis), • Surgical treatment of fractures and dislocations, • Post-traumatic rehabilitation is within the scope of traumatology. The foundations of today’s modern implant and fixation methods were laid in trauma surgery, which made its greatest development during the World War II years. When Dutch military physician Antonius Mathysen invented the plaster fracture fixation (Plaster of Paris cast) in 1851, unhealthy bandages were used that were smeared with egg or horse blood and hardened with albumin. Again, the German surgeon Gerhard Küntscher was sending the soldiers back to the front in a short time with the help of metal rods he placed in the bone marrow in the first world war. It was 1970 when Harborview Medical Center applied this method without opening the fractures. While external fixation methods were applied in the Vietnam War, Gavril Abramovich Ilizarov in Russia broke new ground in 1950 by defining distraction osteogenesis not only in war surgery but also in deformity surgery with fixators inspired by the tensioned wires of the bicycle wheel. While traumatology progresses in this way, Orthopedics, the second basic unit, has historically been the basis of the branch. Jean Andre Venel, who gave the first examples of modern applications in correcting the foot and spine curvature of children, revealed the definition of clinical studies (Orthos-Pedos) that started in 1870. Over the years, with the development of joint and oncology surgery, it has included sub-branch specializations. Fractures and Dislocation Physiotherapy Regenerative Medicine Cellular Treatment Medical Treatment Interventional Treatment Mesotherapy Joint Surgery Oncologic Surgery Pediatric Orthopedic Surgery Hand Surgery Foot and Ankle Surgery Arthroplasty Arhroscopy Minimal Invasive Spine Surgery Robotic Surgery Shoulder and Elbow Surgery Spine Surgery Musculoskeletal Oncology Sports Injuries Surgery

“Friend looks head to head and enemy at feet ..” Our feet are the most important part that carries our weight, which some proudly display, some lamented when hidden in shoes during the winter and come to light in summer with open slippers, which complement our beauty. In healthy individuals with foot structure; Three points are used in contact with the ground. The heel, thumb and little finger comb bone end parts transfer our body weight to the floor. In the foot architecture, the comb in the front and two arches on our longitudinal sole serve as a shock absorbing spring. While both arches are supported by the common beam of the muscles on the soles of the foot, the spinning wheel mechanism distributes the loads between 3 points without injury, so that our weight-bearing feet can resist the loads. While the middle long arc distributes the load to three points between the heel and the anterior arc, it can reduce the riding force by one tenth as a lever. While a healthy foot structure is like this, when the arc disappears in the flat sole, the outer muscles of the foot have to work harder to balance this structure. Therefore, long walking and running fast on flat soles becomes difficult. For whatever reason, when the load distribution is disrupted, calluses, protrusions in the bones that touch the ground or adhere to the beams, deterioration and erosion in the joints begin to occur. Foot problems can be examined in three areas. Back foot problems (Heel pain, bone spurs around the heel, Achilles problems) Midfoot (Plantar fascia problems = heel spur ?, sinus tarsi syndrome, nerve traps) Forefoot problems: Metatarsalgia, Thumb problems, Morton’s neuroma, hammer finger, tailor’s finger, Hindfoot and Heel Is the heel spur real? This diagnosis, which alternates between medical reality and urban legend, divided medical professionals all over the world. The common view of both sides is the presence of ossification at the attachment site of the combined tendon to the heel bone. Is their point of departure the bone problem? Is it resolved by eliminating the causing tendon discomfort. This difference of opinion has also led to heel support and treatment options for them. From simple to complex diagnosis and treatment methods, if the problematic area is not relieved with arch reinforcements, heel supports, and ESWT (External Shock Wave therapy) methods do not help, we can endoscopically shave the combined tendon. The permanent solution can be completed with post-surgical rehabilitation. Heel Cushion Syndrome This situation, which decreases in a few minutes, gives the feeling of walking on a thorny road in the morning; It is caused by the rupture of the natural fat pad wall that surrounds our heel and absorbs the shock on the floor. Challenge with a simple Heel cup with a patient rehabilitation It will disappear automatically. Heel Spurs- Bursitis (Calcaneal Bursitis) Bone Spurs (Haglund deformity) Bursitis, which develops due to the pressure of hard and narrow shoes on the Achilles beam, is the healing tissue caused by the irritation of the bone and the side of the Achilles facing the bone surface. If not treated well, it can become ossified and horned. Comfortable slippers worn on summer days are a great opportunity for treatment. If it is not possible to disintegrate this tissue from the outside like ESWT treatment, it is possible to remove this hard tissue in front of the tendon by closed surgery with ankle arthroscopy. Achilles tendinitis Although it does not seem directly related to the mechanics of the foot, it is very difficult to solve this situation caused by excessive strain without correcting the foot arch. Apart from rest and medical treatment, the heel of the foot that will trigger this situation should be corrected with varus insoles, which pushes the heel outward (flat foot, valgus) or disrupts the inward alignment, and plantar fascia tension should be reduced. If Achilles tendinitis is not treated well, it can result in breakouts. ESWT can be effective. When medical treatment is insufficient, radiofrequency can be applied with tenoscopy. Peroneal Tendinitis Back foot heel is one of the causes of pain. Just like Achilles, it occurs after foot mechanics deterioration and excessive strain. Occurs frequently in ankle fractures, in cases of malunion. Outsole wedges relax in medical treatment. ESWT is useless in this region. Ankle arthroscopy gives extremely good results in resistant cases. Midfoot Plantar Fasciitis Our tendon, which adheres to the heel of the foot, adheres to the heel where all the inner muscles of the foot are strengthened, and the spinning wheel acts as a force arm in walking mechanics. The injury of this structure, which is extremely important in gait mechanics, becomes chronic when it is not supported with the right insoles and its alignment is not regulated, causing the other structures of the foot to become open to load and injured. ESWT can support healing by increasing regeneration in complaints that are not reduced by choosing the right shoes and insoles. Injection treatments are successful. Tenoscopy and endoscopic debridement of the plantar fascia are among the surgical options. Sinus Tarsi Syndrome It includes the discomfort of the joint between the two bones that make up the heel that increases with pressure, which gives a feeling of fullness and swelling in the foot. It is frequently injured after foot sprains and strains. It may progress with the involvement of the joint surfaces between the two bones or with joint inflammation due to purely mechanical reasons. If the insoles do not decrease with intra-articular injection and drug treatment, if intra-articular problems are revealed in radiology, we apply sinus tarsi arthroscopy. Foot Trap Neuropathies Tarsal Tunnel It is the compression of the tibial nerve, which goes to the sole of the foot, without giving the plantar branch or after narrowing the space between the muscles and tendons. It is characterized by heel pain, burning in the sole and numbness in the big toe. EMG test is negative in half of the patients. Treatment is surgical release, cortisone injection can be tried. Dorsal Nerve Compression It is the result of compression of the nerve that goes to the toes on the back of the foot. It may be characterized by numb pain and burning in the second and third fingers. It is common in dancers and runners who wear tight strappy shoes. Treatment is surgical loosening if the injection does not respond. Forefoot Problems Metatarsalji It is one of the most common foot ailments. The metatarsal region is the area formed by the metatarsal bones. A similar dome of the foot is also present here, this time along the toes. Its deterioration causes “Splay Foot” discomfort and is one of the causes of forefoot metatarsalgia. Injury of the foot nerves and their healing in the form of knots, “Morton’s neuroma”, which is characterized by numbness in the fingers and pain in the form of pressing on a pebble, or phantom nerve injury is another cause of foot pain that is very difficult to diagnose. In this case, the treatment is surgery and the nerve node is removed. We frequently use metatarsal pad supports in the treatment of metatarsalgias, and patients benefit from appropriate support insoles after foot analysis. Thumb deformities (Hallux Valgus, Bursitis) The presence of deformity and bone protrusions in the big toe is the fearful dream of many people who care about aesthetics. In particular, mistakes made in surgical treatments and failures that lead to long plaster treatments cause patients to avoid surgery and to be exposed to complex treatments from simple preventive solutions. Not every bone protrusion is Hallux Valgus It is very important to correctly define haluk valgus, which has become an urban legend. First of all, it is a complex condition in which the toe turns inward (pronation) along with the outward orientation of the thumb, and the inner muscles of the feet are shortened. If you have a scalloped foot and the comb bone is directed inward, this is another situation that we call metatarsus primus varus, which is another condition that should be corrected near the completion of the bone development that occurs in puberty or even congenital. If there is no rotation of the metacarpal bone in our thumb, shortening of the ligaments, and no outward curvature of the finger, our bony prominence may be a simple bursitis. The treatment of this condition, which we can describe as a bunion, is simple bursectomy. Contrary to what is known, bone protrusion is not removed during surgery. Rather, it is to harmonize the joint and provide the alignment. After this procedure, the joint should work and be able to press without pain. After the correct surgery, patients can walk with or without a cast within 3 weeks and return to their normal lives. Articular Cartilage Problems Our finger joints can suffer from cartilage injuries, just like knees and large joints. In this case, there may be swelling and pain in the joint. A painless joint can be achieved when the problem on the joint surface is resolved by arthroscopy or small joint surgery. Hammer Finger Deformity Clawing may occur in people who wear loose shoes or move their toes forward when there is no foot box support. It can also occur in certain neurological diseases. This is a condition that should be known to people who want to get rid of bursitis and calluses on their toes during pedicure, and if splint and band treatments do not benefit, it can be surgically corrected. Tailor’s Finger It occurs as a result of forcing the little finger inward on the comb bone, especially in people sitting under their feet. Over time, the bunion becomes painful in the form of bone protrusion. Surgical treatment is required if it is not corrected with splints with early intervention.

1st Edition, February 2008 Birkenmaier, J. Chiu, A. Fontanella & H. Leu Login With endoscopic back surgery, it is aimed to reduce tissue trauma, prevent iatrogenic problems, and preserve spinal segmental motion and stability. The most interesting advantages of endoscopic procedures compared to open surgery are; Smaller incision and less tissue trauma, Minimal blood loss Early return to daily activities and work Easier surgical approach in obese patients Conscious sedation and local and regional anesthesia can be used together Less need for post-operative pain management in many cases As a result, they are procedures in which outpatient treatment is possible. Summary The International Society for Minimal Intervention in Spine Surgery (ISMISS) is an association of professionals dealing with back surgery from all continents, with the general aim of reducing interventional trauma and iatrogenic problems in spinal interventions. Members of the ISMISS founding members are pioneers of endoscopic spinal surgery, while members include experts from all areas of spinal treatments, from minimally invasive pain interventions to disc arthroplasty and fusion surgery. Since its inception in 1989, ISMISS has worked to improve the understanding of the underlying pathology as well as the development of tools and techniques for endoscopic spinal surgery. ISMISS is affiliated with SICOT (International Society of Orthopedic Surgery and Traumatology) and supports SICOT, which aims at clinical skills, training and scientific advancement in the field of spinal procedures. As new procedures, instruments and techniques are discovered, published and marketed faster than ever, ISMISS recognizes that adequate evaluation of treatments in this area is becoming increasingly difficult. ISMISS has begun to prepare independent and diverse guidelines on minimally invasive procedures in order to gain some habits to waist health professionals who want to improve their clinical practice with the latest and best information. These guidelines have been prepared on the basis of a thorough and detailed evaluation of the existing literature and the experiences of experts selected from ISMISS members all over the world and accepted as experts in their fields. The primary focus of the ISMISS guidelines is endoscopic spinal surgery. Correction The field of endoscopic spinal surgery is still very new and developing rapidly. As a result, experiences and observations may differ markedly across cultures, beliefs, and surgical practices. Therefore, we do not claim that these guidelines are whole or specific to any particular case. This work is still evolving and will continue to be updated regularly as new techniques and technologies are introduced, studied and improved. Although updates are planned twice a year, new updates will be made at shorter intervals when necessary. We invite you to participate in this study and share your clinical experiences or research with us. Gold Standards The majority of endoscopic spinal procedures relate to the surgical treatment of lumbar and spinal disc herniations, where microsurgery using the operating microscope is the gold standard when conservative treatments have failed or are not indicated. Microscopic disc surgery with microsurgery, also called microdiscectomy, should be taken as a reference in comparison with endoscopic disc surgery. For many other conditions, such as spinal canal stenosis or painful degenerative disc disease, an undisputed gold standard treatment has yet to be defined. In any case, the main concern of the technical advantages of endoscopic spinal surgery should be patient safety. As a result, all endoscopic spinal procedures aim to increase patient comfort, decrease invasiveness and not increase the complication rate and risk profile when compared with traditional procedures applied for the same indications. Indications Endoscopic strategies have been and are predominantly used in the treatment of the following conditions: Lumbar, thoracic and cervical disc herniations with radicular symptoms Lateral spinal canal (recess) and foraminal stenoses with radicular symptoms Degenerative facet joint cysts with radicular symptoms Contraindications Clinically consistent instabilities central spinal canal stenosis Relative contraindication: Large disc herniations and concomitant cauda equina syndrome or new motor deficit. In these cases, adequate decompression may not be achieved except for those with large interlaminar space and good interlaminar endoscopic access. Diagnostic Standards for Determining Indication In each of the above-mentioned cases, a clear clinical profile completed using patient history and physical and neurological examination is the minimum standard. While degenerative changes seen in radiography and magnetic resonance imaging (MRI) determine the prevalence in asymptomatic cases, evaluation with imaging methods alone can be extremely misleading in such cases when pathological findings do not clearly match with specific clinical symptoms. Physical examination of cervical and lumbar spinal pain syndromes should include the shoulder region, upper extremity, pelvis, sacroiliac joint, and hip joints, respectively. It is not uncommon for painful conditions in these adjacent areas to mimic symptoms resulting from spinal events. In doubtful cases, we recommend contrast assisted diagnostic injections under fluoroscopy guidance to detect the condition that can be treated with endoscopic spinal surgery. A current MRI with adequate and new imaging studies, or computed tomography (CT) is required for surgical procedures in patients with a history of less than 3 months and in whom MRI would not be preferred for imaging. In cases with a change in symptoms, a repeated imaging study is recommended before surgery. If the diagnosis of the monoradicular lesion is doubtful despite the history, physical examination, and imaging studies, additional neurophysiological studies (electromyography, neurography, etc.) may be helpful. Evaluation of Imaging Studies Plain Radiographs Plain radiographs taken in bidirectional and upright position are still considered standard examination for 2 reasons: On the one hand, plain radiographs allow rapid assessment of spinal structure, bone integrity, and potential instability. On the other hand, it allows the evaluation of vertebrae when radicular symptoms do not match the level of the affected disc observed on MRI or CT. Functional radiographs may also be necessary in cases of suspected or identified instability. In selected cases, functional myelography can be a highly valuable test even today (see below). Computed Tomography (CT) Although MRI has replaced CT in evaluating soft tissues, edema, infection, cysts, and other fluid-induced tissue changes, CT still has significance in some diagnostic situations. Apart from MRI, CT can also create images in alternative and also non-standard planes using the original data, thus helping to evaluate foraminal events. Many foraminal problems arise from bony structures, and these bony structures often cannot be adequately evaluated with available MRI resolution and images. This is especially observed in the cervical spine. In cases where MRI cannot be applied, post-myelography CT is a valuable imaging method superior to MRI. Hyperbaric contrast agent application, which is entered from the lumbar level in cervical problems, is an alternative option to the suboccipital technique. Magnetic Resonance (MRI) Many modern magnets (!) Get very good and detailed images when it comes to disc space, ligaments, fluid compartments, neural structures and adipose tissue. On the other hand, sagittal sections often fail to show the posterior foramen enough to assess extraforaminal disc sequestration. When combined with axial slices not parallel to the level of the affected disc, this may miss extraforaminal sequestrations. With the exception of some exceptional centers where functional MRI is used, CT and MRI imaging are usually performed in the supine and sometimes prone position, without axial loads and positional effects on the spine. In some cases, as an effect of body weight, instability, and posture, standing images may appear quite different on CT or MRI than images taken in the supine position. When this condition is suspected, a functional myelogram followed by post-myelography CT is a good option. The fact that functional MRI is an alternative imaging method seems promising for the future. Due to the limited position tolerance in patients suffering from pain today, image noise may occur and therefore the image quality may be adversely affected. Anesthesia Although general anesthesia is preferred by many surgeons for traditional techniques, local anesthesia with or without sedation is an important option for most endoscopic approaches. However, one of the issues that should be emphasized is that a patient lying prone and undergoing local anesthesia may need to completely abandon the technique used and switch to general anesthesia, as well as the need for endotracheal intubation, repositioning the patient and re-preparation of the operation field. Especially in cervical applications, unconscious head and neck movements are very difficult to control and may cause additional risks. Endoscopic Approaches to the Lumbar Spine Anatomical and Technical Evaluation Endoscopic spinal surgery uses dilatation technology instead of making a skin incision in order to minimize tissue trauma in providing the transition from soft tissues (eg skin, subcutaneous adipose tissue and muscle/fascia tissue). Beyond the entry trauma to the tissue, the main difference between endoscopic and microscopic microsurgery is; It provides a 2D view versus a 3D view, and a near view angle versus a far view angle, even though it’s flat. Many instrument sets for endoscopic back surgery are available on the market, and they come in a wide variety according to their technical features and indications for use. Each surgeon is responsible for using the most appropriate surgical set for his/her own surgical technique. While the endoscopic surgical approach to the spine reduces visible surgical trauma, this minimally invasive procedure comes at a cost; a reduced and 2-dimensional field of view and a limited field of view in the surgical field. The surgical approach and access route are chosen largely depending on the regional anatomy for entry into the foramen or spinal canal. These anatomical restrictions are usually caused by bone structures such as facet joints, pedicles and laminae, however, branches originating from nerve roots in foraminal approaches and vertebral arteries in cervical approaches are also important structures that cause restrictions. The properties of the optical system (viewing angle, magnification, etc.), together with the size of the treated canal and the instruments used, determine the precise limits such as which areas can be seen and which lesions can be treated safely. Burr, promotion, etc., which allow endoscopic bone resection from the operation area and enable a larger view by enlarging the operation area. surgical instruments such as. On the other hand, when it is necessary to change the location of the instruments used from the additional access cannulas, blinding augmentation and a large amount of bone resection are required with the terfin. For these reasons, a clear surgical strategy and precise targeting are very important. Double-arm fluoroscopy is a prerequisite for the approach used to be directed to the right place, intraoperative control and recording of the technique used. If the techniques that cause tissue change such as laser or bipolar radiofrequency devices are to be used in endoscopic spinal surgery, the instruments considered to be used and their complications should be fully known. Interlaminar Approach This approach is very similar to the traditional microsurgical approach. The spinal canal is entered through a limited flavotomy and the risk of damage to the dura or neural structures is similar to the microsurgical approach. Depending on the angle of entry into the interlaminar space in the sagittal axis and the level of treatment, reaching the posterior part of the disc may be easy or difficult. Since the interpedicular area is on the opposite side of the ventral epidural area, it is very difficult to reach. When the interlaminar window is too small, this approach cannot be applied without resecting the laminar edge and / or the medial part of the facet joint. This is particularly important for newer and more modern endoscopes with a wider working channel as well as a larger outer diameter. An important advantage of this approach is that it can easily be converted to the open approach. Posterolateral Approach The posterolateral approach is the best known approach for interventions on the lumbar spine and can be used in foraminal and extraforaminal disc herniations as well as intradiscal procedures. In this approach, an angle of approximately 60 degrees is made to the sagittal plane and the foramen is entered from the disc level. It can be applied when the patient is in a prone or lateral decubitus position. In this approach, the main intraoperative risks are damage to the root originating nerve (especially in the presence of severe disc height loss) and damage to the blood vessels. In patients with short pedicle structures and osteophytes in the facet joints, the lateral edge of the superior articular process may need to be shaved to provide sufficient transition clearance. The ventral epidural space can only be reached from this side. Far or Extreme Approach This approach is one of the most recently developed approaches, and it was developed especially under the leadership of Ruetten. Using this approach, in addition to the foraminal and extraforaminal areas, the ventral epidural space other than the interpupicular area can be accessed. This approach provides access to the foramen by making an angle of less than 90 degrees to the sagittal plane, at the level of the facet joints in the coronal plane and through the skin in the prone position. Therefore, it is less likely to encounter facet joints than the posterolateral approach, but in this approach, short pedicle structures and large herniated discs may make it difficult to pass to the ventral epidural area. The risks of surgical intervention are generally the same as for the posterolateral approach, but there is an increased risk of dural injury and an additional risk of injury to the retroperitoneal organs at the upper lumbar levels. Therefore, the retroperitoneal anatomy of the CT or MRI related level should be examined before applying this approach to the upper lumbar levels. Endoscopic Approaches to the Cervical Spine Anterior Approach The anterior approach is very similar to the traditional microsurgical method in which the neurovascular sheath is taken to the outer part of the working canal and the visceral structures to the inner part of the studied canal. The tip of the working arm is placed opposite the end of the anterior longitudinal ligament and the anterior part of the adjacent vertebral body. Unlike traditional microsurgery, disc space can be passed without any discectomy. Cleaning of the herniated disc and osteophytes, if necessary, is accomplished by using a wide variety of special tools, including chisels, pitchers, microresectors, various forceps, drills, hooks and bipolar microelectrodes. Using this approach, the foraminal areas and spinal canal can be reached with perfect control of the operation area, while the same accessibility is not valid for the interpupicular space. The anterior endoscopic approach in the cervical spine relative to other parts of the spine facilitates effective decompression of the spinal canal and / or nerve roots (in addition to the vertebral arteries in selected cases) without the need for disc removal using fusion or arthroplasty. In general, there is no need for drains or immobilization for the wound in the postoperative period. Posterior Approach The posterior approach is advantageous in central spinal canal stenoses caused primarily by posterior structures (primarily by the ligamentum flavum or a collapsed laminar edge) or distant lateral disc herniations. The approach and surgical technique are quite similar to the traditional surgical technique, but in practice, tubes of various diameters and typical endoscopic instruments that pass through them and mentioned in the anterior approach are used. Complications Minimally invasive surgery does not have to bring minimal complications, the learning curve of endoscopic low back surgery tends to be flat and longer than traditional approaches. Dural tears, nerve root damage, bleeding and infection, applications to the wrong level or the wrong side of the hernia can be seen in endoscopic techniques as well as in open techniques. There is also a risk of pneumothorax in thoracic approaches. In addition, some injuries such as dural tears may not be taken seriously or even noticed due to the low pressure washing system of the endoscopic system. When a surgeon begins to perform endoscopic spinal surgery, careful selection of appropriate cases, careful surgical technique, administration of a single perioperative antibiotic (1), and careful postoperative follow-up are highly recommended. When complications occur, it is necessary to evaluate the cases with the same technique as it is applied in open techniques and, if necessary, to switch to open technique. Surgeon’s Qualifications Only surgeons who have sufficient experience in their traditional techniques should apply endoscopic techniques. On the one hand, sufficient experience is required to properly manage potential complications, on the other hand, surgeons with sufficient experience in both techniques can decide whether the open technique or the closed endoscopic approach is better in each case. Adequate training in endoscopic techniques, technical resourcefulness with the instruments used are a priority for the procedures to be applied in clinical situations. Evidence A recent update on the systematic review of the Cochrane study on lumbar disc prolapse found that surgical discectomy (open and microsurgical) applied to carefully selected patients provided faster regression in sciatica pain than conservative treatment (2). It was also mentioned in the same review that there is insufficient evidence to draw correct conclusions on all types of percutaneous discectomy (there is sufficient evidence for chemonucleolysis only). In a systematic review by Maroon, it was reported that none of the minimally invasive techniques developed to be used in the treatment of symptomatic lumbar disc disease had a significant superiority over microdiscectomy (3). It is understood from this that well-designed random studies are needed to compare endoscopic techniques with microsurgical microscopic disc surgery. Most of the publications on endoscopic spinal procedures include the results of case series (usually retrospective), technical developments or personal experiences. However, there are few controlled and randomized controlled studies that can provide evidence about the potential benefits of endoscopic disc surgery. In a randomized controlled study performed in a selected patient group (cases with a single level herniation not exceeding ın of the spinal canal in the sagittal plane, cases without spinal canal stenosis) similar clinical results were obtained in terms of performing endoscopic and open discectomy, however, patients who underwent endoscopic surgery had less postoperative pain and It has been found to have a shorter rehabilitation period (4). In another controlled study, endoscopic disc surgery was found to be superior to microsurgery technique in terms of sciatica pain, low back pain and return to work (5). It has been proven that endoscopic lumbar surgery not only causes smaller incisions, but also causes less tissue damage and a lower systemic inflammatory response (6). In a controlled study in which intraoperative electromyographic monitoring was used and endoscopic and open techniques were compared, it was found that significantly less intraoperative nerve root irritation occurred in patients who underwent endoscopic technique (7). Resources Dimick JB, Lipsett PA, Kostuik JP. Spine update: antimicrobial prophylaxis in spine surgery: basic principles and recent advances. Spine. 2000 Oct 1;25(19):2544-8. Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007(1):CD001350. Maroon JC. Current concepts in minimally invasive discectomy. Neurosurgery. 2002 Nov;51(5 Suppl):S137-45. Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg Am. 1999 Jul;81(7):958-65. Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg. 1993 Feb;78(2):216-25. Huang TJ, Hsu RW, Li YY, Cheng CC. Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orthop Res. 2005 Mar;23(2):406-11. Schick U, Dohnert J, Richter A, Konig A, Vitzthum HE. Microendoscopic lumbar discectomy versus open surgery: an intraoperative EMG study. Eur Spine J. 2002 Feb;11(1):20-6. Additional Resource Chiu JC, Hansraj KK, Akiyama C, Greenspan M. Percutaneous (endoscopic) decompression discectomy for non-extruded cervical herniated nucleus pulposus. Surg Technol Int. 1997;6:405-11. Chiu JC, Clifford TJ, Greenspan M, Richley RC, Lohman G, Sison RB. Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty. The Mount Sinai journal of medicine, New York. 2000 Sep;67(4):278-82. Chiu JC. Anterior Endoscopic Cervical Microdiscectomy. In: Kim D, Fessler R, Regan J, editors. Endoscopic Spine Surgery and Instrumentation. New York: Thieme Medical Publisher; 2004. p. 48-55. Fontanella A. Endoscopic microsurgery in herniated cervical discs. Neurol Res. 1999 Jan;21(1):31-8. Kambin P. Arthroscopic microdiskectomy. The Mount Sinai journal of medicine, New York. 1991 Mar;58(2):159-64. Kambin P. Arthroscopic microdiscectomy. Arthroscopy. 1992;8(3):287-95. Kambin P. (Editor) Arthroscopic and Endoscopic Spinal Surgery Text and Atlas, Second Edition, Humana Press, Totowa, NJ Leu H, Schreiber A. [Percutaneous nucleotomy with discoscopy: experiences since 1979 and current possibilities]. Revue medicale de la Suisse romande. 1989 Jun;109(6):477-82. Ruetten S, Meyer O, Godolias G. Endoscopic surgery of the lumbar epidural space (epiduroscopy): results of therapeutic intervention in 93 patients. Minim Invasive Neurosurg. 2003 Feb;46(1):1-4. Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine. 2005 Nov 15;30(22):2570-8. Schreiber A, Suezawa Y, Leu H. Does percutaneous nucleotomy with discoscopy replace conventional discectomy? Eight years of experience and results in treatment of herniated lumbar disc. Clinical orthopaedics and related research. 1989 Jan(238):35-42.

Minimally Invasive in Canal Stenosis; The reason for non-congenital spinal canal stenosis is low back pain that has not been treated well or in time. In particular, sciatica-like pain that hits the legs with recurrent attacks and requires rest should be healed at the initial level. The spinal motion system consists of disc levels between the vertebrae pairs. Each level of disc and lower / upper vertebrae in the back, called facet joints, provide alignment on the right and left. Minimally Invasive Endoscopic Treatment for Canal Stenosis The vertebrae play a role in the alignment and the facets act as a limiter. While the spinal cord passes from the canal limited by the vertebrae and facets to the coccyx, it proceeds by distributing the nerves through the holes called foramen at every level. The spinal canal is in the center where the spinal cord passes, and the foraminal canal is arranged symmetrically on the right and left, limited by the facets. The most common cause of canal stenosis is the wide-based lumbar hernias occupying the canal, swelling of the facet joints as a result of wear and inflammation, or thickening of the ligaments that limit the canal. These structures narrow the central canal or foramen canal, compress the nerves and cause pain and loss of function (loss of strength and numbness) over time. Since the canal stenosis progresses very slowly, it is often possible to adapt within decades. Therefore, the diagnosis of canal stenosis at an advanced age without obvious spinal discomfort would not come as a surprise. Slowly progressive stenosis can force the limit of endurance with a small hernia and force to consult a physician. Treatment is to widen the canal and remove the structures that cause narrowing. When the facet columns that protect and fix the array are removed during channel expansion, the alignment is continued with metal supports. The relevant level is frozen and the pain is relieved. The basic principle of minimally invasive treatment is to widen the canal without disturbing the alignment. The structures that create canal invasion are removed with the help of an endoscope, foramens are expanded, the central canal is opened without removing the facet columns. Thus, it is aimed to relieve the pain without the need to freeze the level. Since canal stenosis is a disease of advanced age, it can be performed without anesthesia and percutaneous endoscopic spine interventions in terms of preventing the negative effects of metal fixation on osteoporotic bones; Choosing foraminoplasty, sublaminal endoscopy decompressions is increasingly common. Especially in foraminal problems, it will be inevitable to be the gold standard.

The frequency of carpal instability after radius distal tip fractures, Istanbul University, Istanbul Faculty of Medicine, which hosted live surgery courses in Istanbul in the past years and supported the ISMISS congress, this tradition OMID "Spine Minimal Invasive and Interventional Surgery Association" and ISMISS "The International Society for Minimal Intervention in Spinal Surgery will continue with the courses it will organize in June and September.

Before giving information about flatfoot treatment, let's answer the questions "What is Flat Insoles and What are the Effects on the Skeletal System". It can be congenital or acquired. Flat foot is the foot sitting on the ground with a large surface as a result of the loss of the arch of the foot. This situation causes the force that creates the spinning wheel mechanism by spreading to three different points like the stool foot during the transfer of weight, losing this effect on the wide base and causing the resultant force to move the mechanical axle to an unknown area without springing, the alignment is disrupted. The hip-spine-knees are positioned according to the resultant force-mechanical axis relationship. Varus-Valgus internal or external rotations - Excessive lordosis-kyphosis occurs in the spine, posture deteriorates. Since the axis change will disrupt the joint mechanics, abrasions occur and become vulnerable to trauma, falls increase. How is Flat Insoles Treatment Performed? Congenital flat feet may require early surgery. In cases that do not require surgery, massage treatments and shoes with ankle support are given after walking. At the age of two years, axis corrective heel wedges can be added to shoes that support the arch and grip the heel. While it is ensured that the foot bones are in contact with the arch supports at certain angles until the age of six, when ossification is achieved, softer shoes can be used with exercises. Arch support should be continued during the rapid growth period such as adolescence. After the growth is complete, the benefit of padded shoes decreases. If angular changes continue, surgery is considered. Closed flatfoot surgery (Arthroereisis-Arthroerez) is one of the best options. Other options are fusing the foot bones to each other on the axis they should be (Triple Arthrodesis). The foot loses its elasticity, although the axes are straightened, movement becomes difficult when the spring is broken. Acquired flatfoot is treated similarly at an early age. If there is tendon failure, it can be repaired. Wrong sideburns due to fracture are corrected. It usually requires surgical intervention. Which Age Group Is Flatfoot Treatment Applied? Different approaches are applied in all age groups. The application range of closed surgical methods such as arthroeresis may be 14-50 years. It can be applied in selected cases outside these limits. In arthroeresis surgery, a special screw is placed in the space adjacent to the joint of the bones forming the arch called sinus tarsi, allowing the bones to return to their normal axis relations without freezing. Since the foot does not lose its flexibility after this procedure, the spring-spinning mechanism does not deteriorate, the walking mechanics are improved and the strength increases. How Long Does The Flat-Foot Closed Surgery Treatment Take? In 30-45 minutes, the surgery is completed bilaterally. What is the Recovery Process After the Surgery? It can be walked with a special walking boot for 3 weeks. During this period, a cane may be required. 3-6 shoes that cover the ankle with arch support are preferred. Exercises are started with soft walking shoes for 6-12 weeks.