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What is Cellular Therapy? In the field of orthopedics, cellular therapy is widely used in general. The concept of cellular therapy is a broad concept. however, the use of cells prepared under laboratory conditions mostly includes cartilage, fibrocyte and platelets. In use, the source can be bone marrow (stem cell), Plasma (Plasma enriched platelet) or directly the cell itself. Bone marrow and plasma can be put into use in a short time after being subjected to special treatments and filtered. However, for cell production, a production time is required under special culture and laboratory conditions. In general terms, the treatment is called “cellular renewal therapy”. ​ Why are they doing where they were left? Cellular therapy is applied in tissues that do not have the ability to regenerate themselves. The ability of the cartilage cell itself to proliferate is suppressed within the tissue. Therefore, it cannot compensate for the tissue loss in the cartilage. However, the cell sample can be activated outside and reproduced and transplanted to the defect area and healing is prevented with tissues that do not have the quality of cicatrix-cartilage. Thus, organ or limb function is not impaired. ​ How and where are these cells prepared? We first decompose the forehead cells. This is done with various processes in the form of filtration-centrifugation and healthy cells are selected under a microscope. It is then reproduced in suitable media. This reproduction is then continued by providing a certain distribution on a skeleton that we call matrix. When the appropriate volume is obtained, the tissue is ready for delivery. ​ What kind of preparation is made in the region to be given? The area where the tissue will be transferred is prepared adjacent to healthy cells, well-blooded and easy to detect. Dead cells are cleaned, space is opened up to healthy tissue and blood supply is provided. ​ How long does it take to fulfill its new tasks? If the tissue is a person’s own cell, it functions as long as it maintains its vitality without entering the remodeling process, and the cartilage matrix can begin to reproduce within 24-72 hours. The attachment of the tissue will take place in a period of 3-12 weeks, depending on the region it is located in. At the end of 2 years, the tissue skeleton is completely renewed and its continuity with other neighboring cells is ensured. The situation is very different in foreign cells. If cell rejection occurs, the cells are enveloped and killed within 72 hours, leaving only the matrix left behind and leaving cells that mimic cartilage called fibrocytes.. ​ Is it on the agenda to use it in other places? It is possible to use it in all joints, it has come to the fore to use cellular treatment in fractures with super adhesives. ​ How do you think the future of treatment? In the future, we will do all the treatments using cells. Even the nervous tissue that cannot be regenerated will be treated in this way.

It is now possible to make a backup of our tissues to regenerate and heal yourself! While our body has the ability to heal and repair itself when it receives any injury, when this injury or damage occurs in tissues such as joints and muscles, we have little chance. However, with cellular therapy applied in a limited number of centers in Turkey, new cartilage can be transplanted to the patient by producing cartilage in the laboratory from the cartilage cell taken from the person himself. In reality, the cause 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. Don’t say it hurts 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 reason that damages the joint should be eliminated immediately, its recovery should be accelerated and its recurrence should be prevented. 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 must protect our joints and evaluate the chances of timely treatment. In case of joint damage due to rheumatic reasons, it is necessary to stop or reduce the cartilage damage. If it is caused by trauma, it must be repaired. Arthroscopy gold standard Meniscus repair, removal of tears, correction of cartilage surfaces are possible with Arthroscopy, which is known as the gold standard today. Replacing the cartilage is fraught with technical difficulties. The joint damaged by arthroscopy is largely ready to repair itself. Advanced arthroscopic surgery not only detects and fixes 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 is not yet possible for every tissue to copy organs and tissues. Cartilage can be reproduced to some extent and used in cellular treatments. New cartilage from the lab 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. Cells, whose suitability is tested in the laboratory, are put into production, made into tissues 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 treatments can be applied today to eliminate the consequences of diseases or traumas with complete cartilage loss on the joint surface. In superficial losses, instead of such treatments, arthroscopic applications are performed to increase the healing 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 treatment. This situation is a major disadvantage if patients refuse surgery as a treatment option. Who can receive cellular therapy in joint diseases? First of all, the person to be transferred must have full body functions that can heal himself. Cellular therapy applications to the elderly are limited compared to the young. In the area to be treated with cellular treatment, the disease should be terminated and sufficient nutrition should be available for the cells to heal to survive. The alignment and surface relationship of the joint should be intact, and cartilage losses should not be widespread. The subject 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. It can be an economical solution when tissues to be differentiated in stem cell banks are extremely expensive. The age limit can be accepted as 50 years on average when describing the healing capacity. If the loss of cartilage covers the entire surface, cellular therapy cannot be performed because its success decreases considerably. Surgical treatments are much more than the treatment of surface cells in people with active rheumatic disease and deformed joints. These treatments can range from therapies that change the center of gravity to prosthetic surgeries. In summary, stem cells are promising. 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 production of cartilage by the second method “differentiation from stem cells” has become possible even in muscle tissues in highly specialized laboratories. 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 scientific world continues its studies on the cloning of organs and establishing ethical foundations.

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.

Regardless of race, age and gender, it was determined that 80% of each individual suffered from back and neck pain that requires bed treatment at least once in their life. Neck hernia. Although spinal pain is so common, disc-based pain is 27%. The disc structures between the vertebrae have elastic deformations during the transfer of weight, standing upright and during movement. It provides this dynamic effect with the nucleus (nucleus) in its structure and the annulus structure surrounding it. Like a horizontal automobile tire, the disc absorbs the load during bending and loading, reduces and transfers the weight by spreading, then returns to its original state. This suspension effect continues thousands of times during the day. The aim is to maintain the relationship and stability between the vertebrae, apart from meeting the load. While the discs keep the distance between the vertebrae constant at a certain height, the muscle-ligament and nerve structures remain at a certain tension and provide dynamic stability. As a result of the structural changes of the matrix proteins in the disc structure with aging, their water retention properties decrease. With decreasing disc elasticity, water retention ability decreases. Decrease in diffusion feeding increases the matrix cracks, and plastic deformations occur in the fragile disc with reduced elasticity over time, with the permanent structural changes. The height of the disc decreases, the joint structures are eroded by excessive movement, even the disc wall is torn and the nucleus moves and presses on the nerve structures. And as a result, spinal pain occurs. Medical Treatment Requirement does not exceed 8.3% among disc-related pain, while those with outpatient treatment are 2.7%. The number of inpatients in the world is 9 million (0.45%), the group that receives surgical treatment is only 1 million per year in the world. This number includes all open surgical fusion and discectomies. Low back pain treatment is multidisciplinary. Multidisciplinary Approach »Physical therapist " Neurology expert " Physiotherapist »Algologist »Spinal surgeon It is possible with the cooperation of physicians working in their branches. Progressive (algorithmic) treatment principles require anti-inflammatory therapy in primary care and bed rest not exceeding 3 days. In resistant and chronic cases, algologists apply block-pain treatments, physical therapists apply physical therapies. All treatments are supported by muscle strength-posture discipline-ergonomic measures with the support of physiotherapists. Surgical compression of the neural structures is the last step of choice in recurrent resistant cases due to osteoarthritis, significant loss of disc height. Open surgery indications: » Cauda equina syndrome »Progressive neurological deficit »Failure of conservative treatment »Paresthesias that are not obvious but affect life »Pains that progress with attacks and require more than three rest times a year can be counted. The indication for minimally invasive (closed endoscopic) surgeries differs at this stage. Prominent neurological deficit, cauda equina may be a contraindication. Endoscopic surgery has a place in cases requiring bed rest more than three times a year, but without an absolute surgical indication. PAIN, which does not respond to conservative treatment that reduces the quality of life, is NOT THE FATE OF THIS POPULATION: it is a treatment that is purely aimed at improving the quality of life. Open Surgical Treatments »Lumbar Microdiskectomy »Hemilaminotomy / discectomy »Laminectomy / discectomy »Fusion »Nonfusion »Total Disk Replacement » Nucleus Replacement While surgery is moving towards less invasive methods, it is the fastest return to daily life after treatment. Surgical evolution has tended to increase disc height by regenerating the nucleus. While less invasive methods (LESS Invasive) surgeries broke new ground with percutaneous (piercing the skin) fusion (freezing) surgeries with screws, they also tried to increase the height by renewing the disc core with semi-open methods, on the other hand, they tried to reduce pain with external supports that open the disc space. Table-1 Open Surgery Fusion Nonfusion Disc prosthesis Nucleus Replacement Less Invasive Surgery Fusion PLIF-TLIF Nonfusion Xstop vs Nucleus Replacement PDN MISS Surgery Minimal Invasive Intradiscal Discectomy Selective Discectomy Anulus Repair Nucleus Replacement Hippocrates “First, Harmful” (Primum Nil Nocbbere) approach is the current approach. Ideal treatment for surgery progressing towards more and more harmless treatments »Respectful to anatomical structures »Harmless »For the cause »Increasing the quality of life »There should be a treatment that can return to normal life in a short time. Minimally Invasive - Closed Endoscopic Surgery History: » 1857 Virchow begins with his description of disk protrusion. 1901 Horsley applied the first decompression, 1911 Goldthwait cited annulus rupture and nucleus pulposus extrusion as the cause of pain. »1913: Elsberg treated pain with laminectomy treatment used for years in open surgery. »1922 Siccard and Forestier sprinkled the first seeds of minimally invasive techniques that applied the first provocative discography technique using lipiodol. With this examination method, disc pathology could be revealed on x-ray. The pathological level gave pain during the procedure. » 1934: Peet and Echols differentiated between disc herniation and root compression »1937: Defining it as the first endoscopic intervention (MYELOSCOPY) modified from the pool otoscope, the first endoscopy was performed. »1939. Love applied the interlaminar microdiscectomy technique without resecting the bone with a mini incision. »Until 1955 Male Binocular Microscopic Discectomy technique was developed, wars were unorthodox to use medical treatment to improve the quality of life. »1960 Rhizotomies were activated, pain transmission from painful segments was interrupted. » 1974 Shealy performed Rhizotomy by applying Percutaneous (piercing the skin) Radio Frequency procedure. While intra-discal treatments are becoming popular, chymopapapin and Choy laser powered discectomies »1973 Kambin launches endoscopy application » 1977 Hijikata performed Percutaneous Endoscopic Discectomy, 1978 Williams Microscope used in classical discectomy »1980 Anthony Yeung introduced the endoscope specially prepared for spinal endoscopy (Wolf: YESS) to today's surgery. After more than one hundred thousand successful procedures since 1980, Miss Family Tree is gradually branching out. Family tree »Hijikata-Kambin »A. Yeung (Wolf-Yess) »MT. Knight (EKL-Kiss) »H. Leu (Storz-Leu) »T. Hoogland (Joimax-Thessys) »Martin Sawitz, John Chiu, Sang-Ho Lee, Akira Dezava CISS advantages: Patient-centered After minimally invasive surgery, the hospital stay rarely exceeds one day. Returning to work after the procedure is limited to a few days. Recovery is very fast as it does not damage normal tissues. Therefore, specific hospitals with a low number of beds will restore a large number of patients to their health. Short hospital time lowers the cost. The result is excellent for the patient-centered Hospital-Insurance-Employer triangle. Minimally Invasive Surgery Concepts 1. Central Decompression: a. Chemonucleosis: It aims to liquefy and reduce the pressure by injecting chymopapain into the disc. Its indication is limited and it is almost abandoned. b. Nucleotomy: It is one of the standard treatments in the disc. It is the emptying of the disc using mechanical tools. (Figure-1) Figure-1: Nucleoplasty Figure-2: Taken from the Clarus Medical catalog. c. Automatic Nucleotomy: It is the vacuum evacuation of the disc with the help of a motor. (Figure-2) D. Radiofrequency nucleoplasty: It is the denaturation and wrinkling of the nucleus using radiofrequency. (Figure-3) to. Laser ablation: It is the evaporation of the nucleus with laser energy. (Figure-4) f. LASE: Laser assisted endoscope: It provides camera-assisted laser application into the disc with a special very thin probe. It has made a breakthrough in treatment. (Figure-4) 2. Subanular decompression and Annuloplasty a. Subanular decompression: This is the beginning of endoscopic surgery. The disc is removed from the torn annulus from a subanular safe distance. (Figure-5) b. Annuloplasty: The annulus is repaired using laser or radiofrequency energy. (Figure-3-4) 3. Selective Discectomy: It is the last stage. Only the compressing fragment is removed, the disc and annulus are repaired. It will be possible to apply a nucleus portal. a. Foraminoscopy (Figure-6) b. Epiduroscopy (Figure-6) Surgical Technique For lumbar hernia; Under local anesthesia, it is worked from the side in the prone or lateral lying position, the back hernia from the side in the slightly lateral lying position, and the neck hernia from the front. The hernia is reached without damaging the normal anatomical structures by using 5-7 mm special working channel cameras by perforating the skin 0.5-1 cm (Percutaneous). Only the part pressing on the nerve is removed. Disc structure is preserved and its recovery is provided. By Percutaneous Spinal Endoscopy, without cutting normal anatomical structures or bleeding, »Percutaneous endoscopic lumbar discectomy (PELD) (Lumbar Hernia) - Lumbar foraminoscopic - Extraforaminal far lateral - Interlaminar » Percutaneous endoscopic thoracic discectomy (Back Hernia) »Percutaneous endoscopic cervical discectomy (Neck Hernia) Advantages of Percutaneous Endoscopic Surgical Treatment »Local anesthesia is used, the patient does not receive general anesthesia. »The procedure is applied through normal anatomical holes, normal structures are not damaged in order to reach the disc. Therefore, the bleeding is very less. »Selective fragmenttectomy (only the pressing fragment is removed-the disc is preserved) »The disc is protected, the healing of the periphery (Annulus) is stimulated, increasing the healing capacity »In-disc decompression can be made. »With a provocative examination, the level can be determined precisely in multi-level lumbar hernia. »Root inspection (probing) » Foraminoplasty (enlargement of the nerve exit hole) is possible. » Epiduroscopy (examination of the spinal canal) is possible. »Extraforaminal and far lateral examination is possible. Extra-canal compression of the nerve can be easily diagnosed. »Safe percutaneous intradiscal treatment portal Contraindication »Morbid Obesity »Cauda Equina »Complicated hernias (adherent-sequestered) »Open Surgery recurrence » Non-compliant patient »Bleeding Diathesis Future Treatments Percutaneous treatments provide advantages in reaching the disc in the epidural region, the addition of advanced new instruments, genetic advances and robotic surgery, preserving normal tissues and a healthy life will be possible. From emerging treatments; »Anulus repair » Percutaneous nucleoplasty (Injection) »Percutaneous intradiscal stem cell infusion are just a few of them.

Is it Effective in Musculoskeletal Tumors? Used in radiotherapy In malignant and invasive benign skeletal tumors, radiotherapy is applied in addition to chemotherapy before / after surgery. Since sarcoma cells are more sensitive than carcinomatous cells and the majority of skeletal tumors have this structure, radiotherapy continues to be used as part of the treatment. Radiotherapy reveals its lethal effect by stopping the division in cells with increasing proliferative rhythm. Since normal cells are also damaged during regeneration in the entire area where the rays are targeted, Proton Beam Therapy has emerged as a result of investigating therapies that focus directly on the tumor area to reduce unwanted effects. Proton beams, without using X-rays like conventional radiotherapy agents, can deliver intense radiation to the tumor area with beams as wide as the size of the tumor, or even very narrow beams. While reaching the tumor, it is a great advantage that it does not pass behind the targeted tissue, although it causes radiation by passing through the normal tissues. This is why proton beams are tried to be applied to the patient as shortly as possible by giving certain positions, since the focusing of the radiation beam, which concentrates only on the tumor area, cannot be performed yet. With a good planning, no matter how deep the tumor is, the most appropriate treatment is planned by selecting the ray trace. In which types of cancer is it effective? Most childhood tumors are extremely sensitive to radiation. Prostate cancers, Brain tumors, Spinal tumors, Skeletal Sarcomas (Muscle / Bone / Cartilage), It is effective in breast cancers and their metastases. How is proton therapy different from conventional radiotherapy? Proton Beam Therapy is known to cause less tissue damage than conventional radiotherapy. It destroys the cancer cells without damaging the surrounding tissues and the tissues behind the tumor. Compared to conventional radiotherapy, the 3-year survival rate is expected to exceed fifty percent. The number of fully healed cases is increasing. Proton beam acquisition is very costly and difficult compared to conventional radiotherapy. It requires the construction of a special building the size of a football field, in this center all waste systems are specially designed. A proton center costs millions of dollars and can be made operational with at least two years of work. Advantage in Orthopedic Surgery Orthopedic tumor surgery results in limb loss in severe cases. Removal of large areas of limbs, especially pelvis and spine tumors, may not be compatible with life. In this case, it is a fact that Proton Beam Therapy and radiotherapy prolong life in cancers that cannot be reached or removed. In treatments that require limb loss, radiotherapy can never be a preference for limb protection, but it helps prevent limb loss. Orthopedic tumor surgery can be given before surgery to reduce the margins. Concomitant chemotherapy is often applied. After surgery, the disappearance of satellite tumors or the spread of the tumor is greatly reduced by radiotherapy. Tumor Treatment in Our Center International algorithms are valid in the approach to orthopedic tumors in our clinic. Treatment is planned after tumor classification and grading of patients diagnosed with or detected masses. Classification of tumor size (T), lymph node extension (N) and metastasis status (M) is the basis of a classical approach, but when the tumor grading depends on the cell structure, biopsy is the basic step of the algorithm after obtaining almost accurate information about the tumor type according to radiological scientific experience. . Biopsy may be needle, excisional, marginal or may include compartment. Limb preserving or treatments that will cause limb loss are not applied before the cell structure is definite. After the cell structure is determined, the surgeon decides whether the cell is in situ and directs it to the treatment, this decision is definitely surgical, it is made in cooperation with the patient in line with the recommendations of the physicians who will form the council (Oncologist, Radiologist, Pathologist, etc.) If complementary or terminating surgery is delayed at such critical stages, not disrupting radiotherapy and chemotherapy will prolong life and prevent metastasis.

I've been tennis elbow!; The lateral epicondyle is the bone protrusion to which the forearm muscles collectively adhere to the tennis elbow. It can be damaged in daily life with forceful movements such as heavy lifting and pushing. Injury can cause muscle level tears, tendon level separation and rupture. Recovery is homogeneous at this level and chronicity is rare. Tendon is a fragile structure with an intermediate fibrous structure in favor of neither tendon nor bone healing in injuries at the junction of the bone. This structure tears and heals again and again even with simple loads. This growing healing tissue is now the main cause of pain and can only be removed by surgery. I Became a Tennis Elbow! This discomfort mechanism is the skeletal problem called "enthesopathy" that occurs in all bone tendon junctions. It is possible to eliminate tennis elbow enthesopathy by surgery. Previously, in open surgery, the trauma created to reach the region created a new healing tissue, and the tendon was cut instead of the repair. This situation would cause loss of function and weakness. Today, with elbow arthroscopy, we can directly reach and remove the scar tissue without cutting any muscle. With elbow arthroscopy, the treatment-resistant tennis elbow is eliminated. It does not require a plaster cast and the pain will disappear in a short time.

Archery and Spine Problems: In modern life, the use of computers, driving a vehicle, even correspondence on your smartphone has become an important cause of posture disorder, beyond affecting the neck and shoulder posture negatively. In desk jobs, the shoulder on the wheel stays far ahead of its natural position; these can be thought of as movements that push the shoulder blades away from the back. It is well known that back muscles, which become lazy and weakened by using the same muscles for a long time and maintaining the same posture, cause neck pain. Shoulder impingement problems are also common in office workers as a result of involuntary movements that bring their shoulders forward and keep their heads close to the screen. When the malalignment caused by the posture disorder becomes permanent, severe surgical treatments may be required. Strengthening the muscles that allow the shoulder to move backward plays a key role in correcting the alignment. These muscles keep our neck straight and pull the shoulder back through the shoulder blade. The difficulty of strengthening is that if the movements to be made to work these muscles are not done at the right angles, they remain still as a result of the stronger shoulder and chest muscles. For example, spring-loaded devices trying to be pulled in the back region or backward beating of the wings can be painful and difficult to practice because they force the joint boundaries. However, when the “bow” used in ancient archery sports is pulled regularly, the back movement of our shoulder blades and shoulder is easily achieved by balancing the opposite muscles. Archery and Spine Problems: Archery is outlined in three basic movements. Preparation: Holding and stretching. While the archer grabs the bow with his left hand and pulls the arrow backwards with his right hand, the load that starts with the chest muscles is carried to the back muscles by pulling back the shoulder muscles and shoulder. The bow is stretched to the last stage, the rope is pulled until the left arm is parallel to the ground, the right arm is bent at the elbow, and the shoulder is fully back. Balancing = Engagement: Don’t wait on tension. When the spring is fully stretched, only the back and the balancing shoulder and chest muscles work together. This phase is the moment of exercise, which we call the isometric phase (the muscle being contracted without stretching) is the healthiest and the least risk of injury. Shot: While the arrow is pointing towards the target, the load on the bow is released, while the shoulder and scapula move back to the last limit. This movement is a highly harmonious transition-balancing moment that follows the shoulder to go back like a whip and immediately reciprocate the shoulder muscles and pull the shoulder forward. It works the shoulder muscles together with the back muscles. By focusing on the target, archery relaxes the human mind, provides an involuntary contraction habit apart from voluntary movements, and enables the development of muscles that react strongly and reflexively to adverse conditions in daily and business life. In daily life, an archer can prevent the risk of injury with his archer muscles without realizing it, and draw attention with his special stance. It is a very valuable exercise method, especially in those with a tendency to impairment in child development. Archery should be given importance in order to prevent humpback, neck straightening and shoulder squeezing from diseases. You can contact our doctor for more information about your spine pain and spine complaints. You can subscribe to our YouTube channel to follow our videos on the subject.

Painless joint freedom of movement. Stagnant life can lead to unexpected problems such as vascular diseases, internal organ failures, and stroke. The joint moves with the sliding cartilage surfaces. Injury on these surfaces, factors that disrupt the surface also disrupt the opposite side throughout the movement. Over time, both surfaces begin to erode each other. In a small spot, a groove the diameter of the injury appears, the articular cartilage quickly disappears. Joints are ball-slot, hinge structure that works in harmony. The axis of both surfaces must be the same, the covering areas must be the same. We can protect our joint health! Our joints become firmer and stronger as we move. A balanced, protein-rich diet and regular exercise are beneficial. Excessive weight gain should be avoided. A sprained load on the joint may be caused by weakness of muscle strength. Exercises to increase muscle strength should be done. The type of exercise should be appropriate for your level. If you have not walked on a flat road, it is inevitable that you will be injured while running on the treadmill. The fact that the items you use around you are in harmony with you (ergonomic) will reduce your chance of injury. Adapt your surroundings. Accurate diagnosis is possible with examination! When you have a joint injury, you should see an Orthopedics and Traumatology specialist as soon as possible. Radiological examinations performed after the physician’s examination determine the level of injury and the type of treatment. Once the type of injury is determined, the rate of self-repair is understood. Apart from severe injuries, splint-plaster fixations, bandages, therapeutic drugs, painkillers are used that will allow the body to repair itself. Arthroscopic treatment is the gold standard in severe injuries. Don’t let your joint stay still! During injury, recessive treatments may be aimed at restricting the movement of the joint. Immobility of a healthy joint can lead to a decrease in joint lubricity and loss of muscles. Therefore, the treatment is arranged to give action as early as possible. Devices that provide passive movement of the joint surface without weighting can be very effective in treatment. We get help from rehabilitation specialists and therapists for such treatments. Arthroscopic surgery gold standard! Arthroscopy is the gold standard in the diagnosis of delayed healing joint injuries, no matter how advanced and perfect the examination and radiological examinations are. Magnetic resonance imaging may be insufficient for cartilage lesions, plica ruptures and hardening. In this case, intervention is made before joint wear occurs. Today, meniscal tears and ligament ruptures can be treated with arthroscopic methods with excellent results. Correct intervention and stepwise approach are very important when there is a Joint Injury! Your joint may swell after injury, remain motionless and you cannot load. Don’t panic, if you don’t have a real health professional around, a simple bandage, a temporary fix and a cold application is all it takes. Do not be burdened, and rest for a while and contact the health center as soon as possible. Find out exactly what the problem is! You should know what the injury in your joint is, the recovery time and the time to return to normal after recovery. Your doctor will provide information on how joint healing will result. This information can play a key role in explaining your future ailments. Will the treatment affect your daily life and work life? Every person’s daily life expectancy and work life is different. The physician’s decision may vary from recessive treatments to arthroscopic surgical treatments while determining the rest and recovery time. Remember, your joints are the most important part of your life. After the treatment, help may be required to regain the old mobility. In arthroscopic treatments and long angle fixations after severe injuries, we should definitely seek physiotherapy assistance. In simple interventions and diagnostic arthroscopic surgeries, self-exercise may be sufficient most of the time. If it is thought to be inadequate during the controls, it can be included in the rehabilitation program.

The knee joint is the joint where the center of gravity transfers the most complex load during the walking action and is the joint of the movement system that is most exposed to forces from different directions. In the distal of the femur, articulation of the condylar structure with the plateau structure in the proximal of the tibia creates a composite joint structure with cartilage and ligament structures that provide congurency and stability. It should be well known that the knee joint is more than a simple hinge-like biomechanics, as it is thought, but a complex joint system that manages opposing vectors to create motion by changing its axis with rotation during flexion. Surgical procedures or conservative orthotic treatments performed by ignoring knee biomechanics; When combined with misdiagnosis, it causes injury to healthy structures by being under more load, progressing of the disease and decreasing patient satisfaction. Anatomy Osteologically, it consists of the femur, patella, and tibia. The femur provides the hip joint connection and the tibia provides the ankle-foot connection. In gait mechanics, knee loads and the position of the knee, femur/tibia axes, mechanical axis relationship and alignment disorders change the loading forces in the knee joint. There is a 5-7 degree varus angulation between the femoral axis and the mechanical axis. Our mechanical axis is transferred to the ground by two axes of force thought to pass through both hips. This axis continues along the tibial axis just in front of the anterior cruciate ligament attachment in the anteromedial of the knee, passes through the middle of the talus from the ankle and is transferred to the ground at the calcaneus, first and fifth metatarsal heads via the plantar arch. With the increase in the angle of the femur axis with the mechanical axis, the approach of the femurdistal to the midline leads to the “varus deformity” genu varum. The mechanical axis shifts laterally, and excessive tension of the medial structures due to balancing in knee joint mechanics causes the external rupture to be under severe axial loads. The decrease in the angle of the femoral axis and its outward angulation causes the mechanical axis to remain medial to the knee, this is a valgus deformity, called “genu valgum”. The knee joint is of the sino-arthroidal joint type. Rotation, abduction and adduction movements are restricted in its structure designed for movement in the flexion-extension direction. It consists of three compartments and two joints. The patella femoral joint is between the femoral groove and patella facets in the axial direction, it forms the patellafemoral compartment, its movement is up and down (Figure-4). The tibiofemoral joint consists of two compartments; participates in the medial and lateral femoral condyles, meniscal structures and cruciate ligaments involved in flexion, extension and restricted rotation movements. During the hinge movement, the knee axis rotates internally and completes its movement with a multi-axis rotational movement. The range of motion is 120-140 degrees of flexion, 0-5 degrees of extension, and 5-15 degrees of internal rotation during flexion. During flexion, the tibia balances internal rotation with translation. The relationship of the patella femoral joint with the mechanical axis is defined by the Q angle (figure-5). The 12-15 degree angulation between the patellar tendon and the mechanical axis is a very important feature that provides the mechanical stability of the vastus joint tendon-femoral groove and patellar facet and provides knee-hip compensation in gait mechanics. Dynamic-varus-valgus movements provide abduction-adduction-type sitting and range of motion that allows twist movement during squatting and rising. The normal alignment of the knee is 2-3 degrees varus from the mechanical axis. The kinematic axis, on the other hand, is different in flexion and extension and may have individual characteristics depending on the femur/tibia location. With gait analysis or robotic system tests, the external rotation rate of the femur and the relationship of the tibia can be determined. The ligamentous structure of the knee forms the intra-articular ligaments and lateral ligaments and the popliteus complex posterolaterally. Crosslinks resist translational forces as well as rotational stability. The posterolateral complex is strong enough to serve as a pivot as the strongest fulcrum of the knee, which includes the popliteus, lateral meniscus, and the head of the fibula. The structures that stabilize the knee during loading are the collateral ligaments associated with the capsule, the pes anserunus adductor complex in the media, and the iliotibial band structures in the lateral. Looking at the structures that balance the internal and external vectors on the knee joint of an athlete in the squat position, it will be understood that the knee joint has an extremely complex load distribution. The extensor structures and the hamstring muscles that meet it provide the stability of the knee. SEQUENCE PROBLEMS In lower extremity alignment disorders, varus-valgus in the anterior background, recurvatum and flexion deformities in the sagittal plane Genu varum, also known as “That leg” deformity, is mostly based on disorders such as rickets. However, the result of knee osteoarthritis accompanying rotational alignment disorders can also develop in advanced ages. The body center of gravity has been displaced medially and the knee motion axis has lost its parallelism to the ground plane, causing wear. Inner wedge shoes and medial supported knee pads can regulate the patient’s gait even though they do not change the alignment. It should be known that the medial support cannot meet the forces if the continuous use of knee brace causes the lateral supporting muscle groups to atrophy. The alignment can be surgically corrected with tibial osteotomy, which is elevated according to its severity, and femoral osteotomy in advanced mechanical axis impairment. In the genu valgum or “X-crooked leg” deformity, the center of gravity has shifted laterally in the tibia valgus. As the medial structures try to meet the weight vectors, a tendency to excessive wear occurs in the lateral. The leg is in internal rotation. The lateral load is tried to be transferred to the medial with outer wedge shoes, but it is difficult to provide stability with the knee brace as in the genu varum and often requires surgical treatment. KNEE INSTABILITIES The stability of the knee depends on the geometric structure, the weight distribution with the alignment, and the strength of the capsule, ligament, and muscle structures corresponding to it. We can divide these open stabilizers into two: Static: Capsular, capsular ligaments and extracapsular ligaments Dynamic stabilizers: Musculotendinous units (pes anserinus, iliotibial band, patella tendon, hamstrigs, politeus complex, gastrocnemius) In this respect, we can classically examine knee instability in 3 main groups: Unidirectional instabilities; Medial, Lateral Posterior and anterior rotational instabilities; Anteromedial, Anterolateral (flexion and extension type) Posteromendial and posterolateral Combined or Complex instabilities Patellafemoral instabilities Orthotic treatments are used in cases where surgery is not required and to support the healing of tissues repaired after surgery. In this respect, bands and supports and knee pads are designed to resist the vectors encountered by the ligament structures. Choosing the right knee brace is essential in both surgical and conservative treatments. While the treatment is being organized, knee pads that are rigid enough to cause muscle atrophy will usually be used in the first weeks and will be replaced by soft knee pads that feel the impact effect. Likewise, after surgical treatment, the physician may prefer different knee brace options during the rehabilitation phase of the treatment. In this respect, working in harmony with the physician will increase the success of the treatment. AMPUTS Amputations of the knee joint can be done at three different levels; above the knee, disarticulation, below the knee. Since the knee joint is preserved and adductor and lateral stabilization can be achieved in below-knee amputations, prosthesis application is extremely successful. It is easy for the patient to adapt without training. Since the knee joint is completely lost in above-knee amputations, a certain period of training may be required, although compliance with dynamic prostheses with special joints can be achieved very well to ensure weight transfer in the thigh and lower extremity on the prosthesis. Preparing the patient to walk requires more strength. Disarticulation can be performed to allow extremity elongation, which is especially preferred in children of growing age. Requires fairly good stump closure experience. A good surgeon can create a soft tissue-muscle balance that will provide a weight distribution as successful as below-knee amputation. The adaptation process of the patients can be accelerated with education. If the prosthesis application after amputation is not a new generation prosthesis augmented to the bone, we can schedule it in two ways: Immediate during surgery After the postoperative wound has healed Immediate prosthesis application is done with a specially designed foot placed on the plaster with stump care every three days. The orthotic team must be present during the surgery for this prosthesis application, which enables the patient to be mobilized early and considerably reduces the postoperative orbit. In follow-up wound care, the plaster is reapplied each time. Excellent results have been reported in terms of stump development and compliance. A good amputation surgery, appropriate stump flaps, osteomyoplasty and adequate soft tissue support will facilitate prosthesis application. If the nerves are sufficiently deep during amputation so as not to form a neuroma, the success of the practitioner will increase with painless manipulations. RESULT The knee is always open to problems in terms of the load it carries as a large and complex joint. When problem-oriented personal data (alignment, joint and bone compatibility, footprint, gait analysis) are collected well in knee diseases, the source of the problem can be reached and patient satisfaction can be maximized. In this respect, it is very valuable for orthopedic and prosthetic orthotics laboratories to work in harmony in this direction.

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

Although the concept of trauma is defined as a physical injury that changes the body, it is known to have complex biochemical consequences (see: endocrine response to trauma) in a living organism. The skeletal system provides the first defense in physical interactions with its strong carrier, skull and rib cage-like covering feature. Trauma; Whether blunt, penetrating or post-explosive, the skeletal system acts as a protector. Since injuries that occur in this way are very specific and involve many systems; Concepts and specialties such as trauma center, trauma team, trauma surgeon have developed. Orthopedics and traumatology specialist works as part of the trauma team in the treatment of skeletal system injuries such as fractures, dislocations and crushes that occur after trauma. The aim of orthopedic surgery is to remove foreign bodies with injuries resulting from trauma, to repair fractures and to provide body integrity by placing dislocations. First of all, the vital functions of the patient should be corrected by the trauma team. Joints can be placed during these procedures. In particular, determinations and tractions to immediately remove the pressure and correct the alignment, such as significant alignment disorders that may cause limb loss, such as knee dislocation, and spinal fracture, sometimes have to be performed simultaneously in the ABC rule. For example, a neck fracture may require immediate intervention as it will stop the respiratory center from functioning. The traumatized patient should be intervened by trained personnel, it is a known fact that unconscious interventions, even with first aid, will cause loss of life. When the trauma team reaches the area, after the first procedure, “separation=triage”, critical patients undergo immediate resuscitation (resuscitation). Skeletal system problems are carefully evaluated and necessary interventions such as appropriate temporary fixations and stopping bleeding are carried out immediately. Critical dislocations are seated or placed in a safe position, and spinal fractures are carefully identified and prepared for transport. Whether the transport will be carried out by air or by land, it is planned according to the timing of the intervention and the trauma center is warned. After the patient’s vital functions are preserved and the transfer to the center is completed, the internal organs, thoracic cage and skull injuries are treated immediately and the necessary skeletal structures are determined. The timing of the treatment of skeletal trauma needs to be “immediate” in modern orthopedic surgery. The aim is to prepare the patient for action and to protect the patient against catastrophic consequences such as fat embolism. Fractures that are detected and treated early will heal better and reduce the strain on other organ systems. Otherwise, the body balance will be disturbed by the metabolic load in the trauma body. The best rehabilitation is immediate treatment. Skeletal system surgery was performed without creating new wounds as much as possible, which enabled the development of percutaneous surgeries that kept the patient away from new traumas. Today, long bones can be treated with nails embedded in the bone marrow or with plate supports that stay away from the bone. In the near future, fixation materials that dissolve in the body instead of metal, and even bone adhesives will be put into widespread use.

The frequency of carpal instability after distal radius fractures The functional results of 34 wrists of 33 patients who were treated conservatively at the Department of Orthopedics and Traumatology at Gazi University between 1994-97 were evaluated according to the Brujin criteria. According to the Mayo classification, ten were type I, three were type II, eighteen type III, and three were type IV. Carpal instability was detected in 9 (26.4%) of 34 fractures. Of the nine fractures, eight involved the joint …