Non-Surgical Alternatives for Thumb Osteoarthritis
Ross Hauser, MD, Caring Medical Florida, Fort Myers
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Thumb Osteoarthritis Surgery Alternatives
In many patients we see with thumb pain and restricted motion, they have self-managed their thumb problems for as long as they could before pain and loss of mobility, and, especially grip strength and inability to sleep at night makes self-management difficult at best. At this time the patient will seek out their doctor who will likely refer them on to the orthopedist for more specialized help.
As with other joints, many patients are often surprised that their doctor and orthopedist are making the same recommendations for treatment that they, the patient, was using to self manage: non-steroidal anti-inflammatory medications except in stronger doses or a better splint than the one the patient bought for themselves.
When these treatments were not helpful, after a short go-round, cortisone injections were recommended, physical therapy was prescribed, and then after a few weeks or months, the reality of this managed conservative program effectiveness set it. It was not working that well. So now, according to your clinician, you have reached the fork in the road. Surgery or “live with it.”
Surgery or live with it, is there no other way?
In this article, we will examine surgery and non-surgical options. The non-surgical options we will present here are likely new to you as they are not part of the well-accepted “conservative care,” option. In this article, we will talk about regenerative injection techniques that include Prolotherapy. In our clinics, we see and have seen many patients with thumb osteoarthritis. The reason that we see them is that these patients seek out an alternative to thumb surgery.
A patient comes into our office, they tell a familiar story
We have been hearing from thumb pain patients for more than 27 years now. Let’s see how familiar these patient’s stories sound to you:
- I am being recommended to have the surgery. My doctor sees no other way. I have had the cortisone, I wear the hard splints, I take the anti-inflammatories, I have altered my movements to protect my thumbs. I am “bone on bone,” my grip strength gets worse by the day. I have been getting treatments for 2 – 3 years now and my situation is just getting worse. I have been told to make a choice, surgery or wear splints all the time. I am hoping you have another option for me.
- I already had surgery on my right thumb, I guess it went well, my physical therapist says it went well, my surgeon says it went well, but now the problem is my left hand. I am concerned because in my right thumb, the one that was operated on, I still have pain, I don’t have the strength I thought I would have. I am even dropping things more now than before the surgery. I want to explore something different on the left side.
- I need to do something different. My daily routine is to make sure that I have gel pads in the freezer so I can ice my thumb/wrist throughout the day. Fill my pill dispenser with my daily “allowable” pain medications and anti-inflammatories, and check online if a new or better splint is available. I made an appointment to see you because I am at the mercy of thumbs. The latest pain episode started innocently enough, I tried to open my car door. A few minutes of pain later I was finally able to get the door open.
When people reach the point that these people have, the pressure to have surgery becomes stronger and stronger. But is surgery the answer? For some people, it works great, for others, it does not work great. Let’s get to the research.
Surgeons express concern with thumb joint replacement implants
September 2019, The Journal of hand surgery. Research study: Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review.(1)
In this research, surgeons wrote: “Several implant designs (arthroplasties) had high rates of failure due to aseptic loosening, dislocation, and persisting pain. Furthermore, some implants had higher than anticipated failure rates than other implants within each class. Overall, the failure rates of non-implant techniques were lower than those of implant arthroplasty.”
In other words, several implants presented a lot of problems. Some implants being far more problematic than others. Surgery, or treatment without the implants, had lower complication rates.”
Four women who had Trapeziometacarpal joint replacement – their thumbs did not return to a more natural range of motion
When we discuss surgery, it is always best to listen to the surgeons and the challenges they are facing in providing joint replacement surgery.
An April 2018 study from a team of Belgium doctors that appeared in the American Journal of Hand Surgery (2) questioned whether or not a thumb joint replacement surgery provides a good benefit for the patient. Here are the highlights of that study.
- The study begins with four female patients who have stage III osteoarthritis at the Trapeziometacarpal (the base of the thumb). The four female patients had significant loss of range of motion in their thumbs. This lead to a recommendation for TMC (Trapeziometacarpal) joint replacement surgery.
So what happened after the surgery? How was the range of motion in the replaced thumbs?
- To quote the research: “The study highlights that advanced Trapeziometacarpal osteoarthritis mainly restricts the MC1 (first metacarpal bone or the metacarpal bone of the thumb) mobility. We also showed that, whereas total joint arthroplasty (thumb replacement) is able to restore thumb function, it cannot fully replicate the kinematics of the healthy Trapeziometacarpal joint.”
So after thumb replacement the thumb does not return to a more natural range of motion. This may not be an important factor for many people, especially people who have deformity from rheumatoid arthritis (see below), but it is certainly an important factor for people who rely on their hands for work or if they are an artisan. Tell a pianist or a carpenter that his/her thumbs won’t move that well after surgery. See how fast they look for an alternative to their thumb arthritis.
In a February 2020 study from Sweden, doctors reporting in the journal BioMed Central musculoskeletal disorders (3) wrote:
- “One year postoperatively, mean pain at rest was reduced from 50 to 12 of maximum 100. However, pain on load and weakness had not abated to the same extent (mean 30 and 34 of 100, respectively). The mean improvement in Passive Range of Motion (PROM) did not differ between age groups or gender. The result was similar after trapeziectomy with ligament reconstruction and tendon interposition (86% of the patients) and simple trapeziectomy but few patients were operated with the latter method. Pain on load and weakness remains to some extent 1 year after surgery for trapeziometacarpal joint arthritis. “
Thumb osteoarthritis is caused joint instability due to ligaments that are weakened or damaged by overuse or by a traumatic injury. To restore a more natural movement to the thumb joint, you have to examine and explore the repair of the thumb’s ligaments.
To restore a more natural movement to the thumb joint, you have to examine and explore the repair of the thumb’s ligaments. Repairing the thumb ligaments should be the main objective of treatment. We are going to discuss this below.
Research: Thumb osteoarthritis is caused joint instability due to ligaments that are weakened or damaged by overuse or by a traumatic injury.(4)
This according to researchers from Indiana University School of Medicine, Tufts University School of Medicine, University of Bristol, Bristol, and the Dutch university researchers who made this statement in their paper: “Yet more evidence that osteoarthritis is not a cartilage disease,” published in the British Medical Journal.
Trapeziometacarpal joint surgery causes wrist problems and wrist instability
In May 2020, surgeons at the Imperial College London writing in The Journal of hand surgery (5) explored the effects of surgical treatments for trapeziometacarpal osteoarthritis on wrist biomechanics. What they found was “wrist biomechanics were significantly altered following trapeziectomy. . . Trapeziectomy, as a standalone procedure in the treatment of trapeziometacarpal osteoarthritis, may result in the formation of a potentially unfilled trapezial gap, leading to higher wrist muscle forces. This biomechanical alteration could be associated with clinically important outcomes, such as pain and/or joint instability.”
What do weakened ligaments in the thumb do? Cause pain, loss of motion, loss of grip strength, and cause osteoarthritis. “So I have no grip strength because of the thumb ligaments?”
Why occupational or physical therapy was only a little help and only delayed surgery
A team of researchers from Norway published their findings on the benefit or lack of benefits for occupational therapy in the November 2019 issue of Rheumatic & Musculoskeletal Diseases Open.(6)
The goal of the study was to determine “whether occupational therapy, provided in the period between referral and surgical consultation, might delay or reduce the need of surgery in thumb carpometacarpal joint osteoarthritis and to explore predictors for carpometacarpal joint surgery.”
The patients they looked at:
- 180 patients average age 63 years old
- 142 (79%) were women.
- Of the 180 patients, 22 (24%) patients in the occupational therapy group and 29 (32%) in the control group underwent surgery before a 24-month follow-up.
These are not robust results.
The conclusion of the research:
“In conclusion, we found a small non-significant tendency towards a delay and reduction in carpometacarpal joint surgery in patients that received occupational therapy, compared with a control group. Previous non-pharmacological treatment and motivation for surgery were significant predictors of surgery. These results may support a notion that patients with carpometacarpal joint osteoarthritis should be referred to occupational therapy before surgery is considered.”
In the above study, physical or occupational therapy was seen as helpful for a some, not all, and that many go onto to surgery anyway. Why?
Patients are often very confused as to why a physical therapy program did not help their thumb and hand pain as much as they thought it would. This is very typical of the patients we see. They have been to physical therapy for months and nothing seems to have improved. How can this be? Many of these patients have been listening and reading about “great exercises” to strengthen their thumb. These people have been told that exercise will lead to greater pain relief and an increase in mobility. So why is it not working? And because it is not working, are you now equally concerned you are going to be escalated to surgical candidate or have your pain management prescriptions increased in strength?
Loss of strength, muscle power and range of motion are clearly indicators of an impending thumb surgery. In patients with degenerative joint disease, where connective tissue such as the ligaments and tendons that attach bone to bone and muscle to bone are damaged. It is very difficult to derive benefit from strength training where resistance is needed because the ligaments and tendons that help provide that resistance are weak.
- Ligaments hold bone to bone. If they are weak the bone floats out of position.
- If the bones are floating out of position, they are causing the tendons to stretch and become weak. The tendon attachments that hold the muscle to the bone is compromised, strength is lost.
Weak Ligaments in the thumb anatomy explain why cartilage breaks down and why
Thumb arthritis often involves inflammation of the basal joint (the base of the thumb), which is the joint that allows the thumb to swivel and pivot, it is also called the thumb carpometacarpal (CMC) joint or trapeziometacarpal (TMC) joint (as mentioned above), because the trapezium bone joins the metacarpal bone of the thumb.
The basal and metacarpophalangeal (MCP) (the knuckle joint of the thumb), are usually the first areas where the pain is experienced.
- The thumb ligament that joins the wrist to the base of the thumb is called the radial collateral ligament, the same name as the ligament inside the elbow. The thumb ligament that joins the base of the thumb (the first metacarpal) to the succeeding joint (proximal phalanx) is the collateral ligament.
- If the ligaments in these joints are not strengthened, arthritis will eventually occur or worsen.
- Ligament damage and injury in the thumb can create a cascade of arthritic effects. For example, the cartilage that cushions the joint begins to deteriorate and then swelling and pain develop as the bones rub against each other. The ligaments eventually weaken further as they try to overcompensate for the lack of cartilage. The synovial tissue that lines the joint capsules may also become inflamed, leading to fluid accumulation in the joint. Pain, swelling and decreased mobility are the results, as well as a recommendation for surgery.
Ultrasound showing joint instability in a patient with osteoarthritic fingers and thumb
In this video Ross Hauser, MD demonstrates an ultrasound examination showing joint instability in her thumb. (0:42) the ultrasound image and explanation by Dr. Hauser.
Surgery for osteoarthritis of the thumb often includes ligament reconstruction with a tendon and bone removal
Much of the research and attention of surgery for thumb osteoarthritis centers around the removal of the trapezium bone at the base of the thumb. The surgery is called a trapeziectomy.
The trapeziectomy can be performed with variations to the technique. First is the removal of the bone. Some procedures will include a ligament reconstruction to strengthen the compromised anatomy and filling the void left with a forearm tendon. For patients with thumb arthritis being recommended to surgery the term interpositional arthroplasty or commonly referred to as trapeziectomy with LRTI would likely be recommended as a surgical choice.
In addition to the research above, research from the University of Massachusetts Medical School examined various surgical procedures for thumb osteoarthritis. Here are their findings published in the medical journal Hand.(7)
- In the treatment of basal joint arthritis of the thumb, recent studies suggest equal outcomes with regard to long-term pain, mobility, and strength, in patients undergoing either trapeziectomy alone or trapeziectomy with ligament reconstruction and tendon interposition (LRTI).
- A retrospective chart review of 5 surgeons at a single institution performing CMC (wrist joint) arthroplasties from November 2006 to November 2012. A total of 200 thumbs in 179 patients underwent simple trapeziectomy with or without LRTI and with or without Kirschner wire stabilization (wires instead of tendons to stabilize the void), or ligament reconstruction.
- Seventy hands had a postoperative complication. Ten of these complications were considered major, defined as requiring antibiotics, reoperation, or other aggressive interventions.
- Risk of total complications was significantly greater in patients undergoing either trapeziectomy with LRTI or ligament reconstruction in comparison with trapeziectomy with K-wire stabilization. These results suggest an advantage of simple trapeziectomy.
Thumb medicine can sometimes be very amazing in its desire to do the most complicated and invasive things
Joint replacement can be considered in selected patients who require greater strength and range of motion, although it has been associated with a higher complication rate.
Doctors at the Hand Surgery Unit, Department of Orthopedic Surgery, University Hospital, in Granada, Spain, wrote in the medical journal Orthopedics: (8)
- Numerous surgical procedures have been described to treat trapeziometacarpal osteoarthritis, but no approach is currently considered superior.
- Good long-term outcomes have been reported with multiple procedures.
- No studies have been published comparing outcomes of the Arpe joint replacement with those of ligament reconstruction and tendon interposition (LRTI).
- Pain relief and functional improvement were similar between groups.
- Pinch strength and range of motion were superior in the joint replacement group.
- Metacarpophalangeal hyperextension appeared to be prevented in the joint replacement group but increased over the follow-up period in the ligament reconstruction group.
- However, the complication rate was higher in the joint replacement group.
- Conclusion: Joint replacement can be considered in selected patients who require greater strength and range of motion, although it has been associated with a higher complication rate.
Trapeziectomy with or without ligament reconstruction is still considered the gold standard, but the challenges associated with treating its complications limit its indications.
Despite this and other evidence, doctors from the University of Michigan write in the journal Plastic and Reconstructive Surgery: (9) “With a consistent rise in health care spending, adherence to an evidence-based approach in medicine is more important than ever. Most surgeons continue to perform trapeziectomy with ligament reconstruction and tendon interposition, the most expensive surgical option.”
French doctors gave a thorough analysis of the challenges of surgical repair of trapeziometacarpal osteoarthritis. Writing in the journal Hand Surgery and Rehabilitation, (10) they write:
- The demand for surgical treatment for Trapeziometacarpal osteoarthritis is growing and the patients are becoming younger, adding to the challenge.
- Surgery can only be proposed after failure of well-conducted conservative treatment and requires a complete X-ray assessment.
- In the early stages, conservative surgery measures can be used to stabilize the joint or realign it in cases of dysplasia, but in most cases, patients are seen with more advanced arthritis and joint replacement must be considered.
- The ideal arthroplasty technique has yet to be defined. Although many studies have been published on this topic, they do not help define the treatment indications.
- Trapeziectomy with or without ligament reconstruction is still considered the gold standard, but the challenges associated with treating its complications limit its indications.
Medicine can sometimes be very amazing in its desire to do the most complicated and invasive things. Like performing two surgeries when one would have offered similar results with less trauma to the patient.
Here is a situation where an alternative surgical option is given. It failed. Now the doctors had to go back to the original choice surgery to fix the alternative surgery.
Another team of French doctors gave a thorough analysis of the challenges of Total trapeziometacarpal joint replacement. Also writing in the journal Hand Surgery and Rehabilitation, (11) they write:
- Total trapeziometacarpal joint replacement is increasingly being performed for the treatment of basal joint arthritis.
- However, complications such as instability or loosening are also frequent with TMC ball-and-socket joint replacement.
- Management of these complications lacks consensus.
This study examined the results of 12 cases of failed TMC joint replacement that were treated by trapeziectomy with ligament reconstruction and tendon interposition (LRTI) arthroplasty. The study found the Trapeziectomy with LRTI after TMC joint replacement appears to be an attractive salvage procedure.
Simply doctors had to go back to a surgery that could have been the first choice procedure, to repair the damage of an alternative choice surgery. Two surgeries when one would have offered similar results with less trauma to the patient.
Non-surgical options for thumb arthritis: The research on Prolotherapy
Making your thumb function better and move naturally without surgery is certainly an appealing option. Can this be realistically done? In the many patients that we have seen over the years, Prolotherapy injection treatments into the thumb have provided excellent results. Will this treatment work for everyone? The answer is no. Will it work for you? That is something that is discussed after a physical examination of the thumb and a discussion with the patient of the goals of their treatment.
The goal of the Prolotherapy treatment is to bring stability to the thumb. Degenerative wear and tear arthritis occurs because of hypermobility/loose ligaments. In other words, the bones of your thumbs are moving around too much. This hypermobility is causing thumb joint erosion due to unnatural wear patterns in the joint. To compensate and hold your thumb together as best as possible, your body starts to grow bone (bone spurs) in the joint. Prolotherapy injections would be best given in the earlier stages of the disease before bone spur formation became a problem.
In 2000, K. Dean Reeves, MD lead a study published in the Journal of Alternative and complementary medicine (12). These were the findings of this research on Prolotherapy for finger and thumb degenerative disease:
The objective of the study was to determine the clinical benefit of dextrose prolotherapy (injection of growth factors or growth factor stimulators) in osteoarthritic finger joints.
The study participants were selected based on:
- Six months of pain history in each joint studied as well as one of the following:
- grade 2 or 3 osteophyte (bone spur/overgrowth)
- grade 2 or 3 joint narrowing (loss of joint space), or
- grade 1 osteophyte plus grade 1 joint narrowing.
- Distal interphalangeal (DIP) – the uppermost finger joints
- Proximal interphalangeal (PIP), the second finger joints
- and trapeziometacarpal (thumb CMC) joints were eligible. Thirteen patients (with seventy-four symptomatic osteoarthritic joints) received active treatment, and fourteen patients (with seventy-six symptomatic osteoarthritic joints) served as controls.
The findings: “Dextrose prolotherapy was clinically effective and safe in the treatment of pain with joint movement and range limitation in osteoarthritic finger joints.”
In our research published by Caring Medical in the Journal of Prolotherapy, (13) we were able to document the beneficial use of Prolotherapy Injections. Prolotherapy was administered to 13 patients suffering from basal thumb arthritis in 17 thumbs. Here are our highlights:
- Considered a conservative treatment in comparison to surgery, Prolotherapy is a simple procedure, in which solutions of dextrose are injected into the afflicted area.
- Sessions occur over a period of time. The number of injections administered depends on the individual’s progress or failure to progress. A series of injections over three to six months was shown to reduce pain, improve function, and, thereby, improve the quality of life for the patients in this study.
- Patients typically need three to six treatments to achieve the best outcome, scheduled approximately four weeks apart.
- The procedure takes a few minutes.
- A patient could expect to receive 10-15 injections per session for basal thumb arthritis.
- Patients usually report a mild discomfort in the injected area that may last 24-48 hours after treatment.
- Normal activities can be resumed as soon as 24 hours.
Prolotherapy enables TMC joint arthritis sufferers to avoid surgery and its possible adverse effects. The substantial advantages and minimal drawbacks (e.g., aversion to needles), as well as the reduced risks and increased rewards of Prolotherapy over conventional treatments, suggest that this option for the second most common joint arthritis—that of the thumb—should be considered by doctors and patients.
Demonstration of Prolotherapy treatment for the thumb
The treatment starts at 1:15 of the video: Ross Hauser, MD comments and narrates:
- (1:15) Treatment begins. This patient has thumb, hand and finger pain and loss of function
- (2:00) Narration summary and thumb injections: When a patient comes in with these problems we always start on the thumb because that is where we often find the most degenerative problems in hand pain.
- (2:15 – 3:00) Injections at the base of the thumb and the thumb’s metacarpal and interphalangeal joints.
Thumb Joint boutonniere deformity
Also presented in the Journal of Prolotherapy, (14) our research and clinical team was documented a clinical case of a 57-year-old female afflicted with rheumatoid arthritis received treatment for a 35-degree interphalangeal (IP) thumb joint deviation.
The thumb deviation clinically described as a boutonniere deformity was treated with a combination of Prolotherapy and splinting. She wore a custom three-point splint for six weeks and received three separate Prolotherapy treatments within that six-week period. After treatment, the deviation decreased from 35 degrees to 10 degrees, and her thumb pain decreased from 7 to 1 on a pain scale of 10 as the highest level.
Platelet Rich Plasma (PRP)
Many people who are exploring non-surgical options to their thumb osteoarthritis may have come upon research surrounding the use of Platelet Rich Plasma (PRP).
In basic terms, PRP involves the application of concentrated platelets (harvested from your own blood), which release growth factors to stimulate recovery in non-healing injuries. These growth factors, such as platelet-derived growth factor, transforming growth factor and others, proliferate fibroblasts which means they spark the production of new connective tissue and cartilage. Specifically, PRP enhances the fibroblastic events involved in tissue healing including chemotaxis (the chemical attraction of repair cells to the site of injury, proliferation of cells, proteosynthesis (create of proteins), reparation, extra-cellular matrix deposition (this is a subject all in of itself, and the remodeling of tissues. The bottom line here is that PRP helps the healing process
The preparation of therapeutic doses of growth factors consists of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In other words, PRP is done just like any other Prolotherapy treatment, except the solution used for injection is plasma enriched with growth factors from your own blood.
We are going to explore the research on PRP first and then discuss the combined use of PRP and Prolotherapy.
The professional pianist returns to the piano
An October 2019 case review was written up in the journal Rheumatology International, (15) Here university doctors in Spain described a case of Platelet-rich plasma for thumb carpometacarpal joint osteoarthritis in a professional pianist. The hope of the researchers was: “Presenting this case, our aim is to draw attention of healthcare providers dealing with thumb carpometacarpal joint osteoarthritis to PRP as a safe, beneficial therapy for this condition which needs further assessment in randomized controlled trials.”
Here is what they reported:
- “A 59-year-old male professional pianist presented with chronic, mild onset of right thumb base pain involving a progressive lack of pinch strength in his right hand, and severe difficulties with playing. Three PRP injections were administered to the thumb carpometacarpal joint on a 1-week interval regime.
- Clinical outcomes were assessed by using the visual analog scale (VAS) for pain, grip and pinch strength, and the Quick-DASH Questionnaire.
- Functional outcome was excellent according to the patient’s capability with daily living activities and specific playing demands.
- At 12 months follow-up, no recurrences or complications were identified, with the musician returning to his previous level of performance 2 weeks before the end of this period.
- Patient self-reported satisfaction was high and he reported to return to his routine piano activity with no limitations.”
Let’s point out that this was a case to illustrate what Platelet Rich Plasma could do for one professional musician and to shed light on the potential of the treatment. The treatment while beneficial to many, may not help everyone.
PRP vs cortisone
In the October 2018 issue of the medical journal Cartilage (16) , a team of researchers from Greece and the United Kingdom published their clinic observation in the use of PRP vs. Cortisone ion the treatment of thumb osteoarthritis
- This research centered on the trapeziometacarpal joint and carpometacarpal joint of the thumb.
- Thirty-three patients with grades: I-III osteoarthritis. Divided into two groups
- Group A – (16 patients) received 2 ultrasound-guided PRP injections
- Group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval.
- After 12 months’ follow-up, the PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of pain, function and patients’ satisfaction
Combined use of PRP and Prolotherapy
When a patient presents a more advanced case of osteoarthritis we may suggest a more aggressive treatment to include the PRP preparation. Why? The PRP has been shown in many studies, including the one we just cited to be more effective in cartilage degeneration. Moreso even than the simple dextrose Prolotherapy injections. In our clinics, based on over 27 years of experience in treating patients with thumb osteoarthritis, we have found that injecting PRP to attack the cartilage breakdown and injecting Prolotherapy to tackle the instability of the joint by addressing and strengthen weaken ligaments provide the patients with superior results. In the right patient, PRP and Prolotherapy as a combined treatment would be favored.
Stem Cell Therapy for thumb osteoarthritis
Another more aggressive treatment we may employ is Stem Cell Prolotherapy. This combined treatment of stem cells and Prolotherapy presents the same clinical benefits as PRP Prolotherapy except we are using, bone marrow aspirate concentration or bone marrow-derived stem cells. We want to make it clear that we perform stem cell therapy on very few patients. Why? Because we can usually achieve the patient’s goal of treatment with simpler procedures. Bone marrow stem cell therapy is usually reserved for the most advanced cases.
Stem cell therapy in an injection of your own harvested stem cells. Stem cell therapy is typically utilized when we need to “patch” holes in cartilage and stimulate bone. We explore this option in patients when there is more advanced osteoarthritis and a recommendation to a joint replacement has been made or suggested.
Our published research in the journal Clinical Medicine Insights. Arthritis and musculoskeletal disorders (17) demonstrates and documents clinical results in patients receiving bone marrow-derived stem cells and dextrose Prolotherapy.
If you have a question about Thumb Osteoarthritis Surgery Alternatives, get help and information from our Caring Medical staff
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