What are the benefits of minimally invasive hand and wrist surgery. How does arthroscopic surgery differ from percutaneous procedures. What conditions can be treated with these advanced techniques.

Understanding Minimally Invasive Hand and Wrist Surgery

Minimally invasive hand and wrist surgery represents a significant advancement in orthopedic treatment, allowing surgeons to address bone and soft tissue injuries through small incisions rather than traditional open surgeries. This approach offers numerous benefits, including reduced trauma to surrounding tissues, faster recovery times, and minimal scarring.

The techniques used in minimally invasive hand and wrist surgery can be broadly categorized into two main types:

• Arthroscopic surgery
• Percutaneous procedures

Both methods aim to achieve optimal surgical outcomes while minimizing patient discomfort and recovery time.

Arthroscopic Surgery: A Closer Look

Arthroscopic surgery involves the use of a miniaturized video camera inserted into the joint space through a small incision. This camera, known as an arthroscope, provides high-resolution images of the internal structures, which are then projected onto a monitor in the operating room.

How does arthroscopic surgery work? The surgeon uses these real-time images to guide specialized instruments inserted through additional small portals, allowing for precise diagnosis and treatment of various hand and wrist conditions.

Applications of Arthroscopic Surgery in Hand and Wrist Treatment

Arthroscopic techniques have revolutionized the treatment of several hand and wrist conditions, including:

1. Distal radius fractures
2. Ligament injuries
3. Cartilage damage
4. Synovitis
5. Triangular fibrocartilage complex (TFCC) tears

One of the most significant advancements in this field has been the arthroscopic treatment of distal radius fractures, pioneered by Dr. Scott W. Wolfe and his colleagues.

Innovative Treatment for Distal Radius Fractures

Distal radius fractures, commonly known as wrist fractures, are the most frequent upper extremity fractures. These injuries often result from high-impact incidents such as sports injuries or falls from height. The complex nature of these fractures, often involving multiple bone fragments and joint surface disruption, makes them challenging to treat.

Dr. Wolfe’s innovative technique combines arthroscopy with percutaneous fixation, offering several advantages over traditional open surgery. This method involves:

1. Initial external fixation using threaded pins and a frame
2. Arthroscopic visualization to realign joint fragments and remove loose bone pieces
3. Use of bone grafts or substitutes to fill structural defects
4. Percutaneous insertion of pins, wires, or screws to stabilize bone fragments during healing

What are the outcomes of this innovative approach? A study evaluating seven patients treated with this technique showed impressive results:

• All patients were pain-free and had returned to work
• Average recovery of 92% range of motion compared to the uninjured wrist
• 98% recovery of maximal grip strength
• Minimal complications

Percutaneous Fracture Treatment: A Game-Changer in Wrist Surgery

Percutaneous fracture treatment represents another significant advancement in minimally invasive hand and wrist surgery. This approach involves performing surgical procedures by inserting instruments or fixation devices directly through the skin, guided by X-rays or fluoroscopy.

How does percutaneous treatment differ from traditional methods? Unlike open surgery, percutaneous techniques allow for fracture fixation with minimal soft tissue disruption, potentially leading to faster healing and reduced risk of complications.

Revolutionizing Scaphoid Fracture Treatment

One area where percutaneous treatment has made a substantial impact is in the management of scaphoid fractures. The scaphoid, a small bone in the wrist, is particularly prone to healing complications due to its unique blood supply.

Percutaneous fixation of scaphoid fractures offers several advantages over traditional cast treatment:

• Faster healing times
• Reduced immobilization period
• Earlier return to daily activities and work
• Lower risk of nonunion or delayed union

Expanding Applications of Minimally Invasive Techniques

As technology and surgical expertise continue to advance, the applications of minimally invasive hand and wrist surgery are expanding. These techniques are now being used to treat a wide range of conditions, including:

1. Carpal tunnel syndrome
2. Trigger finger
3. Dupuytren’s contracture
4. Ganglion cysts
5. Tendon repairs

How are these conditions benefiting from minimally invasive approaches? By utilizing smaller incisions and specialized instruments, surgeons can achieve comparable or superior outcomes to traditional open surgery while minimizing tissue trauma and scarring.

Advanced Procedures and Future Directions

The field of minimally invasive hand and wrist surgery continues to evolve, with ongoing research and development of new techniques and technologies. Some exciting areas of advancement include:

Biologic Augmentation

Dr. Wolfe is currently leading an FDA-approved clinical trial investigating the use of a novel biologic compound to accelerate healing in percutaneously-treated fractures. This research has the potential to further improve outcomes and reduce recovery times for patients undergoing minimally invasive procedures.

3D-Printed Implants and Customized Instrumentation

Advancements in 3D printing technology are enabling the creation of patient-specific implants and surgical guides. How does this benefit patients? Custom-designed implants can provide a more precise fit, potentially improving functional outcomes and reducing the risk of complications.

Robotic-Assisted Surgery

While still in its early stages for hand and wrist procedures, robotic-assisted surgery holds promise for enhancing surgical precision and consistency. This technology may enable even more complex procedures to be performed through minimally invasive approaches in the future.

Weighing the Benefits and Limitations of Minimally Invasive Techniques

While minimally invasive hand and wrist surgery offers numerous advantages, it’s important to consider both the benefits and potential limitations of these techniques:

Benefits

• Reduced tissue trauma
• Faster recovery times
• Minimal scarring
• Lower risk of infection
• Improved visualization of internal structures
• Earlier mobilization and return to function

Limitations

• Steeper learning curve for surgeons
• Higher initial equipment costs
• Not suitable for all patients or conditions
• Potential for conversion to open surgery in complex cases

How do surgeons determine the best approach for each patient? The decision to use minimally invasive techniques depends on various factors, including the specific condition, patient characteristics, and surgeon expertise. A thorough evaluation and discussion between the patient and surgeon are essential to determine the most appropriate treatment strategy.

Patient Selection and Preoperative Considerations

Successful outcomes in minimally invasive hand and wrist surgery rely heavily on proper patient selection and preoperative planning. Factors that surgeons consider when determining candidacy for these procedures include:

1. Nature and severity of the condition
2. Patient age and overall health status
3. Bone quality and healing potential
4. Previous surgeries or injuries to the affected area
5. Patient expectations and activity level

What preoperative steps are crucial for optimal outcomes? A comprehensive evaluation typically involves:

• Detailed medical history review
• Physical examination
• Advanced imaging studies (X-rays, CT scans, or MRI)
• Discussion of treatment options and expected outcomes
• Patient education on the procedure and recovery process

By carefully considering these factors, surgeons can ensure that minimally invasive techniques are applied to the most appropriate cases, maximizing the potential benefits for patients.

Postoperative Care and Rehabilitation

While minimally invasive hand and wrist surgery often results in faster recovery times, proper postoperative care and rehabilitation remain crucial for optimal outcomes. The specific protocol will vary depending on the procedure performed and individual patient factors, but generally includes:

Immediate Postoperative Period

• Pain management
• Wound care and dressing changes
• Elevation and ice application to reduce swelling
• Limited use of the affected hand or wrist

Early Rehabilitation Phase

• Gentle range of motion exercises
• Gradual increase in activities as tolerated
• Occupational therapy for hand function
• Scar management techniques

Advanced Rehabilitation

• Progressive strengthening exercises
• Functional training for daily activities and work tasks
• Sport-specific exercises for athletes
• Ongoing monitoring and adjustment of the rehabilitation program

How does rehabilitation differ for minimally invasive procedures compared to traditional open surgery? While the general principles remain similar, patients who undergo minimally invasive surgery often progress through rehabilitation stages more quickly due to reduced tissue trauma and faster initial healing.

The collaboration between surgeons, hand therapists, and patients is essential for achieving optimal functional outcomes and ensuring a smooth return to daily activities and work.

Ongoing Research and Future Perspectives

The field of minimally invasive hand and wrist surgery continues to evolve rapidly, driven by ongoing research and technological advancements. Some areas of current investigation and future potential include:

Tissue Engineering and Regenerative Medicine

Researchers are exploring the use of stem cells, growth factors, and bioengineered scaffolds to enhance tissue healing and regeneration following minimally invasive procedures. These approaches hold promise for improving outcomes in complex cases and potentially addressing conditions that were previously challenging to treat.

Advanced Imaging and Navigation Systems

The development of more sophisticated intraoperative imaging and navigation technologies may further enhance the precision and capabilities of minimally invasive hand and wrist surgery. These advancements could enable surgeons to perform increasingly complex procedures through smaller incisions with greater accuracy.

Wearable Technology and Telemedicine

The integration of wearable devices and telemedicine platforms may revolutionize postoperative monitoring and rehabilitation following minimally invasive procedures. These technologies could provide real-time feedback on patient progress, allowing for more personalized and effective recovery programs.

How might these advancements impact patient care in the future? As research progresses and new technologies emerge, minimally invasive hand and wrist surgery is likely to become even more precise, effective, and accessible to a broader range of patients.

The ongoing collaboration between surgeons, researchers, and industry partners will be crucial in driving innovation and improving outcomes for patients with hand and wrist conditions.

Minimally Invasive Hand and Wrist Surgery

1. Overview
2. Arthroscopic Surgery
3. Percutaneous Fracture Treatment
4. Percutaneous Soft Tissue Procedures
5. Complications, Outcomes and Advanced Procedures

Overview

Minimally invasive hand and wrist surgery refers to treatment of bone and soft tissue injuries without the need for traditional open incisions. Instead, with the aid of various tools and techniques, the orthopedic hand surgeon is able to visualize and repair the affected area through one or more small incisions or portals in the skin. Benefits of this approach include reduced risk of injury to surrounding healthy soft tissues, a speedier recovery, and minimized scarring.

Minimally invasive hand and wrist surgeries may be divided into two categories, those that employ arthroscopy to directly visualize internal structures and those that use indirect techniques of visualization and percutaneous surgery. In arthroscopic surgery, the orthopedic surgeon inserts an instrument equipped with a miniaturized video camera into a joint space to obtain a magnified, high-resolution image of the joint. This image is projected onto a monitor in the operating suite. The surgeon can directly visualize and treat the affected tissues using additional instruments that are inserted through accessory portals. During percutaneous procedures, the hand surgeon performs surgery by inserting instruments or fracture fixation devices directly through the skin, and most often monitors the accurate placement of these devices with the use of x-rays or fluoroscopy.

Arthroscopic Surgery

Fractures of the distal radius (commonly known as wrist fractures) are the most common fractures of the upper extremity. These fractures frequently result from a high-impact incident, such as a sports injury or a fall from a height, and are often broken into a number of fragments. In addition, the joint surface of the wrist is frequently disrupted, creating the potential for the long-term development of pain, stiffness and arthritis.

Illustration of distal radius fractures, also known as wrist fractures.

Scott W. Wolfe, MD, Chief Emeritus, Hand and Upper Extremity Service at HSS, pioneered an arthroscopic technique for treatment of distal radius fractures with colleagues while at Yale University. “This surgery actually combines arthroscopy with percutaneous fixation, to yield strong fixation with minimal additional trauma to the injured soft tissues around the fracture,” he explains. Treatment begins with external fixation of the bone, using threaded pins and a frame. The orthopedic surgeon then uses the arthroscope and small instruments to realign the joint fragments and removes any small fragments of bone that may have broken loose. Bone grafts (or more recently, bone graft substitutes) may be used to fill any structural defects resulting from the break. Using a percutaneous technique, pins, wires or screws are inserted to hold the bone fragments in place during healing-a period of approximately six weeks.

Dr. Wolfe and his colleagues evaluated seven patients who were treated with this technique at a period ranging from between 12 and 45 months following surgery (average follow-up was 27 months). Their published findings showed that all seven patients were free of pain and had returned to work. On average these individuals recovered 92% of their range of motion and 98% of their maximal grip strength in the affected wrist, when compared with the uninjured wrist. Complications were minimal.

Image showing a patient with external fixation frame in place.

X-ray image showing percutaneous fixation.

Dr. Wolfe is currently the Principle Investigator on an FDA-approved clinical trial that is investigating the use of a new biologic compound to further accelerate the healing of these percutaneously-treated fractures.

Other arthroscopic procedures

Other arthroscopic procedures to treat the hand and wrist include:

Percutaneous Fracture Treatment

New methods of fixation for scaphoid fractures represent the most dramatic revolution in the treatment of wrist injuries in the last three decades. Fractures of the scaphoid (also called the carpal navicular) usually occur in sporting accidents or during a fall on the outstretched hand. The scaphoid has a peculiar blood supply that renders it vulnerable to delayed healing or even failure to unite. Delayed or incomplete treatment can lead to severe wrist arthritis. While cast treatment is a time-honored treatment method that enjoys a high rate of success, the three to four month casting period that is necessary for healing can be quite disruptive to occupational and daily activities. Surgical treatment with percutaneous surgery enables rapid healing without the confinement of a cast.

Illustration of bones of the left wrist and hand.

“Historically, a number of these fractures were missed and there was a high-rate of failure of the bones to heal properly,” says Dr. Wolfe. “Now, diagnosis of scaphoid fractures has been improved with the use of advanced imaging methods and treatment of these fractures can be performed with arthroscopy, fluoroscopy, or both. ” Images obtained with fluoroscopy can then be used to guide the insertion of screws (through a 1 to 2 mm incision) into the bone to stabilize it. Once the fixation is complete, the patient is generally able to recover while wearing only a removable splint, and is able to begin range of motion exercises almost immediately after surgery. Surgery is completed in less than an hour. In the past, an open procedure was required and the patient then wore a cast for up to 2 or 3 months postoperatively. Healing rates for percutaneous scaphoid fracture fixation are as high as 100%.

Other fractures

Several fractures may now be treated using percutaneous fixation techniques, including those of the phalanges and metacarpals. For severe fractures involving the finger joints, the patient’s finger is sometimes placed in an external fixator apparatus, and the surgeon employs fluoroscopy to guide the placement of wires and screws for bone stabilization.

Photo showing percutaneous fixation of the proximal interphalangeal joint.

X-ray image of external fixator for the proximal interpalaneal joint.

This treatment allows the patient to begin gentle motion within a few days of surgery. Early rehabilitation of these complex injuries has been shown to decrease the occurrence of post-operative joint stiffness when compared with traditional open techniques.

Percutaneous Soft Tissue Procedures

Percutaneous procedures for soft tissue injuries include treatment for trigger finger, a condition in which a tendon becomes entrapped within a tight sheath in the palm, and painfully snaps during routine use of the hand. Release is provided by dividing the stenotic sheath. In traditional surgery, this required an open incision in the palm of the hand. Percutaneous technique allows the surgeon to accomplish the same surgical result without an incision, using a special needle.

Illustration of trigger finger.

Illustration of percutaneous trigger finger release.

Treatment for carpal tunnel syndrome, while not strictly defined as a percutaneous procedure, is somewhat similar. In this condition, the patient experiences pain and numbness in the hand as a result of compression of the median nerve in the carpal tunnel of the wrist. To alleviate this pressure, some hand surgeons utilize an endoscopic technique rather than the traditional open surgery. Small instruments are inserted beneath the skin to identify and release the transverse carpal ligament. The procedure creates more room in the carpal tunnel and relieves nerve compression.

These mini-incision techniques have been shown to provide comparable long-term results to traditional, open surgery and provide a quicker return to activities in the short-term. It also provides a good option for patients who cannot tolerate a large incision in the palm of the hand, such as those who rely on a cane or crutches for ambulation.

Complications, Outcomes and Advanced Procedures

Minimally invasive surgery has been shown to be safe and effective for a number of hand and wrist conditions. However, no surgery is without risk. The surgeries, not unlike their open counterparts, still involve the possibility of nerve or blood vessel injury. According to Dr. Wolfe, the best way to ensure a successful outcome and minimize that risk is to seek care from an orthopedic surgeon with specialized training and experience in surgery of the hand.

“These procedures are not replacing traditional surgery,” he adds. “While they may ultimately prove to result in better and faster recovery, they are not appropriate for everyone. Electing to have minimally-invasive hand or wrist surgery is a patient and surgeon-guided decision.”

Advanced Procedures

With the growing interest in, and successful outcomes of minimally invasive surgery, Dr. Wolfe anticipates that more procedures will become available in the future, including-with the development of smaller instrumentation-use of arthroscopy in smaller, tighter joints.

Updated: 6/22/2009

Summary prepared by Nancy Novick • Diagnostic imaging examinations provided by HSS Radiologists

Authors

Scott W. Wolfe, MD

Attending Orthopedic Surgeon, Hospital for Special Surgery
Professor of Orthopedic Surgery, Hand Surgery and Nerve Repair, Weill Cornell Medical College

Endoscopic Arthroscopic Hand Wrist Surgery Richardson Rockwall TX

Minimally invasive hand and wrist surgery helps patients find relief from fractures, carpal tunnel syndrome, arthritis, and other common ailments, without the extensive open incisions of more invasive treatment options. This approach allows for a shorter hospital stay and faster recovery, enabling you to return to your usual day-to-day activities sooner rather than later. Minimally invasive procedures are often delineated as either employing arthroscopic efforts, or following a more indirect path of assessment and care.

Arthroscopy allows the medical team to view internal damage, diagnose severity, and apply subsequent treatment through the use of a camera, or scope, inserted through a small incision. The procedure is viewed and administered via a video monitor, allowing for some of the smallest, most intricate bone structures to be treated with focused surgical precision. The following hand and wrist issues are often subject to arthroscopic efforts during diagnosis and/or treatment:

• Wrist fractures
• Arthritic spur removal
• Cartilage repair

Wrist Fractures

Wrist fractures are common amongst bone and joint injuries, and may include more specific damage to the distal radius, distal radioulnar joint, or scaphoid. While the distal radioulnar joint is the meeting point of the radius and ulna, the scaphoid is located between the thumb and forearm.

Proclivity to wrist fractures can be found amongst youth (period of growth), those of advanced age (decreased bone density), and athletes in impact sports; however, anyone can be subject to situational damage or injury, requiring orthopaedic care. Based on your unique situation and needs, an orthopedic hand and wrist surgeon will prescribe a course of regimented treatment and recovery.

Arthritic Spurs

Arthritic spurs are a form of osteophyte, a bony projection that develops along a joint, causing pain or limited range of motion. These formations are often a sign of your body’s effort to increase surface area and better distribute weight within a joint that has been progressively damaged by arthritis. Not all arthritic spurs require surgical intervention; however, in the most severe cases, arthroscopic treatment may be recommended.

Cartilage Damage

Cartilage, a flexible connective tissue within the hand and wrist, may be subject to either traumatic injury, or gradual wear-and-tear. Damage to cartilage is often painful and persistent, as the body has very limited ability to self-heal, requiring medical intervention for successful repair. In cases of such injury, arthroscopy will often be a first measure in diagnosis, even if more varied treatment methods are later applied.

Carpal Tunnel Syndrome

A common source of hand and wrist pain, carpal tunnel syndrome is most often treated through non-invasive techniques. Numbness and discomfort develops over time, as the synovium (tissues surrounding the wrist’s flexor tendons) swell. While healthy synovium provide for optimal tendon lubrication and finger movement, this swelling will exert unwanted pressure on the median nerve, which in turn causes crowding within the carpal tunnel and more limited motion. Common causes for the development of carpal tunnel syndrome include:

• Heredity
• Exhaustive hand and wrist use
• Repetitive hand and wrist motions
• Hormonal changes
• Natural aging
• Diabetes, arthritis, and/or glandular imbalances

In the treatment of carpal tunnel syndrome, your physician will begin by examining the severity of your unique case. Tests may include a physical performance assessment, electrophysiological diagnostics, and/or x-rays. The goal will be to confirm the presence of carpal tunnel syndrome, assess all factors contributing to limited wrist movement, and determine the best method for successful treatment.

Many individuals suffering from carpal tunnel syndrome are candidates for non-surgical treatment, including the efforts of:

• Bracing/splinting
• Prescription of a medication regimen
• Avoidance of exhaustive and/or repetitive motions
• Steroid injections

Should non-invasive methods prove unsuccessful, your orthopaedic surgeon may recommend more in-depth intervention and ligament repair. If surgery is recommended, your physician will work with you to determine the best approach (often endoscopic), as well as provide guidance for both short and long-term recovery.

Contact Our Practice

Our surgeons are fellowship trained in Hand and Microsurgery. If you are in search of expert hand and wrist care, contact our office.

types, symptoms, causes, diagnosis and treatment in Moscow at the Center for Surgery “SM-Clinic”

General information

Kinds

Symptoms

Causes

Diagnostics

Surgical treatment

Expert opinion of a doctor

Prevention

Rehabilitation

Question answer

General information

Aseptic necrosis of the scaphoid is a complication of wrist injuries in which a piece of bone undergoes degeneration.

The treatment of the disease is carried out by a traumatologist or orthopedist.

Pathology is more common in men 20-40 years old who are engaged in manual labor. The predominant hand is affected. In 10% of cases bilateral necrosis is observed.

Hand injuries account for about a third of all injuries of the musculoskeletal system. The damage to the navicular bone is dominant. It is located in the first row of the carpal bones, connects to the radius and is quite easily injured with excessive stress on the wrist or when falling on an open palm.

A feature of the bone is an insufficiently branched vascular network. In the event of a fracture, bone fragments may be left without proper nutrition, which creates favorable conditions for the development of complications. The development of a false joint is more often observed (bone fragments do not completely grow together, a gap remains between them, which leads to the appearance of pathological mobility). In 15-30% of cases, the injury is complicated by necrosis of the navicular bone.

In some cases, a fracture is the result of local degenerative changes in the bone (Kinböck’s disease). The nature of their development has not been established. Bone tissue degeneration is associated with trophic disorders in this area due to microtraumas, peculiarities of the anatomy of the ulna, and also as a result of undiagnosed fractures.

Species

Symptoms of aseptic necrosis of the navicular bone

Necrosis is a dynamic process. In the case of a post-traumatic complication, the symptoms appear gradually. The main symptom is aching pain in the wrist area, as well as local swelling along the midline on the back of the hand.

With the progression of Kienböck’s disease, pain is mild, aching, transient. Discomfort is aggravated by exertion or after working with your hands. Paroxysmal pain occurs at the time of the fracture. Its intensity is significantly lower than in classical bone injuries.

There may be limited mobility of the wrist, impaired flexion and rotation of the fingers, and lack of tendon contours.

Causes

Diagnosis

Aseptic necrosis of the scaphoid is diagnosed using imaging diagnostic procedures. As a screening study, radiographic scanning of the wrist joint in three projections is performed. Signs of necrotic changes are a change in the shape and structure of the bone, depressed fractures, fragmentary lesions, signs of osteoarthritis. With erased symptoms, the clinical situation is detailed using CT or MRI. Magnetic resonance imaging makes it possible to distinguish necrosis from ligament injuries, hygromas, stenosing ligamentitis, etc.

Surgical treatment

Necrosis of the navicular bone is treated exclusively by surgery. Operations are aimed at restoring vascularization (blood supply and trophism) of the damaged bone fragment. The method of intervention is selected on a personal basis, taking into account the stage of development of necrosis, the condition of other bones of the joint and the general level of health.

The procedure is performed on an outpatient basis under local anesthesia and involves the installation of a distraction apparatus with wires on the wrist for 6-8 weeks. Treatment is supplemented with special exercises and physiotherapy. After removing the apparatus, a back plaster splint is applied to the wrist. Physiotherapy exercises and physiotherapy are continued until complete recovery. In the future, the patient should gradually increase the load on the joint.

A modern method of assisting with aseptic necrosis of the scaphoid bone is replacing plastic with a tendon-periosteal-bone graft. The necrotic bone fragment is removed, the articular surfaces of other bones are prepared, after which an autograft is placed. The implant and the preserved fragment of the navicular bone are fixed with a screw to create compression. The operation helps to get rid of chronic pain and restore the functions of the wrist.

Doctor’s expert opinion

Prophylaxis

To prevent necrosis of the navicular bone, it is necessary to dose the load on the wrist and avoid injury to the hand. In case of damage or groundless occurrence of pain of any intensity, you should consult a doctor. Timely initiation of treatment for a fracture of the navicular bone allows you to fully restore its trophism and avoid complications.

Rehabilitation

Surgical treatment requires hospitalization of the patient for 3 days. After the operation, the wrist is immobilized with a plaster cast for 5 weeks. Then make a control x-ray in two projections. With successful consolidation (healing) of the bones, the plaster is removed, and the patient is prescribed physiotherapy exercises to restore the functions of the joint.

Question-answer

With complaints, patients turn to an orthopedic traumatologist, who prescribes an additional examination and establishes an objective diagnosis, on the basis of which treatment is carried out. In the process of diagnosis, a consultation with a rheumatologist may be required.

In advanced cases, surgical treatment may not be appropriate. The possibility of carrying out the operation is determined on a personal basis.

An unsatisfactory result of treatment is possible in case of violation of recommendations regarding rehabilitation. For example, the patient may re-injure the wrist, overly actively engage in the development of the joint. It is important to strictly follow the instructions of your doctor.

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