Advanced Treatment of Tennis Elbow (Lateral Epicondylitis of the Humerus) without Cutting ~About the treatment of hard-to-heal tendon diseases
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It all started with a slight injury to a tendon.
Tennis elbow (lateral epicondylitis of the humerus) is a common condition that causes pain on the outside of the elbow, most commonly in people in their 40s and 50s, with no difference between men and women. It is most common in tennis and badminton players, but it can also occur in people who do not play tennis but overuse their arms in daily activities or at work.
Tennis elbow is not just a result of overuse; it is also caused by a muscle on the outside of the elbow called the extensor carpi radialis short and extensor digitorum generalis, which extends the wrist and fingers.Aging tendonsare strongly entangled. Tendons are made of collagen and become brittle with age. This is why tendons are damaged not only in sports, but also by slight overuse in daily life. If the injury is caused by a slight movement, the movement is repeated during daily life, which does not allow time for the injury to heal and continues to damage the tendon. This is why tendon injuries are difficult to heal.
By the time pain appears and a hospital visit is made, it is not uncommon for the tendon to be quite advanced in its damage.
Our clinic will perform ultrasound and MRI as much as possible to examine the tendon and evaluate the extent of the damage.
Easiest to heal is the first 3 months.
Humans have a natural healing ability. Even tendon injuries will naturally repair themselves after a good rest. However,Restoration requires 2-3 monthsThe reality is that many people are not able to rest until they are fully healed in
In addition, natural healing has an expiration date, usually three months after the injury, and its ability to heal diminishes. It is important to rest the tendon as much as possible after noticing the pain and to strive for healing within three months.
Prevent the vicious cycle of inflammation (to avoid refractoriness)
If the initial damage does not heal and the damage persists for several months, the increased blood flow response to repair may be excessive,Pain Nerves and Inflammation Vessels(also known as moyamoya vessels)Proliferation ofThe local blood flow decreases and edema develops. In this case, it is difficult for the body to repair the damage, and the inflammation persists in the chronic phase (refractory). In the chronic phasescar tissueNormal tendon regeneration does not occur due to the infiltration of an inflammatory tissue called
To prevent this, it is important to avoid prolonged inflammation as much as possible. Using a variety of treatments that eliminate the inflammatory vessels and nerves that cause inflammation.Vicious cycle of inflammationto break down and promote tissue repair and regeneration.
Progression of tendon damage
Vicious cycle of inflammation
Initial Treatment Options
Treatments can be varied, but usually the least painful treatments are chosen. For cases that are difficult to cure, we will choose treatments such as injections, regenerative medicine, or surgery. Naturally, they will choose treatments that cause pain, require time off work, and increase costs.
(1) Treatments (other than injections) to try first
1. rehabilitation Improve flexibility of muscles, tendons, and joints, remove adhesions, improve motor function, and provide guidance for daily living.
2. massage, stretching Conditioning: self-performed conditioning
Extracorporeal shock wave therapy (shock wave)Shockwave: reduction of nerve and inflammatory vessels and activation of repair cells by shockwave
4. ultrasound therapy Tissue blood flow increase and swelling reduction by microvibration
5. taping and orthotics Reduces load on tendons and protects them
6. drug therapy Relief of pain inflammation
(2) Injection therapy
1. steroid injection :Reduction of inflammation and pain
2. hydro release :Removal of adhesions of nerves, tendons, and blood vessels, improved sliding, increased blood flow
3. prolotherapy : Tendons freshened and strengthened with glucose
Steroid injections may worsen the more they are given
Steroids are commonly used because of their pain-relieving effect, but long-term results are not good. The strong anti-inflammatory effect of steroids temporarily eliminates the inflammation that causes the pain, but the pain disappears, causing overuse of the affected area, which in turn leads to tendon damage that becomes more serious before the patient knows it. Also, on steroids themselves,Weakening action on collagenBecause of the presence of the "I", repeated injections can cause not only tendon damage but also tendon rupture, osteonecrosis, and ligament damage, and we believe that only multiple injections should be used and other treatments should be considered if the patient is still not cured.
Treatment for advanced and chronic phases
If initial treatment does not cure the disease, the following various treatments may be tried. Many of these are newer injection-based therapies that have been developed in recent years and are not covered by some insurance plans. There are many different types of treatments, and the choice of treatment will depend on the situation. Finally, if symptoms do not improve, surgical treatment is the treatment of choice.
In addition, a combination of multiple treatments will be used if a single treatment method cannot be applied.
(1) Treatment to reduce inflammation of tendons
1. steroid injection :Reduction of inflammation and pain(Injection frequency: multiple injections only)
2. inflammatory vascular treatment＊ : Reduction of inflammatory blood vessels that inhibit regeneration, and promotion of tissue regeneration through improvement of edema and blood flow.
3. scraping＊ : Treatment using a needle to physically break inflammatory blood vessels
(2) Treatment to promote tendon regeneration and flexibility recovery
1. prolotherapy : glucose injections to strengthen collagen in tendons
2. hyaluronic acid injection＊Hydro-Release : Injections to improve adhesions, sliding disorders, and blood flow disorders in tendons and surrounding tissues.
3. fenestration＊Drilling＊ Needle stimulation of tendon parenchyma and bone parenchyma to stimulate tissue regeneration by platelets.
4. biotherapy (PFC-FD(Therapy)＊ Injection administration of regenerative factor extracted from concentrated autologous platelets
5. arthroscopic surgery Arthroscopy to remove synovial membrane and folds that contain defective tissue.
6. incisional surgery Classical surgery = Nirchl's method, in which an incision is made and the defective tendon and synovial tissue is removed.
7.TENEX®︎Surgery (percutaneous tendon synovectomy)＊Surgery to emulsify (soften) and freshen tendons by ultrasound
8. non-surgical synovectomy＊Surgery to remove and freshen the scarred area inside the damaged tendon with a tiny device.
(iii) Surgical therapy to repair tendons
1. incisional surgery Tendon suture surgery performed through an incision
2. non-surgical tendon suture surgery＊ : Next-generation minimally invasive hybrid surgery for echo-guided resection of defective tendon synovectomy and tendon suture of the tendon.
(4) Surgery to stabilize joints
1. ligament reconstruction Surgery to reconstruct ligaments for unstable joints in severe cases where tendon damage has progressed to ligament damage.
Our clinic features: Combination of minimally invasive treatments
At our clinic, we tailor our case-specificpersonalized treatmentWe are committed to We try to provide the best possible treatment, mainly conservative treatment, up to the final surgical treatment. Therefore,At our clinic, we do not perform traditional incisional surgery. By not making incisions, we minimize surgical damage as much as possible,(i)Excision of defective tissueand(2)Suturing of tendonsgo as far ashybrid surgeryThe company is performing the following activities. If the damage is significant, theregenerative medicineand otherInflammation reduction treatmentThis is done through a combination of the following
Surgery that requires incisions is often avoided by patients with advanced disease, and the disease often worsens because the surgery is not performed at the appropriate time.
Each minimally invasive treatment is recommended at the appropriate time because it is not as burdensome as incisional surgery.
Also,Non-ablative" surgeryhas the advantage that it can be performed with reduced bleeding even in patients on anticoagulation therapy due to complications. Since other complications can also be reduced, as will be discussed later, "no-cut" surgery is considered a new technique that fills the gap between injections and conventional surgery.
Features of our clinic's tennis elbow treatment
- Minimally invasive (small wounds and little pain) treatment using echo and arthroscopy
- Next-generation, non-cutting surgical treatment for tendon repair and suturing without incision
- Hybrid" treatment, which enhances the certainty of surgical treatment
Minimally invasive conservative treatment methods are presented.
Extracorporeal shock wave therapy (Shock wave)
By applying shock waves over the skin to the affected area, it reduces inflammatory blood vessels and painful nerves that cause pain and improves symptoms. It also destroys defective tendons and causes angiogenesis to regenerate new tendons.
(2) Ultrasound therapy
Ultrasonic microvibrations increase blood flow and reduce edema,local circulationThis treatment aims to regenerate the tendon by improving the blood flow to the tendon. In addition, heat therapy and electrotherapy can be used together (combination therapy), which can be expected to further improve blood flow if performed simultaneously.
(iii) Hydro release
Injections of saline or Ringer's solution containing lactate solution are injected into the affected area to relieve adhesions, decreased gliding (movement), circulatory problems, and irritation to the nerves. Targeted areas include the tendon itself, surrounding muscles, nerves, and blood vessels. Circulation is improved, and tendon and nerveAdhesions are removed and sliding improvesThe injection site is then injected into the elbow, and the movement and tightness are eliminated, creating a situation where repair can easily occur. The effect of injections is different for the same tennis elbow, so multiple injections are performed,Combined with rehabilitationThen it is effective.
4) Hyaluronic acid injection
Hyaluronic acid is originally produced in the body, but it is said to be more effective than hydrolysis because of its higher water retention and viscosity compared to saline solution. However, since it is not covered by insurance, it is only used for those who wish to use it when Hydrolysis is less effective.
(5) Inflammation Vascular Therapy
The cause of the obstruction of the tendon repair process is the chronicity of the inflammation. Inflammation is strongly vascularized, and pain substances released from blood vessels, nerve growth factors, amplify the pain. The inflammation-reducing effect of steroids reduces these factors, but does not eliminate the blood vessels, so the pain will recur when the steroids are removed.
Inflammatory vascular therapy" uses an embolization substance to plug the inflammatory vessels themselves, thereby eliminating the inflammatory vessels themselves, reducing pain and improving inhibition of tendon repair. The embolic substance, which is a microparticle, selectively clogs only the small inflammatory vessels, not the normal vessels, so it does not interfere with normal blood flow. Steroid-likeNo side effectsand after treatment.No life restrictionsThe indications for treatment of various diseases are being expanded due to its many advantages, including the following
(6) Scraping
Inflamed blood vessels invade from the surrounding area, causing swelling inside the tendon and inhibiting blood flow.Avulsion around the tendonThe procedure is called "scraping," a new technique that eliminates the invasion of inflammatory blood vessels by doing so. In order to reduce the burden on the body as much as possible, our clinic performs the procedure using only a needle under echo-guidance without incision. (This may not be possible depending on the condition of the patient's disease.)
(7) Prolotherapy
This is a treatment in which a chemical solution containing glucose is injected into the affected area. This treatment uses the difference in osmotic pressure to penetrate the affected area at the cellular level, causing tissue regeneration and tendon hardening. By causing a local reaction to the collagen, the body's natural healing power is drawn out and tendon regeneration is promoted. RelativelyHighly safeThe treatment is not restricting my life,Try it out from the early stageTreatment.
(8) Fenestration drilling
It is believed that a variety of repair-promoting factors are required for damaged tendons to repair. Most are found in platelets in the blood, and chronically injured tendons lack these repair-promoting factors. They are normally released at the time of injury, but over time they are no longer released and repair does not occur. Fenestration is done by inserting a needle into the tendon, which causes bleeding inside the tendon, which then causes the tendon to bleed again.facilitate repairTreatment.
Tendons are also attached to bone, and inside that bone is a region known as the bone marrow. Within the bone marrow is blood rich in repair-promoting factors and blood stem cells that grow into the tendon. Therefore, at the same time as fenestration of the tendon, numerous holes are drilled into the interior of the bone toLeakage of blood in the bone marrow into the tendonDrilling is a treatment that makes the patient's hair grow longer.
Fenestration and drilling are usually performed simultaneously to promote tendon repair. Postoperative activities of daily living are possible, depending on pain, but the surgical manipulation may cause some swelling and pain, so heavy work and sports are prohibited for about one month after surgery.Rest is neededwill be.
(9) PFC-FDTherapy (PRP(Therapy)
The patient's own blood is collected and the richness contained within the plateletsRestoration-promoting Factors, ,anti-inflammatory factoris collected, concentrated, and administered to the affected area.PRPRegenerative medicine, also known as therapy, is a type of regenerative medicine in which the cellular components are removed and the concentration process is refined.PFC-FDTherapy. Because it can administer higher concentrations of repair-promoting factors than the fenestration and drilling described above, it is a good indication for difficult cases that do not improve and for those who are seeking an early return to work, such as athletes and sports enthusiasts.
About the cost of treatment
Part of the treatment for tennis elbow is at your own expense. The cost of treatment is as follows
(in Japanese history)Surgical costs include all anesthesia, fees, pre- and post-operative medications, drug costs, and surgical technique fees).
| Treatment | Treatment fee (tax included) |
|---|---|
| hyaluronic acid injection | ¥5,500 |
| Inflammatory Vascular Therapy | ¥55,000 |
| scraping | 38,500 yen |
| fenestration drilling | ¥55,000 |
| PFC-FD Therapy | ¥165,000 |
| PFC-FD2.0 Therapy | ¥220,000 |
[On the cost of self-funded treatment.
Self-funded treatment not covered by insurance may not be covered by life insurance or accident insurance benefits. In addition, benefits from workers' compensation insurance, liability insurance, and various public subsidies are also not available.
However, since it is a medical expense, it is deductible.
Unique "no-cut" surgery using echo
If there is no improvement with the conservative treatments already mentioned, surgical treatment will be considered. Surgery for "non-surgical" tennis elbow is,(1) Tendon synovectomyand(2) Tendon sutureThere are
Echo-guided minimally invasive surgery is still performed only in a few medical institutions in Japan and abroad. Although technically challenging in some respects, the reality is that few orthopedic surgeries have yet introduced echo guided procedures. At our clinic, we are striving to achieve better results by using techniques developed by our own physicians with clinical experience overseas. We hope to be of service to our patients as a local clinic that can provide state-of-the-art treatment.
- (1) Surgery for tendon synovectomy without cutting
Chronic tennis elbow is a hotbed of inflammation due to the proliferation of faulty tissue and synovial membrane at the tendon attachment site. Since removal of these defective tissues can relieve pain, they used to be excised through an incision. In recent years, arthroscopic surgery has been used to remove the synovial membrane within the joint, and has proven to be effective to a certain degree. Arthroscopic surgery often required hospitalization and general anesthesia, and lesions of the tendon synovium outside the joint were difficult to deal with and could remain symptomatic. The risk of ligament damage is also considered problematic. At least two wounds are required to insert the camera and manipulation device.
To compensate for the weaknesses of arthroscopic surgery, we have developed our own method ofExtra-articular approachThis is a non-surgical tendon synovectomy procedure that allows using an injection needle and a very small synovectomy device.1Wound of a placeand cause pain and inflammation.Minimal scarring and removal of scar tissue that inhibits tendon regenerationIt is a minimally invasive surgery that uses a device that is thinner than an arthroscope. The device used is thinner than an arthroscope and does not use a tube called a mantle, so it can be performed without incisions. Moreover, it can be performed under local anesthesia,day tripThe new method is less painful and less burdensome than conventional arthroscopic surgery.
Fenestration drilling to promote tendon regeneration andPFC-FDWe recommend that these therapies be performed at the same time whenever possible, as the additional therapies will promote more regeneration.
However, if the tendon is severely damaged and the area to be resected is large, the problem is that the tendon is detached from the bone. If the tendon is not ingrown to the bone, a scar will form again and pain will not be relieved, making surgery for tendon suture an indication for the next step in the procedure.
- (2) Surgery for tendon suture without cutting
If the tendon is ruptured to a large extent or there is a lot of scar tissue that needs to be cleaned, there will inevitably be a gap between the ruptured and retracted tendon and its original position (bone), where scar tissue will form again and inflammation will continue, which may not relieve the pain. Conventionally, an incision is made to remove the scar tissue and the torn tendon is sutured through a hole in the bone. As expected, this required general anesthesia and hospitalization, and had the disadvantage of a large scar. Many people are concerned about the scar on the outside of the elbow, as it is the part of the elbow that is visible in summer when wearing short sleeves.
Therefore, our clinic has developed and introduced our own one-day surgery to suture tendons without incision. The surgery of suturing tendons without cutting is performed by (1)Surgery for Tendon SynovectomyIn addition to (1), (2) suture the ruptured tendon to the bone.Tendon suture surgeryof the two procedures at the same time.hybrid surgeryIt is.
Specifically, the ultrasound is guided accurately under local anesthesia only and under ultrasound guidance.Remove only scarsAfter the tendon is freshened, intraoperative radiographs are taken while the ruptured tendon is being examined.bone anchor(clasp) and sutured to the bone. Hybrid surgery allows for simultaneous cleaning and repair of the tendon, increasing the effectiveness of the treatment.
Day trip,Leaves no scarsThis means that women do not have to worry about postoperative scarring, and there is less pain. In addition to being minimally invasive and less likely to cause adhesions around the joint, this procedure is expected to improve safety by reducing the risk of infection and complications.
However,Tendon regeneration and bioproduction takes 1 to 2 monthsTherefore, heavy work and sports should be avoided during this time. Daily life is usually possible from early on.Bathing is possible on the same day.It is.
Ultra-high definition echoes are used to ensure safety.
The clinic uses0.1With a resolution of mm24MHzultrahigh-resolution echoIt is. No cut = not visible, but only employed at some university hospital levels.Echocardiography useful in upper extremity surgeryBecause of the instrumentation, the inside can be seen accurately without having to cut. It is considered a highly safe treatment.
Treatment performed by a board-certified hand surgeon
Surgical manipulation without incision requires reliable knowledge and skill. Among the plastic surgery specialists in our clinic,Board certified hand surgeon with expertise in upper extremity surgeryThe treatment will be performed by The treatment will be provided by specialists who have acquired clinical experience in Japan and abroad.
Differences between "no-cut" surgery and conventional surgical treatment
Our clinic has developed our own "no incision" surgery to improve the shortcomings of the current surgical procedures. Unlike incisional surgery, the first feature of this technique is that it does not require an incision.Less painThe most important thing to remember is that the surgery can be done on a day trip and leaves no scars. Of course, the procedure can be done on a day trip, leaving no scars, and allowing the patient to take a bath on the same day.Less risk of infection, ,Little bleeding.The main advantage is that the location of nerves, ligaments, and blood vessels can be determined before the surgery. The greatest advantage is that the location of nerves, ligaments, and blood vessels can be ascertained before surgery,Highly safeThis is to say. Even with incisional surgery, the nerve is not visible as the incision is made, and if one is not careful, the scalpel can cut a nerve branch. In endoscopic surgery, nothing can be seen until the optical camera enters, and even if it can be seen, the field of view is narrow, so there is a fear of nerve damage to operate outside the field of view. We believe that "no incision" surgery is the ultimate safe surgery that does not involve any incision and yet does not damage the neurovascular system.
Advantages of non-surgical tendon suture surgery
| Downward risk | Advantages |
|---|---|
| Hemorrhage/hematoma | day trip |
| infection | Less operating time |
| No stitches required | Less pain from tourniquet wrapped around arm |
| Anesthesia solution volume | No need for post-operative disinfection visits every two days |
| drug allergy | Leaves no scarring |
| Nerve and blood vessel injury | Bathing is possible on the day of surgery |
| Skin induration/keloids | Avoid potential hazards of endoscopic procedures (cartilage damage and nerve damage due to intra-articular manipulation) |
| range of motion limitation | High-definition echocardiography is used to confirm the placement of nerves and blood vessels, etc., prior to surgery, thus ensuring safety. |
| CRPS |
Recommended for
Since the disease is more common in middle-aged and older women, this is a beneficial treatment for these patients.
(1) Those who wish to return to water work at an early stage.
Those who do not wish to have scars on their elbows.
(3) Those who want to reduce the number of hospital visits
4) Those who are sensitive to pain
(5) Patients with a history of taking anticoagulants or other medications.
6) Those who want to prevent disease before it gets worse.
(7) Those who play sports that require the use of elbows
8) Those who cannot take time off work
(ix) Those who are advised by their doctor to undergo surgery but do not want to undergo an incision and are unable to take the plunge.
(10) Those who cannot afford general anesthesia or hospitalization.
Are there any complications or disadvantages of the surgery?
The use of high-definition echoes allows for better understanding of nerves, blood vessels, and tendons, and there is less risk of nerve damage than with endoscopic surgery. In addition, bleeding, postoperative wound pain, and scarring are less likely than with other techniques because there are no wounds.
However, because any surgery or procedure is invasive to the body, there is a risk of a small number of complications. Specifically, there are the following risks: (1) allergies due to drugs; (2) complications due to swelling, bleeding, or hematoma; (3) infection; (4) nerve or blood vessel damage; (5) pain or resulting movement disorders; (6) thrombosis or embolism; (7) skin scars, keloids, or wound pain; (8) joint contracture or joint instability (when joints are manipulated); and (9) other complications (CRPS) and other unforeseen complications (e.g., problems not only in the affected area but in other parts of the body as well). Since the future can be unpredictable, we will take the best possible measures (administration of drugs, additional surgical procedures, additional treatment, resuscitation, emergency medical care, etc.) depending on the situation. In case of emergency, we may perform the surgery without your consent, but we ask that you understand this before accepting the surgery.
Which specific treatment should I choose?
【【Phase 1] After the onset of the disease1~ (after a number N)2Within a month
Since the tendon is still freshly damaged, this is a time when natural healing is expected. Treatment focuses on rehabilitation, with guidance on how to improve movement to prevent new damage.
(1) First.Rehabilitation, stretching instruction, orthotic therapy, extracorporeal shock wave therapy, ultrasound therapyWe will provide thorough initial treatment, such as
(ii) If the pain is severesteroid injectionTry multiple times.
(iii) If rehabilitation does not improve nerve and tendon sliding or flexibilityhyaluronic acid injection, ,hydrorelease injectionThe following is a list of the most common types of products that can be used.
【【Phase 2] Those who have been injecting steroids for more than a few months or have received multiple injections of steroids.
Because of the possibility of transitioning to refractory cases, (1)-A, ,Btreatment to enhance the tendon's ability to repair itself, in addition to the treatment of
(1) ProlotherapyInjection is the simplest treatment aimed at strengthening the tendon and is often the first treatment tried in the [second stage] because it has no lifestyle restrictions and few side effects.
(2) If the pain is severe or the inflammation is persistent, such as repeated recurrence even with steroid injections, the purpose is to eliminate the inflammatory vessels,Inflammatory Vascular TherapyThe following is a list of the most common types of products that can be used.
(iii) As a stimulation therapy for tendon and bone, it is a bit invasive,fenestration drillingThe following is a list of the most common types of products that can be used.
【【Phase 3] Those who have been in the program for at least six months.
In refractory cases, scar tissue with inflammation has grown, and the ruptured tendon is difficult to repair. It is often necessary to remove the scar tissue and suture the ruptured tendon.
(1) If you wish to receive treatment with the least amount of pain as possible, we recommend the following methods to enhance your own natural healing power.Regenerative Medicine (PFC-FDTherapy,PRP(Therapy)The following is a list of the most common types of products that can be used.
(ii) To eradicate inflammatory blood vessels in the tendonscrapingto be performed. Because the techniques and tools used are similar, to increase the effectiveness of scrapingfenestration drillingat the same time.
(iii) If there is a lot of scar tissue (proliferation of inflammatory synovium), symptoms are difficult to remove because of inflammation and proliferation of painful nerves. In such cases, the proliferated synovectomy is excised.TENEX®︎Percutaneous tendon synovectomy bySurgery for non-surgical tendon synovectomyis applicable.
4) If the gap between the tendon and the bone is large enough for a synovectomy alone, the tendon must be surgically sutured because the gap cannot be filled by self-regeneration of the tendon. At our clinic, instead of conventional incisional surgery, we use a proprietarynontraumatic tendon sutureThe following is a list of the most common types of products that can be used.
(5) In the most severe cases of instability to the extent that the elbow wobbles or due to intra-articular free bodies or synovial hyperplasia,Ligament Reconstruction(This is not done at our clinic because it requires general anesthesia. (This is not done at our clinic because it requires general anesthesia.)
Treatment Options
In general, less effective treatments tend to be less painful, can be performed while continuing to work or play sports, and are less expensive, but require more frequent visits and are less effective. Conversely, the more effective treatments tend to be more painful, restrictive, and expensive.
For Patients Considering Surgery
Due to the magic of the word "surgery," there are many cases in which the appropriate treatment is not given at the right time, the disease has progressed, and surgery is chosen only after the tendon has become irreversible. We have devised this non-surgical procedure in the hope that if we can minimize the pain and fear as much as possible, the patient will be able to undergo surgery at an earlier stage, recover well, and return to his or her life.
The "no-cut" surgery is a unique technique developed at our clinic. As a pioneer clinic in Japan that introduced this technique early on, we have developed a delicate and precise method that is not available at other clinics, reducing the risk of inadequate tendon repair and neurovascular damage, and advancing safety and certainty.
When patients are asked to choose whether to receive treatment covered by insurance or at their own expense, we explain the advantages and disadvantages of these treatments to them and let them make their own choice. We will then do our best to provide the treatment of your choice. We believe that a relationship of trust with our patients is of utmost importance. We cannot provide treatment without mutual trust. Please feel free to contact us if you have any questions.
If you have any concerns, please inquire with the doctor until you are satisfied. We will explain everything as carefully as possible so that you will be able to enter into treatment with full understanding.
Responsible for writing Orthopedic Surgeon, Hand Surgery Specialist/Instructor
Yuki Toya
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