Blog

  • Effectiveness and relevant factors of platelet?rich plasma treatment in managing plantar fasciitis: A systematic review

    Abstract

    Background: Plantar fasciitis (PF) is a common foot complaint, affects both active sportsmen and physically inactive middle age group. It is believed that PF results from degenerative changes rather than inflammation. Platelet?rich plasma (PRP) therapy has been introduced as an alternative therapy for PF. This study is aimed to systematically review to the effectiveness and relevant factors of PRP treatment in managing PF. Materials and Methods: A search was conducted in electronic databases, including PubMed,Scopus, and Google Scholar using different keywords. Publications in English?language from 2010 to 2015 were included. Two reviewers extracted data from selected articles after the quality assessment was done. Results: A total of 1126 articles were retrieved,but only 12 articles met inclusion and exclusion criteria. With a total of 455 patients, a number of potentially influencing factors on the effectiveness of PRP for PF was identified. In all these studies, PRP had been injected directly into the plantar fascia, with or without ultrasound guidance. Steps from preparation to injection were found equally crucial. Amount of collected blood, types of blood anti?coagulant, methods in preparing PRP, speed, and numbers of time the blood samples were centrifuged, activating agent added to the PRP and techniques of injection, were varied between different studies. Regardless of these variations, superiority of PRP treatment compared to steroid was reported in all studies. Conclusion: PRP therapy might provide an effective alternative to conservative management of PF with no obvious side effect or complication. The onset of action after PRP injection also greatly depended on the degree of degeneration.

    Read More

  • Sciatica: Treatment with intradiscal and intraforaminal injections of steroid and oxygen-ozone versus steroid only

    Abstract

    Purpose:

    To prospectively compare the clinical effectiveness of intraforaminal and intradiscal injections of a mixture of a steroid, a local anesthetic, and oxygen-ozone (O(2)-O(3)) (chemodiscolysis) versus intraforaminal and intradiscal injections of a steroid and an anesthetic in the management of radicular pain related to acute lumbar disk herniation.

    Materials And Methods: Medical Ethical Committee approval and informed consent were obtained. One hundred fifty-nine patients (86 men, 73 women; age range, 18-71 years) were included and were randomly assigned to two groups. Seventy-seven patients (group A) underwent intradiscal and intraforaminal injections of a steroid and an anesthetic, and 82 patients (group B) underwent the same treatment with the addition of an O(2)-O(3) mixture. Procedures were performed with computed tomographic guidance. An Oswestry Low Back Pain Disability Questionnaire was administered before treatment and at intervals, the last at 6-month follow-up. Patients and clinicians were blinded as to which treatment was performed. Results were compared with the chi(2) test.

    Read More

  • The Efficacy of Platelet-Rich Plasma in the Treatment of Rib Fractures.

    Abstract

    Background: €ƒRib fracture is the most common result of thoracic traumas. Intrapulmonary shunt, alveolar capillary membrane damage, intra-alveolar hemorrhage, and hypoxia may develop following rib fractures. Therefore, prompt treatment is important. The aim of this experimental study was to analyze the effects of platelet-rich plasma (PRP) on rib fractures to secure a speedier and more efficient treatment method. Materials and Methods €ƒThe study involved 18 New Zealand white rabbits, randomly divided into three groups as Group 1, the sham group with no surgical intervention; Group 2, the control group in which simple rib fractures were applied and no treatment; and Group 3, in which rib fractures were applied and then PRP treatment was administered. Results €ƒThe mean recovery plate thickness measurements were found to be statistically significantly higher in the PRP group compared with the other groups (p < 0.005). A thicker fibrotic cell proliferation and the formation of many capillaries were observed around the growth plate in the PRP group compared with the other groups. These structures were lesser in the control group compared with the PRP group and at the lowest level in the sham group. Larger and distinct callus formation was observed and a new intramedullary field in the PRP group. Conclusions €ƒPRP is a reliable and effective autologous product with minimal side effects, which can be considered as an alternative treatment in patients with rib fractures and used easily in pseudoarthrosis, surgical fracture, or flail chest.

    Read More

  • Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis

    Abstract

    Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi-randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.

    Read More

  • Platelet-rich Plasma and Bone Marrow-derived Mesenchymal Stem Cells in Sports Medicine

    Abstract

    Regenerative medicine is a fast-growing field in orthopedic sports medicine. Platelet-rich plasma contains multiple factors that have been shown to augment healing, thereby stimulating its use in multiple areas of acute and chronic injuries. Mesenchymal stem cells have pluripotent potential to form into tissues pertinent to orthopedics, such as cartilage and bone. As such, there is been a surge in the research directed toward steering those stem cells into a particular lineage as part of treatment for a variety of soft-tissue, cartilage, and bone pathologies. Overall, there are promising reports of their potential success, but there is a need for continued investigation into the efficacy of platelet-rich plasma and stem cells in sports medicine.

    Read More

  • Impact of platelet-rich plasma injection timing on healing of Achilles tendon injury in a rat model.

    Abstract

    Objective: The aim of this study was to evaluate the impact of the timing of platelet-rich plasma (PRP) application on the healing of Achilles tendon injury in a rat model.

    Methods: Fifty-four female Sprague-Dawley rats were divided into 4 groups: PRP preparation group (n=6); Achilles tendon tear and 150

    Read More

  • Efficacy of Platelet-Rich Plasma versus Hyaluronic Acid for treatment of Knee Osteoarthritis: A systematic review and meta-analysis

    Abstract

    Introduction: Knee osteoarthritis is a very common chronic degenerative disease that could impose significant costs to the health system. Although osteoarthritis can affect all joints, knee osteoarthritis is the most common type among adolescents. Non-surgical treatments include corticosteroids injection, hyaluronic acid, and platelet-rich plasma. The aim of this study was to investigate the efficiency of platelet-rich plasma versus hyaluronic acid for the treatment of knee osteoarthritis.

    Methods: Pubmed, Cochran library, Scopus and Ovid databases were investigated to identify related studies from 2000 through August 2015. To study the efficiency, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) outcome using the Standard Mean Difference (SMD) index was calculated using a random model and a confidence interval of 95%. In addition, sensitivity and cumulative analysis were conducted. The data were analyzed using RevMan 5.3.5 and Stata 12 software.

    Results: Seven studies with 722 subjects (364 participants in PRP and 358 participants in the HA group) were analyzed. The WOMAC PRP compared to HA, SMD = −0.75 (95% CI: −1.33 to −0.18, I2 = 92.6%) in treatment of knee osteoarthritis was statistically significant and PRP was more effective.

    Conclusion: The results of this meta-analysis two years after PRP injection showed the efficacy of PRP versus HA. However, further studies are required to determine the longer-term effects.

    Read More

  • Good prognosis factors after a platelet rich plasma (PRP) injection for tendinopathies ?

    Abstract

    Introduction : Platelet-rich plasma injections are a recent treatment for chronic tendinopathies. However, this theraeutic remains controversed in litterature. Up to now, there is no prognosis factors identified to predict a good evolution after injection of PRP.

    Purpose: The aims of this study were to evaluate the effect of PRP injection followed by a standardized reeducation protocol among patients suffering from different tendinopathies and to determine the good prognosis factors, if any.

    Methods : 51 patients suffering from different tendinopathies and refractory to conventional physiotherapy were treated with a PRP injection. Prior to the injection, a blood sample was drawn and some biological parameters (glycemia, cholesterol level, ...). A pain assessment was then made using a visual analog scale (VAS) and a pressure algometer. The same assessment was carried out after 6 weeks and 12 weeks when possible.

    Results : There is an overall significant improvement VAS score at the end of the 12 weeks follow- up. However, no correlation was found between the evolution of the clinical scores and the biological parameters measured.

    Discussion and Conclusions : A PRP injection followed by a program of eccentric rehabilitation positively affects the algo-functional scores of patients with tendinopathie who were refractory to conventional physiotherapy, whatever their initial biological parameters.

    Read More

  • Does platelet-rich plasma decrease time to return to sports in acute muscle tear? A randomized controlled trial

    Abstract


    Purpose: The aim of this study is to report the effects of autologous PRP injections on time to return to play and recurrence rate after acute grade 2 muscle injuries in recreational and competitive athletes.


    Methods: Seventy-five patients diagnosed with acute muscle injuries were randomly allocated to autologous PRP therapy combined with a rehabilitation programme or a rehabilitation programme only. The primary outcome of this study was time to return to play. In addition, changes in pain severity and recurrence rates were evaluated.


    Results: Patients in the PRP group achieved full recovery significantly earlier than controls (P = 0.001). The mean time to return to play was 21.1 ± 3.1 days and 25 ± 2.8 days for the PRP and control groups, respectively (P = 0.001). Significantly lower pain severity scores were observed in the PRP group throughout the study. The difference in the recurrence rate after 2-year-follow-up was not statistically significant between groups.


    Conclusions: A single PRP injection combined with a rehabilitation programme significantly shortened time to return to sports compared to a rehabilitation programme only. Recurrence rate was not significantly different between groups.

    Read More

  • Mesenchymal stem cells (MSCs) as skeletal therapeutics-an update

    Abstract

    Mesenchymal stem cells hold the promise to treat not only several congenital and acquired bone degenerative diseases but also to repair and regenerate morbid bone tissues. Utilizing MSCs, several lines of evidences advocate promising clinical outcomes in skeletal diseases and skeletal tissue repair/regeneration. In this context, both, autologous and allogeneic cell transfer options have been utilized. Studies suggest that MSCs are transplanted either alone by mixing with autogenous plasma/serum or by loading onto repair/induction supportive resorb-able scaffolds. Thus, this review is aimed at highlighting a wide range of pertinent clinical therapeutic options of MSCs in the treatment of skeletal diseases and skeletal tissue regeneration. Additionally, in skeletal disease and regenerative sections, only the early and more recent preclinical evidences are discussed followed by all the pertinent clinical studies. Moreover, germane post transplant therapeutic mechanisms afforded by MSCs have also been conversed. Nonetheless, assertive use of MSCs in the clinic for skeletal disorders and repair is far from a mature therapeutic option, therefore, posed challenges and future directions are also discussed. Importantly, for uniformity at all instances, term MSCs is used throughout the review.

    Read More

  • Return to Sports After Bone Marrow-Derived Cell Transplantation for Osteochondral Lesions of the Talus

    Abstract

    Objective: Arthroscopic \"one-step\" technique based on bone marrow-derived cell transplantation (BMDCT) have achieved good results in repairing osteochondral lesions of the talus (OLT), overcoming important drawbacks of older techniques. It may be particularly adequate for the treatment of athletes in order to permit a safe and stable return to sports. The aim of this study was to report the results at 48 months of a series of athletes and the factors influencing the return to sports.

    Design: Case series. A total of 140 athletes underwent a \"one-step\" BMDCT repair of OLT. All the patients had the cells harvested from the iliac crest, condensed and loaded on a scaffold, and then implanted. Patients were evaluated clinically by the American Orthopaedic Foot and Ankle Society (AOFAS) scores and Halasi score.

    Results: AOFAS score improved from 58.7

    Read More

  • Dr Weglein with Dr Lytgot from new zealand at annual orthopedic prolotherapy meeting

    Dr Weglein with Dr Lytgot from new zealand at annual orthopedic prolotherapy meeting

    Read More

  • Choice of intra-articular injection in treatment of knee osteoarthritis: platelet-rich plasma, hyaluronic acid or ozone options

    Abstract

    Purpose: This study was performed to compare the efficacy of treatment in three groups of patients with knee osteoarthritis (OA) given an intra-articular injection of platelet-rich plasma (PRP), hyaluronic acid (HA) or ozone gas.

    Methods: A total of 102 patients with mild-moderate and moderate knee OA who presented at the polyclinic with at least a 1-year history of knee pain and VAS score ≥4 were randomly separated into three groups. Group 1 (PRP group) received intra-articular injection of PRP ×— 2 doses, Group 2 (HA group) received a single dose of HA, and Group 3 (Ozone group) received ozone ×— four doses. Weight-bearing anteroposterior-lateral and Merchant\'s radiographs of both knees were evaluated. WOMAC and VAS scores were applied to all patients on first presentation and at 1, 3, 6 and 12 months.

    Results: At the end of the 1st month after injection, significant improvements were seen in all groups. In the 3rd month, the improvements in WOMAC and VAS scores were similar in Groups 1 and 2, while those in Group 3 were lower (p < 0.001). At the 6th month, while the clinical efficacies of PRP and HA were similar and continued, the clinical effect of ozone had disappeared (p < 0.001). At the end of the 12th month, PRP was determined to be both statistically and clinically superior to HA (p < 0.001).

    Conclusion: In the treatment of mild-moderate knee OA, PRP was more successful than HA and ozone injections, as the application alone was sufficient to provide at least 12 months of pain-free daily living activities.

    Read More

  • The Chondrogenic Effect of Intra-articular Hypertonic-dextrose (prolotherapy) in Severe Knee Osteoarthritis

    Abstract

    Background: Dextrose injection is reported to improve KOA-related clinical outcomes, but its effect on articular cartilage is unknown. A chondrogenic effect of dextrose injection has been proposed.

    Objective: To assess biological and clinical effects of intra-articular hypertonic dextrose injections (prolotherapy) in painful knee osteoarthritis (KOA).

    Design: Case series with blinded arthroscopic evaluation before and after treatment.

    Setting: Physical medicine and day surgery practice.

    Participants: Symptomatic KOA for at least 6 months, arthroscopy-confirmed medial compartment exposed subchondral bone, and temporary pain relief with intra-articular lidocaine injection.

    Intervention: Four to six monthly 10 mL intra-articular injections with 12.5% dextrose.

    Main outcome measures: Visual cartilage growth assessment of 9 standardized medial condyle zones in each of 6 participants by three arthroscopy readers masked to pre/post injection status (total 54 zones evaluated per reader); biopsy of a cartilage growth-area post-treatment, evaluated using H&E and Safranin-O stains, quantitative polarized light microscopy, and immunohistologic cartilage typing; self-reported knee specific quality of life using the Western Ontario McMaster University Osteoarthritis Index (WOMAC, 0-100 points).

    Results: Six participants (1 female) with median age of 71, WOMAC composite score of 57.5 points and a 9-year pain duration received a median 6 dextrose injections and follow-up arthroscopy at 7.75 (4.5-9.5) months. In 19 of 54 zone comparisons all three readers agreed that the post-treatment zone showed cartilage growth compared with the pre-treatment zone. Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibro- and hyaline-like cartilage. Compared with baseline status, the median WOMAC score improved 13 points (p=.013). Self-limited soreness after methylene-blue instillation was noted.

    Conclusions: Positive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in symptomatic grade IV KOA participants suggesting disease-modifying effects and the need for confirmation in controlled studies. Minimally invasive arthroscopy (single-compartment, single-portal) enabled collection of robust intra-articular data.

    Read More

  • Five and ten year follow-up on intradiscal ozone injection for disc herniation

    Abstract

    Background: Disc herniation is the most common cause for spinal surgery and many clinicians employ epidural steroid injections with limited success. Intradiscal injection of ozone gas has been used as an alternative to epidural steroids and surgical discectomy. Early results are positive but long-term data are limited.

    Methods: One hundred and eight patients with confirmed contiguous disc herniation were treated with intradiscal injection of ozone in 2002-2003. One-hundred seven patients were available for telephone follow-up at 5 years. Sixty patients were available for a similar telephone follow-up at ten years. Patients were asked to describe their clinical outcome since the injection. Surgical events were documented. MRI images were reviewed to assess the reduction in disc herniation at six months.

    Results: MRI films demonstrated a consistent reduction in the size of the disc herniation. Seventy-nine percent of patients had a reduction in herniation volume and the average reduction was 56%. There were 19 patients that ultimately had surgery and 12 of them occurred in the first six months after injection. One of these 12 was due to surgery at another level. Two surgeries involved an interspinous spacer indicated by stenosis or DDD. All other surgeries were discectomies. Of the patients that avoided surgery 82% were improved at 5 years and 88% were improved at 10 years. Other than subsequent surgeries, no spine-related complications were experienced.

    Conclusions/Level of Evidence: We conclude that ozone is safe and effective in approximately 75% of patients with disc herniation and the benefit is maintained through ten years. This is a retrospective review and randomized trials are needed.

    Clinical Relevance: Intradiscal ozone injection may enable patients to address their pain without multiple epidural injections and surgery. The benefit of ozone is durable and does not preclude future surgical options. The risk reward profile for this treatment is favorable.

    Read More

  • Intra-articular Treatment of Knee Osteoarthritis: from Anti-inflammatories to Products of Regenerative Medicine

    Abstract

    Objectives: Knee osteoarthritis (OA)1 is a debilitating condition that may ultimately require total knee arthroplasty (TKA).2 Non-operative treatments are bracing, oral analgesics, physical therapy, and intra-articular knee injection (IAKI).3 The objective of this paper is to provide a systematic literature review regarding intra-articular treatment of knee OA and insight into promising new products of regenerative medicine that may eventually have a substantial effect on treatment.

    Methods: A literature search was executed using Medline, Cochrane, and Embase with keywords \"knee osteoarthritis\" and \"injection.\" Specifically, 45 articles that discussed intra-articular knee injection using corticosteroids, hyaluronic acid, analgesics, local anesthetics, and newer products of regenerative medicine, such as platelet-rich plasma (PRP)4 and mesenchymal stem cells (MSC),5 were analyzed. Of these, eleven were level 1, three were level 2, twelve were level 3, two were level 4, and seventeen were level 5 evidence. Papers included animal models.

    Results: Local anesthetics have potential side effects and may only be effective for a few hours. Morphine and ketorolac may provide significant pain relief for 24 hours. Corticosteroids may give patients weeks to months of effective analgesia, but complications may occur, such as systemic hyperglycemia, septic arthritis, and joint degradation . Hyaluronic acid is a natural component of synovial fluid, but efficacy with respect to analgesia is controversial. Platelet-rich plasma formulations, autologous conditioned serum, autologous protein solution, and mesenchymal stem cell injections contain anti-inflammatory molecules and have been proposed to attenuate joint destruction or potentially remodel the joint.

    Conclusions: Currently, knee OA treatment does not address the progressively inflammatory environment of the joint. More investigation is needed regarding products of regenerative medicine, but they may ultimately have profound implications in the way knee OA is managed.

    Read More

  • Regeneration of articular cartilage using adipose stem cells

    Abstract

    Articular cartilage (AC) has limited potential for self-regeneration and damage to AC eventually leads to the development and progression of osteoarthritis (OA). Cell implantation strategies have emerged as a new treatment modality to regenerate AC. Adipose stem cells/adipose-derived stromal cells (ASCs) have gained attention due to their abundance, excellent proliferative potential, and minimal morbidity during harvest. These advantages lower the cost of cell therapy by circumventing time-consuming procedure of culture expansion. ASCs have drawn attention as a potential source for cartilage regeneration since the feasibility of chondrogenesis from ASCs was first reported. After several groups reported inferior chondrogenesis from ASCs, numerous methods were devised to overcome the intrinsic properties. Most in vivo animal studies have reported good results using predifferentiated or undifferentiated, autologous or allogeneic ASCs to regenerate cartilage in osteochondral defects or surgically-induced OA. In this review, we summarize literature on the isolation and in vitro differentiation processes of ASCs, in vivo studies to regenerate AC in osteochondral defects and OA using ASCs, and clinical applications of ASCs.

    Read More

  • Clinical Outcomes of Biologic Treatment for Chronic Tendinopathy

    Abstract

    Biological interventions, such as ultrasound guided platelet rich plasma (PRP) injections, are a second line treatment worth considering for recalcitrant tendinopathy, but efficacy and effectiveness have not been established yet. The use of PRP has been most commonly studied in lateral epicondylitis, with nine randomized controlled trials and seven prospective controlled studies in the medical literature. Corticosteroid injection was used as the comparator in six studies, autologous blood in three, and local anesthetic agents in two studies. Recent meta-analyses showed that PRP and autologous blood are superior to corticosteroids in pain reduction and ameliorating functionality in epicondylitis. PRP efficacy on supraspinatus tears are controversial, and PRP is better than controls in two out of five studies, when compared with corticosteroids and dry needling. Patellar tendinopathy is examined in four controlled studies, and eight case series, PRP ameliorated outcomes but not in all cases. Whether more than one injection should be given is under discussion. Achilles tendinopathy was examined in three prospective controlled studies (a single injection), and six case series. Patients showed improvements regarding baseline values, but two controlled studies failed to reveal differences with controls. Pooling data across studies is challenging because of heterogeneity in outcome scores and comparators. Tendinopathy progression and outcomes are poorly monitored with self-reported questionnaires that are not sensitive enough to discriminate local changes. Molecular indicators of tendon health and disease can help to assess whether the condition progress or heal after biological interventions. The international consensus about the design of clinical studies should be pursued.

    Read More

  • Platelet-rich plasma limits the nerve injury caused by 10% dextrose in the rabbit median nerve

    Abstract

    Introduction: We evaluated the effect of platelet-rich plasma (PRP) injection in a rabbit model of dextrose-induced median nerve injury.

    Methods: New Zealand white rabbits (n = 15) were divided randomly into 3 groups. Three different regimens (group 1: 0.1 ml saline; group 2: 10% dextrose with PRP; group 3: 10% dextrose with saline) were injected within the carpal tunnel. Electrophysiological and histological findings were evaluated 12 weeks after the injection.

    Results: The mean median motor latency in group 3 was significantly longer than that in groups 1 and 2. The cross-sectional area of the median nerve and subsynovial connective tissue thickness in group 3 were significantly larger than those in groups 1 and 2.

    Conclusion: PRP injection may be effective in controlling median nerve injury, as demonstrated by improvement in electrophysiological and histological findings 12 weeks after dextrose injection.

    Read More

  • A new strategy to tackle severe knee osteoarthritis: Combination of intra-articular and intraosseous injections of Platelet Rich Plasma

    Abstract

    Introduction: Knee osteoarthritis (KOA) is a mechanically induced, cytokine and enzyme-mediated disorder involving all the joint tissue of the knee. Rebuilding a physiological-homeostatic network at the tissue level following knee organ failure, such as in severe KOA, is a daunting task with therapeutic targets encompassing the articular cartilage, synovium and subchondral bone. Intraarticular infiltration of plasma rich in growth factors (PRP) has emerged as a promising symptomatic approach, although it is insufficient to reach the subchondral bone.

    Areas covered: This review addresses current molecular and cellular data in joint homeostasis and osteoarthritis pathophysiology. In particular, it focuses on changes that subchondral bone undergoes in knee osteoarthritis and evaluates recent observations on the crosstalk among articular cartilage, subchondral bone and synovial membrane. In addition, we review some mechanistic aspects that have been proposed and provide the rationale for using PRP intraosseously in KOA.

    Expert opinion: The knee joint is a paradigm of autonomy and connectedness of its anatomical structures and tissues from which it is made. We propose an innovative approach to the treatment of severe knee osteoarthritis consisting of a combination of intraarticular and intraosseous infiltrations of PRP, which might offer a new therapeutic tool in KOA therapy.

    Disclaimer: As a service to authors and researchers we are providing this version of an accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proofs will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to these versions also.

    Read More

FirstPrevious | Pages 6 7 8 9 10 [11] 12 13 14 15 16 of 30 | Next | Last
Schedule a Consultation

For all appointments & inquiries