Taos Orthopaedic Institute 
Patient Guide to Knee Arthritis

 

Understanding Knee Arthritis

If you suffer from knee pain, it’s possible you have arthritis. Knee arthritis is caused by the deterioration of the bone lining in the knee joint called cartilage.

The two most common types of knee arthritis are osteoarthritis and rheumatoid arthritis.  Other causes are trauma, avascular necrosis or loss of blood supply to the knee joint, and prior knee surgery.

Osteoarthritis

The most common type of knee arthritis is osteoarthritis which is wear and tear.

 

Osteoarthritis is a progressive, degenerative disease in which the cartilage of the knee slowly wears away. Cartilage serves as insulation between the bones of the joint, and when the cartilage of the knee joint wears away due to osteoarthritis, the resulting pain and inflammation can be debilitating.

Your chances of osteoarthritis of the knee increase with age; the condition most often affects middle-aged and older people. Osteoarthritis may first appear between the ages of 30 and 40, although symptoms may not be present in the early stages. By the age of 70, almost everyone will have some degree of this type of knee arthritis.

Causes
The question of what causes osteoarthritis of the knee has not been answered. Prior knee injuries seem to increase the likelihood of osteoarthritis, but many people with knee arthritis have never had a serious knee injury. Osteoarthritis is the most common form of arthritis, and many people have a genetic predisposition to this chronic disease.

Symptoms
The primary symptoms of osteoarthritis are pain in the knee as well as swelling and stiffness joint.

In the early stages of osteoarthritis the pain may be mainly associated with activity. As the cartilage wears away and the bones rub against each other, pain can become more severe and constant, interfering with regular daily activities and disrupting sleep.

Treatment
In the early stages of osteoarthritis, treatment may involve several techniques.

Behavioral and lifestyle changes including losing weight and changing routines to avoid painful situations can be very effective in relieving pain.

Pain medications such as Tylenol or non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen (Advil or Motrin) or Naproxen (Aleve) may also provide relief from pain.

Physical therapy may improve muscle strength and joint mobility, reducing the symptoms of osteoarthritis in the knee.

Bracing may correct malalignment.

Joint fluid therapy such as oral glucosamine or injection of hyaluronic acid (HA) may lubricate the knee and reduce the pain and swelling of the joint. A corticosteroid injection may also be used to reduce pain; in this procedure an anti-inflammatory agent is injected directly into the joint.

Arthroscopy or partial or total knee replacement surgery may be necessary as the disease progresses and daily functioning becomes more impaired.

Rheumatoid Arthritis

Unlike osteoarthritis, rheumatoid knee arthritis involves inflammation of the lining of the joint, known as the synovium. Though less common than osteoarthritis, rheumatoid arthritis is among the most debilitating of the over one hundred forms of arthritis. Rheumatoid arthritis usually develops in middle age, but may occur in the 20s and 30s.

Causes
The exact cause of rheumatoid arthritis is unknown. It’s possible that a virus or bacteria may trigger the disease in people with a genetic predisposition to rheumatoid arthritis. Many doctors think rheumatoid arthritis is an autoimmune disease in which the tissue of the joint’s lining is attacked by the body’s immune system. It’s also possible that rheumatoid arthritis is caused by severe stress. The disease sometimes occurs after a life-changing event such as divorce, loss of a job or a severe injury.

Symptoms
The primary symptoms of rheumatoid arthritis include pain and swelling in the joints and difficulty moving. Other symptoms may include loss of appetite, fever, loss of energy, anemia, and rheumatoid nodules (lumps of tissue under the skin).

Treatment
Treatment of rheumatoid arthritis usually involves medications such as NSAIDs, aspirin and analgesics. In severe cases, surgery may be indicated to replace the knee joint with an artificial joint.

Understanding Knee Surgery Alternatives

Before deciding on knee surgery, Taos Orthopaedic Institute may try several knee surgery alternatives to relieve the pain and inflammation in your knee.

Knee Surgery Alternatives: Lifestyle Modification
The first alternative to knee surgery is lifestyle modification. This may include weight loss, avoiding activities such as running and twisting which can aggravate the knee injury, modifying exercise to no- and low-impact, and other changes in your daily routine to reduce stress on your knee.

Knee Surgery Alternatives: Exercise and Physical Therapy
Exercise and physical therapy may be prescribed to improve strength and flexibility. Exercises may include strengthening exercises such as riding a stationary bike, and stretching exercises such as flexing the ankle up and down, tightening and holding thigh muscles, sliding the heel forward on the floor, leg lifts, and knee extensions.

Exercise can strengthen your leg muscles and reduce your pain. If you really need knee surgery, this may not help, but many forms of knee pain can be mitigated by exercise.

Knee Surgery Alternatives: Pain Medications and Anti-inflammatory Medications
Arthritis pain is caused by inflammation in the knee as the bones rub against each other due to eroded cartilage. Reducing pain and inflammation of the tissue in the knee can provide temporary relief from pain and delay knee surgery.

For most patients, Tylenol is a safe pain medication. Anti-inflammatory medications (non-steroidal anti-inflammatory drugs or NSAIDs) such as Ibuprofen (Advil or Motrin) or Naproxen (Aleve) may also provide relief from pain and swelling. A corticosteroid injection may also be used to reduce pain; in this procedure a powerful anti-inflammatory agent is injected directly into the joint.

Knee Surgery Alternatives: Glucosamine/Chondroitin
A dietary supplement called glucosamine/chondroitin may improve the joint’s mobility and decrease pain from arthritis of the knee. Glucosamine and chondroitin sulfate can slow the deterioration of cartilage in the joint, reducing the pain of bone on bone. Both are naturally occurring molecules in the body. Glucosamine is thought to promote the growth of new cartilage and repair of damaged cartilage, while chondroitin is believed to promote water retention, improving the elasticity of cartilage, and also to inhibit cartilage-destroying enzymes.

Knee Surgery Alternatives: Joint Fluid Therapy
While medications and supplements can be helpful in reducing inflammation and pain and help you delay or avoid knee surgery, there are trade-offs. Drug therapies may have systemic side effects, and there is a limit to how much pain reduction can occur.

In a procedure called joint fluid therapy, a series of injections is made directly into the knee. This therapy is designed to reduce pain by improving lubrication in the knee, replacing the synovial fluid that lubricates the knee. Hyaluronate or hyaluronic acid (HA) is used for the treatment of osteoarthritis knee pain in patients who have failed to get adequate relief from simple painkillers or from exercise and physical therapy.

A solution made of highly purified, sodium hyaluronate is used in this procedure. HA is made from a natural chemical found in the body and is found in particularly high amounts in joint tissues and in the fluid (synovial fluid) that fills the joints.

The body’s own hyaluronan acts like a lubricant and shock absorber in synovial fluid of a healthy joint. Osteoarthritis reduces your synovial fluid’s ability to protect and lubricate your joint.

A physician administers an injection of HA solution into your knee once a week for 5 weeks (a total of 5 injections). This helps to re-lubricate your knee and reduce the pain of osteoarthritis, possibly delaying or helping you avoid knee surgery.  The series of 5 injections can last for 1 year and be repeated each year.

Bracing
A brace may be used to provide external stability to the knee joint. Braces are devices made of plastic, metal, leather and/or foam and are designed to stabilize a joint, reduce pain and inflammation, and strengthen the muscles of the knee. By putting pressure on the sides of the joint, the brace causes the joint to realign, which in turn decreases the contact between the two rough bone surfaces and reduces the pain while increasing mobility.

Understanding Total Knee Replacement

A total knee replacement involves cutting away the damaged bone of the knee joint and replacing it with a prosthesis. This ‘new joint’ prevents the bones from rubbing together and provides a smooth knee joint.

If you are considering knee surgery the following total knee replacement information might help you understand the procedure and implants better.

Your knees work hard during your daily routine, and arthritis of the knee or a knee injury can make it hard for you to perform normal tasks. If your injury or arthritis is severe, you may begin experience pain when you�re sitting down or trying to sleep.

Sometimes a total knee replacement is the only option for reducing pain and restoring a normal activity level. If Taos Orthopaedic Institute and you decide a total knee replacement is right for you, the following information will give you an understanding about what to expect.

Implant Components
In the total knee replacement procedure, each prosthesis is made up of parts. The tibial component has two elements and replaces the top of the shin bone or tibia. This prosthesis is made up of a metal tray attached directly to the bone and a plastic spacer that provides the bearing surface.

The femoral component replaces the bottom of the thigh bone or femur. This component also replaces the groove where the patella, or kneecap, sits.

The patellar component replaces the surface of the knee cap, which rubs against the femur. Patellar component problems are a most common cause of knee replacement complications.  For most patients, Taos Orthopaedic Institute uses a specially designed implant which eliminates the need for kneecap resurfacing.  This state-of-the-art technique eliminates this most common cause of mechanical failure of total knee replacement!

The Procedure
Before you are taken to the operating room you�ll be given medication to help you relax, and the anesthetist will talk with you about the medications he�ll be using. You may have an injection which will make your leg numb for many hours after the surgery and take away pain.  In the operating room, you will be placed under full anesthesia.

Once you are ‘under’, the surgeon will begin by making an incision in your leg to allow access to the knee joint. He’ll then expose the joint and place cutting jigs or templates on the end of the femur or thigh bone and the tibia or leg bone. These jigs allow the surgeon to cut the bone precisely so that the prosthesis fits exactly.

Now it’s time to place the prosthesis. This begins with the tibial prosthesis, which is cemented in place using special bone cement.  Next the metal component is cemented to the femur. The plastic spacer is then attached to the tibial tray. This will provide the weight-bearing surface of the leg.  If this component should wear out while the rest of the artificial knee is sound, it can be replaced. This is known as a revision. Finally, our state-of-the-art prosthesis and technique allow the patella to be spared while painful knee cap spurs are removed. The incision is closed, a drain is put in, and the post-operative bandaging is applied.

Returning Home
You will be discharged after three to five nights in the hospital when you can get out of bed on your own and walk with a walker or crutches.

At home you should begin ambulation with a support as tolerated. Keep your incision clean and dry and watch closely for any signs of infection.

You’ll continue your home exercise program and have home or outpatient physical therapy, where you will work on an advanced strengthening program and such exercises as stationary cycling, walking, and aquatic therapy.

Your long-term rehabilitation goals are a range of motion from 0 to at least 90 degrees of knee flexion, mild or no pain with walking or other functional activities, and independence in all activities of daily living.

Understanding Knee Replacement Alternative Bearing Material for Younger, Heavier or More Active Patients

OXINIUM is "Strong As An Ox!"

Not all implant devices are made of the same material. Due to significant advancements in technology, metallurgy and process, there is a revolutionary new material for implant devices that, quite literally, is "As Strong As An Ox!"

To date, cobalt chrome has been the material of choice for joint implants because of its strength and relative hardness. However, studies have shown that cobalt chrome implants roughen over time when implanted in your body. Every time a roughened replacement joint rubs against the plastic bearing surface, the plastic surface begins to wear out.

 

Laboratory studies have demonstrated that even a single scratch on the cobalt chrome surface can increase the rate of plastic wear by 10 times. Over time, the plastic surface wears out, and additional surgery is necessary to replace the worn implants. Recent studies have proven through controlled wear testing that a "scratched" or "roughened" cobalt chrome implant will dramatically increase the production of plastic wear debris, and substantially reduce the life span of an implant.

 

Oxinium or oxidized zirconium is the name of the material, and it is 4,900 times superior in terms of hardness, smoothness and resistance to scratching and abrasion compared to the cobalt chrome metal usually used for total knee replacement. Oxinium actually incorporates the best features of all available material options (ceramic and cobalt chrome) without the risks associated with either.

A younger, heavier or more active patient can expect an Oxinium replacement to be long-lasting and allow normal activities with less fear of undergoing a repeat replacement surgery.

Understanding Minimally Invasive Surgery (MIS) Total Knee Replacement

Have you heard about MIS Total Knee Replacement?  Few have; soon all will.

As in the field of arthroscopic surgery where invasive procedures are now performed with minimally invasive techniques, Knee Replacement procedures can now be MIS.

While Total Knee Replacement is traditionally performed through a large, tendon-cutting incision, MIS can now be performed via a 4 to 5 inch tendon-sparing, mini-incision.  The result: less patient pain, shorter hospitalization and faster recovery and rehabilitation!

James H. Lubowitz, MD, has not only attended courses and visited leading surgeons who are developing MIS Total Knee technique.  Dr. Lubowitz is himself such a leading developer, a teacher, lecturer, designer, industry consultant and educational course Faculty member.  In addition, Taos Orthopaedic Institute and Holy Cross Hospital in Taos are national surgeon visitor sites for MIS instruction.

Mini-incision Total Knee Replacement has been performed in Taos since 2003. Dr. Lubowitz is one of the first surgeons in the nation and believed to be the first surgeon in New Mexico to routinely offer his patients the MIS Total Knee.

Understanding Partial Knee Replacement Surgery

If you are considering knee surgery, the following partial knee replacement information may help you understand your alternatives.

Knee pain from arthritis can be particularly debilitating because we use our knees in almost all of our daily activities. If you are experiencing severe knee pain that interferes with your normal functioning, your doctor may recommend a partial knee replacement, also known as uni-compartmental knee replacement or UNI.

This procedure is less invasive than total knee replacement and may give relief to people suffering from arthritis of the knee or a knee injury. Partial knee replacement surgery replaces only the damaged area of your knee joint, may require only one day of hospitalization, and results in dramatically less recovery time when compared with total knee replacement surgery.

The knee can be divided into three compartments: the medial compartment, the lateral compartment, and the patello-femoral compartment. The uni-compartmental implant is designed to replace either the medial or lateral compartment.  The uni-compartmental knee replacement is a less invasive option for patients with knee arthritis that is isolated to either one compartment of the knee. This minimally invasive procedure provides several benefits to patients who have a moderately active lifestyle and are within normal weight ranges.

 

The procedure leaves a very small incision compared to a total knee replacement. There is no disruption of the muscles in the front of the knee which leads to more rapid rehabilitation. The procedure is often performed with no bone cuts and no cement. There is minimal blood loss in a partial knee replacement. The procedure causes less post-operative pain and requires greatly reduced hospitalization compared to a total knee replacement. There is also a reduced need for anesthesia and post-operative medication.

 

After the surgery, patients are able to walk and experience a faster rehabilitation and recovery. After achieving full recovery, most patients experience an increased range of motion when compared to total knee replacement.

Understanding Prevention of Knee Replacement Complications

In a small percentage of people, as with all major surgical procedures, knee replacement complications can occur. These risks include swelling, infection, bleeding, persistent pain, vascular and circulatory disorders, neurological symptoms, blood clots, anesthesia risks and even death in the rarest of cases. Your medical condition and general health contribute to the potential for complications.

 

The common complications of total knee surgery can now be largely avoided.  Each patient receives a thorough preoperative medical evaluation by an internist as well as routine pre-admission testing.

 

Below is a list of potential knee replacement complications and steps that we take at Taos Orthopaedic Institute and Holy Cross Hospital in Taos to prevent these complications.  In addition, we list steps that you, the patient, can take to prevent their occurrence.

Thrombophlebitis or Blood Clot
This condition is also known as deep vein thrombosis (DVT), and it occurs when the large veins of the leg form blood clots and, in some instances, become lodged in the capillaries of the lung and cause a pulmonary embolism (PE). While phlebitis (or inflammation of the leg veins) is not rare, the incidence of fatal pulmonary emboli (or blood clots to the lungs) has been almost totally eliminated. The following steps are taken to avoid knee replacement complications due to blood clots:

*  Foot and ankle exercises increase blood flow and enhance venous return in the lower leg after surgery

* Blood-thinning medication (anticoagulants) are prescribed after surgery

* Elastic wraps or support stockings (TED hose) are worn after surgery

* Continuous Passive Motion (CPM) machines and early mobilization, ambulation, and physical therapy are prescribed after surgery

* Plexipulse foot compression pumps increase blood flow and enhance venous return in the lower leg after surgery

IMPORTANT: If you develop swelling, redness, pain and/or tenderness in the calf muscle, chest pain, or shortness of breath, report these symptoms to your orthopaedic surgeon immediately.

Infection
Although great precaution is taken before, during, and after surgery, infections do occur in a small percentage of patients following knee replacement surgery. Thanks to our use of antibiotics, expeditious surgery, and a surgical team wearing sterile exhaust hood operating room space suits, the infection rate at our institution is below average.

In addition, steps our patients take to minimize this knee replacement complication include:

* Iodine showers before surgery

* Dental evaluation for abscess or infection before surgery

* Strict incision care guidelines after surgery

IMPORTANT: If you develop redness, swelling, tenderness, increased drainage, foul odor, persistent fever above 100.4 degrees orally, and increasing pain report these symptoms to your orthopaedic surgeon immediately.

Pneumonia
Because your lungs tend to become "lazy" as a result of the anesthesia, secretions may pool at the base of your lungs, which may lead to lung congestion or pneumonia. The following steps are taken to minimize this complication:

* Deep breathing exercises: Patients take deep breaths and cough out any secretions each hour after surgery while awake

* Incentive Spirometer: This simple device gives you visual feedback while you perform your deep breathing exercises. Your nurse or respiratory therapist will demonstrate proper technique. Patients take 10 deep breaths using the incentive spirometer each hour while awake

Knee Stiffness
In some cases, the mobility of your knee following surgery may be significantly restricted and you may develop a contracture in the joint that will cause stiffness during walking or other activities of daily living. The following steps must be taken to maximize your range of motion following surgery:

* Continuous Passive Motion (CPM) machines are prescribed after surgery to slowly and gently bend and straighten the knee while you rest

* Physical therapy begins on post-surgical Day #1 to begin range of motion exercises and walking

* Edema control to reduce swelling (ice, compression stocking, and elevation)

* Adequate pain control so you can tolerate the rehabilitation regime

Understanding Total Knee Replacement: Preparation, Surgery and Recovery

Sometimes a knee replacement is the only option for reducing pain and restoring a normal activity level.  If Taos Orthopaedic Institute and you decide that knee surgery is right for you, here is an idea of what to expect during days leading up to, the day of, and the days after your surgery.

Preparing For Your Operation

 1.   Betadine (iodine) showers are advised twice daily for two weeks before surgery to lower the bacteria count of the skin.  You can obtain Betadine Skin Cleanser from most pharmacies without a prescription.

 2.     Multiple vitamins are advised, one daily for two weeks before surgery.

 3.     Discontinue aspirin and anti-inflammatory drugs (arthritis medications) two weeks before surgery.

 4.     There is a program known as auto transfusion for those who are able to give their own blood.  Your blood will be held for your own use and returned at the time of surgery.  Arrangements for this procedure can be made with our office. 

 Additionally, patients participating in this program need to take supplemental iron tablets as well as a multivitamin.

 5.     A dentist must check your teeth for any abscess or infection prior to surgery.

 6.     A complete medical evaluation must be performed prior to surgery by your primary care physician.  You will also obtain the necessary preoperative studies such as a chest x-ray, blood counts and electrocardiogram.

 The Day of Surgery

 1.     Absolutely nothing should be taken by mouth to eat or drink after midnight on the night before surgery.  It is essential that your stomach be completely empty at the time of your operation.

 2.     Your knee will be shaved and scrubbed by an OR nurse prior to the operation to ensure cleanliness.

 3.  Antibiotic medications will be started just prior to surgery and continued after the operation intravenously.

 4.     You will be taken to the operating room approximately twenty minutes before the scheduled time of your surgery.  You will be asked to wear a hospital gown and to remove any jewelry as well as dentures or wigs.  Your valuables should be left at home or with your family.  If this is not possible, please leave them with the nursing staff who will arrange security.

 5.    You will receive preoperative medications by injection to help you relax and be more comfortable during preparations for your surgery.

 6.   You will be transported to the operating room on a stretcher or bed.  There you will be given medication by the Anesthetist to put you to sleep once you are in the room.  There are a wide variety of techniques used for anesthesia, all of which prevent pain during the surgical procedure.  If you wish, it is even possible to be awake during your surgery.

 AFTER SURGERY

 1.  You will be in the recovery room in your bed with your knee cushioned in a Continuous Passive Motion (C.P.M.) machine.  This cradle will help you with your physical therapy by slowly increasing the motion of your knee throughout your hospital stay.

 2.      Intravenous fluids and antibiotics are often given for the first two post-operative days.  You may eat and drink as you are able to tolerate liquids and food. 

 3.      The nurses and physical therapist will show you how to move in bed and how to exercise your legs.

 4.      Several measures are taken to prevent blood clots.  Elastic stockings and foot compression pumps are worn and calf exercises are encouraged. A special medication will be administered to help prevent blood clots from forming. Early ambulation, mobilization and physical therapy (post-surgical Day #1) are also important to improve circulation and to prevent complications.

 5.     The surgical dressing is removed two days after surgery.  There may be small drainage tubes that are usually removed two days after surgery.

 6.     Exercises to strengthen the arms and legs and to encourage circulation are performed throughout the entire postoperative period.

 7.     Pain control is achieved by a variety of effective measures including pills, injections, PCA (patient controlled analgesia), and epidural analgesia.  PCA is given via an IV into the arm, and pain relief can be achieved by pressing a button to administer your own medication.  In addition, pain and sleeping medications are available and can be obtained simply by asking or notifying the nursing staff.  If the drug prescribed does not appear satisfactory, please notify the nursing or medical staff so that a substitute may be ordered.

 8.     Ambulation with a walker is started on the first postoperative day.  The physical therapist will help with walking and bending the knee twice a day.  Walking is performed with the assistance of the physical therapist and by the Nursing Staff. Your family can also assist you when you are strong enough. 

 Preparation for Leaving the Hospital

Goals

The hospital time is primarily devoted to increasing your level of independence and bending your knee.  We prescribe daily physical therapy sessions to increase range of motion of your knee.  Stair climbing may be instructed as well as the basic activities of daily living.

Prior to being discharged from the hospital, you must be able to:

1.  Get in and out of bed yourself.

2.  Walk confidently in the hallway with a walker or crutches.

3.  Climb stairs.

4.  Be able to bathe and care for yourself.

5.  Understand all the dos and don'ts for being at home.

6.  You also must be able to bend your knee an acceptable amount.

If you are unable to achieve these goals in the hospital, these tasks can be accomplished by transferring you for additional treatment at an Inpatient Rehabilitation Center or in a Skilled Nursing Facility prior to your discharge to home. 

When you go home, outpatient or home physical therapy services will be arranged. In special cases, a home nursing or health aide may be recommended. You may need someone to provide food and run errands.  Our Social Service Department will help you with the details of these arrangements.  Please ask our team (nurses, doctors, physical therapists, social service department, etc.) to help you to make these decisions.

           

Understanding Life after Knee Replacement Surgery

 

Knee Condition and Mobility

Once you've had knee replacement surgery and completed rehab, your knee should have range of motion and strength sufficient for all your daily tasks such as walking and climbing stairs.

 

Thanks to your new knee, you will be able to do many of the activities you did before your knee surgery, but with little or no pain.  Most people with total knees can do recreational walking, swimming, golf, light hiking, recreational biking, ballroom dancing and stair climbing without difficulty. Usual activities such as housekeeping, gardening, driving, dancing, and sex are encouraged. Exercise is important on a regular basis

 

Maintain Your Ideal Weight

 Increased forces on your knee may lead to wear or loosening; your weight directly correlates with the amount of force on the knee joint.

 

Infectious Precautions

 Infectious precautions are important to prevent the artificial joint from infection. You must take antibiotic pills prior to any invasive procedure such as dental work or gastrointestinal studies. 

 

Periodic Office Visits

 Patients receiving total knee replacement should see Taos Orthopaedic Institute periodically after surgery.  This varies depending on the individual.  This follow-up visit helps diagnose any potential complications which may arise and allows us to monitor the successful or poor outcomes of all total knee replacements.  (Please keep us informed of any changes in your status or address).

 

Activities to Avoid

Even though your activity level is likely to increase, a knee replacement surgery means that high-demand or high-impact activities must be avoided. You should definitely avoid running or jogging, contact sports, jumping sports, and high impact aerobics.

 You should also try to avoid vigorous hiking, aggressive skiing, singles tennis, repetitive lifting exceeding 50 pounds, and repetitive aerobic stair climbing.  The safest aerobic exercises are biking (stationary and traditional) or swimming because these place very little stress on the knee joint.

 

How Long Your Implant Should Last

The average total knee currently lasts 10-20 years before the components wear out. In some cases, worn components can be easily switched out for new ones, but revision surgery is always an experience doctors and patients want to avoid if at all possible.

 Fortunately, there have been significant advances in materials and designs that extend the life of total knee replacements.  Oxinium means 85% less wear for younger, heavier or more active patients with a goal of avoiding the need for revision surgery due to long term wear.

This Taos Orthopaedic Institute Patient Guide to Knee Arthritis has been prepared in cooperation with Smith & Nephew Orthopaedics:





Copyright 2003  www.Knee-Replacement-Info.com.

  Updated: July 31, 2010