Frequently Asked Questions (FAQ). Alphaklinik - The international specialists for knee, back and shoulder problems

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Frequently Asked Questions (FAQ)

Is it true that the bones rub against each other after removal of part of the meniscus?

In the first place, it is important to know that in a joint it is not the bones but the articular cartilage that covers the bony ends that rub against each other. It goes without saying that in the ideal situation both menisci are intact. As soon as a piece is detached and if it cannot be sutured back because of the patient's age or the localization of the tear, the torn part has to be removed. Such a piece has lost its weight-bearing function and it is the far lesser evil to remove it than to leave it in place. Both the bony and cartilagenon structures will adapt to the resulting changes in the weight-bearing situation and international statistics have demonstrated the risk of subsequent osteoarthritis developing to be minimal.

Do meniscal repairs also heal in an elderly patient?

First of all we have to acknowledge that not all types of meniscal tears lend themselves to suture or repair. Only tears near the joint capsule, where there is sufficient blood supply, have a good tendency to heal. In this zone such tears would also heal in an elderly patient. In the case of the tear being located a few millimeters away from that zone towards the free edge of the meniscus, healing is insecure, even in a young individual, and in an elderly patient one would not even attempt to suture such a tear.

I have arthritis in the knee and my doctors tell me there is nothing to be done about that and that I have to live with the condition. Is that true?

The current doctrine on this topic says that arthritis is a continuing wear and tear desease for which there is no causal therapy. In the case of the patient being old enough - meaning about 65 years for men and 60 years for women -, total knee replacement is felt to be a good solution. In younger individuals, pain and discomfort could be aleviated, but the arthritic process as such could not be healed. Fortunately this is not the case! (Further information: arthritis of the knee joint - who says you can't do anything about it? ). There is a whole array of techniques to close articular cartilage defects even if they reach down to bone. These techniques aim at filling the defects with a repair tissue (fibrocartilage) which, similar to a toothfilling, will remain in place permanently. The repaired tissue filling the defect both serves to protect the underlying bone and also support the surrounding articular cartilage and protect it from further damage. Techniques to achieve this goal include the so-called shaving, microfractures and abrasion, which all aim at stimulating fibro-cartilagenous regrowth. The outcome of such surgical interventions does not only depend on the expertise of the surgeon but also on the patient's discipline to closely follow the guidelines given to him. There is no place for resignation in the treatment of osteoarthritis. With such a comprehensive overhaul of the joint's articular surfaces the need for total knee joint replacement can be postponed by many years.

Further information can also be found in Dr. Toft's new book titled: "Arthritis of the Knee - What do you mean, nothing can be done?" which can be viewed here.

My doctor says that it is not necessary to replace a torn cruciate ligament, for he himself left his cruciate tear unoperated and he is doing fine. What are your comments?

With a sedentary lifestyle and a portion of good luck, some patients do get by after a cruciate tear without incurring subsequent injuries. Unfortunately such histories are rather the exception. Most patients continue to suffer from repetitive dislocations of the joint which, in turn, ruin the menisci, the articular cartilage surfaces, and the remaining ligaments. (Further information: torn cruciate ligament - surgery in every case?). In the light of present - day minimally invasive techniques in anterior cruciate ligament replacement, the leading knee centers of the world, especially in America, have given up the previous "wait and see" attitude and have begun to stabilize such joints early in the desease process to minimize the risk of subsequent injury. Following about 3500 cruciate replacements performed here at Alpha, we can only support this attitude! Your doctor's opinion is probably based on his previous experience with big cuts, plaster immobilization, and long hospital stays when it was not unusual for a patient to develop osteoarthritis because of the surgery itself. On a technical basis, too, implantation of the new cruciate wasn't nearly as precise as it is today. Such negative attitudes toward cruciate replacement are unfounded against the background of modern knee surgery. This is like asking someone if you would need a safety belt driving a car. Of course you can drive a car without a belt, at least as long as you don't have an accident. If you do have one, you had better fastened your belt before!

There is a lot of talk of chondral-cell transplantation these days. Can this technique heal arthritis?

Chondral cell transplantation, developed by Prof. Petersson of Gothenburg, Sweden, involves the removal of small cartilage chips obtained at a diagnostic arthroscopy which are then sent to a special laboratory for isolation and multiplication. These multiplied cartilage cells will be sent back to the surgeon about 3 weeks following the arthroscopy and the surgeon can then use this solution in an open surgery to fill in the articular cartilage defect. For the liquid not to be lost into the joint cavity, the defect has to be sutured over with a patch of the patient's own periosteum so that the multiplied cells can then begin synthesizing new articular cartilage in that closed cavity. It takes 2 to 3 months for these cells to produce enough cartilage to fill the defect completely. The new tissue, called hyaline - like cartilage, closely resembles normal articular cartilage when viewed under the microscope. When it comes to closing small defects, especially on the femoral condyles, this is an excellent technique. Unfortunately in a number of places in the knee joint this procedure cannot be used at all. Also, as was expressly pointed out by the inaugurator of the method, cartilage cell transplantation has no place in surgery for osteoarthritis even if the media were eliciting a lot of hope in this direction.

Further information can also be found in Dr. Toft's new book titled: "Arthritis of the Knee - What do you mean, nothing can be done?" which can be viewed here.

My doctor says I have a hole in the knee and he suggests that mosaic-plasty be performed. What is that and will it cure my problem?

Mosaic-plasty involves the transplantation of the patient's own cartilage with underlying bone in the form of punched cylinders from areas in the knee where the articular cartilage is not badly needed. These cylinders gained from those areas will then be transplanted into the defect, generally in the main weight-bearing zone, to replace the lost articular cartilage together with bone. You have certainly heard of hair transplants where hair together with the root and some surrounding skin is punched out in the back and then reimplanted in the front to cover the bold areas. Osteochondral transplantation is very similar to this and after using a number of such cylinders we get a pattern resembling a mosaic, hence the name. To fill holes in the knee such as yours, this procedure is very suitable. We at Alpha perform mosaic plasty quite frequently, especially to treat defects on the femoral condyles. Similar to chondro cell transplantation, osteochondral transplantation has its limits in defect size, defect location and is equally unsuitable for the treatment of osteoarthritis.

I'm 69 years old and I have arthritis in the knee. My doctor says that at my age total knee joint replacement would be the best solution and

As far as the age bracket for total knee joint replacement is concerned, your doctor is absolutely right. Internationally a border line of 65 years is given for total knee replacement, at least for male patients. This is a general rule which has to be adapted to the individual case, of course. In this area, one should not work with stereotypes, knowing that even patients in their 70ies and 80ies might be very active so that total joint replacement would not be a good option for them. In this age group, to which you belong too, the goal is joint preservation and excellent outcomes have been produced in patients 80 and more here at Alpha. These procedures generally include abrasion aiming at recovering the bare bony surfaces, frequently combined with correction of the long axis of the leg - high tibial osteotomy. (Further information: arthritis of the knee joint - who says you can't do anything about it? ). This type of surgery is known to be well-tolerated even in the elderly patient. As far as the patient is disciplined enough to keep the necessary non-weight-bearing protocol, even in this age group it is possible to regain full functionality including sports activities, without artificial joint components for that matter. With this comprehensive reconstructive procedure hardly being offered by anyone else in Germany, it is understandable that your doctor was not familiar with these techniques and that he advises you to have total knee joint replacement.

Further information can also be found in Dr. Toft's new book titled: "Arthritis of the Knee - What do you mean, nothing can be done?" which can be viewed here.

At 45 I'm still very athletic and last winter I tore my anterior cruciate ligament. My doctor says that at my age one doesn't operate on cruciates anymore. Am I really too old for that?

We are well aware of this policy followed in other hospitals to assume an arbitrary age limit of 40 years for replacement candidates and we have a number of patients who experienced the same as you. After looking back on a 16-year experience on 3.500 patients we can safely tell you that there is no such thing as an age limit. (Further information: torn cruciate ligament - surgery in every case?). We have replaced cruciate ligaments in patients older than 70 years, who resumed alpine skiing and tennis with no problems at all. The opinion you cite from your doctor probably dates back to a time when patients over 40 were already very sedentary and inactive and it was felt at the time that big surgery didn't match with the patients needs. While such a reasoning was understandable at the time, it has no place in modern day knee surgery. Both the techniques have changed for the better and the patients, too, stay a lot more active. There was a paper back in 1998 published in the "American Journal of Sports Medicine" which especially deals with this "myth" of the 40-year age limit. To summarize, at the age of 45 and being athletic on top of it, cruciate replacement is almost mandatory in your case, provided, of course, the surgery is performed in a competent matter.

A few years ago I underwent knee surgery involving shaving of my knee-cap because of what they called chondromalacia patellae. I was advised to stay on crutches for just a few days. Initially I felt improved but now I am worse then before. Do you think my

You are referring to the trimming (shaving) of degenerative and frayed articular cartilage on the back surface of the knee-cap. If such a condition is left as it is, you either have to significantly reduce your physical activity or you must face an ongoing rub-off of articular cartilage particles and loss of cartilage substance of your knee-cap. This may result in an osteoarthritis of the so-called patello-femoral joint.It was certainly a good idea to shave such a defect, provided of course that the technique was performed competently. Unfortunately most orthopedic surgeons misinterpret shaving as a smoothing of articular cartilage, attempting to make the cartilage as smooth as possible. This is a big mistake, of course. The smooth surface does not allow a blood clot to attach itself and thus repair is prevented with the result of the surface remaining open and exposed to the detrimental effect of certain enzymes in the joint fluid. If such degeneration continues and 1 or 2 years later the knee-caps starts scenario "creaking" again and the situation is worse in so far as more articular cartilage has been lost in the meantime. Then there is another group of surgeons who think it is a good idea to perform shaving only very superficially, thinking that then at least they didn't do anything wrong. This, too, is a misconception. Once articular cartilage fronds are left too long, the blood clot has no chance at all to attach itself firmly so that repair in this case, too, will be prevented. But even if we would assume that the shaving was performed correctly, it was wrong to leave you on crutches for just a few days. This early weight-bearing certainly squeezed the blood away clot away from the treated articular surface, thus preventing tissue repair. So much as to the question if your knee was "messed up". The situation being as it is, we feel that the procedure has to be repeated, provided all the factors explained above are taken into consideration. At any rate, you should reckon with a 8-week non-weight-bearing period after which time your articular cartilage defect will have healed over. It is also possible that, depending on the tracking of your knee-cap under direct arthroscopic vision, a decompression called "lateral release" has to be performed at the same time.

Further information: knee cap problems - when the conveyor-belt is off center.

My doctor says articular cartilage cannot regrow. On your website, you write that abrasion produces new cartilage. Which of the two opinions is correct?

Your doctor's statement that articular cartilage cannot regrow is basically true. However, it is wrong to draw the conclusion that articular cartilage cannot heal. Not unlike skin healing where you can see the difference between original skin and skin scar for life, articular cartilage does not heal with its original tissue (hyalin cartilage) but with a repair tissue (fibrocartilage). It is a blessing that articular cartilage does have this property of healing defects with fibrocartilage, even though this sounds a little bit like a second rate solution. These repair fill -ins allow to recreate a smooth articular surface even if the defect reached down to bone. Following completion of the process, after about 8 weeks, all the defects are sealed off and the advantage is that this new tissue will not be rubbed off or worn down because the collagen fibres are oriented parallel to the joint surface. This also stops the on-going particle rub-off of degenerative articular cartilage which allows the knee to return to a normal metabolism. The repair tissue is certainly inferior to intact hyaline cartilage but is superior to grade-3 degenerative cartilage or no cartilage at all.

Further information can also be found in Dr. Toft's new book titled: "Arthritis of the Knee - What do you mean, nothing can be done?" which can be viewed here.

My knee-cap is known to be off-center and my knee is painful when climbing or descending stairs. An orthopedic surgeon suggested creating a capsular window while my family orthopedist says I should not have it done. Who is right?

The knee-cap being off-center is a situation similar to what happens in knock-knees or bow legs. Deviations from the normal distribution of conpressive forces between joint surfaces, especially if aggravated by additional accidents, may give rise to early arthritis in the respective joint region. If your knee-cap is only off-center and if your articular cartilage is still intact, it may still make sense to recentralize the gliding path of the knee-cap by what is called a lateral release. (Further information: knee cap problems - when the conveyor-belt is off center). In such a case it is certainly not a good strategy to wait for the articular cartilage to break open and degenerate before you perform reconstructive surgery. If, in addition to your knee-cap being off-center, you can sense a lot of noise behind your knee-cap, articular cartilage damage must be assumed. Then, in addition to the lateral release, shaving chondroplasty should be performed, too. When treating articular cartilage, it is important for the surgeon to be familiar with the modern principle of both athritis surgery and chondral healing including the pertinent postoperative procedure. It is natural for a patient to have a tendency to believe the doctor that says surgery isn't necessary but we feel that in your case the orthopedic surgeon was right that said that you should have the "capsular window".

In medicine, are the Americans really more advanced?

It is a fact that the major part of new developments in medicine, especially in knee surgery, within the last 30 to 40 years came from America. The American system is less hierarchically structured and offers more leeway for young, innovative and dynamic doctors as apposed to the situation in the"old world" in Europe, especially in Germany. As far as these conditions are concerned, but also regarding outcomes as reported in the international literature one must admit that in medicine the Americans are more advanced. This is one of the reasons why we at Alpha maintain a close contact with our American colleagues and why we keep attending their congresses to learn the latest developments but also to report our own results. In this context it is equally important to us to follow closely the international literature which, admittedly, is also basically dominated by the Americans. This general statement, however, does not invalidate the fact that some specialized centers in Europe have managed close the gap between the Americans and the Europeans. Here at Alpha, for example, we perform procedures such as abrasion arthroplasty (bioprosthesis) which you will have difficulty finding even in America. Although the concept was developed by Doctor Lanny Johnson from Lansing, Michigan, the technique has never been universally adopted. The extremely long non-weight-bearing periods (without which the procedure cannot be successful) were too difficult to sell to Americans who want to be back to the job or to their sport within no time and so a potentially beneficial procedure had a tough time finding a place in the armamenterium of arthritis surgery. In Germany, by contrast, non weight-bearing periods of 2 to 3 months are absolutely acceptable to both patients and employers, thanks to a more advanced social security system. To summarize we can say that proportionately you find more specialists in America but that the top surgeons in Germany are on a par with their peers in America. Unfortunately the number of real top surgeons in Germany is comparatively small, because conditions for the development of such "superspecialists" are not good.

My friends say that an average person cannot afford treatment at Alpha. What do you say to that?

Statistically, about one third of our patients are not private patients so that they have to pay out of their own pocket because the non-private health schemes that they belong to will not cover the costs here at Alpha. By contrast, private insurance companies do cover the costs because our price structure is comparable to that of other hospitals. So we don't think that we deserve the reputation of being "terribly expensive". In case you have a special problem and you know your diagnosis and what should be operated on, you can contact our administration and ask for an exemplary bill to give you an overview of the costs involved. You will see for yourself that the sums of money will be within the framework of what you can expect in other hospitals for the same treatment.

I am facing surgery and I am more concerned about the anesthesia than about the surgery itself. How often do complications occur during an anesthesia?

Compications under anesthesia are either due to insufficient preoperative internal check-ups where important risk factors were overlooked or to the fact that an anesthesist was doing a negligent job performing the anesthesia itself. As far as the preoperative check-up is concerned, at Alpha, nobody will end up at an operating table without the most accurate and comprehensive check by Alpha's internists. Our Anesthesiologists are very experienced specialists in their field, with experience in intensive medicine, and at Munich's Heart Center and they are absolutely capable of dealing with any kind of complication that might arise during an anesthesia. Sometimes, especially in university hospitals, complications occur because young and inexperienced doctors who are still in training are performing anesthesias without sufficient supervision. In case you consider having the surgery at some hospital, we find it pertinent to ask about the frequency of complications under anesthesia. Here at Alpha, for that matter, in over 20,000 anesthisias we didn't have a single death or severe complication that might have entailed some permanent damage to the patient.

One of my friends was operated on a knee joint and got an infection. Now the knee is relatively stiff, painful, and arthritic. How often does such a complication occur?

In 1997, the German news magazine "Focus" published official infection statistics from German hospitals saying that the overall infection rate in German hospitals is 3 %. From the international literature in the field of orthopedics we know that for all orhopedic interventions the infection rate is roughly 2% and for arthroscopic interventions 1%. Here at Alpha-Klinik our infection rate is in the range of 0.05%, which is 1/20th of the international average for arthroscopic surgeries. Provided correct techniques were used during the surgery, the latest technology was available and the patient was followed up closely postoperatively, joint infection should be a rarity. Unfortunately we see an increasing number of patients from elsewhere who even after simple meniscectomies, sometimes even after diagnostic arthroscopies, incur joint infection, sometimes with catasthrophic outcomes. Of course, such things should not happen. Unfortunately in Germany there is no obligation to notify infections to central agencies such as the medical board. Unlike in America, the German patient cannot obtain the appropriate figures for a hospital of his choice from the local Medical Board. This is certainly a gap in the legislation that needs to be closed.

Skiing in Austria I tore my cruciate ligament and was advised to have it operated on immediately. I was told sugery in the acute stage is better and more successful. Now, 6 months later, I cannot stretch out the knee and I can only bend it to about 90 deg

According to international statistics and experience gathered within the last 5 to 6 years, the risk of excessive scar formation in a joint following early anterior cruciate ligament surgery is about 5-times higher as if you wait until about the 4th or 5th postinjury week. In most knee centers in the United States this waiting time is now almost a standard procedure. The risk of arthrofibrosis (this is what you have) developing has been reduced significantly by following these guidelines. Unfortunately arthrofibrosis not only reduces joint mobility but also transforms the production site of the joint fluid in such a way that such joints remain to be too dry and thus subject to subsequent osteoathritis. Even if an orthopedic surgeon manages to regain full joint mobility by an arthroscopic intervention called arthrolysis which involves removal of all the intra-articular scar tissue, such a joint will be far from normal and most probably not regain its previous functional level. At this point we do not want to speculate about the reasons why early surgery had been suggested to you. At any rate, it is important to remobilize the joint by removal of the excessive scar tissue in a gentle way, if you will. After 6 months we would strongly advise against having mobilization under anesthesia attempting to break the scarry adhesions of the joint. This might cause additional damage to the articular cartilage and later give rise to the development of osteoarthritis. After an arthroscopic arthrolysis you will need about 5 to 6 months until you reach a "plateau" which means that the knee will retain its range of motion even if you stop having physiotherapy several times a week.

How do I find the "right doctor" for me?

As you probably know, in Germany and elsewhere, doctors and other members of the health profession are not allowed to advertise. This prohibition dates back to former times where it was important to protect the population from questionable healers and it made sense at that time. However, in the meantime this legislation has degenerated into an information barrier for the patient, with the result that the patient today is left alone in his search for the "right doctor". So, in the absence of better techniques, it is still advisable to call and listen around your friends and relatives to find out about the right doctor for the right problem. Of course, it is important to find people that had the same or a similar problem as you. Unlike in America, German patients still hesitate to ask their doctor for some telephone numbers or addresses of previously treated patients so that they can call and interview them. When confronted with the doctor that wants to operate on you, you should not hesitate to ask for such a reference list and if the doctor gives you the list without much ado you can probably trust him, especially if your interviewees give you positive report concerning that doctor.

There is always talk about athletes healing faster after an operation than normal people. Why is their healing so much faster?

First of all, we would like to do away with the myth of athletes healing faster than normal people. One factor, though, is different with athletes and this is motivation. They want to get fit as fast as possible, because there is big money involved in a lot of these careers. Sometimes however overambitious surgeons, athletes, coaches, and other officials may help ruining the outcome. You may remember the case of the French national team player Papin, formerly on the Bayern Munich team, who didn't get fit after a "simple meniscal surgery" in spite of a lot of effort on his part. The condition was caused by chondral lesions which either had been overlooked or which had been disregarded in an attempt to "save time" and get the player back on the field as soon as possible. Unfortunately it took quite a while for the treating doctors to recognize the real cause of his condition and only after another surgery in Marseilles where the chondral lesions had been treated did the knee heal and the player went back to play. With cruciate ligament replacements, too, you shouldn't exspect any miracles. You may or may not remember the cruciate ligament surgery of Lothar Matthäus and you will also remember that it took about 6 months for him to return to active playing. The biologic processes of transplanted tissues remodelling and growing in can hardly be accelerated. Much of the talk of the fast healing in athletes is a myth serving to create pressure vis a vis the surgeon and also the athlete himself. The only time saving part in the process is, as mentioned before, the athletes motivation in the postoperative rehab. The rehabilitation period is certainly shorter than with recreational athletes or with non-athletes, a finding that is understandable in the light of the physical condition of most professional athletes.

Further information can also be found in Dr. Toft's new book titled: "Arthritis of the Knee - What do you mean, nothing can be done?" which can be viewed here.

I keep hearing people speak of "simple" meniscal surgery. A friend of mine and also some aquaintances had such simple meniscal surgeries and they seemed to have big problems. How can that be?

Although widely used and reiterate by almost everybody, there is no such thing as a simple meniscal surgery. Cleaning out damaged meniscal tissue from the tear zone, which unfortunately is predominantely located in the hind-most parts of the meniscus, requires a highly specialized surgeon, a sensitive hand as well as a number of little tricks during the surgery itself to achieve the goal of solving the meniscal problem without damaging any structures such as articular cartilage on the way. Technically, anterior cruciate ligament replacement, although viewed as being particularly complicated, is much less demanding. Even total knee joint replacement, probably mind-boggling to the lay person, is a comparatively simpler operation. The problems that you mentioned following so-called simple meniscal surgeries go back to 2 main causes. The first concerns the doctor not seeing well enough during the surgery and leaving large parts of the torn meniscus in place, thus causing similar symptoms as before the surgery. In such a scenario, the patient has to undergo a second arthroscopic surgery by a more experienced surgeon who then will do the rest of the job and if no articular cartilage damage have been caused by the first surgery, the patient will then return to full functionality including sports activities. The second type involves surgeons who, in an attempt to get the meniscal problem solved, will try to reach the goal at whatever cost. Such a surgeon will then force his way to the posterior and not-easy-to-reach area of the meniscus and will probably succeed solving the meniscal problem, but at the expense of the articular cartilage and /or other structures such as ligaments. Such additional damage to important structures may give rise to the development of osteoarthritis at a later date. When comparing the two seenarias, however, it is certainly preferable if a surgeon cannot solve the meniscal problem but leaves all the other structures intact. In this case, it is easy, for a second specialist to solve the problem and get the patient back on track. In the presence of major damage to the articular cartilage caused by the first surgeon, a second surgeon can still do something sensible about the situation but he cannot work miracles and undo the damage by recreating the original situation. To summarize, we would like to warn against assuming that meniscal surgery is beginner's surgery and that you can have this type of surgery done in any hospital around the corner. A good method of testing the surgeon preoperatively is to ask him for an unedited video recording of the surgery itself. Only confident surgeons can afford to give such a documentation into the patient's hands.

My doctor says I need special injections to build new cartilage in my knee. Is this possible and will it help?

Amongst the newer preparations commonly known as chondroprotectives, hyaloronic acid is the most important substance that is currently being used. Hyaloronic acid is a part of hyalin articular cartilage and is part of the matrix that is responsible for the "hyaline" aspect of cartilage. When treating superficial roughening of articular surfaces such injections do have a place. The two most commonly used substances are Hyalart of which you get 5 injections at weekly intervals and the other one is Synvisc of which 3 weekly injections will do. In case of more advanced osteoarthritis, such injections may produce temporary relief but you should not expect any healing properties from these substances. Especially in cases where the patient for professional or other reasons is unable to have immediate surgery done, it might be advisable to treat the joint with a series of such injections as a temporary measure. In this context, it should be emphasized that such injections have to be administered under absolutely sterile conditions and that a joint infection that might arise from a contaminated needle or syringe might have a catastrophic outcome and is a far too high a price for the little relief that the injection can give you. We would warn against wide-spread, indiscriminate use of such substances, especially with an eye to the risks involved.

Further information can also be found in Dr. Toft's new book titled: "Arthritis of the Knee - What do you mean, nothing can be done?" which can be viewed here.

My mother has severe arthritis in the knee. Her doctor says because of her old age she should not have surgery. Her doctor says that a series of PST should be given to her. What is PST and will this help?

PST stands for "pulsed signal therapy". The treatment involves the application of pulsed electro-magnetic fields in the form of a loop into which the knee will be put for about an hour each session. This treatment is assumed to promote methabolic processes on a cellular level and thus stimulate the body's own healing potential. There seems to be empirical evidence for the efficacy of this therapy, especially as far as pain relief is concerned. In case your mother should be held unfit to have surgery because of her old age or because of some internal medical problems, such a PST treatment might make sense. But apart from that, we would suggest that you have another doctor reassess your mother's physical state and see if some additional treatment might improve her status to a point where it might be advisable and acceptable to subject her to total knee joint replacement, which will certainly be more beneficial than just the PST treatment.

Further information: Better than it's reputation - Knee joint replacement.

Additional information can also be found in Dr. Toft's new book titled: "Arthritis of the Knee - What do you mean, nothing can be done?" which can be viewed here.