News & Articles

Knee Pain

Dr. Mark Bursztyn
The knee is a major weight bearing joint that is subjected to many additional stresses beyond just weight bearing. It is for this reason that knee pain can affect every segment of the population. Individuals who participate in sports or are quite active may sustain ligamentous injuries, meniscus tears, tendon injuries, or articular cartilage lesions. These injuries may be due to acute trauma, overuse, or both. People who have endured a lot of wear and tear over time may develop osteoarthritis.

The first step in addressing one's knee pain is to diagnose the problem. An orthopedic surgeon would take a patient's history, and perform a physical examination. Routinely, X-rays are obtained as well. Although most patients that present with knee pain do not have any broken bones, X-rays are of vital importance in working up knee pain. In some cases, particularly if there is any concern about an ACL or meniscus tear, an MRI will be ordered. In most cases, a diagnosis can be made based on the patient's history and physical examination. Sometimes, imaging studies such as X-rays and MRIs are necessary in order to make a definitive diagnosis.

Once a diagnosis is made, treatment options are discussed. Most knee problems can be treated conservatively. Anti-inflammatory pain medication and physical therapy can be extremely helpful. Sometimes injections can be administered to relieve pain as well. When the problem is one that doesn't sufficiently respond to conservative treatment, surgery may be recommended.

The most common surgery orthopedic surgeons perform is a knee arthroscopy. As technology has evolved over the past 35 years, so has the capability of arthroscopic surgery. This is a minimally invasive procedure that can help to treat common injuries such as meniscus tears, articular cartilage lesions, and ligament ruptures.

The single most common cause of knee pain is arthritis. Like most knee disorders, this can be treated conservatively with medication and/or physical therapy. Injections are also frequently administered to help relieve arthritis pain. In the past few years, a lot of research has been conducted which has studied alternatives to conventional corticosteroid or viscosupplementation injections. When conservative treatment doesn't adequately manage arthritis pain, the last resort is knee replacement surgery. In recent years, prosthetic implants and surgical techniques have evolved so that knee replacements are lasting longer than ever before.

Not all spinal stenosis needs a back fusion

Dr. Gonya
Spinal stenosis is a common diagnosis among patients with back pain and sciatica. The term lumbar spinal stenosis refers to a narrowing of the space available for the nerves in the low back. The common symptoms of spinal stenosis include radiating pain which can start in the back and buttocks and travels to the thighs and calves which makes walking and standing for prolonged periods challenging. Often, patients with spinal stenosis discover that by leaning on a walker or shopping cart helps alleviate the radiating pain and burning and heavy sensation in the legs. The reason for this is due to a natural opening of the space available for the nerves when we pitch or bend forward. The natural history of spinal stenosis is episodic flare ups which are often are self-limiting in nature improving with time, anti-inflammatories and activity modifications. In a small percentage of patients, the symptoms become chronic and affect a patient’s quality of life. The limiting effect on function and independence is often a catalyst for patients to seek a more definitive intervention. This is when the care of a spine surgeon is most needed.

The most common goals of low back (lumbar) spine surgery include:
  • Decompression of the spinal canal to allow more space for the nerves to function
  • Stabilization of individual motion segments of the spine which are moving out of sync
The gold standard for surgical management of lumbar spinal stenosis is a lumbar laminectomy. The lamina of our spine are the vertical bony "roofs" which overlay the spinal nerves. A traditional laminectomy removes the complete "roof" to allow the surgeon access to the spinal canal to release and remove the build-up of inflammatory tissue which is causing the stenosis. Often metal rods and screws are added to increase the stability of the area of decompression.

Are there any new options available for this common problem? Can a fusion be avoided? Yes!

A device now available prevents the need for excess muscle to be cut, affords a smaller incision with less blood loss and a quicker recovery back to normal activity. The device’s name is Coflex. It is a metallic spacer which is placed in between the lamina (the vertical bony ‘roof’) to allow for a continuous opening of the canal. This device is press-fit into the space after a microscope is used to minimally invasively open-up the canal to release the stenosis without removing excess bone and allowing for normal motion after the surgery by avoiding a fusion. The device recreates the normal tendency of patients to try lean forward to open-up the space for the nerves in the spinal canal. But now with the decompression done and the device in place the patient can stand up and walk with a straight posture and for longer distances and duration. The procedure is done under general anesthesia and is usually performed in under two hours. An overnight stay in the hospital is recommended. The patient is up walking the day of surgery and independent in activities of daily living right away.

diagram of spine

Fracture Recovery

Dr. Bursztyn
Unfortunately, broken bones are injuries that can affect anyone - young or old, weekend warrior or professional athlete. Although different segments of the population may be more susceptible to certain types of fractures, common themes exist in regards to recovery.

Let's begin with what the definition of a fracture is. A couple of misconceptions exist that we should clear up. I often hear people say things like "it's not broken - it's just fractured", or "it's only a 'hairline' fracture".

By definition, a fractured bone IS a broken bone. The term "hairline fracture" usually refers to what is more appropriately called a "non-displaced fracture". However, it's important to recognize that these can still be serious injuries. In this regard, sustaining a fracture can sort of be like getting pregnant. Either you're pregnant or you're not- just like either your bone is fractured or it's not. Technically speaking, a fracture is any structural disruption of a bone.

As orthopedic surgeons, we treat fractures in order to get them to heal in a manner that allows the injured person to optimally recover. Sometimes they require casts or splints, sometimes they don't. Sometimes lower extremity fractures require the use of crutches, sometimes they don't. Sometimes fractures require surgery, but thankfully, they usually don't. There are several themes that apply to the healing of nearly all fractures.

Fracture healing typically takes place in three stages. The first stage is INFLAMMATION. This is the body's response to injury. Certain cells that promote healing flock to the sight of injury and go to work. This begins as soon as the fracture is sustained.

The second stage is the REPAIR stage. This is when actual new bone starts to fill in the fracture sight. Usually, this stage begins around two weeks after the injury, and generally takes around six weeks. Once this stage is complete, the fracture is basically considered healed.

The REMODELING stage refers to changes that go on within the bone once the fracture has healed. Remodeling occurs along lines of stress. Therefore, more bone forms where there is more of a load which requires support.

The key to healing most fractures is to first immobilize the broken bone. If a cast or splint can get the job done, then that's what is used. Unfortunately, some fractures can't be sufficiently immobilized this way. Sometimes they may also be in such bad positions, that they need to be put back into a more acceptable position. In these cases, surgery is usually necessary. Once the broken bone is immobilized, healing can take place. If there is too much motion at the fracture site, the bone is much less likely to heal.

Once the fracture has healed, the goal is to get the injured person back to optimal function. Usually, the pain has significantly improved once the fracture has healed. However, people that have had splints or casts on may be stiff. In addition, the injured body part may be somewhat weaker shortly after the fracture has healed. These are important factors to consider. Premature return to certain activities may predispose people to further or recurrent injury. Physical therapy can sometimes be extremely helpful in expediting peoples' safe return to their desired activities. All fractures do NOT heal the same way, so it's of vital importance that your orthopedic surgeon's treatment plan is adhered to.

Causes of Osteoarthritis

Dr. Mark Bursztyn
The most common cause of knee pain in adults is osteoarthritis. By definition, osteoarthritis is joint inflammation due to wear and tear of the articular cartilage that covers the bones inside the joint. The knee, and other weight bearing joints such as the hip, are more prone to osteoarthritis. The two main reasons for this are the fact that these joints are subjected to repetitive loads, as well as the tendency for some people to have those joints aligned in ways that are more susceptible to wear and tear.

In some ways, the articular cartilage inside our joints is analogous to the tires on a car. If you leave your car in the garage, the tires won’t wear out. However, if you put a lot of miles on your car, those tires will wear out much more quickly. As the articular cartilage in our joints wears out more and more, we can eventually develop narrowing of the space between the bones. In advanced stages, this can lead to "bone on bone" arthritis.

People can also naturally have their bones aligned in ways that may predispose them to developing osteoarthritis. Individuals that are "bow-legged" or "knock-kneed" can place more of a load on certain parts of their knee joints, and therefore be more prone to wear and tear of the cartilage.

Another cause of osteoarthritis is significant acute injury to the cartilage within the joint. For example, patients that sustain fractures to portions of their thigh or shin bones within the knee joint are more prone to developing osteoarthritis within that joint. This is termed "post-traumatic" osteoarthritis.

Finally, recent research has revealed that there is a genetic component to arthritis as well. Just like certain traits and some diseases, osteoarthritis can run in families.