Knee, Ankle & Foot

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Knee Instability, Dislocation and Subluxation

The knee is made up of four main bones: the femur (thigh bone), the tibia (shin bones), the fibula (outer shin bone) and the patella (knee bone).

Knee cap/patella instability means that the knee cap/patella joint is too loose and is able to slide around too much in the socket. In some cases, the unstable patella actually slips out of the socket. If the patella slips completely out of the socket, it is a dislocation. If not treated, instability can lead to arthritis of the knee joint. Patella instability may be treated by bracing, physical therapy or by surgically stabilizing.

Patellar dislocation happens when a direct blow or sudden twist occurs and the patella (kneecap) slips out of its normal position and can cause intense pain with swelling of the knee. Medial patella-femoral ligament (MPFL) is sometimes torn during patella dislocation, sometimes leading to patella instability and may require ligament reconstruction to stabilize the patella.

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. The goal of the ACL reconstruction surgery is to prevent instability and restore the function of the torn ligament, creating a stable knee.

The kneecap is designed to fit in the center of the trochlear groove and slide evenly within the groove. Patellar subluxation is when the kneecap is pulled towards the outside of the knee and does not slide centrally within its groove creating discomfort with activity and pain around the side of the kneecap. Depending on the severity of the subluxation, the improper tracking could lead to dislocation of the patella. For patients who have significant pain or recurrent dislocations, Dr. Kostman may recommend surgery once he has assessed the underlying issue that needs to be corrected.

Meniscus Injuries

Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella) and two meniscus (wedge-shaped pieces of cartilage) that act as shock absorbers between your thighbone and shinbone.

A meniscus tear is a common injury to the cartilage that stabilizes and cushions the knee joint and may be caused by turning the knee quickly or twisting it with the foot planted and the knee bent or by the aging process.  You may experience pain, swelling, stiffness, cracking or popping and an inability to straighten the knee.

Menisci tear in different ways. Tears are noted by how they look, as well as where the tear occurs in the meniscus. Common tears include bucket handle, flap, and radial. Sports-related meniscus tears often occur along with other knee injuries, such as anterior cruciate ligament (ACL) tears. Sudden meniscus tears often happen during sports. Players may twist the knee, causing a tear. Direct contact, like a tackle, is sometimes involved. Older people are more likely to have degenerative meniscus tears. Cartilage weakens and wears thin over time. Aged, worn tissue is more prone to tears.

While physical examination may predict whether it is the medial or lateral meniscus that is damaged, a diagnostic procedure, like an MRI or knee arthroscopy, can locate the specific part of the cartilage anatomy that is torn and its appearance. There are four ligaments that stabilize the knee joint at rest and during movement: the medical and lateral collateral ligaments (MCL, LCL) and the anterior and posterior cruciate ligaments (ACL, PCL).

If anti-inflammatory medications and physical therapy rehabilitation fail to strengthen the muscles around the knee and stabilize the joint, Dr. Kostman may recommend arthroscopic knee surgery which will allow him to assess the cartilage tear and potentially repair it while preserving as much cartilage as possible. Procedures include meniscus repair, sewing the torn edges together, partial meniscectomy, trimming away only the torn area, and smoothing the injury site leaving the healthy meniscus alone.

Cartilage Injuries

Articular cartilage is the smooth, white tissue that covers the ends of bones where they come together to form joints. Healthy cartilage in our joints makes it easier to move and allows the bones to glide over each other with very little friction. Once cartilage damage occurs, surgical techniques to stimulate the growth of new cartilage may be used as cartilage does not heal itself well. This procedure can relieve pain, allow better function and possibly delay or present the onset of arthritis.

The main component of the joint surface is a special tissue called hyaline cartilage. When this cartilage is damaged, the joint surface may no longer be smooth. Moving bones along a damaged joint surface is difficult and causes pain. The goal of cartilage restoration procedures is to stimulate new cartilage growth, or transplant healthy cartilage to a diseased area.

Non-Surgical Treatment of Cartilage Injuries/Degeneration

Normal joint fluid contains a substance called hyaluronan. It acts like a shock absorber and lubricant in your joint and is needed to help the joint work properly and allows the cartilage surfaces of the bones to glide upon each other smoothly.

Lubricant injections contain a gel-like mixture made with Hyaluronan (also known as viscosupplementation) which supplements the fluid in your knee and helps lubricate and cushion the joint – reducing pain, increasing mobility and allowing for more activity. This involves an injection typically once a week for three weeks.

Platelet Rich Plasma (PRP) Injections decrease inflammation in treating osteoarthritis and other cartilage defects. Dr. Kostman can inject PRP directly in the affected joint which may aid in pain reduction, improved joint function and possibly slow, damage to cartilage. Platelet-rich plasma is derived from a sample of the patient’s own blood. The therapeutic injections contain plasma with a higher concentration of platelets than is found in normal blood.

Minimally Invasive Total Knee Replacement

Total knee replacement (knee arthroplasty) is a common orthopaedic procedure that is used to replace damaged or worn surfaces of the knee with an implant which relieves pain and increases mobility.

The traditional approach to knee replacement uses a long vertical incision in the center of the knee to view and access the joint. If minimally invasive total knee replacement is an option for you, Dr. Kostman will use a shorter incision and a different, less-invasive technique to expose the joint – reducing postoperative pain and speeding recovery. Specially designed surgical instruments are used to place the implants properly. Shorter incisions allow for fewer muscles to be cut and detached and less tissue damage.


Tendons are tough and flexible bands of tissue that connect muscle to bones. Tendonitis occurs when the tendons become inflamed, irritated or incur microscopic tears. In most cases, it is difficult to determine the cause of tendonitis but when it is identified, it is usually due to overuse or overload. Tendonitis is most commonly found in the elbow, knee, wrist and heel.

Treatment Options

There are many non-surgical methods to help manage pain and live an active lifestyle.

Viscosupplementation is a procedure where gel-like fluid called hyaluronic acid is injected into the knee or shoulder joint for those who suffer from osteoarthritis. Hyaluronic acid acts as a lubricant to enable bones to move smoothly over each other and as a shock absorber for joint loads while enabling movement and reducing pain but is not used to treat tendonitis.

Platelet-rich plasma (PRP) injections stimulate healing of injured tendons, ligaments, muscles and joints and can be injected directly into the inflamed tissue/injured area. PRP injections contains a portion of the patient’s own blood and are most effective in the treatment of chronic tendon injuries, especially tennis elbow as well as acute sports injuries such as ligament and muscle injuries

Stem cell injections is a procedure where the patient’s stem cells are injected along damaged joints or tendons that are affected by damage torn, utilizing your own body’s mechanisms and growth factors to promote healing. Relief can be significantly felt at 1 to 2 months and may continue to improve at 3 to 6 months.

Ankle Fractures, Sprains and Strains Repair

There are three bones that meet at the ankle – tibia and fibula of your lower leg and the talus of your foot and are held together by ligaments. An evaluation will determine whether damage has occurred to the bone, ligament, or tendon.

An ankle fracture is a break in one or more of the bones.

An ankle sprain is the term that describes damage to ligaments when they are stretched beyond their normal range of motion. A ligament sprain can range from many microscopic tears in the fibers that comprise the ligament to a complete tear or rupture.

Ankle strains are when the tendons that stabilize and protect the ankle become inflamed (tendinitis) as a result of overuse or trauma. Acute tendon tears can result from a sudden trauma or force. Microscopic tendon tears that accumulate over time, because of being repeatedly over stretched, and don’t heal properly lead to a condition called tendinosis. Tendons can also rupture. Subluxation refers to a tendon that slips out of place.

Ankle arthroscopy is a surgical procedure that uses a fiber-optic viewing camera and small surgical tools to operate in and around the ankle joint through small incisions. Ankle arthroscopy is performed for the surgical evaluation and treatment of a variety of ankle conditions and has a quicker recovery time than traditional open surgery. Ankle arthroscopy may be used for patients who have debris in ankle from torn cartilage or a bone chip as well as ligament damage and offers a speedier recovery, less scarring and fewer complication than open surgery.

Peroneal Tendon Repair

The peroneal tendons run on the outside of the ankle just behind the bone called the fibula. Tendinitis implies that there is inflammation in the tendon. Tendinosis means there is enlargement and thickening with swelling of the tendon. The type of treatment depends on the type of tendon tear, its location and the extent of damage. Dr. Kostman will repair the tendon if it is split down the center, he will suture the tendons together with an intratendinous stitch technique.

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