Greenwich Hospital Announces New Chief of Staff, ONS Neurosurgeon Paul Apostolides, MD

Paul Apostolides, MD Neurosurgeon

Paul Apostolides, MD

Dr. Apostolides, Section Head of the division of Neurosurgery at Greenwich Hospital, has been appointed hospital Chief of Staff as of January 1. Dr. Apostolides joined Greenwich Hospital’s medical staff in 1998 and has served on many committees including the credentialing committee, executive committee and peer review committee. For three years prior to his current appointment, he was Assistant Chief of Staff. He has served on the Greenwich Hospital Board since 2012.

A graduate of Stanford University and University of Massachusetts Medical School, Dr. Apostolides completed his residency and fellowship training at the Barrow Neurological Institute. He is board certified by the American Board of Neurological Surgery, and is in practice with Orthopaedic & Neurosurgery Specialists (ONS) in Greenwich. He specializes in minimally invasive as well as complex reconstructive spinal surgeries.

ONS is an advanced multi-specialty orthopedic and neurosurgery practice serving patients throughout Fairfield and Westchester Counties and the New York Metropolitan area. ONS physicians provide expertise in the full spectrum of musculoskeletal conditions and injuries, sports medicine, minimally invasive orthopedic, spine and brain surgery, joint replacement and trauma. For more information, visit, or call (203) 869-1145.

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MRI versus the Stress Test: Which one do you need?

Sean C. Peden, MD

Sean C. Peden, MD

Sean Peden, MD is an orthopedic surgeon who specializes in foot and ankle surgery. Dr. Peden has expertise in treating a variety of foot pain and deformity related conditions including Achilles tendonitis, ankle instability, cartilage injuries, bunions and hammer toes and keeps up to date with the latest breakthroughs in the field. Most recently, the unnecessary reliance on the MRI compared to conducting a simple stress test has caught his attention. The following is what he wants you to know:

Nowadays orthopaedic surgeons will frequently order Magnetic Resonance Imaging (MRI) studies for patients suffering from acute or chronic musculoskeletal injuries. Radiographs, also known as plain films, show a two dimensional projection or shadow of bone. It is useful for diagnosing obvious displaced fractures, but subtle findings are often missed.

MRI is an advanced technology that provides information in three dimensions about bone, tendon, muscle, ligament, fat, swelling, fluid, etc etc (unlike plain films, which just show bone). Basically it shows us just about everything we need to know, short of nerves and other subtle dynamic findings. It uses no radiation and is incredibly safe.

But in the setting of an ankle fracture – where either the fibula or tibia is broken near the ankle and our job as surgeons is to determine which ankles will be fine with a cast and which need a surgical correction – MRI IS OF NO ADDED BENEFIT. What I want to determine is this setting is whether the fracture is “stable.”

An unstable fracture will shift with time, even with a good cast, and certainly once a patient begins walking. Shifting is a very bad thing, especially in the ankle. It leads to abnormal pressures on the joint, cartilage wearing, degenerative changes, and stiffness, also known as post traumatic arthritis. In an active and healthy patient that is unacceptable. A significantly better outcome is achieved with a one hour surgery to fix the fracture and restore anatomic alignment and stability.

The main problem with MRI is that it is a static test. The images are taken with the patient lying flat on a table. There is no weight or force across the ankle joint. While MRI can image the ligaments, in the setting of an ankle fracture these ligaments are always injured, but whether they are injured to the point of instability is indeterminable.

A simple test that costs very little and takes about 5 minutes is a stress radiograph. Using either gravity or the hands of a surgeon, and mild stress is placed across the ankle joint. If the joint widens or shifts I know that it will do the same in the future. The most up to date orthopaedic literature supports stress x-rays, not MRI, as the best way to decide between surgical and non-surgical treatment.

The other problem with MRI is cost and time. It is a 30-45 minute test and carries with it a significant cost. The burden of the cost is shared by the patient, the insurance company, and society as a whole. With the skyrocketing costs of healthcare in our country we should reject the notion of ordering tests when they should have no effect on our decision.

A 2014 article supports this from the Journal of Bone and Joint Surgery, the official scientific journal of the American Academy of Orthopaedic Surgeons.

Posted in Foot and Ankle, Greenwich Community, Medical Expertise, Orthopedics, Treatment, Uncategorized | Tagged , , | Leave a comment

Accomplished Orthopedic Surgeon joins ONS Sports Medicine Team

Marc Kowalsky MDOrthopedic surgeon and fellowship trained sports medicine specialist Marc Kowalsky, MD has joined the ONS team. Dr. Kowalsky has expertise in conservative and operative treatments of upper and lower extremity sports injury, as well as complex shoulder and elbow pathology including degenerative disease, and trauma.  He has a particular interest in the management of shoulder and elbow arthritis, instability, rotator cuff tears, labral injury, and cartilage disorders.

Dr. Kowalsky looks for rehab-focused, non-operative solutions whenever possible, recommending surgery when it will be most effective. His goal is to return patients quickly, safely and fully to their best function and performance.

Dr. Kowalsky earned his medical degree at Tufts University School of Medicine, Boston, MA where he also earned an MBA in Health Management. He did his residency in orthopedic surgery at Columbia University Medical Center, New York Orthopaedic Hospital in New York, NY. He also completed fellowship training in shoulder and elbow surgery at Washington University School of Medicine, Saint Louis, MO and in sports medicine at Lenox Hill Hospital, Nicholas Institute of Sports Medicine & Athletic Trauma, New York, NY.

He has authored original research manuscripts, review articles, and textbook chapters focusing on AC joint reconstruction, rotator cuff repair, and shoulder replacement. He currently serves as a reviewer for the Journal of the American Academy of Orthopaedic Surgery and the Journal of Shoulder and Elbow Surgery.

“Dr. Kowalsky will be a great asset to our practice as we meet the growing demand for musculoskeletal care in Fairfield and Westchester counties,” said Dr. Seth Miller. “His high level of training and accomplishments reflect the ONS standard of offering the highest level of care possible to our patients.” He is in network with Aetna and Oxford/United Healthcare.

Posted in ONS Surgical Team, Orthopedics, Shoulder and Elbow, Sports Medicine, Surgery | Leave a comment

Shoulder Pain? (Part II)

Shoulder_Pain_blogRemember last week’s post? Dr. Kowalsky ended the last installment with listing a multiple options one could take to repair a rotator cuff tear due to the fact that it is very unlikely for the condition to heal on its own. The following is a more in depth description of what makes up this part of the body and what to do after the symptoms of arthritis of the shoulder appear.

The glenohumeral joint of the shoulder includes the humeral head, or ball, and the glenoid, or shallow socket.  Both joint surfaces are coated with articular cartilage, the pearly-white, smooth surface that allows near friction-free, painless movement of one surface on another.  Typical wear-and-tear osteoarthritis occurs due to the degeneration of the joint surface.  As the articular cartilage erodes, the underlying bone can become exposed, change in shape, and create symptoms.  Patients typically present with pain deep within the joint.  The pain can be associated with mechanical symptoms, such as catching, clicking, or grinding, as well as loss of motion.  For some patients, typically those with mild or moderate arthritis, there is a role for conservative management.

However, the most reliable means for pain relief, improved motion and function for patients with moderate or severe arthritis is shoulder replacement.  This procedure is performed by removing and replacing the arthritic ball with a metal implant, and by resurfacing the socket with a plastic implant, restoring low-friction, pain-free motion. Implant design and surgical technique for the treatment of both rotator cuff tears and shoulder arthritis continue to evolve.   These innovations empower shoulder and elbow surgeons to individualize the treatment plan to a specific patient and problem.

Tonight, March 12 at 6:30 pm at Greenwich Hospital,  Dr. Kowalsky will give a health talk on “Common Causes and Solutions to Chronic Shoulder Pain” will discuss the causes, symptoms, and treatment of rotator cuff tears and shoulder arthritis.  The event will highlight important recent advances in the management of these conditions that have been associated with improved long-term outcomes.

The program is free and open to the public.
Registration Requested. Call (203) 863-4277, or register online at

Posted in Greenwich Hospital, Health Seminar, Joint Replacement, Medical, Medical Expertise, Treatment | Tagged , , | Leave a comment

Staying in the Game: Non-operative Treatment of Low Back Pain

On Wednesday, April 8th at 6:00 PM, Jeffrey Heftler, MD of ONS (Orthopaedic and Neurosurgery Specialists, PC) and Greenwich Hospital, and Alicia Hirscht, DPT, SCS, CSCS, of ONS Physical Therapy, will present a free health seminar, Staying in the Game: Non-operative Treatment of Low Back Pain. The seminar will focus on common causes of low back pain and non-surgical treatment options including, physical therapy, medicines, and injections and will be held Waveny Life Care Network, 3 Farm Road, New Canaan, CT.

Doctor Photos_HeftlerDr. Heftler is an interventional physiatrist who specializes in spinal injections and other non-operative treatments for spinal and musculoskeletal disorders. “Many Americans experience low back pain over the course of their lifetime” said Dr. Heftler. “The vast majority of people with low back pain are able to achieve and maintain relief without requiring surgery.”

Physical-Therapy_Alicia-Hirscht-221x300Alicia Hirscht, DPT, SCS, is board certified by the American Physical Therapy Association in Sports Physical Therapy where she is the Senior Clinical Specialist. Alicia lectures regularly in the community on injury prevention, adolescent sports medicine and women’s health.

The program is free and open to the public. Registration is requested. To register call, 203-594-5310 or register online at For more information on topics related to orthopedics, sports medicine and neurosurgery, visit the calendar page.

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Shoulder Pain? (Part I)

Marc Kowalsky MD

Marc Kowalsky, MD.

ONS welcomes Dr. Kowalsky,  a board-certified orthopedic surgeon with expertise in rehab-focused, as well as operative treatments for upper and lower extremity sports injury, and complex shoulder and elbow conditions including degenerative disease, trauma, and revision surgery. He has also authored original research manuscripts, review articles, textbook chapters focusing on AC joint reconstruction, rotator cuff repair, and shoulder replacement, and now he is adding to the educational articles ONS provides.

Shoulder pain is the second most common musculoskeletal complaint to a primary care physician, behind only back pain. Twenty percent of the population will suffer from shoulder pain during their lifetime.  A variety of conditions can contribute to shoulder pain, ranging from rotator cuff problems to arthritis of the shoulder joint.

The rotator cuff tendon consists of the tendons of the four muscles that originate on the shoulder blade and insert on the humerus adjacent to the ball of the shoulder joint.  These muscles participate in rotation and elevation of the arm.  A bursa, or fluid-filled sac, lies on top of the rotator cuff tendon, and helps to protect or shield the tendon from the adjacent structures of the shoulder as the tendon glides.

Although most people who present to their physician with a rotator cuff problem likely have simple tendonitis, or bursitis, some may in fact have a rotator cuff tear.  At least twenty-five percent of people over the age of sixty may have a tear in the rotator cuff tendon.  Most of these tears are chronic and degenerative in nature, without any traumatic cause.  These patients experience shoulder pain with motion away from the body and overhead, typically along the side of the shoulder and arm.  They may also experience night pain that awakens them from sleep.

Some patients may also notice weakness, depending on the size of the tear.  A rotator cuff tear, once present, is unlikely to heal on its own, and may enlarge over time.  Nevertheless, many patients with a tear can be successfully treated with conservative means, including physical therapy, oral anti-inflammatory medication, and perhaps an injection of corticosteroid.  For those patients who do continue to experience pain due to a rotator cuff tear, operative repair is an option.  This procedure is typically performed arthroscopically, and consists of anchoring of the torn tendon to its attachment site with a series of small screws, or anchors.  Ultimately this procedure is effective in improving a patient’s pain and overall function. (…to be continued)

If this topic interests you keep an eye out for the next installment and attend Dr. Kowalsky’s upcoming seminar on March 12th at Greenwich Hospital. The program is free and open to the public.
Registration Requested. Call (203) 863-4277, or register online at

Posted in Greenwich Hospital, Injury Prevention, Joint Replacement, Medical, Medical Expertise, Neck Pain, Orthopaedic Conditions, Orthopaedic Research, Seminars, Uncategorized | Leave a comment

Stem Cells: The Potential

2015 Paul SethWEB

Paul Sethi, MD

The following educational blog about stem cells and their potential was written by Dr. Sethi, a leading research physician at ONS. He speaks at academic and instructional medical conferences in the US and abroad and his research on surgical advances for the shoulder, elbow and knee is regularly published in leading medical journals. He also collaborates with outside companies for education and research purposes and to develop medical procedures on the shoulder, elbow and knee, and is President of the ONS Foundation for Clinical Research and Education.

Most cells in our body develop into a specific cell type, for example, cells that populate the kidneys.  Similar to our staying on a “career path,” these cells stay in the same line and continue to produce and generate cells to function within the body part.  In contrast, stem cells are basic human cells that have not chosen a cell type (job) but have the potential to give rise to many different cell types in the body. This is exciting because stem cells may be able to create new cells in existing healthy tissues and may help to repair tissues in those structures that are injured or damaged.

As orthopedic surgeons, we have focused our attention on mesenchymal stem cells. Unlike embryonal stem cells, mesenchymal stem cells are obtained from living adult tissue: from bone marrow in your pelvic bone and sometimes from blood or adipose tissue.  Bone marrow stromal cells are the specific mesenchymal stem cells that, in the proper environment, can differentiate into cells that are part of the musculoskeletal system. They can help to form bone, tendon, articular cartilage or even ligaments – all critical elements of musculoskeletal regeneration.

At this point, stem cell procedures in orthopedics are at an experimental stage.  It is expected, however, that as more knowledge of tissue engineering is obtained, stem cell procedures will become more common.  Active research and current clinical applications show promise in three specific areas of orthopedic regeneration surgery. These areas are:

Bone Fractures and Nonunions:  Traditionally, bone defects have been treated with solid bone, material placed at the site of the fracture or nonunion. Stem cells and progenitor cells are now placed along with the bone graft to stimulate and speed the healing. These may be used in the absence of a bone graft, avoiding a potentially painful surgical procedure.

Articular Cartilage and Arthritis:  The lining of joints is called the articular cartilage. Damage to the articular cartilage can frequently lead to degeneration of the joint and painful arthritis. Current techniques treat articular cartilage damage by grafting and transplanting cartilage to fill the defects. It is hoped that stem cells, injected into the joints, will create growth of primary hyaline cartilage to restore the normal joint surface.

Ligaments and Tendons
:   Mesenchymal stem cells may also develop into cells that are specific to connective tissue leading to faster healing of ligament and tendon injuries, such as quadriceps or Achilles tendon ruptures. In this case, stem cells would be included as part of a primary repair process.  We anticipate our future ability to repair the ACL instead of surgically replacing the ligament.

Overall the use of stem cells holds a lot of promise but the research is still ongoing. ONS is here to heal as well as educate so keep an eye out for more blogs related to this and other insightful academic topics.

Posted in Orthopaedic Research, Uncategorized | Tagged | Leave a comment

PRP: A step forward in regenerative medicine

Dr Kessel

Dr. Tamar Kessel, physiatrist, with a C-arm

Dr. Kessel is a physiatrist who specializes in non-operative treatments of musculoskeletal injuries and has an interest in the use of ultrasound to target medications to the precise location of tissue damage. One procedure that optimizes on ultrasound technology is the new and progressive treatment in regenerative medicine, PRP (Platelet Rich Plasma). Utilizing therapeutic injections, like PRP, has been shown to be safer and to greatly improve treatment results.  The treatment has even received significant attention from the media and has been used by members of the New York Football Giants, other NFL players and elite athletes. Dr. Kessel is committed to providing the highest quality medical care and achieving the best outcomes for her patients.

PRP is a new treatment in regenerative medicine that uses the patient’s own blood and platelets to promote healing and helps the body optimize on its own natural processes. The patient’s own blood is drawn then placed in a centrifuge machine that separates the blood, leaving the platelet rich plasma ready to be removed. Afterwards, the PRP is placed right into the area of damage using ultrasound. Most people benefit from one injection but depending on the severity of the damage, it could take up to three. This method can help heal injuries including tendon/ligament injuries (Achilles Tendonitis), tennis elbow, cartilage loss, arthritis, and small tears (rotator cuff tears and meniscal injuries).

Note: Because PRP is given in the hopes of optimizing the initial inflammatory response of healing, anti-inflammatory medications should likely be stopped at the time of PRP treatment. Please consult your physician before any procedure.

Posted in Greenwich Community, Medical, Medical Expertise, Orthopaedic Research, Sports Injury, Sports Medicine, Treatment, Women's Sports Medicine | Tagged , , , , , | Leave a comment

Shoulder Pain? If you can’t do the simple things you once did, you may be suffering from a shoulder condition.

Shoulder Pain
: March 12, 2015, 6:30 p.m.
Where: Noble Auditorium, Greenwich Hospital
Speaker: Marc Kowalsky, MD

Severe shoulder arthritis and chronic shoulder pain can make daily-life activities, like combing hair, reaching for a lamp or putting on a sweater extremely difficult. Marc Kowalsky, MD, orthopedic surgeon and shoulder specialist will talk about reliable solutions for chronic shoulder pain. It is important to learn about your options in order to make the best decision for you. You will have the opportunity to ask questions at the conclusion of the talk.

The program is free and open to the public. Registration Requested. Call (203) 863-4277, or register online at

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“Maximizing Your Child’s Athletic Potential” Success


Dr. Delos with Allan Houston

Last Thursday’s talk on “Maximizing Your Child’s Athletic Potential” was a success. A big thank you goes out to the Junior League of Greenwich for making it possible with their focus on improving the community and empowering others to further health and education! Ultimately they brought together the perfect combination of experts to inform the public about the youth and the sports they love.

Dr. Delos, of ONS and Greenwich Hospital, was a panel speaker at this event. He specializes in sports medicine and arthroscopic treatment of knee and shoulder disorders. Before ONS, Dr. Delos was the Assistant NFL Team Physician for the New York Giants and was team physician for a number of local high school and college athletes.

Other panel members consisted of Andy Barr, Director of Performance and Rehab for the New York Knicks, Mubarak “Bar” Malik, Head of Strength and Conditioning for the New York Knicks, and Allan Houston, one of NBA’s all-time greatest long range shooters and Olympic gold medalist, as the moderator. Each participant reinforced the importance of parents taking interest in the development of their young athlete and properly guiding them to the path of success. Parents attending this event were very attentive, and came prepared with questions.

Conversations covered the fundamental topics, like proper sleep habits and nutrition. For example, a young athlete’s nutrition should increase in relation to the amount of activity they experience daily. This may be common knowledge to an adult but for an adolescent, proper amounts of sleep and good nutrition that balances the amount of activity should be added to their routine.

Aside from the basic topics of discussion, there was a myth to be busted as well; to find out the details of the myth and for more information about the questions that were asked at the event, please read the article written by the Greenwich Freepress.


Photography credit goes to the Delos family, thank you!

Posted in Adolescent, Community Outreach, Greenwich Community, Greenwich Hospital, Health Seminar, Management, Medical, Medical Expertise, News and Announcements, Physical Medicine, Prevention, Throwing Injuries, Uncategorized, Women's Sports Medicine | Tagged , , , , , , , , | Leave a comment