“This new block provides excellent anesthesia and analgesia to foot and ankle surgeries and preserves motor function of the ankle joint. The results are very promising,” said Enrique A. Goytizolo, MD, an anesthesiologist at HSS and senior author of the study. “New protocols of early rehabilitation of foot surgeries can be instituted, since patients have no pain with movement of the foot.”

An ultrasound-guided popliteal block is the current standard anesthetic technique for foot and ankle surgeries, but the study findings show that using an ultrasound-guided mid-calf block could enable earlier rehabilitation protocols and an overall faster recovery from surgery.

A popliteal block numbs the sciatic nerve at the level of the popliteal fossa, which is a diamond-shaped space behind the knee joint. A mid-calf block is placed farther down the leg, between the popliteal fossa and the ankle, and numbs the posterior tibial nerve, superficial and deep peroneal nerves, sural, and saphenous nerves. A mid-calf block provides prolonged analgesia for any foot or ankle surgery while preserving motor function of the ankle joint.

Twenty patients who were scheduled to receive foot or ankle surgery at HSS were recruited for the study. The procedures included total ankle replacement, ankle arthroscopy, bunionectomy, cheilectomy, and Achilles tendon repair. Participants were assessed in the post-anesthesia care unit (PACU) and again before discharge to record the time when the mid-calf block ended, presence of paresthesia, and any other side effects. On postoperative days 1, 2, and 7, participants were asked about their pain on a numerical rating score (NRS), their medication use, and other symptoms.

The researchers found that the median duration of analgesia from the mid-calf block was 18.2 hours, with an interquartile range of 4.5-24.0 hours. All 20 patients were able to flex their toes in the PACU.

The average pain score in the PACU was 0.8 +/- 2.1 at rest, and 1.1 +/- 2.3 with movement. Three participants were excluded for sensitivity analysis because they received additional surgery in surgical areas not covered by the mid-calf block. Among the 17 patients in the sensitivity analysis group, these scores were both 0.3 +/- 1.2 at rest and with movement.

“The mid-calf block provides reliable, consistent, and excellent anesthesia and analgesia for foot and ankle surgeries,” said Dr. Goytizolo. “Follow-up research and patient treatments following this study should include a fast-track rehabilitation program for patients who have total ankle replacement surgeries with a mid-calf block.”

The findings of this study will also inform future randomized control trials on the mid-calf block.

Reference

1. Marko Popovic BS, Alex Illescas MPH, Pa Thor PhD, Jacques YaDeau MD PhD, Constantine Demetracopoulos MD, Scott Ellis MD, Vincent LaSala MD, Matthew Roberts MD, Anne H. Johnson MD, Mark Drakos MD, Enrique Goytizolo MD. “Mid-Calf Block for foot and ankle surgery: A pilot study.” Presented at: 48th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 20-22, 2023; Hollywood, FL.

Kaler, who is from Long Island, says the surgery changed her life. She can now engage in activities most people take for granted – walking normally without pain, wearing shoes she likes, being able to do her job, working in her backyard.

“You have no idea how grateful I am. Before the surgery, my left ankle was collapsing, it could barely support my weight,” says Kaler, a slim 5 foot 7. “All my shoes were worn out on one side.” Her ankle was so unstable, she lived in fear that she would fall or break it, despite the rigid plastic brace she wore from her foot to her knee, day in and day out. She could only wear one type of shoe that she needed to replace every three months.

As a child, Kaler recalls constantly twisting her ankle. Her parents took her to several doctors, and she was given a shoe insert to help with her high foot arches. Years later, arthritis set in, and the pain worsened and became more debilitating. Cortisone shots could only do so much, and she resumed the search for a long-lasting solution. Four doctors said nothing could be done. One orthopedic surgeon said the problem might be corrected with four separate surgeries, which she declined.

Then she learned about total ankle replacement during an appointment with a doctor at HSS Long Island. It’s a complex surgery performed by relatively few orthopedic surgeons, and she was referred to Dr. Demetracopoulos, director of the HSS Total Ankle Replacement Center at the main hospital in Manhattan.

“One of the few centers of its kind, we have a team of foot and ankle specialists, anesthesiologists, radiologists, nurses and physical therapists who have extensive experience in ankle replacement,” he explains. “We strive to provide the best possible care for each of our patients and have grown our volume to become one of the top institutions nationwide in ankle replacement.”

Kaler says her consultation with Dr. Demetracopoulos gave her hope, and she would not be disappointed. She had the surgery in April 2021. “He saved my life. I never cry, but I cried in front of him, I was so grateful,” she says.  

“Ankle replacement is considered when patients are no longer able to manage arthritis pain with nonsurgical treatments such as physical therapy, appropriate footwear, an ankle brace or anti-inflammatory medication,” Dr. Demetracopoulos explains. “They have consistent pain that limits their activities and affects their quality of life.”

Like other types of joint replacements, the surgery involves replacing the damaged bone and cartilage in the ankle with a prosthesis. The implant, made of metal and plastic, has the shape of a natural joint and seeks to provide normal, pain-free movement.

The last 15 years have brought vast improvements in ankle replacement implants, technology and surgical techniques, making it a viable option for many patients suffering from severe arthritis, says Scott Ellis, MD, another orthopedic surgeon specializing in foot and ankle surgery at HSS.

One of the most noteworthy advances in ankle replacement is patient-specific instrumentation, or PSI, Dr. Ellis says. It entails obtaining a CT scan of the patient’s ankle and developing a customized presurgical plan tailored to the individual’s anatomy. “PSI has been a game changer. It enables us to choose an implant that is the perfect size and map out a very precise surgery for optimal alignment and positioning,” he says. 

For people considering an ankle replacement, the first step is a thorough assessment of the ankle and the foot, and a discussion of patient goals and expectations. Imaging and other tests determine if a patient is a candidate. For someone whose ankle is very stiff with limited mobility or a severe deformity, a fusion of the ankle bones might be a better option and is also very successful in relieving pain, the HSS experts say. An ankle fusion would also be a better option for someone with weakened bones or osteoporosis. The benefit of ankle replacement over fusion is better movement after surgery.

Sometimes an ankle replacement needs to be combined with another procedure, as it was in Kaler’s case. “Hers was a complex surgery. She had a type of foot that predisposed her to ankle instability,” Dr. Demetracopoulos explained. “In addition to treating her arthritis with the ankle replacement, we needed to treat the instability by repairing the ligaments in her ankle and by correcting the alignment in her foot, so it was in the right position.” 

Kaler says she experienced no pain after surgery, which Dr. Demetracopoulos attributes to advances in nerve block anesthesia and pain management protocols after the procedure. He notes that each patient experiences pain differently, though.  

The HSS doctors expect 90 percent of ankle replacements to last 10 years. If the implant wears out, patients could be candidates for a revision ankle replacement or an ankle fusion. The physicians follow and monitor patients in a joint replacement registry at HSS. “One of our core missions at HSS is not only to deliver the care and do the best surgery we can for our patients, but to collect data over time that we can share with other surgeons and clinicians,” Dr. Demetracopoulos says.  

Kaler says the surgery has enabled her to regain her confidence. She can now drive her stick-shift Mini Cooper and carry out her demanding job responsibilities at a major home improvement store. “I’m all over the place, to the point where my friends and colleagues are saying, ‘slow down,’” she adds, making up for lost time and living life to the fullest.

This year, the gala will be hosted by Al Roker, weatherman and co-host of NBC’s Today Show and CEO of Al Roker Entertainment, with special guest Saquon Barkley, running back of the New York Giants, on Monday, June 3, 2019 at the American Museum of Natural History in New York City.

“We are delighted to commemorate the extraordinary successes of Steve Tisch who has excelled in various disciplines of business, media and entertainment,” said Louis A. Shapiro, president and CEO at HSS. “Through his entrepreneurial spirit, artful storytelling and purposeful philanthropy, Steve inspires others to meet the greatest challenges with courage and perseverance.”

“Dr. Deland’s devotion to patient care and steadfast commitment to advancing the science and techniques to improve surgical treatment of foot and ankle conditions are living proof of the mission of HSS,” said Todd J. Albert, MD, surgeon-in-chief and medical director at HSS. “His foot and ankle registry, [the Rose Registry] is the largest in the nation supporting clinical studies and national publications that have, and will continue to, enhance foot and ankle care for patients in years to come.”

The event will begin at 6:15 p.m. with a dinner to follow at 7:15 p.m. Guests will include leaders from the worlds of business, health, finance, media, sports, the arts and government.

Jonathan T. Deland, MD

Jonathan T. Deland, MD is a foot and ankle surgeon at HSS and the Susan W. Rose and Jonathan T. Deland Chair for Research in Foot and Ankle Surgery. He serves as the Director of Quality and Innovation for the Foot and Ankle Service, having been its Chief and oversees the Aim Laboratory at HSS.

In addition to his devotion to foot and ankle surgery, Dr. Deland is an avid researcher. He presents his research nationally and internationally and has authored over 100 journal articles and 12 book chapters. His research focuses on improving the surgical treatment of foot deformities and total ankle replacements. Mrs. Susan W. Rose and Dr. Deland established the Rose Registry, one of the largest foot and ankle registries for clinical research in the nation. The registry supports clinical studies and national publications to advance foot and ankle care.

Dr. Deland’s interest in biomedical engineering has led him to co-invent a total ankle replacement and an Achilles tendon repair device. He and co-inventors are currently designing a new total ankle replacement as well as an ankle joint spacer for young patients with ankle arthritis.

Mr. Herbert Black and Dr. Deland teamed up to have the most advanced robotic gait simulator constructed at HSS in the Aim Laboratory, funded by Mr. Black. The gait simulator makes the most advanced biomechanical research in foot and ankle possible. Mr. Black and other supporters provide funding for its ongoing projects.

Steve Tisch

Steve Tisch is an Academy Award-winning producer, partner at Escape Artists Productions, Chairman, Executive Vice President and Co-Owner of the New York Football Giants, and a committed philanthropist. He is the only person with both an Oscar and a Super Bowl ring, winning Best Picture for “Forrest Gump” in 1994, and receiving two Super Bowl rings as Chairman of the Giants for Super Bowls XLII and XLVI.

For more than four decades, Steve has successfully produced compelling stories in film and television, from the critically acclaimed television movie, “The Burning Bed” starring Farrah Fawcett, to "Risky Business" and "The Pursuit of Happyness." Steve has been involved with the New York Giants since his father, Preston Robert Tisch, purchased 50 percent of the franchise in 1991. Steve worked closely with John Mara, President and CEO of the Giants, on the planning and construction of MetLife Stadium, which was completed in the spring of 2010 and ranked as the number one grossing stadium in the world in 2012. Tisch and Mara were named Best NFL Owners by Forbes in 2011.

Tisch also generously contributes his time and resources to a variety of organizations in arts, health and education. Steve is currently on the Board of Trustees of the Los Angeles County Museum of Art, is a founding Trustee of The Geffen Theatre in Los Angeles, is on the Board of Advisors of the Tisch School of the Arts at New York University and The Preston Robert Tisch Brain Tumor Center at Duke University, and previously served on the board of the Sundance Institute.

For more information, please visit https://www.hss.edu/36th-tribute-dinner.asp.

The research paper, titled, "The Use of Three-Dimensional (3D) Biometric Measurements to Predict Additional Alignment Procedures in Total Ankle Replacement" was presented today at the American Academy of Orthopaedic Surgeons Annual Meeting in Las Vegas. 

"The foot and ankle is a highly complex anatomical and biomechanical structure, and preoperative evaluation of deformities in patients undergoing total ankle replacement is challenging," said Constantine A. Detracopoulos, MD, an orthopedicsurgeon specializing in foot and ankle surgery at Hospital for Special Surgery and senior investigator. "The final decision to perform associated corrective alignment procedures and soft tissue balancing is made during surgery following insertion of the ankle replacement components."

Conventional x-rays are limited in their ability to characterize foot and ankle deformities due to their two-dimensional nature, according to Cesar de Cesar Netto, MD, who presented the study. The complexity of the foot and ankle and the importance of weight-bearing in diagnosis have prompted the use of standing CT scans to provide a more complete 3D picture of alignment and deformities, he noted. 

At HSS, the weight-bearing CT is standard of care. "This is a growing research field in foot and ankle orthopedics. The goal is to determine how this technology can improve our patient outcomes," Dr. Demetracopoulos noted. 

The researchers launched a pilot study to determine if the information provided by the standing CT could improve surgical planning prior to ankle replacement. Software designed for the scanner was used to calculate a new biometric measurement called the Foot and Ankle Offset (FAO). Surgeons could use this information to assess the alignment of the foot underneath the ankle and predict which additional surgeries, such as tendon transfers or osteotomies, might be needed during total ankle replacement. 

"Proper alignment is critical to the success of ankle replacement surgery and the longevity of the implant," said Dr. Demetracopoulos, who noted that the study, which included 12 patients, was the first of its kind. "The key in ankle replacement is to optimize not only the alignment of the ankle, but the alignment of the foot underneath."

The researchers found that an increased FAO significantly predicted the number of additional alignment procedures needed during ankle replacement. "We believe that the use of biometrics and measurements provided by the CT scan can enhance the preoperative assessment and surgical planning of total ankle replacement," Dr. Demetracopoulos said. "Future research will determine if it leads to improved outcomes, as well."

• Come from Away: Joint Patients Who Live Far from Hospital Offer Model for More Efficient Use of Post-Surgery Resources
  • Bradford S. Waddell, MD, and colleagues presented a study that found that patients who lived further from their chosen hospital are more likely to visit the ER for follow-up.
• HSS Orthopedic Surgeons Addressing Opioid Epidemic Head On
  • HSS surgeons including Michael P. Ast, MD, Michael M. Alexiades, MD, Michael B. Cross, MD, and Peter K. Sculco, MD, share insights on developing a pain management pathway to reduce the use of opioids after joint procedures.
• Study: CT Scan Prior to Spine Fusion Surgery Finds Significant Number of Patients Had Undiagnosed Osteoporosis
  • Alexander P. Hughes, MD, and colleagues presented data that nearly half of patients tested actually had osteoporosis or osteopenia.
• Study: Intravenous and Pill Form of Acetaminophen Work Equally Well After Hip Replacement as Part of Pain Management Plan
  • Geoffrey H. Westrich, MD, and colleagues compared acetaminophen in both intravenous and pill form as pain management after hip replacement.
• Study Suggests Hip Replacement Patients Can Skip Hip Precautions
  • Peter K. Sculco, MDand colleagues present research finding that low-risk patients may not need standard hip precautions for post-surgical recovery from a total hip replacement with a posterior approach.
• Spine Evaluation is Critical to Reduce Dislocations in Revision Total Hip Arthroplasty
  • Jonathan M. Vigdorchik, MD, and colleagues found that a new assessment tool prior to surgery has significantly reduced the rate of recurrent dislocations.
• One-stage Revision for Periprosthetic Joint Infection Gains Traction
  • Michael B. Cross, MD, and colleagues present findings that this technique for PJI may offer lower cost and quicker restoration of function than a two-stage revision.
• Study: Surgery to Remove Herniated Discs in the Neck Can Be Safely Performed in Outpatient Setting in Select Patients
  • Sheeraz Qureshi, MD, MBA, and colleagues report study results that found that anterior cervical discectomy and fusion can be safely performed in an outpatient setting for some patients.
• Study: Minimally Invasive Spine Stabilization Safe, Effective Alternative to Spine Fusion in Patients Under 65
  • Frank P. Cammisa Jr., MD, and colleagues share results on two treatment options for younger patients with lumbar spinal stenosis.
• Diabetics More Likely to Experience High Blood Sugar After Joint Surgery
  • Bradford S. Waddell, MD, and colleagues report that people with diabetes who undergo joint replacement surgery have an increased chance of developing infections and other complications. 
• Study: Weight-Bearing CT Scan and 3D Biometrics Can Enhance Assessment and Presurgical Planning for Total Ankle Replacement  
  • Constantine A. Demetracopoulos, MD, presents first study to evaluate the role of 3D biometric tools in pre-operative assessment for patients undergoing total ankle replacement.
• New Basic Science Study Finds Muscle-Derived Activated Endothelial Cells May Be Promising for Treatment of Soft Tissue Injuries
  • Scott A. Rodeo, MD, and colleagues receive the Charles Neer award from the American Shoulder and Elbow Surgeons Society for their paper on cell-based approaches to improve treatment of soft tissue injuries.

He interviews Jonathan T. Deland, MD, foot and ankle surgeon at HSS, as well as his patient, Frosty Blakeslee, who underwent the procedure a few years ago.

"My ankle hurt 24/7. I had to think about how I walked up the stairs and down the stairs from the kitchen to the living room," said Blakeslee, who is a certified professional ski instructor.

Blakeslee found Dr. Deland who recommended an ankle replacement over a fusion. He showed her a new generation prostheses that restores nearly normal function.

"Patients get good relief of pain, they can have little discomfort," said Dr. Deland. "It's like a 'wow operation'. They go 'wow, this is terrific!'"

Blakeslee regained 100 percent mobility and is able to get back on the slopes.

This coverage originally appeared in NewYork.CBSLocal.com. The original article is no longer available online.

The group, led by Constantine Demetracopoulos, MD, foot and ankle surgeon at HSS, received the honor for their paper, "Influence of Tibial Component Position on Altered Kinematics Following Total Ankle Arthroplasty During Simulated Gait." The article describes experiments to determine how surgical replacement of the joint can affect patient mobility after the procedure.

The surgeon team consisted of Drs. Jonathan Deland, Scott Ellis, and Guilherme Saito, who performed the study in conjunction with Daniel Sturnick in the Biomechanics Department at HSS. The research team utilized a unique robotic gait simulator, which is able to reproduce normal walking gait using human cadavers. The simulator was developed through a generous donation by Herbert Black, owner and CEO of American Iron and Metal Company, under the leadership of Dr. Jonathan Deland, foot and ankle surgeon at HSS.

The findings from the study could help surgeons fine-tune their techniques during ankle replacement to reduce the risk that patients experience complications later on, said Dr. Demetracopoulos. It may also help companies that make artificial joints design implants that are more anatomically friendly and less prone to wear.

"For patients who have ankle arthritis and have an ankle replacement, how we do the replacement and how we position the replacement device is critical to matching the kinematics of normal gait and the success of the procedure," Dr. Demetracopoulos said.

Total ankle arthroscopy (TAA), or ankle replacement surgery, is an option for patients with severe arthritis of the joint. For the procedure, surgeons replace the patient’s diseased ankle with a prosthetic joint composed of metal and plastic. Although the procedure is becoming more common, it is much less so than knee or hip replacement procedures, which number in the hundreds of thousands per year each. As a result, relatively little is known about the best ways to perform the procedure, particularly when it comes to positioning the replacement parts in the bone, or how variations in surgical techniques may affect outcomes.

Ankle replacement surgery is thought to provide patients greater flexibility and motion in the joint than an alternative procedure, ankle fusion. However, despite the significant improvement in pain and mobility following ankle replacement, whether an ankle prosthesis can restore normal walking gait remains unclear. 

For the new study, Dr. Demetracopoulos and his colleagues sought to learn how placement of the ankle implants during TAA affects range of motion. To do so, they implanted artificial ankles (Salto Talaris, Integra LifeSciences) into eight leg sections obtained from cadavers. (The use of cadavers allowed the researchers to more accurately assess ankle motion before and after implant surgery, and also avoided having to expose living patients to excessive radiation from imaging tests.)

To monitor motion, Dr. Demetracopoulos’ group surgically grafted ligaments and tendons from the original joint to sensors. The legs were mounted on a robotic platform with computer software that tracked movement of the ankle in three dimensions: up/down bending of the ankle, side-to-side tilting, and rotation of the bones. "As you bend your ankle up and down, the bone is doing a little bit of all three: From the very top to the very bottom, it’s bending down, it’s tilting and it’s rotating. It doesn’t move like a hinge," Dr. Demetracopoulos explained.

Using the robotic platform to simulate a walking gait, the HSS team found that ankle motion appeared to be restored in two degrees of movement--up/down and side to side tilting. However, rotational motion was significantly greater than before the procedure.  

"We were able to show that the technique of how the replacement is positioned is what drives that rotation," Dr. Demetracopoulos said.

The HSS researchers say the asymmetrical design of the implant used in the study—one of the oldest devices to reach the market that is currently still in use— may play a role in their findings. Newer implant designs may be less prone to such rotational motion, and the group is in the process of trying to evaluate those devices.