OUR EXPERTISE

 

Our office specializes in treating, preventing, and repairing injuries & defects of the foot and ankle.

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Arthroscopy & Tendoscopy of the Foot & Ankle

We apply arthroscopy & tendoscopy for many pathologies including:

  • Ankle joint (osteochondral lesions, arthritis, fractures, ligament injuries, posterior ankle impingement)
  • Subtalar joint (arthritis)
  • Metatarsal phalangeal joint (Hallux rigidus)
  • Peroneal tendons
  • Posterior tibial tendon
  • Flexor halluces longus tendon
  • Achilles tendon (Haglund’s deformity, Achilles tendinosis)
Arthroscopy is a minimally invasive operation in a joint which is done by ‘keyhole.’ A camera is inserted into the joint to look inside while small instruments are used to treat the problem. Dr. Kennedy is the pioneer and world’s expert of arthroscopic surgery and advanced methods of treatment in the foot and ankle.
Tendoscopy is a procedure to see inside of a tendon sheath- very similarly to arthroscopy. The same small camera and special instruments are used to treat tendon disorders without traditionaly large incisions. These techniques allow patients to get back to their life more quickly than open surgery.

Osteochondral Lesions

Depending on the size and characteristics of your Osterochondral lesion, we have two different treatment options:

1. Reparative Treatment – Bone marrow stimulation (Microfracture)
2. Replacement Treatment – Autologous osteochondral transplantation (OATS)

This procedure is indicated for smaller lesion and can be done arthroscopically. Multiple holes are made in the exposed bone and they allow bone marrow stem cells to come into cartilage defect site. At the same time BioCartilage (Arthrex) is utilized, which contains key components for cartilage repair such as type II collage, proteoglycans and growth factors. To promote cartilage repair into more normal-like cartilage, we also use bone marrow aspirate concentration or platelet-rich plasma. BioCartilage.
This procedure is an osteochondral replacement technique by inserting a cylindrical graft and indicated for larger lesion or large cystic lesion. Donor site is typically from non-weight bearing portion of ipsilateral knee or from allograft. The results are promising. 90% of athletes returned to competitive sports activity at pre-injury level.
Shimozono Y, Yasui Y, Ross AW, Kennedy JG. Osteochondral lesions of the talus in the athlete: up to date review. Curr Rev Musculoskelet Med. 2017 Feb 10.

Yasui Y, Ross AW, Kennedy JG. Platelet-Rich Plasma and Concentrated Bone Marrow Aspirate in Surgical Treatment for Osteochondral Lesions of the Talus. Foot Ankle Clin. 2016 Dec;21(4):869-884.

Flynn S, Ross KA, Hannon CP, Yasui Y, Newman H, Murawski CD, Deyer TW, Do HT, Kennedy JG. Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus. Foot Ankle Int. 2016 Apr;37(4):363-72.

Fraser EJ, Harris MC, Prado MP, Kennedy JG. Autologous osteochondral transplantation for osteochondral lesions of the talus in an athletic population. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1272-9.

Haleem AM, Ross KA, Smyth NA, Duke GL, Deyer TW, Do HT, Kennedy JG. Double-Plug Autologous Osteochondral Transplantation Shows Equal Functional Outcomes Compared With Single-Plug Procedures in Lesions of the Talar Dome: A Minimum 5-Year Clinical Follow-up. Am J Sports Med. 2014 Aug;42(8):1888-95.

Murawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 2013 Jun 5;95(11):1045-54.

Ankle Instability

Every day an estimated one out of every 10,000 people sprain their ankle, an injury in which one of the two major ligaments on the outer portion of the ankle is stretched and/or torn.

In the great majority of cases, individuals who see a physician for their injury are instructed on how to reduce pain and inflammation. They may be advised to wear an air cast or participate in physical therapy to strengthen the ankle muscles, in order to make a full recovery.

The remaining population—about 10% of people—develop ankle instability, a condition in which, although the ligament has healed, it has done so in a lengthened position. As a result, the person is prone to a feeling of the ankle “giving out” and to additional sprains. Athletes such as ballet dancers, who already have looser-than-average ligaments, are particularly likely to develop this condition.

Surgical treatment is reserved for patients who have persistent symptoms despite functional treatment. Surgery is often achieved with anatomic ligament repair (modified Bröstrum procedure) but some patients require ligament reconstruction using free tendon grafts. We have developed a novel method of hybrid reconstruction using the peroneal longus tendon.

Kennedy JG, Smyth NA, Fansa AM, Murawski CD. Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population. Am J Sports Med. 2012 Oct;40(10):2309-17.

Sports Injuries to the Foot & Ankle

Achilles tendon injuries are the most common tendon injuries of the lower extremity. Both non-operative and surgical treatment offer advantages and potential complications, but surgery decreases the re-rupture rate in comparison to non-operative treatment. We combine PRP or BMAC with the treatment to help quickly return patients to sports activity.
Anterior ankle impingement, also referred to as “athlete’s ankle” or “footballer’s ankle,” occurs when bone or soft tissue in the anterior ankle joint becomes inflamed due to repetitive stress. This can lead to bone spurs on the tibia or talus and synovitis. This will cause pain, swelling and restricted range of motion of the ankle, especially dorsiflexion. In persistent cases, surgery is beneficial. The procedure can be done arthroscopically and special instruments are used to shave away redundant soft tissues and bone spurs.
This occurs when bone and soft tissue at the back of the ankle becomes inflamed due to repetitive stress. This will cause pain, swelling and restricted range of motion of the ankle, especially plantarflexion. It is often associated with an extra bone, called os trigonum. This syndrome is commonly found in ballet dancers, gymnasts, and footballers. These extra bones and inflamed soft tissue can be removed arthroscopically with two minimal incisions in the back of the ankle.
This type of fracture is caused by overuse and repetitive stress on the fifth metatarsal. Jones fractures frequently affect athletes, causing lost playing time. Surgery is recommended due to poor blood supply to this area, and high likelihood of re-injury. We place a screw in the bone through a minimal incision and apply bone marrow aspirate concentrate (BMAC) for quick recovery. BMAC contains the patient’s own stem cells and growth factors which promote quick bone healing.
Ross KA, Murawski CD, Smyth NA, Zwiers R, Wiegerinck JI, van Bergen CJ, Dijk CN, Kennedy JG. Current concepts review: Arthroscopic treatment of anterior ankle impingement. Foot Ankle Surg. 2017 Mar;23(1):1-8.

Zwiers R, Wiegerinck JI, Murawski CD, Fraser EJ, Kennedy JG, van Dijk CN. Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature. Arthroscopy. 2015 Aug;31(8):1585-96.

Murawski CD, Kennedy JG. Percutaneous internal fixation of proximal fifth metatarsal jones fractures (Zones II and III) with Charlotte Carolina screw and bone marrow aspirate concentrate: an outcome study in athletes. Am J Sports Med. 2011 Jun;39(6):1295-301.

Yasui Y, Hannon CP, Hurley E, Kennedy JG. Posterior ankle impingement syndrome: A systematic four-stage approach. World J Orthop. 2016 Oct 18;7(10):657-663.

Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, Kennedy JG. Posterior hindfoot arthroscopy: a review. Am J Sports Med. 2014 Jan;42(1):225-34.

Smyth NA, Murawski CD, Levine DS, Kennedy JG. Hindfoot arthroscopic surgery for posterior ankle impingement: a systematic surgical approach and case series. Am J Sports Med. 2013 Aug;41(8):1869-76.

Zwiers R, Wiegerinck JI, Murawski CD, Smyth NA, Kennedy JG, van Dijk CN. Surgical treatment for posterior ankle impingement. Arthroscopy. 2013 Jul;29(7):1263-70.

Tendon Injuries to the Foot & Ankle

The peroneal tendons run on the outside of the ankle just behind the fibula. They turn the foot out and provide stability to the ankle during weight-bearing. Tendinosis means inflammation in the tendon. This usually occurs in the setting of overuse or irritation. Patients will usually present with pain right around the back of the fibula. Most patients improve without surgery. We use shockwave therapy and PRP treatments to help stimulate healing growth. Surgical treatment is indicated if the pain does not get better despite the use of these treatments, and can be done by tendoscopy. Tendoscopic surgery is minimally invasive, which allows patients to recover quickly.
This condition is degeneration and inflammation of the posterior tibial tendon. This tendon lies immediately behind the medial malleolus. Tendon disorders result from long-standing biomechanical problems, such as flatfoot. Patients experience pain behind the medial malleolus and standing on the toes becomes difficult. Conservative treatment consists of mechanically off-loading the tendon by using orthotics, with shockwave therapy or PRP injections to heal the tendon itself. Surgery is indicated if the pain does not get better despite the use of these conservative treatments. Early stage flatfoot deformity can be treated with the use of arthroereisis screw with tendoscopic delivered PRP. This is a minimally invasive surgery instead of traditional big surgery.
The Achilles tendon degenerates and becomes inflamed in this condition. The tendon can swell and cause pain. This is common in athletes, runners and people who have calf tightness. Most patients improve without surgery. We use shockwave therapy and also platelet-rich plasma (PRP) which contains numerous growth factors. In some cases, surgery may be required but arthroscopic surgery can be applied.
Murawski CD, Smyth NA, Newman H, Kennedy JG. A single platelet-rich plasma injection for chronic midsubstance Achilles tendinopathy: a retrospective preliminary analysis. Foot Ankle Spec. 2014 Oct;7(5):372-6.

Kennedy JG, van Dijk PA, Murawski CD, Duke G, Newman H, DiGiovanni CW, Yasui Y. Functional outcomes after peroneal tendoscopy in the treatment of peroneal tendon disorders. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1148-54.

Yasui Y, Tonogai I, Rosenbaum AJ, Moore DM, Takao M, Kawano H, Kennedy JG. Use of the arthroereisis screw with tendoscopic delivered platelet-rich plasma for early stage adult acquired flatfoot deformity. Int Orthop. 2017 Feb;41(2):315-321.

Gianakos AL, Ross KA, Hannon CP, Duke GL, Prado MP, Kennedy JG. Functional Outcomes of Tibialis Posterior Tendoscopy With Comparison to Magnetic Resonance Imaging. Foot Ankle Int. 2015 Jul;36(7):812-9.

Ling JS, Ross KA, Hannon CP, Egan C, Smyth NA, Hogan MV, Kennedy JG. A plantar closing wedge osteotomy of the medial cuneiform for residual forefoot supination in flatfoot reconstruction. Foot Ankle Int. 2013 Sep;34(9):1221-6.

Arthritis of the Foot & Ankle

Osteoarthritis is the most common type of “wear and tear” arthritis. While there is no cure for this pathology, in which cartilage is lost progressively in the ankle joint, many biologics have been more recently studied as a regenerative injection treatment. We use not only PRP, but also BMAC, amniotic stem cells, fat cells.

The gold standard of surgical treatment of advanced ankle arthritis is traditionally fusion of the ankle joint. The arthrodesis can be performed arthroscopically with minimal invasive incision. Arthroscopic arthrodesis allows patients to quickly rehabilitate and fusion rates are comparable or better than a traditional open procedure.

Distraction arthroplasty with a external fixator is also an option. This technique stretches the joint apart for a period of time with a frame and unloads the ankle joint, allowing healing of the damaged joint. This can be helpful in patients in whom it is desirable to prolong the need for fusion or replacement.

Yasui Y, Hannon CP, Seow D, Kennedy JG. Ankle arthrodesis: A systematic approach and review of the literature. World J Orthop. 2016 Nov 18;7(11):700-708.

Biologics

PRP is produced from a person’s own blood. It is a concentration of one type of cell, known as platelets, which circulate through the blood and are critical for blood clotting. Platelets and the liquid plasma portion of the blood contain many factors that are essential for the cell recruitment, multiplication and specialization that are required for healing.

After a blood sample is obtained from a patient, the blood is put into a centrifuge, which is a tool that separates the blood into its many components. Platelet rich plasma can then be collected and treated before it is delivered to an injured area of bone or soft tissue, such as a tendon or ligament.

PRP is given to patients through an injection, and ultrasound guidance can assist in the precise placement of PRP. After the injection, a patient must avoid exercise for a short period of time before beginning a rehabilitation exercise program.

Bone marrow aspirate concentrate is made from fluid taken from bone marrow. The bone marrow aspirate contains stem cells that can help the healing of some bone and joint conditions. Bone marrow aspirate concentrate is obtained with a minimally invasive procedure that avoids the risks of an open bone graft procedure.

Stem cells can be used to help with bone healing, cartilage repair and new blood vessel growth. Using stem cells may treat delayed union or nonunion of bone fractures, cartilage defects, osteonecrosis, chronic tendon problems or chronic wounds.

Shockwave Therapy

Shockwave therapy is a non-invasive method that uses pressure waves to treat various musculoskeletal conditions. This causes blood vessel formation and increased delivery of growth factors to the affected area to stimulate the repair process and relieve pain. Shockwave therapy is not painful and takes only 5 minutes. Shockwave therapy has been used for treatment of a variety of conditions including: Plantar fasciitis, Achilles tendinosis, Peroneal tendinosis, Posterior tibial tendinosis, stress fracture, and various kinds of soft tissue injuries.

“I feel very fortunate to have been a patient of Dr Kennedy and his team – they completely changed my life and my ability to enjoy it.”

Neal O. // NYC