Technology and AI Guide Personalization of Foot and Ankle Procedures
In This Article
- Repairing defects in feet and ankles is generally more complicated than caring for joints like the knee or hip
- This is due to factors such as the greater number of bones, ligaments, vasculature, the smaller size of the bones; and the weight-bearing stress put on these parts
- The Foot and Ankle Research and Innovation Lab (FARIL) at Mass General Brigham is focused on addressing this challenge by providing a patient-specific approach rather than a general approach
Repairing defects in the feet and ankles is generally more complicated than caring for joints like the knee or hip. This is due to factors such as the greater number of bones, ligaments, nerves, and blood vessels in the foot and ankle; the smaller size of the bones; and the amount of weight-bearing stress put on these parts. Moreover, patient-to-patient variabilities play a significant role in the decision-making process and treatment plans.
Subscribe to the latest updates from Orthopaedics Advances in Motion
The Foot and Ankle Research and Innovation Lab (FARIL) at Mass General Brigham is focused on addressing this challenge. The lab uses the latest technologies to advance orthopedic care for patients with a wide range of foot and ankle conditions.
"One program we are especially proud of is the Patient-Specific 3D Instrument Development Initiative, or PSI," says orthopedic surgeon Soheil Ashkani-Esfahani, MD, MPH, who directs FARIL. "This initiative is made up of clinicians, scientists, engineers, and other specialists with diverse backgrounds who work together to improve the quality of care for patients with foot and ankle disorders."
AI and 3D Simulation Add Value to Specialized Imaging Techniques
FARIL's PSI initiative is a patient-specific initiative driven by numerous state-of-the-art technologies including novel 3D printers, 3D simulation software, state-of-the-art X-ray imaging devices, and a weight-bearing CT scanner.
"Weight-bearing CT is a fairly novel device," Dr. Ashkani-Esfahani says. "It allows us to see the congruence of the joints and alignment of bones bilaterally when patients are standing up rather than lying down."
Artificial intelligence (AI) and 3D-simulation software can greatly increase the usefulness of these scans and enable the creation of 3D virtual models. For example, if a patient has an injury in one foot, scans of the other foot can help determine what that individual's anatomy would look like under normal conditions. Based on that, the clinicians can decide the best treatment plan to restore a patient's normal anatomy.
In a study conducted by the FARIL team and published in November 2024 in Scientific Reports, the authors showed that using weight-bearing CT combined with advanced 3D modeling and computational biomechanics could accurately assess joint alignment and pressure in trans-syndesmotic ankle fractures. These tools help surgeons predict patient outcomes more reliably, allowing them to identify stable fractures that can heal without surgery. This approach not only improves patient satisfaction and quality of life by avoiding unnecessary procedures but also reduces healthcare costs by minimizing surgical interventions.
Furthermore, in another study published in February 2024 in Foot and Ankle International, the FARIL team showed that weight-bearing CT with AI-assisted 3D modeling and finite element analysis can predict arthritis risk in ankle fractures by identifying displacements that increase joint stress, aiding in prevention and treatment.
Technology Aids Minimally Invasive Surgical Procedures
Combining AI, 3D design, and novel imaging technology such as portable X-ray or weight-bearing CT scans also makes performing minimally invasive surgical (MIS) procedures easier.
The team can design guides to help surgeons perform MIS surgeries using small cuts on patient's skin. AI can also assist with predicting and designing the surgical plan. For example, a surgical guide can help the surgeon pass the MIS burr to cut a specific portion of the calcaneus in patients with Haglund's deformity — a bony bump on the back of the heel that can cause pain and swelling. AI also assists the surgeon in determining how much bone needs to be cut to achieve the optimum results, based on a primary X-rays or CT scans.
"This makes MIS easier and safer by eliminating the need for frequent imaging and reducing the radiation exposure and costs that come with that imaging," Dr. Ashkani-Esfahani says. "It will also save time and increase confidence in the surgeons conducting these types of surgeries."
He adds that this degree of planning helps patients to become comfortable with the procedures they will be undergoing, which improves patient satisfaction and quality of life.
The surgical plans, guides, implants, and other devices are custom-designed based on each patient's anatomy along with other factors, such as the individual's socioeconomic status, underlying health conditions, expectations, and stage in life. The ultimate goal is to provide the highest satisfaction rate for patients.
"How we decide the treatment plan and address a repair in an 80-year-old with osteoporosis is very different than in a young person with an athletic injury," Dr. Ashkani-Esfahani says.
The FARIL team is currently working on an AI-based application named MISTRY, which provides a personalized plan for orthopedic surgeons to conduct MIS surgeries on the foot and ankle. This project is lead by FARIL's medical postdoc, Atta Taseh, MD, under the supervision of internationally recognized MIS surgeons, Christopher Miller, MD, and Dr. Ashkani-Esfahani.
3D Printing Technology Advances Research
Omer Subasi, PhD, a former engineering postdoc at FARIL and current adjunct professor at Northeastern University, was first author of a study published in July 2023 in Computers in Biology and Medicine that used computational techniques to explore bone plate design.
The study demonstrated that additively manufactured, stiffness-reduced bone plates can effectively address stress shielding, one of the most significant complications in orthopedic implants and one that slows bone healing. This advance, which employed strategic modulation of lattice infill parameters to create custom bone plates, highlights one potential application of the technology.
"The process of creating patient-specific interventions with computational design and 3D printing really lands in my wheelhouse as a bioengineer focused on 3D designing and simulations," says Dr. Subasi, who trained as a biomedical engineer. "Using these patient CT scans, followed by 3D segmentation by experts, allow us to create custom, novel surgical instruments."
Technology Boosts Quality of Life and Cost Savings
All of these technologies contribute not only to improvements in patients' quality of life but also to substantial cost savings.
"Because we are able to plan procedures so well in advance, the time spent in the operating room will be shorter," Dr. Ashkani-Esfahani says. "Additionally, patients who receive this very personalized treatment have lower rates of infection and other complications and require less rehabilitation and fewer follow-up visits, which saves time and costs to a great extent."
Advancing Education through Virtual Reality
Utilizing advanced imaging technologies such as weight-bearing CT scans and portable X-ray machines, along with 3D simulation and modeling capabilities, the FARIL team has been developing the Orthopaedic Mixed Reality Initiative. This innovative virtual reality platform enhances orthopedic education and patient engagement by allowing users to visualize conditions in an interactive 3D environment.
This platform is being developed by a multidisciplinary team including Kendal Toy, FARIL's clinical research coordinator and Yale-trained bioengineer along with Bedri Karaismailoglu, MD; Lercan Aslan, MD; Lorena Bejarano-Pineda, MD; Abhiram Bhashyam, MD, PhD; Christopher Bono, MD; Mitchel B. Harris, MD; and Dr. Ashkani-Esfahani. Its aim is to enable orthopedic trainees and patients to explore diagnoses with expert surgeons, review imaging and planned surgical procedures, and interact with 3D models derived from patient-specific CT scans and 3D models of the implants and instruments.
FARIL Efforts Have Global Reach
The benefits of FARIL's research go far beyond patients treated at Mass General Brigham, as international postdocs and surgeons who are trained at FARIL return to their home countries. This led to an initiative called FARIL International, which currently includes ambassadors in Türkiye, India, Belgium, Canada, and the Netherlands.
One expert who trained at FARIL is Dr. Karaismailoglu, now an associate professor in orthopedics and traumatology and director of the CAST research center at Istanbul University-Cerrahpasa in Türkiye. Dr. Karaismailoglu has made significant contributions to patient-specific treatment in foot and ankle surgery.
As the lead author of a study published in Foot and Ankle Surgery in February 2024, he demonstrated that each burr pass in minimally invasive calcaneal osteotomy leads to predictable reductions in calcaneal length and changes in key anatomical angles. By mapping these trends, his research helps surgeons optimize the number of burr passes for precise, patient-specific corrections, enhancing surgical planning and outcomes.
In another study, published in Foot and Ankle Surgery in January 2025, together with Dr. Christopher Miller and Dr. Ashkani-Esfahani, he explored the role of X-ray–based heatmaps in minimally invasive midfoot procedures. His findings show that these heatmaps can improve surgical navigation by mapping the trajectories of critical neurovascular structures and tendons, helping surgeons identify high-risk areas for iatrogenic injuries.
This technique enhances surgical accuracy and reduces complications, marking another step forward in optimizing foot and ankle surgery. "The inclusive environment at FARIL has been instrumental in expanding my professional network on both national and international levels," Dr. Karaismailoglu says. "I am delighted to engage in collaborations with scientists and surgeons from across the globe."