Two to Five-Year Outcomes of Total Ankle Arthroplasty with the Infinity Fixed-Bearing Implant: A Concise Follow-up of a Previous Report

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes

Background

Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury.

Purpose

To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex).

Study Design

Case series; Level of evidence, 4.

Methods

Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed.

Results

Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports.

Conclusion

Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial

BACKGROUND

End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF).

OBJECTIVE

To determine which treatment is superior in terms of clinical scores and adverse events.

DESIGN

A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307).

SETTING

17 National Health Service trusts across the United Kingdom.

PATIENTS

Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure.

INTERVENTION

Patients were randomly assigned to TAR or AF surgical treatment.

MEASUREMENTS

The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible.

RESULTS

Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]).

LIMITATION

Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques.

CONCLUSION

Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%.

PRIMARY FUNDING SOURCE

National Institute for Health and Care Research Heath Technology Assessment Programme.

Electrodes Donate Electrons for Nitrate Reduction in a Soil Matrix via DNRA and Denitrification

Microbial strains and indigenous microbiota in soil slurries have been reported to use electrons from electrodes for nitrate (NO₃^-) reduction. However, few studies have confirmed this in a soil matrix hitherto. This study investigated if, and how, an electric potential affected NO₃^- reduction in a soil matrix. The results showed that, compared to a control treatment, applying an electric potential of -0.5 V versus the standard hydrogen electrode (SHE) significantly increased the relative abundance of NO₃^--reducing microbes (e.g., Alcaligenaceae and Pseudomonadaceae) and the abundances of the nrfA, nirK, nirS, and nosZ genes in soil matrices. Meanwhile, the electric potential treatment doubled the NO₃^- reduction rate and significantly increased the rates of production of ammonium (NH₄⁺), dinitrogen (N₂), and nitrous oxide (N₂O). The amount of NO₃^--N reduced under the electric potential treatment was comparable to the sum of the amounts of N observed in the increased N₂O, N₂, NH₄⁺, and nitrite (NO₂^-) pools. An open-air experiment showed that the electric potential treatment promoted soil NO₃^- reduction with a spatial scale of at least 38 cm. These results demonstrated that an electric potential treatment could enhance NO₃^- reduction via both denitrification and dissimilatory NO₃^- reduction to ammonium (DNRA) in the soil matrix. The mechanisms revealed in this study have implications for the future development of potential techniques for enhancing NO₃^- reduction in the vadose zone and consequently reducing the risk of NO₃^- leaching.

Survivorship and long-term outcome of a consecutive series of 200 Scandinavian Total Ankle Replacement (STAR) implants

AIMS

We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.

PATIENTS AND METHODS

Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan-Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year.

RESULTS

A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up.

CONCLUSION

STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty.

The potential of L. scoparium, K. robusta and P. radiata to mitigate N-losses in silvopastural systems

Silvopastoral systems aim to enhance economic, cultural and social principles by sustainably combining forest management with agriculture. In these typically high-nitrogen (N) environments, plant species selection can profoundly influence N fluxes. For grazed pastures, plants may be exposed to urine patches that have received the equivalent of up to 1000 kg N ha^-1. We aimed to determine the growth and N fluxes in three potential trees that may be used in silvopastoral systems: L. scoparium, K. robusta and P. radiata. Plants were grown in a greenhouse lysimeter experiment, with controlled irrigation and temperature and exposed to N at rates of 200 kg ha^-1 equiv. for 15 weeks, followed by the addition of 800 kg ha^-1 N equiv, to simulate a urine patch. Urea produced a positive growth response of all plant species. Treatments containing L. scoparium and K. robusta leached lower amounts of nitrate (NO₃^-) (2 kg ha^-1 NO₃^-) compared to P. radiata (53 kg ha^-1). Measurements of N₂O over 20 days after the application of 800 kg N ha^-1 indicated an inhibitory effect of L. scoparium and K. robusta on denitrification, hence loss of N via N₂O. Both L. scoparium and K. robusta demonstrated that they have potential to reduce N-losses in silvopastural systems, while producing valuable biomass.

Nitrous oxide and methane emissions from cryptogamic covers

Cryptogamic covers, which comprise some of the oldest forms of terrestrial life on Earth (Lenton & Huntingford, ), have recently been found to fix large amounts of nitrogen and carbon dioxide from the atmosphere (Elbert et al., ). Here we show that they are also greenhouse gas sources with large nitrous oxide (N2 O) and small methane (CH4 ) emissions. Whilst N2 O emission rates varied with temperature, humidity, and N deposition, an almost constant ratio with respect to respiratory CO2 emissions was observed for numerous lichens and bryophytes. We employed this ratio together with respiration data to calculate global and regional N2 O emissions. If our laboratory measurements are typical for lichens and bryophytes living on ground and plant surfaces and scaled on a global basis, we estimate a N2 O source strength of 0.32-0.59 Tg year(-1) for the global N2 O emissions from cryptogamic covers. Thus, our emission estimate might account for 4-9% of the global N2 O budget from natural terrestrial sources. In a wide range of arid and forested regions, cryptogamic covers appear to be the dominant source of N2 O. We suggest that greenhouse gas emissions associated with this source might increase in the course of global change due to higher temperatures and enhanced nitrogen deposition.

The treatment of intractable plantar fasciitis with platelet-rich plasma injection

BACKGROUND

Whilst most cases of plantar fasciitis can be settled with existing conservative treatment, a few intractable cases can be difficult to resolve. New biologic treatments have been proposed for a variety of soft tissue problems.

OBJECTIVE

Evaluate the effectiveness of platelet rich plasma (PRP) in chronic cases of plantar fasciitis.

PATIENTS AND METHODS

Patients with plantar fasciitis not responded to a minimum of 1 year standard conservative management were offered PRP therapy. Injections were performed in theatre as a day case. Roles-Maudsley (RM) scores, Visual Analogue Scores (VAS), AOFAS scores and 'would have injection again' were collated pre-operatively, three and six months.

RESULTS

Prospective data was collected of 50 heels (44 patients). At six month review, RM score improved from mean 4 to 2 (p<0.001), VAS improved from 7.7 to 4.2 (p<0.001) and AOFAS improved from 60.6 to 81.9 (p<0.001). 28 patients (64%) were very satisfied and would have the injection again. No complications were reported.

CONCLUSION

In these chronic cases, PRP produce an efficacy rate, approaching 2 out of every 3. The procedure was safe with no reported complications. The authors feel PRP may have some role in treatment, and merits further study with a prospective randomised trial.

Oral health and impact on performance of athletes participating in the London 2012 Olympic Games: a cross-sectional study

BACKGROUND

Oral health is important both for well-being and successful elite sporting performance. Reports from Olympic Games have found significant treatment needs; however, few studies have examined oral health directly. The aim of this study was to evaluate oral health, the determinants of oral health and the effect of oral health on well-being, training and performance of athletes participating in the London 2012 Games.

METHODS

Cross-sectional study at the dental clinic within the Polyclinic in the athletes' village. Following informed consent, a standardised history, clinical examination and brief questionnaire were conducted.

RESULTS

302 athletes from 25 sports were recruited with data available for 278. The majority of athletes were from Africa, the Americas and Europe. Overall, the results demonstrated high levels of poor oral health including dental caries (55% athletes), dental erosion (45% athletes) and periodontal disease (gingivitis 76% athletes, periodontitis 15% athletes). More than 40% of athletes were 'bothered' by their oral health with 28% reporting an impact on quality of life and 18% on training and performance. Nearly half of the participants had not undergone a dental examination or hygiene care in the previous year.

CONCLUSIONS

The oral health of athletes attending the dental clinic of the London 2012 Games was poor with a resulting substantial negative impact on well-being, training and performance. As oral health is an important element of overall health and well-being, health promotion and disease prevention interventions are urgently required to optimise athletic performance.

Silastic arthroplasty of the first metatarsophalangeal joint as salvage for failed revisional fusion with interpositional structural bone graft

Silastic arthroplasty of the first metatarsophalangeal joint should be considered a viable salvage procedure either for cases of previously failed fusion with interpositional tricortical bone grafting, or for cases of painful previous Kellers, as it can restore length back to the toe, power, stability of gait and therefore reduce pain.

Dissolved organic nitrogen: an overlooked pathway of nitrogen loss from agricultural systems?

Conventional wisdom postulates that leaching losses of N from agriculture systems are dominated by NO(3)(-). Although the export of dissolved organic nitrogen (DON) into the groundwater has been recognized for more than 100 yr, it is often ignored when total N budgets are constructed. Leaching of DON into stream and drinking water reservoirs leads to eutrophication and acidification, and can pose a potential risk to human health. The main objective of this review was to determine whether DON losses from agricultural systems are significant, and to what extent they pose a risk to human health and the environment. Dissolved organic N losses across agricultural systems varied widely with minimum losses of 0.3 kg DON ha(-1)yr(-1) in a pasture to a maximum loss of 127 kg DON ha(-1)yr(-1) in a grassland following the application of urine. The mean and median values for DON leaching losses were found to be 12.7 and 4.0 kg N ha(-1)yr(-1), respectively. On average, DON losses accounted for 26% of the total soluble N (NO(3)(-) plus DON) losses, with a median value of 19%. With a few exceptions, DON concentrations exceeded the criteria recommendations for drinking water quality. The extent of DON losses increased with increasing precipitation/irrigation, higher total inputs of N, and increasing sand content. It is concluded that DON leaching can be an important N loss pathway from agricultural systems. Models used to simulate and predict N losses from agricultural systems should include DON losses.

Frozen autografts: an alternative to graft disposal

The use of fresh frozen tendon allografts is a well-documented surgical technique. We present a case where a harvested semitendinosus autograft was preserved by deep-freezing, having abandoned the initial procedure due to infection. After treatment of the infection the graft was subsequently used to reconstruct the postero-lateral corner complex with no deleterious effect at 1 year.