Arthroscopic Broström-Gould repair has comparable radiological and clinical outcomes compared to traditional open Broström-Gould repair in high-demand patients.

PURPOSE: This study sought to confirm whether traditional open Broström-Gould repair and arthroscopic Broström-Gould repair for chronic ankle instability (CAI) would produce comparable radiological and clinical outcomes in high-demand patients. METHODS: This retrospective case-cohort study included high-demand patients, as determined by a pre-injury Tegner Activity Level ≥ 6, who underwent Broström-Gould repair and were followed up for ≥ 2 years. Patients were divided into the arthroscopic Broström-Gould repair group (AS Group) and the open Broström-Gould repair group (Open Group). Perioperative radiological assessments were performed. The Tegner Activity Levels, Foot and Ankle Outcome Scores (FAOSs), Karlsson and Peterson (K-P) scores, and American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores were evaluated clinically. RESULTS: A total of 65 patients (31 from the AS Group and 34 from the Open Group) were included in the study. There were no differences in age, sex, body mass index, preoperative anterior talar translation, talar tilt, signal-to-noise ratio, FAOS, K-P score, or AOFAS score between the two groups (n.s.). The preinjury median Tegner Activity Level was 7 and unchanged at the final follow-up in both groups. Postoperative stress radiographs showed improvement; however, the groups did not differ significantly. The FAOS, K-P scores, and AOFAS scores improved in each group (P < 0.001). However, the clinical scores did not differ between the groups (all n.s.). CONCLUSIONS: Traditional open and arthroscopic Broström-Gould repair for CAI in high-demand patients had comparable radiological and clinical outcomes. Clinically, arthroscopic Broström-Gould repair may represent a viable surgical alternative to open Broström-Gould repair in high-demand patients. LEVEL OF EVIDENCE: Level III.

Return to Sports Activities After Flexor Hallucis Longus Transfer for Neglected Achilles Tendon Rupture.

Transfer of the flexor hallucis longus (FHL) is known to be effective in the treatment of neglected Achilles tendon rupture (ATR). However, evidence on the return to sports activity levels and clinical outcomes is not sufficient. The aim of this study was assessing clinical outcomes and level of sports activity after FHL tendon transfer for treatment of neglected ATR. Twenty-eight patients who underwent FHL transfer for neglected ATR were analyzed retrospectively. Sports activity status was assessed using the Tegner Activity Scale (TAS). Clinical outcomes were evaluated using the Achilles tendon total rupture score and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale. By the post hoc power analyses, the power level of more than 80% was identified. The preinjury median TAS score was 4 point and unchanged at the last follow-up. The mean Achilles tendon Total Rupture Scores and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale scores at the last follow-up were 81 and 93, respectively. While the median TAS was unchanged, 9/28 patients suffered from lower activity level after the procedure. In conclusion, midterm results of FHL transfer for neglected ATR were shown to be favorable. The median TAS score was maintained. Nonetheless, 32% of patients returned to sports activities with a TAS score 1 point lower than that at preinjury and with less favorable clinical outcomes.

Clinical Outcomes of Supramalleolar Osteotomy in Intermediate Stage of Varus Ankle Osteoarthritis in Joint Preservation.

Supramalleolar osteotomy (SMO) is an effective treatment for intermediate-stage varus ankle osteoarthritis (OA). This study aimed to investigate how clinical outcomes were associated with radiological changes and cartilage regeneration shown on arthroscopy before and after SMO in patients with intermediate-stage varus ankle OA. Twenty-six cases with intermediate-stage varus ankle OA underwent SMO with at least 1 year of postoperative follow-up. Clinical assessment was performed preoperatively and postoperatively using the visual analog scale (VAS), American Orthopedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, and their associations with postoperative changes in tibial ankle surface angle (TAS), talar tilt, tibial lateral surface angle, and heel alignment ratio. The degrees of cartilage regeneration in the tibia plafond and talar dome were observed via second-look arthroscopy. Afterward, their associations with the corresponding clinical outcomes were analyzed. There were significant changes in the TAS, talar tilt, and heel alignment ratio (p < .001, for all). However, there were no significant changes in the tibial lateral surface angle (p = .864) at the final follow-up compared to its preoperative value. Postoperative changes in TAS (p = .013) and the degree of cartilage regeneration (p = .028) in the talar dome significantly influenced the final follow-up AOFAS score. Changes in the TAS angle and the degree of cartilage regeneration after SMO were predictors of clinical outcomes after SMO. In particular, greater changes in the TAS angle corresponded to better clinical outcomes.

Assessment of perioperative total blood loss during total ankle arthroplasty.

BACKGROUND: Although many authors have discussed total blood loss after arthroplasty of the knee, hip, and shoulder, reports on perioperative blood loss after total ankle arthroplasty (TAA) are rare. The purpose of this study was to assess total blood loss after TAA and to identify correlated factors. METHODS: A total of 103 cases (99 patients) of TAA for end-stage ankle osteoarthritis were enrolled in this study. Perioperative total blood loss was divided into intraoperative and postoperative blood loss. The patient-related variables evaluated for total blood loss were age, sex, body mass index, American Society of Anesthesiologists Classification score, comorbidities, history of previous ankle surgery, preoperative use of anticoagulants, platelet count and prothrombin time/international normalized ratio. Operation-related variables including type of anesthesia, operation time, TAA implant, and procedures performed in addition to TAA (if any) were evaluated to analyze correlations with total blood loss. In addition, the rate of transfusions after surgery was identified, and risk factors for transfusion were statistically analyzed. RESULTS: The total blood loss was mean 795.5±351.1mL, which included 462.2±248.5mL of intraoperative blood loss and 333.2±228.6mL of postoperative blood loss. Sex, TAA implant, and additional bony procedures performed along with TAA were significantly correlated with total blood loss (p=0.039, 0.024, 0.024, respectively) but the other variables were not significant (p>0.05). Transfusions were administered for 4 cases (3.8%) but no risk factors for transfusion could be identified. CONCLUSION: The total blood loss after TAA was 795.5mL and the rate of transfusions was 3.8%. This study demonstrated that male sex, use of TAA implants with a larger cutting surface, and bony procedures performed in addition to TAA were associated with an increase in total blood loss after TAA. The findings of this study will help surgeons to better predict blood loss and make optimal surgical plans accordingly. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Clinical outcomes after arthroscopic microfracture for osteochondral lesions of the talus are better in patients with decreased postoperative subchondral bone marrow edema.

PURPOSE: Magnetic resonance imaging (MRI) findings of subchondral bone marrow edema (SBME) in osteochondral lesions of the talus (OLT) after arthroscopic microfracture are associated with poor clinical outcomes. However, the relationship between SBME volume change and clinical outcomes has not been analyzed. It was hypothesized that clinical outcomes correlated with SBME volume change and extent of cartilage regeneration in patients with OLT. METHODS: 64 patients who underwent arthroscopic microfracture for OLT were followed up for more than 2 years. SBME volume change was measured by comparing preoperative and 2-year follow-up MRI. Clinical outcomes were assessed using the visual analogue scale (VAS) and the American orthopedic foot and ankle society ankle-hindfoot scale (AOFAS) at the 2-year and final follow-up. To compare clinical outcomes, patients were categorized into two groups: decreased SBME (DSBME) group (cases without SBME on either MRI or with a decreased SBME volume between the MRIs) and increased SBME (ISBME) group (cases with new SBME on postoperative MRI or with an increased SBME volume between the MRIs). Additionally, the effects of age, sex, body mass index, symptom duration, OLT size, OLT location, containment/uncontainment, preoperative subchondral cysts, pre- and postoperative SBME volumes, and MRI observation of cartilage repair tissue score on clinical outcomes were analyzed. RESULTS: The DSBME group included 45 patients, whereas the ISBME group included 19. The mean age was 40.1 ± 17.2 years, and mean follow-up period was 35.7 ± 18.3 months. Preoperative SBME volume was significantly higher in the DSBME group, while the ISBME group had higher volumes at the final follow-up. In both groups, the VAS and AOFAS scores significantly improved at the final follow-up (p < 0.001, < 0.001). The VAS scores were significantly lower in the DSBME group at the 2-year and final follow-up (p = 0.004, 0.011), while the AOFAS scores were significantly higher (p = 0.019, 0.028). Other factors including cartilage regeneration did not affect clinical outcomes. CONCLUSION: SBME volume change correlated with clinical outcomes after arthroscopic microfracture for OLT. Clinical outcomes were worse in patients with new postoperative SBME and increased postoperative SBME volume. In patients with an unsatisfactory clinical course that show decreased SBME via postoperative MRI, an extended follow-up in a conservative manner could be considered. LEVEL OF EVIDENCE: Level III.

The signal intensity of preoperative magnetic resonance imaging has predictive value for determining the arthroscopic reparability of the anterior talofibular ligament.

PURPOSE: Arthroscopic all-inside anterior talofibular ligament (ATFL) repair is a common surgical technique for chronic ankle instability (CAI), and the condition of the ATFL remnants is associated with its reparability. ATFL reparability can affect the clinical course, but the relationship between magnetic resonance imaging (MRI) findings and the intraoperative ATFL reparability is still unclear. The purpose of this study was to investigate the relationship between ATFL signal intensities according to MRI and intraoperative ATFL reparability. METHODS: This study included 55 cases of CAI (n = 37) and osteochondral lesion of the talus (n = 18) that underwent MRI followed by subsequent arthroscopy. MRI signal intensity was measured preoperatively to calculate the signal to noise ratio (SNR). During arthroscopy, the presence of an ATFL tear was checked and the ATFL tension was classified as taut, mild laxity, or laxity; ATFL quality was classified as excellent (normal), moderate (abnormal but reparable), or poor (irreparable). It was then analyzed whether there was a relationship between the intraoperative findings and the SNR. RESULTS: The mean SNR was 23.4 ± 21.6. The SNR was significantly different according to the presence of an ATFL tear and ATFL tension and quality (all P = 0.001). The SNR was better correlated with ATFL quality (r = 0.708) than the presence of a tear (r = 0.545) or degree of tension (r = 0.653). The diagnostic SNR cutoff point to distinguish a normal ATFL from an abnormal but reparable ATFL was 11.2, and that to distinguish between an irreparable and reparable ATFL, was 32.3. CONCLUSION: The SNR, representing MRI signal intensities, is highly correlated with the intraoperative measures of the ATFL. Therefore, the SNR had predictive value for determining the arthroscopic reparability of the ATFL. LEVEL OF EVIDENCE: Level III.

Influence of Depressive Symptoms on the Clinical Outcomes of Total Ankle Arthroplasty.

Many studies have reported the relevance of depression on clinical outcomes after knee or hip arthroplasty. However, no study has investigated this relationship in total ankle arthroplasty (TAA). This study aimed to study the relationship between depressive symptoms and clinical outcomes after TAA. This retrospective comparative study investigated 40 patients who underwent TAA for end-stage ankle arthritis. Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression Scale and Patient Health Questionnaire-9. Preoperative and postoperative clinical outcomes were compared using the visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores by classifying the subjects into depressive and nondepressive groups. The mean follow-up duration was 24.3 ± 7.3 (range 14 to 37) months. There were 13 and 27 subjects in the depressive and nondepressive groups, respectively. There were no significant differences in the baseline characteristics and preoperative VAS and AOFAS scores between them. The postoperative VAS score was significantly higher in the depressive group (3.1 ± 2.4) than in the nondepressive group (1.4 ± 2.3; p < .001). The postoperative AOFAS scores in the depressive and nondepressive groups were 89.3 ± 13.4 and 95.0 ± 8.1, respectively, showing a significantly superior result in the latter group (p < .001). The clinical outcomes after TAA were poorer in the patients with depressive symptoms than in those without. Depressive symptoms are patient-specific factors or independent predictors that show less improvement after TAA. Therefore, clinical considerations of these symptoms are essential before TAA.

Evaluation of Stress Radiographs Taken Before and After Spinal Anesthesia in Patients With Chronic Ankle Instability.

Stress radiography is known as an important diagnostic tool for confirming mechanical instability in patients with chronic ankle instability. However, there are no reports on how muscle guarding caused by the stress applied on the ankle during stress radiography affects test outcomes. Thus, this study aimed to analyze the effects of muscle guarding caused by stress radiography on outcomes by performing stress radiography before and after anesthesia. This is a prospective study involving 32 patients who were diagnosed with chronic ankle instability through patient history, physical examination, and magnetic resonance imaging studies. Varus and anterior drawer stress radiographs were taken before and after anesthesia in the operating room, and the findings were compared. On the post-anesthesia stress radiographs of the affected ankle, talar tilt and talar anterior translation were significantly increased by 2.55° ± 2.64° and 1.54 ± 2.03 mm, respectively (mean ± standard deviation; p < .05). These parameters were also significantly increased by 2.08° ± 2.62° and 1.27 ± 1.37 mm, p < .05, on the post-anesthesia radiographs of the unaffected ankle. Before anesthesia, 26 of 32 patients had positive stress radiographs, but 31 patients had positive results after anesthesia. Talar tilt and talar anterior translation significantly increased after anesthesia. Therefore, in CAI patients, efforts to reduce muscle guarding should be made before stress radiographs are taken. Moreover, when interpreting results, it should be noted that muscle guarding might have reduced the measurements of stress radiographs, leading to diagnostic false negatives.

Anterior osteophyte resection of the ankle joint to increase range of motion in haemophilic ankle arthropathy.

INTRODUCTION: Haemophilic ankle arthropathy may cause joint bleeding, pain, stiffness, erosion and progressive motion limitations, including a decreased range of motion (ROM) secondary to anterior osteophyte impingement. AIM: The purpose of this study was to investigate changes in the ROM and symptoms after synovectomy and anterior osteophyte resection for haemophilic ankle arthropathy. METHODS: We retrospectively reviewed 41 ankles in 35 patients with haemophilic arthropathy who underwent arthroscopic and/or open synovectomy. The mean follow-up period was 59.5 months. Indications for the procedure included a lack of improvement with conservative management, and the presence of haemarthrosis and arthralgia. We assessed radiographic images, ankle joint range of motion, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score and patients' subjective satisfaction preoperatively and at the last follow-up. RESULTS: Arthroscopic synovectomy was performed in 32 ankles, open synovectomy in 6, and arthroscopic synovectomy with additional mini-open debridement in 3. Ankle dorsiflexion improved from a mean of 2.7° preoperatively to a mean of 7.5° at the final follow-up (P = 0.003), whereas plantar flexion improved from a mean of 30.7° preoperatively to a mean of 32.7° at the final follow-up (P = 0.276). The AOFAS score improved from 62.2 preoperatively to 79.1 at the final follow-up (P < 0.001). Patient satisfaction was "excellent" in 11 ankles, "good" in 22, "fair" in 3 and "poor" in 5. CONCLUSION: Arthroscopic and/or open synovectomy with anterior osteophyte resection and early rehabilitation in adolescents and adults with haemophilic ankle arthropathy showed improved ankle dorsiflexion and AOFAS scores.

Following the correction of varus deformity of the knee through total knee arthroplasty, significant compensatory changes occur not only at the ankle and subtalar joint, but also at the foot.

PURPOSE: This study aimed to assess radiological changes of the ankle joint, subtalar joint and foot following the correction of varus deformity of the knee with total knee arthroplasty (TKA). It was hypothesized that following the correction of varus deformity by TKA, compensatory reactions would occur at the subtalar joint in accordance with the extent of the correction. METHODS: For this prospective study, 375 knees of patients who underwent TKA between 2011 and 2012 were enrolled. The varus angle of the knee, talar tilt of the ankle joint (TT), ground-talar dome angle of the foot (GD), anterior surface angle of the distal tibia and lateral surface angle of the distal tibia, heel alignment ratio (HR), heel alignment angle (HA), and heel alignment distance (HD) were measured on radiographs obtained pre-operatively and at post-operative 6 months. RESULTS: The mean correction angle in varus deformity of the knee was 10.8 ± 4.1°. TT and GD changed significantly from 0.4 ± 1.9° and 6.5 ± 3.1° pre-operatively to 0.1 ± 1.8° and 0.2 ± 2.1°, respectively (p = 0.007, p < 0.001). No correlation was found between the preop-postop variance in mechanical axis of the lower extremity (MA) and TT, but there was a strong correlation between the preop-postop variance in MA and GD (r = 0.701). HR, HA and HD also changed significantly post-operatively, and the preop-postop variance in MA showed correlations with the preop-postop variances in HR, HA and HD (r = 0.206, - 0.348, and - 0.418). TT and the three indicators of hindfoot alignment all shifted to varus whereas GD was oriented in valgus. CONCLUSION: Following the correction of varus deformity of the knee through TKA, significant compensatory changes occurred not only at the ankle and subtalar joints, but also at the foot. The findings of this study are useful in predicting the orientation of changes in the ankle and subtalar joints and the foot following TKA, and in determining the sequence of surgery when both the ankle and knee have a problem. In other words, changes in the parts of the lower extremity below the ankle joint following the correction of varus deformity of the knee must be considered when TKA is planned and performed. Patients who have problems at the ankle, subtalar, and foot joints in addition to varus deformity of the knee are recommended to undergo knee joint correction first. LEVEL OF EVIDENCE: II.

Determining the Mechanism for Low Sludge Yields in the Cannibal Solids Reduction System.

Extracellular polymeric substances (EPS) and solids concentrations in samples from the Interchange Bioreactor (IBR), and return activated sludge (RAS) from Cannibal facilities having low and high sludge yields, were analyzed to understand the mechanisms behind low sludge production. Low sludge yields correlated to more EPS degradation, higher concentrations of iron, and reducing conditions in the IBR. In the low yield facilities, iron was reduced when the RAS passed through the anaerobic and reducing conditions of the IBR, and this led to more EPS solubilization and degradation. This "futile cycle" of EPS production and degradation appears to may have been most responsible for reducing sludge yields.

Ankle Arthritis Combined With Chronic Instability of the Syndesmosis After Ankle Fracture With Syndesmotic Injury: A Case Report.

Syndesmotic injuries associated with ankle fractures are commonly treated with reduction and fixation using a transfixing screw. On rare occasions, however, progression to chronic instability of the syndesmosis is observed. Several surgical techniques have been applied in such cases but usually without a report on the results. We report a case of chronic syndesmotic instability and ankle joint osteoarthritis after ankle fracture-dislocation in a 21-year-old male patient who underwent distal tibiofibular arthrodesis. During the relatively long 4-year, 1-month follow-up period, the pain and activity improved from the patient's preoperative condition. Radiographs demonstrated cessation of arthritic changes in the ankle that had initially displayed joint space narrowing. Our findings suggest distal tibiofibular arthrodesis as an option to consider for the treatment of young and active patients with arthritic changes in the ankle joint with concomitant chronic instability of the syndesmosis.

Effect of Preoperative Stress Radiographic Findings on Radiographic and Clinical Outcomes of the Modified Broström Procedure for Chronic Ankle Instability.

The purpose of the present study is to evaluate whether findings of instability on preoperative stress radiographs of patients with chronic ankle instability affects the radiographic and clinical outcomes after a modified Broström procedure. A total of 45 consecutive patients (45 ankles) who had undergone the modified Broström procedure for unilateral ankle joint instability and were followed up for ≥2 years were selected. The patients were classified into 2 groups according to the results of the preoperative stress radiographs: 1 group with positive findings (35 [77.8%] patients; stress-positive group) and 1 group with negative findings (10 [22.2%] patients; stress-negative group). The radiographic and clinical outcomes were compared between the 2 groups. The mean preoperative talar tilt measured on the stress radiograph was 14.4° ± 4.2° and 4.8° ± 2.6° in the stress-positive and stress-negative groups, respectively, a statistically significant difference. Postoperative talar tilt improved in both groups, with a mean final talar tilt of 5.4° ± 3.4° in the stress-positive group (p < .001) and 3.0° ± 1.5° in the stress-negative group (p = .038). The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score in the stress-positive and stress-negative groups improved from 65.1 ± 14.6 to 90.0 ± 6.3 (p < .001) and 72.5 ± 9.3 to 92.6 ± 7.8 (p = .007), respectively. The mean postoperative satisfaction rate was 83.9 ± 11.9 and 85.0 ± 11.8 in the 2 groups. No statistically significant differences were seen in the preoperative and postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scores or in postoperative satisfaction rates between the 2 groups.

Use of Ilizarov External Fixation Without Soft Tissue Release to Correct Severe, Rigid Equinus Deformity.

The purpose of the present retrospective study was to report the correction of severe, rigid equinus deformities using an Ilizarov external fixator alone, without adjunctive open procedures. Ten feet in 10 patients with rigid equinus deformities were enrolled and underwent gradual correction using an Ilizarov external fixator alone, without additional open procedures. The range of ankle joint motion was measured preoperatively and at the last follow-up visit. The radiographic outcome was assessed using the lateral tibiotalar angle on ankle radiographs taken preoperatively, immediately after removal of the Ilizarov fixator, and at the last follow-up visit. The mean duration of external fixator treatment was 40.1 ± 13.5 days. The preoperative mean ankle range of motion was -55.5° ± 22.2° of dorsiflexion and 63.0° ± 20.8° of plantarflexion. At the last follow-up visit, the mean dorsiflexion had increased to -2.5° ± 6.8° and the mean plantarflexion had decreased to 30.5° ± 12.6°. The mean lateral tibiotalar angle was 152.9° ± 19.7° preoperatively, 103.9° ± 9.4° immediately after removal of the Ilizarov external fixator, and 113.9° ± 11.6° at the last follow-up visit. Immediately after fixator removal, all the patients had clinical correction of their deformity to a plantigrade foot using the Ilizarov external fixator alone, with a mean correction of 49.0° ± 17.4°. Some recurrence was noted at the last follow-up examination, with a final mean correction of 39.0° ± 18.0°. The present study has demonstrated successful correction of severe, rigid equinus deformity with the use of an Ilizarov external fixator without the need for adjunctive soft tissue procedures. This method can be effective for patients with a high risk of complications after open procedures owing to their poor soft tissue envelope.

MPFL reconstruction with proximal rather than distal femoral tunnel position leads to less favorable short-term results.

BACKGROUND: This study aimed to compare the clinical and radiological outcomes of medial patellofemoral ligament (MPFL) reconstruction (MPFLR) between anatomic femoral tunnel positions: proximal (near adductor tubercle [AT]) and distal (near medial epicondyle [ME]). HYPOTHESIS: MPFLR with the proximal femoral tunnel position has worse clinical and radiological outcomes than those with the distal femoral tunnel position. PATIENTS AND METHODS: Fifty-five patients who underwent isolated MPFLR with proximal or distal femoral tunnels with at least 2 years of follow-up were retrospectively analyzed. Based on postoperative CT images, 28 patients were classified as group AT and the remaining 27 patients were classified as group ME. The International Knee Documentation Committee, Lysholm, Tegner, Kujala scores, and complications were evaluated. Radiologically, the Caton-Deschamps Index (CDI), patellar tilt angle, patellofemoral osteoarthritis (PFOA), patellofemoral cartilage status by the International Cartilage Repair Society (ICRS) grade, bone contusion, and MPFL graft signal intensity were evaluated. RESULTS: All clinical scores significantly improved in both groups (p<0.01). No statistically significant difference was noted between the two groups in regards to their preoperative demographic data, postoperative clinical scores, complications, or radiological findings (CDI, patellar tilt angle, PFOA, bone contusion, and graft signal intensity). The group AT had worse cartilage status on the medial facet of the patella (p=0.02). The ICRS grade for the medial facet of the patella statistically progressed in group AT compared to group ME (p=0.04) as well. DISCUSSION: Both groups showed significantly improved clinical outcomes. However, for the medial facet of the patella, MPFLR with the proximal femoral tunnel position had worse cartilage status and ICRS grade progression than those with the distal femoral tunnel position. LEVEL OF EVIDENCE: III; retrospective comparative study.

Using a two-stage hydrogen-based membrane biofilm reactor (MBfR) to achieve complete perchlorate reduction in the presence of nitrate and sulfate.

We evaluated a strategy for achieving complete reduction of perchlorate (ClO(4)(-)) in the presence of much higher concentrations of sulfate (SO(4)(2-)) and nitrate (NO(3)(-)) in a hydrogen-based membrane biofilm reactor (MBfR). Full ClO(4)(-) reduction was achieved by using a two-stage MBfR with controlled NO(3)(-) surface loadings to each stage. With an equivalent NO(3)(-) surface loading larger than 0.65 ± 0.04 g N/m(2)-day, the lead MBfR removed about 87 ± 4% of NO(3)(-) and 30 ± 8% of ClO(4)(-). This decreased the equivalent surface loading of NO(3)(-) to 0.34 ± 0.04-0.53 ± 0.03 g N/m(2)-day for the lag MBfR, in which ClO(4)(-) was reduced to nondetectable. SO(4)(2-) reduction was eliminated without compromising full ClO(4)(-) reduction using a higher flow rate that gave an equivalent NO(3)(-) surface loading of 0.94 ± 0.05 g N/m(2)-day in the lead MBfR and 0.53 ± 0.03 g N/m(2)-day in the lag MBfR. Results from qPCR and pyrosequencing showed that the lead and lag MBfRs had distinctly different microbial communities when SO(4)(2-) reduction took place. Denitrifying bacteria (DB), quantified using the nirS and nirK genes, dominated the biofilm in the lead MBfR, but perchlorate-reducing bacteria (PRB), quantified using the pcrA gene, became more important in the lag MBfR. The facultative anaerobic bacteria Dechloromonas, Rubrivivax, and Enterobacter were dominant genera in the lead MBfR, where their main function was to reduce NO(3)(-). With a small NO(3)(-) surface loading and full ClO(4)(-) reduction, the dominant genera shifted to ClO(4)(-)-reducing bacteria Sphaerotilus, Rhodocyclaceae, and Rhodobacter in the lag MBfR.

Relationship between Foot Width Reduction and Clinical Outcomes after Chevron Osteotomy for Hallux Valgus Deformity.

Background: Radiological correction of hallux valgus deformity is the objective of operation and related to successful outcomes. Nonetheless, footwear problems related to foot width can also affect the clinical outcome. Few studies have analyzed changes in foot width, and data on clinical outcomes after correction of hallux valgus deformity are scarce. Methods: The study included 159 cases with symptomatic hallux valgus deformity who underwent proximal or distal chevron metatarsal osteotomy and were followed up for a mean of 32.8 months. Radiologically, the hallux valgus angle, intermetatarsal angle, first metatarsal head width, bony foot width, and soft-tissue foot width were analyzed. Clinically, the visual analog scale for pain and American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score were evaluated. Results: The preoperative hallux valgus was corrected radiologically at the last follow-up. The bony foot width was reduced by 9.4%, and the soft-tissue foot width was reduced by 7.1% (p < 0.001 for all). The mean AOFAS score improved from 51.2 preoperatively to 89.4 at the final follow-up (p < 0.001). In multiple regression, the perioperative changes of bony foot width were associated with final AOFAS score (p = 0.029). Conclusions: Chevron osteotomy performed for hallux valgus deformity resulted in satisfactory radiological and clinical outcomes. Perioperative changes in bony foot width showed a significant correlation with AOFAS score. Therefore, to correct hallux valgus deformity, it is necessary to correct known radiological indicators sufficiently and make efforts simultaneously to reduce the foot width optimally.

Effects of three-dimensional image based insole for healthy volunteers: a pilot clinical trial.

Insoles are used to treat various foot diseases, including plantar foot, diabetic foot ulcers, and refractory plantar fasciitis. In this study, we investigated the effects of 3-dimensional image-based (3-D) insole in healthy volunteers with no foot diseases. Additionally, the comfort of the 3-D insole was compared with that of a custom-molded insole. A single-center, randomized, open clinical trial was conducted to address the effectiveness of insole use in a healthy population with no foot or knee disease. Two types of arch support insoles were evaluated for their effectiveness: a 3-D insole and a custom-molded insole. Fifty Korean volunteers participated in the study and were randomly allocated into the "3-D insole" (n = 40) or "custom-molding insole" (n = 10) groups. All subjects wore 3-D insoles or custom-molded insoles for 2 weeks. The sense of wearing shoes (Visual Analog Scale [VAS] and score) and fatigue of the foot were used to assess the insole effects at the end of the 2-week study period. The 3-D insole groups showed significantly improved sense of wearing shoes (VAS, p = 0.0001; score, p = 0.0002) and foot fatigue (p = 0.0005) throughout the study period. Although the number of subjects was different, the custom-molding insole group showed no significant changes in the sense of wearing shoes (VAS, 0.1188; score, p = 0.1483). Foot fatigue in the 3-D insole group improved significantly (p = 0.0005), which shows that a 3-D insole might have favorable effects on foot health in a healthy population. Trial Registration: Clinical Research Information Service Identifier: KCT0008100.

Radiologic changes of ankle joint after total knee arthroplasty.

BACKGROUND: The authors noticed that ankle joint osteoarthritis was not uncommon when lower extremity malalignment, such as a knee varus deformity, was present as a result of severe osteoarthritis of the knee. The purpose of this study was to analyze radiologic changes of the ankle joint after total knee arthroplasty. METHODS: This study included 142 cases in 110 patients who underwent total knee arthroplasty and were followed for at least 3 years. The varus knee group included 128 cases and the valgus knee group included 14 cases. On anteroposterior standing lower extremity radiographs, varus and valgus angles of the knee were measured preoperatively and at the last follow-up. The angle between the ground surface and the distal tibial plafond as well as the upper talus was also measured. In addition, tibial anterior surface angle, talar tilt, space between the medial malleolar distal tip and the medial articular surface of the talus, and medial tibiotalar joint space of the ankle joint were measured. RESULTS: Out of 142 cases, 50 (35.2%) had arthritis in the ankle before total knee arthroplasty and 31 (21.8%) had newly developed or progressive arthritis after surgery. In particular, the varus knee group demonstrated statistically significant differences in preoperative varus deformity, preoperative talar tilt, and postoperative correction angle between the cases that developed or had progressive arthritis and those that did not show any changes (p < .05). CONCLUSIONS: After total knee arthroplasty, arthritis developed or progressed in the ankle of many cases radiographically. In particular, when the preoperative talar tilt increased medial to the ankle or the postoperative correction angle was large, the incidence of arthritis in the ankle joint increased. The authors recommend more cautious follow-up on the symptoms of the ankle joint after total knee arthroplasty.

Effect of NaCl on nitrate removal from ion-exchange spent brine in the membrane biofilm reactor (MBfR).

The H(2)-based membrane biofilm reactor was used to remove nitrate from synthetic ion-exchange brine at NaCl concentrations from ∼3 to 30 g/L. NaCl concentrations below 20 g/L did not affect the nitrate removal flux as long as potassium was available to generate osmotic tolerance for high sodium, the H(2) pressure was adequate, and membrane fouling was eliminated. Operating pHs of 7-8 and periodic citric acid washes controlled membrane fouling and enabled reactor operation for 650 days. At 30 psig H(2) and high nitrate loading rates of 15 to 80 g/m(2) d, nitrate removal fluxes ranged from 2.5 to ∼6 g/m(2) d, which are the highest fluxes observed when treating 30 g/L IX brine. However, percent removals were low, and the H(2) pressure probably limited the removal flux.