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.

Nitrate as an alternative electron acceptor destabilizes the mineral associated organic carbon in moisturized deep soil depths.

Numerous studies have investigated the effects of nitrogen (N) addition on soil organic carbon (SOC) decomposition. However, most studies have focused on the shallow top soils <0.2 m (surface soil), with a few studies also examining the deeper soil depths of 0.5-1.0 m (subsoil). Studies investigating the effects of N addition on SOC decomposition in soil >1.0 m deep (deep soil) are rare. Here, we investigated the effects and the underlying mechanisms of nitrate addition on SOC stability in soil depths deeper than 1.0 m. The results showed that nitrate addition promoted deep soil respiration if the stoichiometric mole ratio of nitrate to O2 exceeded the threshold of 6:1, at which nitrate can be used as an alternative acceptor to O2 for microbial respiration. In addition, the mole ratio of the produced CO2 to N2O was 2.57:1, which is close to the theoretical ratio of 2:1 expected when nitrate is used as an electron acceptor for microbial respiration. These results demonstrated that nitrate, as an alternative acceptor to O2, promoted microbial carbon decomposition in deep soil. Furthermore, our results showed that nitrate addition increased the abundance of SOC decomposers and the expressions of their functional genes, and concurrently decreased MAOC, and the ratio of MAOC/SOC decreased from 20% before incubation to 4% at the end of incubation. Thus, nitrate can destabilize the MAOC in deep soils by stimulating microbial utilization of MAOC. Our results imply a new mechanism on how above-ground anthropogenic N inputs affect MAOC stability in deep soil. Mitigation of nitrate leaching is expected to benefit the conservation of MAOC in deep soil depths.

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.

Global Research Alliance N2 O chamber methodology guidelines: Introduction, with health and safety considerations.

Non-steady-state (NSS) chamber techniques have been used for decades to measure nitrous oxide (N2 O) fluxes from agricultural soils. These techniques are widely used because they are relatively inexpensive, easy to adopt, versatile, and adaptable to varying conditions. Much of our current understanding of the drivers of N2 O emissions is based on studies using NSS chambers. These chamber techniques require decisions regarding multiple methodological aspects (e.g., chamber materials and geometry, deployment, sample analysis, and data and statistical analysis), each of which may significantly affect the results. Variation in methodological details can lead to challenges in comparing results between studies and assessment of reliability and uncertainty. Therefore, the New Zealand Government, in support of the objectives of the Livestock Research Group of the Global Research Alliance on Agricultural Greenhouse Gases (GRA), funded two international projects to, first, develop standardized guidelines on the use of NSS chamber techniques and, second, refine them based on the most up to date knowledge and methods. This introductory paper summarizes a collection of papers that represent the revised guidelines. Each article summarizes existing knowledge and provides guidance and minimum requirements on chamber design, deployment, sample collection, storage and analysis, automated chambers, flux calculations, statistical analysis, emission factor estimation and data reporting, modeling, and "gap-filling" approaches. The minimum requirements are not meant to be highly prescriptive but instead provide researchers with clear direction on best practices and factors that need to be considered. Health and safety considerations of NSS chamber techniques are also provided with this introductory paper.

Application methods of tracers for N2O source determination lead to inhomogeneous distribution in field plots.

Source determination of N2O has often been performed using stable isotope incubation experiments. In situ experiments with isotopic tracers are an important next step. However, the challenge is to distribute the tracers in the field as homogeneously as possible. To examine this, a bromide solution was applied as a stand-in tracer using either a watering can, a sprayer, or syringes to a relatively dry (25% gravimetric moisture content) or wet (30%) silt loam. After 1 h, samples were taken from three soil depths (0-10 cm), and analyzed for their water content and bromide concentration. The application with syringes was unsuccessful due to blocked cannulas. Therefore, further laboratory experiments were conducted with side-port cannulas. Despite a larger calculated gravimetric soil moisture difference with watering can application, more Br- tracer was recovered in the sprayer treatment, probably due to faster transport of Br- through macropore flow in the wetter conditions caused by the watering can treatment. The losses of Br- (33% for the watering can, 28% for the sprayer treatment) are equivalent to potential losses of isotopic tracer solutions. For application of 60 at% 15NH4 +, this resulted in theoretical enrichments of 44-53 at% in the upper 2.5 cm and 7-48 at% in 5-10 cm. As there was hardly any NO3 - in the soil, extrapolations for 15NO3 - calculated enrichments were 57-59 at% in the upper 2.5 cm and 26-57 at% in 5-10 cm. Overall, no method, including the side-port cannulas, was able to achieve a homogeneous distribution of the tracer. Future search for optimal tracer application should therefore investigate methods that utilize capillary forces and avoid overhead pressure. We recommend working on rather dry soil when applying tracers, as tracer recovery was larger here. Furthermore, larger amounts of tracer lead to more uniform distributions. Further studies should also investigate the importance of plant surfaces.

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.

Effects of denitrification and transport on the isotopic composition of nitrate (δ18O, δ15N) in freshwater systems.

Nitrate isotopes (δ15N-NO3- and δ18O-NO3-) are a potentially powerful tool for tracking the biological removal of reactive nitrogen (N) as it is transported from land to sea. However, uncertainties about, 1) the variability of the strength of biological isotopic fractionation during anaerobic benthic NO3- reduction (the kinetic enrichment factor: εdenit), and, 2) how accurately these εdenit values are expressed in overlying aerobic surface waters (the effective enrichment factor: εeff), currently limit their use in freshwater systems. Here we used a combination of incubation experiments and numerical modelling to construct a simple framework for defining freshwater εdenit based on interactions between benthic denitrification and diffusive transport to surface waters. Under non-limited, anaerobic conditions the εdenit values produced in submerged soils (n = 3) and sediments (n = 4) with denitrification rates between 10 and 600 mg N m-2 d-1 ranged from -3‰ to -28‰. Critically, model results indicated that diffusive transport would homogenise this to an effective fractionation range of -6 ±â€¯4‰. Evidence for biological and hydrological variability of NO3- isotope fractionation means that values measured in aerobic surface water environments are most appropriately evaluated by a range of fractionation values, rather than commonly used single 'site specific' εdenit values.

Turf Toe Injury - Current Concepts and an Updated Review of Literature.

Turf toe injuries can be a disabling if not recognized and treated early. A high index of suspicion, based on the mechanism of injury and appropriate imaging, helps in the timely diagnosis. These injuries are frequently known to occur on artificial playing surfaces, because of the increased traction at the shoe-surface interface. Stress and instability testing are key components to assess the need for surgical intervention. Accurate timely diagnosis and treatment can allow full return to physical activities for most athletes, back to their pre-injury level.

Explaining the doubling of N2 O emissions under elevated CO2 in the Giessen FACE via in-field 15 N tracing.

Rising atmospheric CO2 concentrations are expected to increase nitrous oxide (N2 O) emissions from soils via changes in microbial nitrogen (N) transformations. Several studies have shown that N2 O emission increases under elevated atmospheric CO2 (eCO2 ), but the underlying processes are not yet fully understood. Here, we present results showing changes in soil N transformation dynamics from the Giessen Free Air CO2 Enrichment (GiFACE): a permanent grassland that has been exposed to eCO2 , +20% relative to ambient concentrations (aCO2 ), for 15 years. We applied in the field an ammonium-nitrate fertilizer solution, in which either ammonium ( NH4+ ) or nitrate ( NO3- ) was labelled with 15 N. The simultaneous gross N transformation rates were analysed with a 15 N tracing model and a solver method. The results confirmed that after 15 years of eCO2 the N2 O emissions under eCO2 were still more than twofold higher than under aCO2 . The tracing model results indicated that plant uptake of NH4+ did not differ between treatments, but uptake of NO3- was significantly reduced under eCO2 . However, the NH4+ and NO3- availability increased slightly under eCO2 . The N2 O isotopic signature indicated that under eCO2 the sources of the additional emissions, 8,407 µg N2 O-N/m2 during the first 58 days after labelling, were associated with NO3- reduction (+2.0%), NH4+ oxidation (+11.1%) and organic N oxidation (+86.9%). We presume that increased plant growth and root exudation under eCO2 provided an additional source of bioavailable supply of energy that triggered as a priming effect the stimulation of microbial soil organic matter (SOM) mineralization and fostered the activity of the bacterial nitrite reductase. The resulting increase in incomplete denitrification and therefore an increased N2 O:N2 emission ratio, explains the doubling of N2 O emissions. If this occurs over a wide area of grasslands in the future, this positive feedback reaction may significantly accelerate climate change.

Nitrous Oxide Fluxes, Soil Oxygen, and Denitrification Potential of Urine- and Non-Urine-Treated Soil under Different Irrigation Frequencies.

Despite increased use of irrigation to improve forage quality and quantity for grazing cattle ( Linnaeus), there is a lack of data that assess how irrigation practices influence nitrous oxide (NO) emissions from urine-affected soils. Irrigation effects on soil oxygen (O) availability, a primary controller of NO fluxes, is poorly understood. It was hypothesized that increased irrigation frequency would result in lower NO emissions by increasing soil moisture and decreasing soil O concentrations. This would favor more NO reduction to dinitrogen (N). We examined effects of high (3-d) versus low (6-d) irrigation frequency with and without bovine urine addition to pasture. Nitrous oxide fluxes were measured daily for 35 d. Soil O, temperature, and water content were continuously measured at multiple depths. Inorganic nitrogen, organic carbon, and soil pH were measured at 6-d intervals. Measurements of denitrification enzyme activity with and without acetylene inhibition were used to infer the NO/(NO + N) ratio. The NO/(NO + N) ratio was lower under high- compared with low-frequency irrigation, suggesting greater potential for NO reduction to N with more frequent irrigation. Although NO fluxes were increased by urine addition, they were not affected by irrigation frequency. Soil O decreased temporarily after urine deposition, but O dynamics did not explain NO dynamics. Relative soil gas diffusivity (/) was a better predictor of NO fluxes than O concentration. On a free-draining soil, increasing irrigation frequency while providing the same total water volume did not enhance NO emissions under ruminant urine patches in a grazed pasture.

Influence of copper on expression of nirS, norB and nosZ and the transcription and activity of NIR, NOR and N2 OR in the denitrifying soil bacteria Pseudomonas stutzeri.

Reduction of the potent greenhouse gas nitrous oxide (N(2)O) occurs in soil environments by the action of denitrifying bacteria possessing nitrous oxide reductase (N(2)OR), a dimeric copper (Cu)-dependent enzyme producing environmentally benign dinitrogen (N(2)). We examined the effects of increasing Cu concentrations on the transcription and activity of nitrite reductase (NIR), nitric oxide reductase (NOR) and N2 OR in Pseudomonas stutzeri grown anaerobically in solution over a 10-day period. Gas samples were taken on a daily basis and after 6 days, bacterial RNA was recovered to determine the expression of nirS, norB and nosZ encoding NIR, NOR and N(2)OR respectively. Results revealed that 0.05 mM Cu caused maximum conversion of N(2)O to N(2) via bacterial reduction of N(2)O. As soluble Cu generally makes up less than 0.001% of total soil Cu, extrapolation of 0.05 mg l(-l) soluble Cu would require soils to have a total concentration of Cu in the range of, 150-200 µg g(-1) to maximize the proportion of N(2)O reduced to N(2). Given that many intensively farmed agricultural soils are deficient in Cu in terms of plant nutrition, providing a sufficient concentration of biologically accessible Cu could provide a potentially useful microbial-based strategy of reducing agricultural N(2)O emissions.

Using near infrared light to manage symptoms associated with restless legs syndrome.

The purpose of this study was to determine whether the application of near infrared (NIR) light could positively modulate symptoms associated with restless legs syndrome (RLS). Twenty-one subjects with RLS were treated with NIR three times weekly for four weeks. Baseline measures of: (1) international restless legs syndrome rating scale (IRLSRS) score; (2) Semmes Weinstein monofilament (SWM) test; (3) visual analog pain scale (VAS); (4) ankle-brachial index (ABI); and (5) sonographic imaging of the popliteal and posterior tibial arteries were compared to post-treatment values. NIR (850 nm) was delivered transcutaneously at 8 J/cm(2) to four locations on each leg and the plantar surface of each foot. A pre-test-post-test one group design was employed. Baseline and post-treatment measures were compared using either a dependent t-test when data were normal or the Wilcoxon signed rank test in the absence of normality. A significant improvement in IRLSRS scores was observed. Sensation improved from less than protective in 16.6% of sites tested at the baseline to 13.4% post-intervention. There was a significant improvement in ABI scores. VAS and sonographic imaging measures other than ABI remained unchanged. The use of NIR to modulate symptoms associated with RLS was supported by the data.

The effect of lignite on nitrogen mobility in a low-fertility soil amended with biosolids and urea.

Lignite has been proposed as a soil amendment that reduces nitrate (NO3(-)) leaching from soil. Our objective was to determine the effect of lignite on nitrogen (N) fluxes from soil amended with biosolids or urea. The effect of lignite on plant yield and elemental composition was also determined. Batch sorption and column leaching experiments were followed by a lysimeter trial where a low fertility soil was amended with biosolids (400 kg N/ha equivalent) and urea (200 kg N/ha equivalent). Treatments were replicated three times, with and without lignite addition (20 t/ha equivalent). Lignite did not reduce NO3(-) leaching from soils amended with either biosolids or urea. While lignite decreased NO3(-) leaching from an unamended soil, the magnitude of this effect was not significant in an agricultural context. Furthermore, lignite increased cumulative N2O production from soils receiving urea by 90%. Lignite lessened the beneficial growth effects of adding biosolids or urea to soil. Further work could investigate whether coating urea granules with lignite may produce meaningful environmental benefits.

Confirmation of co-denitrification in grazed grassland.

Pasture-based livestock systems are often associated with losses of reactive forms of nitrogen (N) to the environment. Research has focused on losses to air and water due to the health, economic and environmental impacts of reactive N. Di-nitrogen (N2) emissions are still poorly characterized, both in terms of the processes involved and their magnitude, due to financial and methodological constraints. Relatively few studies have focused on quantifying N2 losses in vivo and fewer still have examined the relative contribution of the different N2 emission processes, particularly in grazed pastures. We used a combination of a high (15)N isotopic enrichment of applied N with a high precision of determination of (15)N isotopic enrichment by isotope-ratio mass spectrometry to measure N2 emissions in the field. We report that 55.8 g N m(-2) (95%, CI 38 to 77 g m(-2)) was emitted as N2 by the process of co-denitrification in pastoral soils over 123 days following urine deposition (100 g N m(-2)), compared to only 1.1 g N m(-2) (0.4 to 2.8 g m(-2)) from denitrification. This study provides strong evidence for co-denitrification as a major N2 production pathway, which has significant implications for understanding the N budgets of pastoral ecosystems.

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.

Are albumin and total lymphocyte count significant and reliable predictors of mortality in fractured neck of femur patients?

Hip fractures are a significant cause of mortality and morbidity in the elderly. It is important to identify factors that predict an increased mortality following hip fracture. The aim of this study was to identify significant predictors of mortality at 6 and 12 months following hip fractures. Three hundred patients above the age of 65 were identified who were admitted in to the hospital with fracture neck of femur. Two hundred and seventy-four patients were operated and were included into the study. Variables collected were age, gender, significant comorbidities, admission albumin level and admission total lymphocyte count (TLC). Admission time and subsequent time to surgery were also analysed. Our study showed that albumin and TLC were found to be the only clearly significant mortality predictors at 12 months and a delay of up to 4 days to surgery does not significantly increase the mortality at 12 months.

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.

Biogeochemistry and community ecology in a spring-fed urban river following a major earthquake.

In February 2011 a MW 6.3 earthquake in Christchurch, New Zealand inundated urban waterways with sediment from liquefaction and triggered sewage spills. The impacts of, and recovery from, this natural disaster on the stream biogeochemistry and biology were assessed over six months along a longitudinal impact gradient in an urban river. The impact of liquefaction was masked by earthquake triggered sewage spills (~20,000 m(3) day(-1) entering the river for one month). Within 10 days of the earthquake dissolved oxygen in the lowest reaches was <1 mg l(-1), in-stream denitrification accelerated (attenuating 40-80% of sewage nitrogen), microbial biofilm communities changed, and several benthic invertebrate taxa disappeared. Following sewage system repairs, the river recovered in a reverse cascade, and within six months there were no differences in water chemistry, nutrient cycling, or benthic communities between severely and minimally impacted reaches. This study highlights the importance of assessing environmental impact following urban natural disasters.

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.