HOW COME NO ONE TOLD ME THIS IS A SERIES AHHHHHH. I WAS NOT PREPARED….
Alright. I wasn't that into the first 30-40%. It wasn't bad at all, but I just wasn't really connecting. Mariko is on the way to her betrothed (the prince) when she gets attacked by who she believes is the Black Clan. She manages to escape (as told by the synopsis), but she refuses to return home and tell of her survival until she can figure out who paid the Black Clan to kill her. So, she infiltrates their camp and attempts to gain their trust.
Anyway, about half way through, once we're into the Black Clan hideout, things start to get interesting. And they just keep getting better and better. I literally could not put it down past the 70% mark. Like holy wowza… SO GOOD. It was non stop, action packed, with so many fun turns. AND THE END AHHHHH WHAT DO I DO NOW?!?!
I TOTALLY GUESSED THE TWIST TOO. And I don't even care that I guessed it because it was so great. I was actually hoping I was right because just.. yes. So good.
4. The scene where Mariko falls from the… cliff thing.
I did have a few small complaints – one being the magic system. It was really confusing and not really explained at all – no rules were mentioned and it seemed very random. I'm assuming this will be explained much more in the next book, but it was odd to me that it was so sporadic.
The only other thing was the writing- not that it was bad. It just felt a bit dry and hard to follow at times. I felt the same way about Ahdieh's other series too – 'The Wrath and the Dawn'. Whatever, the story here is amazing.
All in all, I totally recommend this. I'd read it again in a heartbeat.
Ahhh, this sounds absolutely amazing and your review is making me so much more excited to read it!!
Yay I can't wait for you to read it! You must tell me what you think!
Yay I'm so excited for this!
Oh wow this totally made my day! Thank you so so much! I love trying to find some unique and lesser heard of novels – there's so many out there that totally deserve recognition! Anyway I really appreciate that and I LOVE your blog as well!
Haha aww yay! That means so much to me- thank you for saying that! You'll have to let me know when you read any of them /what you think!
Hello! So I also read an ARC of this, and totally agree, the first part was a bit slow. It got much better after the falling into water scene *wink wink*, I just feel like in general Mariko started changing from that moment on to be more confident. And I totally agree Mariko repeated a lot of stuff, it was a bit too much some times! I actually really liked The Wrath and the Dawn which left me slightly disappointed with this book because I though Shazi was more badass!


You have probably been thinking about a trip to Iran after hearing about its alluring historical attractions and its superbly hospitable people. Iran is not what the media portray. Actually, it is a relatively modern country with a young educated population. Iran trip will definitely be an experience you'll never forget.
Like other tourists, British citizens also need a visa to travel to Iran. The only difference is that the process of obtaining Iran visa is more time consuming for UK citizens (like Americans and Canadians). Even though it may seem a bit challenging to apply for and get Iran visa, this country is surly worth it. Every year, hundreds of British citizens visit Iran.
To make sure the British travelers are safe in Iran, it is obligatory for them to travel on an organized (group or private) tour and be accompanied by a licensed guide during their Iran trip. After confirming your tour, Fotros travel agency, as your host, applies for Iran visa and when the authorization code or Visa Grant Number is issued from the Iranian Foreign Ministry, all you need to do is to stop in an Iranian Embassy (London, Dublin, etc.) to get your visa sticker using this code. Your passport must be valid for a minimum period of 6 months from the date a visa application for Iran is submitted. If your passport contains an Israel stamp, you may be refused entry to Iran. For more information about Iran visa click here.
You may also wondering about what to wear in Iran. Dress code in Iran for women and men are based on Islamic law. You could read more about this here.
Best time to visit Iran is from mid-April to early June and late September to early November. Iran is home to 22 UNESCO registered sites and has numerous wonders to be explored, from vast deserts to high mountains. "Fotros Travel Agency" applies for your Iran visa and perform memorable tours for British citizens.
To plan and book your Iran tour, contact our team.


About Session: This opening session will shed a light on Indonesia's Blockchain status and the future outlook for blockchain.
Our experts will shed light on the current implementation programs and also highlight the areas of development of blockchain technology in Indonesia.
First getting into blockchain years ago during his former role as Innovation Director at Fairfax Media Australia, Steven is now Partner at Blockchain Fund SPC an M.A.S licensed fund and cofounder of Blocktech Indonesia. Steven is also currently the Chairman of Asosiasi Blockchain Indonesia, who's mission is to help drive the healthy and positive growth of Blockchain technology Indonesia.
CashCow Coin tokenises direct cattle investment allowing token holders to invest their coins on our platform to purchase calves.
Our farming partners will grow the calves until they are ready to be sold on the market. Profits will be shared between Farmers, ICO Investors and CashCow Coin Token Holders. CashCow Coin will launch exclusively in Indonesia October 2018.
About Session: Blockchain has been around for almost a decade now. What will the next decade bring? No one knows for sure, but there is one certainty - many challenges along the way. Chief amongst them is the challenge of scalability: how can blockchain technology be effectively applied in industries as different as insurance and gaming? And how can public blockchain platforms support a comprehensive ecosystem when even the mighty Ethereum network was shut down by CryptoKitties? Achain has the answer to these questions and many more!
Riki Arif Gunawan is acting as a Head of Subdirectorate Technology - Directorate of Information Security, Ministry of Communication and Informatics.
His job is to compose regulation and promote implementation of Digital Signature in Indonesia. He had been doing his work for almost 7 years, focusing on Digital Signature implementation in digital documen and on line services. He and his team have been encouraging and assiting many institutions to use digital signature. He also colaborate with many agencies for promoting digital certificate in government and financial institution such as Ministry of Finance, Ministry Internal Affair, BKN, OJK, Fintech Association and eCommerce Association.
About Session: Having worked in the AI industry for 7 years, our team realized that what was stopping AI from progressing faster is the high computational demand and cost, as well as the lack and cost of data. That is why we are building DeepBrain Chain, an AI computing platform powered by blockchain that aims to lower computational cost, facilitate safe sharing of data and accelerate the progress of AI.
DeepBrain Chain will empower the whole AI industry, it can bring AI companies up to 70% savings on computing costs. Our Marketing Director Eric Yin will talk to you about the future of AI and Blockchain.
Eric Yin is acting as Marketing Director of DeepBrain Chain, a motivative and proficient senior leader expertise in marketing aspect. He used to lead and coach multinational enterprise in various industries such as Unilever, Uber, Yili Group and Mobike. His splendid career life provides him mature and exclusive point of view in order to enhance DBC with outstanding marketing strength.
About Session: Blockchain has the potential to leapfrog technology advancements in emerging markets, in both the public and private sectors. Listen to the experts share their insight on this groundbreaking technology. Understand the rise of Blockchain and Decentralised applications and what this means for the future of the tech Industry. CIOs of end user companies can use this panel discussion to evaluate, plan for and adopt blockchain wherever it has the potential to support business, economic and social objectives.
Dr Walter Tonetto is a former Visiting Professor in The University of Tokyo and Waseda University, Japan; more recently Senior Research Fellow in the School of Commerce at the University of South Australia. Author and keynote speaker, he is at the forefront of various Blockchain initiatives in SE Asia. He is Vice-President ASEAN for Digital Town and in key positions in various other companies.
Zach is Co-Founder and Chief Development Officer of Intrepid Ventures. Intrepid Ventures invests in, designs and builds blockchain powered companies.
Early stage investor in Blockchain, Crypto Currency, Bitcoin, Ethereum, DLT, Digital Health, IoT, Data & Analytics and Sensors.
About Session: Nasdaq launched a blockchain prototype last fall, almost 10 other exchanges are in the pipeline to adopt or experiment with Blockchain technology. If they can move towards blockchain, why can't blockchain exchanges embrace traditional practices to bridge the gap? Where is the roadblock? Learn about this and other innovative solutions on exchanges.
Santos Sinha has been a much sought after security professional in the banking sector for much of his professional life. His thorough understanding of Fintech and Legal aspects of the business has enabled him to innovate and disrupt with ease. He brings his extensive experience from his time at Price Water House Coopers, Bank of America, Master Card among others.
Will Blockchain-based Transactions Accessible for Mainstream Consumers?
About Session: Blockchain technology and digital currencies continue taking center stage in 2018. A survey conducted in India, Indonesia, Japan, Russia, UK, and the USA revealed that around 70% of the respondents agree that most people will be using digital currencies in the next ten years. How will these blockchain-based transactions be accessible to the mainstream, especially the unbanked ones? The presentation will take a closer look at how the blockchain technology will revolutionize the future of transaction and investigate the challenges of blockchain-based transaction among mainstream consumers.
Constantin is the President of Pundi X and a founding member of the Indonesian Blockchain Association. He has 17 years of experience as founding CEO of two fintech companies: Infinetworks and E2Pay.co.id, pioneering Internet Banking, Mobile Banking and e-payment services in Indonesia. Previously, he worked at Accenture in Chicago and Jakarta. Constantin holds an M.Sc Computer Science (Purdue University) and a B.Sc Computer Science (University of Tulsa).
About Session: Danny Baskara, Vexanium's founder and CEO will talk about his project - Vexanium, a decentralized marketing ecosystem for merchants.


A reliable Supply Chain ensures that merchandise flows from suppliers to the shelf in an efficient manner. Improving the flow of goods results in improved service to a Retailer, ensuring their customers have the products they need while shopping.
While the need for Supply Chain reliability has long been understood; leading retailers are implementing Supply Chain Reliability programs that drive performance in key supply chain metrics (fill rate and on-time arrival). Penalties are charged to Suppliers on shipments that don't achieve certain thresholds (early, late and short).
The consequences of non-compliance reach beyond penalties and the administrative costs, having the potential to impact commercial partnerships with Retailers. At the core of Supply Chain Reliability is the need to drive improved collaboration and alignment with Retailers.
TPG understands how to help Suppliers achieve reliability with Retailers. We have significant expertise working with Manufacturers to improve overall reliability of the total Supply Chain.


Lock in a great price for Pension Vicus – rated 8.6 by recent guests!
The place is clean, situated very close to the river bank and in a quiet neighborhood - so perfect for an evening/morning walk. My room was on the first floor, at street level - surprisingly quiet.
Easy late check in with the keybox system. The room was very spacious, the bathroom was very clean. The bed was convenient. There was enough parking space for each and every guest.
Though we arrived after reception had closed, the room was ready and the key was in the key box outside.
Very clean and comfortable as overall impression. The room was warm enough, despite it was snowing outside. Free parking for guests.
The hotel is a walkable distance to the city center and tourist attractions.
We liked being out of the city center, but within walking distance, about 20 minute walk. It was also quiet and more affordable. Also, there was a fridge in the room. Breakfast was good.
The receptionist was very helpful and pleasant. Breakfast was adequate for cost. Rooms were great, clean and comfortable.
Location is good for people who enjoy a long walk. an excellent location for exploring area and are cyclists. A good accomodation for an active holiday in this area of southern germany.
Pension Vicus This rating is a reflection of how the property compares to the industry standard when it comes to price, facilities and services available. It's based on a self-evaluation by the property. Use this rating to help choose your stay!
One of our top picks in Passau.Quietly located just 1,000 feet from the banks of the River Danube, Pension Vicus offers a hearty buffet breakfast and free on-site parking. Bright rooms include free Wi-Fi.
Featuring a flat-screen TV, rooms at Pension Vicus are decorated in sunny colors. The private bathroom also features free toiletries and a hairdryer.
Breakfast is served each morning in the cheerful breakfast room.
Pension Vicus is 1.2 mi from Passau Central Station.
When would you like to stay at Pension Vicus?
Sunny room features free Wi-Fi and a flat-screen TV.
Certain rooms feature a balcony. Subject to availability, guests can request a balcony at an additional EUR 3 per day.
House Rules Pension Vicus takes special requests – add in the next step!
Pension Vicus accepts these cards and reserves the right to temporarily hold an amount prior to arrival.
Guests planning to arrive later than 18:00 are kindly asked to contact Pension Vicus in advance. Contact details will be included in your booking confirmation.
Please inform Pension Vicus of your expected arrival time in advance. You can use the Special Requests box when booking, or contact the property directly using the contact details in your confirmation.
Easy to find. Parking is available.
This property advertises washing/drying facilities (even on their room card) - but this is NOT TRUE. Towels were extremely thin and hard. Linen was not changed unless requested. B'fast was scanty - no fresh fruit (a few apples that had been there for weeks). Owner was most inhospitable - most staff the same, but they probably take their queue from the owner. Entry code didn't work - arriving after 9pm, I had to phone for help. No information on local eateries.
It was a little walk from town. But a nice walk along the old rail track.
The pension was very quiet.
There was no place to sit outside, nor a common area inside to sit with our friends.
Position a bit far from where we needed to be to catch our boat for bike/ boat trip as there was no transport readily available on the Saturday. Had to walk the 5 km as taxi was going to be 3 hours and buses not much better.
The location was a bit out of town. OK if you have bikes but a bit of a hike without them. Room was OK with skylights. No proper window as it was on the top floor partially in the roof.
Very friendly and welcoming staff and owners.
All was sparkling ! Very Colored !
Room good, food good, staff good - all just as we needed.


We woke up round 5.00 and get ready by 6.00 in morning with the forest guards already present there. We found the vehicle belongs to lodge actually going towards the start point of trek for getting woods, we were offered a lift and saved almost 2/3 km journey. While reaching the point we found the actual trek would start from other side of Jiabharali river a boat was waiting for us to get in that side. The river was quite deep as mentioned by the boatman and experiencing sunrise over Jiabharali river was simply fascinating. We had to walk another km or so on sands of Jiabharali to reach forest beat office and there we had to submit our permits and got the order to start our trek. The trek was fascinating inside the thick forest, we saw sambar deer, elephants, buffalos and many different birds. At some point of time our guard was little nervous as the herd of buffalos were almost charging to us but somehow we got escaped but the chilling current of nervousness flowing through our bones, we visited so many natural parks, wild life sanctuaries in India, but none seems to be so wild and virgin like what we felt in Nameri. We finished our trek of 8kms in almost slightly more than 2 hours. Then again 1 km trek on sand to catch boat and then 2 km walk on other side took us to Resort. We had a fabulous breakfast there as after a long time I walked for more than 10km at a stretch. I gave a call to Ashim and he was already on his way towards Nameri from Tinsukia. Good news but we were so tired, we left the idea of rafting as we had to go another 45 mins towards Bhalukpong by a car and the place was too hot to enjoy the rafting at noon. We preferred to take a much sought after rest after hectic 8 days of traveling and by evening Ashim reached safely with a new Bolero, that just ran less than 1000 km as per its Odo. We were happy and gone to sleep early as tomorrow we would enter more into Central Arunachal towards Ziro.
With Ashim we started with new energy for the next and more interesting leg of our journey. We started quite early and for first 10km again it was a big struggle to proceed with extremely bad roads. After 10 km, road was smooth enough to sail at 60kmph easily. We reached Balipara which is around 17km from Nameri and there we take left on to NH52 for next 200km on very good surface where you could cruise around 80 kmph easily. We took our breakfast at Biswanath Chairali and moving through right (North) bank of Brahmaputra and as I mentioned this is the biggest hurdle in exploring Arunachal as every time you have to navigate through Assam in East-West direction and that definitely increase driving time, distances and most importantly complex permit issues as you have to repeatedly come out of various check gates from Arunachal and get into it through some other gates. 30km before North Lakhimpore, we took left turn towards Kimin Check gate and once again we had to face the bad roads. Till Kimin Check gate road was bad but surprisingly improved to some extent once we entered Arunachal again. Kimin is one of the closest check gates from Assam through which you can access Central Arunachal districts like Lower Subansiri, kurung Kamey. Serpentine roads through thick forest roads over hilly region had high similarity with Bhalukpong though road was better here and as usual number of tourists were much less in this circuit. Our permits were checked in Kimin Check Gates and then we were allowed to enter Arunachal. When I have come to this topic, I must say obtaining a month long tourist permit is difficult at least from Kolkata, they refused me to issue even 2 non-overlapping permits for 2 different regions and finally I had to get one in my name and other in my wife's name sending her to Arunachal House to get rid of this problem. So those who are planning for more than 14 days trip and covering more than one check gate and especially planning to get it done from Kolkata, please plan accordingly. We booked our stay at Ziro Circuit House, but the circuit house is actually located at Hapoli, 5 km before Ziro town. You would get some alternative accommodation too in Ziro but Circuit House seems to be the most value for money, not just because of its cost but the excellent location, you would be able to see the whole Hapoli town from the circuit house. The drive from Nameri to Hapoli was almost 365km out of which 100km was in hilly terrain and so it was a tiring day for all of us. Ziro's height was 5500 ft much lower than even Dirang but believe me, I have very rarely experienced more colder place than this in my life, don't know how much the temperature was but it was chilling and even more difficult to sustain that what we faced in 10K ft height at Tawang. Nameri Eco Resort Manager specifically told us about this infamous cold of Ziro but that time we didn't put much importance to that considering it was just 5500 ft height. But certainly it was a cold place may be because of some special air circulation or for some other reason. We were tired, had our dinner and quickly retired for the day.
This was our first full day in Tawang and the day was neither fully clear, nor completely cloudy, it was slightly foggy and cold morning and we were ready for our trip to Zemithang. Zemithang is towards extreme western end of Tawang district and the state of Arunachal, in the border of China (Tibet) and Bhutan. This is around 100km from Tawang and day trip would cost you a full day. Apart from the famous Chorten in Gorsam (Just few km before Zemithang), the natural beauties of the place would keep you spell bound. This is completely different than what you see in high mountains of Tawang, the whole route is through much lower elevation and you would find lots of trees and greeneries and amazing fall colors (even in early December) through out the route. The terrain matches more closely to Bhutan and now a new road is almost built up to border of Bhutan and work is being progressed for a connecting road from Bhutan end, which when completed, would give a new corridor of business between Bhutan and India apart from existing borders in Phuntsoling (through WB) and Somdrup Jonkhar (through Assam). The road is one of the best I found in Arunachal Pradesh and scenery is simply mind boggling. I also strongly suggest if possible stay a day in Zemithang, there is an Inspection Bungalow which usually be available and enjoy the serenity of the place. If you are traveling in October / November, even better is to plan a round trip from Tawang to PTSO to Madhuri Lake to Y Junction to Taksang Gompha and then to Zemithang and then back to Tawang through the valley route. I missed it as the road between Y Junction and Taksang was blocked and even road to Madhuri lake experienced heavy snowfall for last few days. The chorten at Gorsam usually be opened once in 7 years and it's very famous to Buddhists. We tried to move another 8 km in a half broken roads towards the border at Kenzamane and stopped by ITBP there, they didn't allow us to proceed without formal pass from Tawang Brigade but I heard from them, if you could go till border (another 3 km from that point), you could see the Tibetan village on the other side of McMahan line.
This is situated 90 Kms from Tawang town. This Stupa is the largest Stupa of the area. This Gorsam Chorten is believed to have constructed in the early part of 12th century by Lama Pradhar, a Monpa monk. The semi-circular dome niddling high into the sky rests upon a three-terraced plinth. Four miniature stupas are also set on the four corners of the lower most terraced of the plinth. The base is squared with each side about 170 fts. in length with a niche running along its whole length and 120 manis are set in wooden frames. A well-paved footpath goes around the Stupa for pilgrims to go round about praying (Kora).
After spending a nice day at Lumla and Zemithang, we started our return journey through same route towards Tawang, my intention was to take the high mountain route through Taksang and Y Junction and but everyone at Zemithang advised us not to take that route because of then weather and it was raining there in the valley means snowing in the upper reach and the road is very isolated and you might not get any help if you get stranded. So coming back through same road was the only possibility and we reached Tawang in evening when light was just fading out. After reaching hotel I first enquired about Bumla permit and Hotel manager told the road was blocked beyond PTSO and people couldn't even reach Madhuri Lake on that day. I called Pabitra and he initially told me that day permit was not issued by army and they would evaluate situation on next day and issue if situation improves, sounded convincing but somewhere I smelt something wrong in his behaviour. I started quizzing him in depth, asked him to handover the permit he obtained from DC Office and I planned to visit myself the brigadier office. Then he started fumbling and told he would be able to manage it tomorrow and when I insisted he told that he couldn't collect the permit from DC office itself, now that was surprising, when I asked why, he started showing lame excuses like power was gone, photo copy machine was not running, DC was not there and many more. Now I asked him to return my money back, he said he had to travel to Army HQ in a cab, so he spent 200 there, when I encountered him why he gone to army when he didn't collect the DC permit in first place, he couldn't answer but stuck to his earlier stand he would refund me partially. This was really irritating, first of all he messed up my Bumla plan and next he was trying to be smart. I called up directly Rampal and spoken to him at length explaining him the situation. Once he intervened Pabitra returned me the money he took but snapped Bumla from my itinerary. So lessons learnt is don't trust these hotel guys, if you want to visit Bumla, either connect to local cabs and spend a full day in Tawang and get involved in the process of obtaining permits unless you know someone very reliable. Anyway we decided two things on that day, first we would try to go on next day as much as we can as from that day evening it started snowing quite heavily even in Tawang town, so realistically we might not have much of a chance to reach Bumla and second was we would leave Gayki Khang and move to some more value for money hotel as we really took this permit incident as a cheating from hotel's part. We retired for the day and prayed for a nice day tomorrow.
When I last visited Arunachal, 2 years back I fell in love with the state, the awesome landscape starting from rainforests of eastern part to alpine meadows of western part meeting mighty Himalayas, the high mountains all around, deep gorges carving its way with blue waters gushing in, you can clearly see and feel the rapids from top. Waterfalls in almost every bend, in one turn its vast blue sky and in next turn in completely filled up with fog and mist. Arunachal will surprise you in every moment, the other aspect is the diversified culture, it's completely a tribal state and there are 101 recognized tribes in Arunachal and mostly believe in different religions like Donyi Polo (Sun and Moon), Hinduism, Christianity etc. The state has borders with 3 foreign countries, Bhutan in west, Tibet (Now People Republic of China) in North and Myanmar in East. Tourism is not developed except the western part of Tawang sector, which was developed by late Mr. Dorje Khandu, the former chief minister of Arunachal who belonged to Tawang. The state buses sparsely run through the main towns but still Shared Sumo service is the most common mode of transport for locals, in almost all districts you would still find 30% villages not having any road connectivity and still depend on long trek to meet their daily needs. Actually northern part of Arunachal was more closely connected with Tibet through 4/5 different passes until British drew McMahan line in 1913 as per Shimla Accord with Tibet. The usual business with Tibet had been going on until China disregarded the McMahan line and attacked India in 1962 in both Ladakh and Arunachal sector. Since then all the passes were closed and the whole border with China/Tibet was closed and people were forced to walk 3/4 days through treacherous mountains and dense forests to come down to Indian plains to start their new lives. When we visited places like Gelling, merely a km from McMahan line, the elders were telling us the sad stories how they suddenly got partitioned from their near and dear ones living just couple of km across other side of border since 1962. The state is covered by mountains from west to east and deep river gorges from North to South including Kameng, Subansiri, Siyom, Siang, Dibang and Lohit that created mighty Brahmaputra river system. So traveling the state is extremely difficult from west to east as there is a lack of trans-Arunachal highway which is presently being built with the aid from Central Govt. Every time you have to come down 300 km to Assam and then again have to go up another 300km to reach another spot. So you need at least 45 days just for a touch and go trip to visit the prominent areas of state. So better if you could make multiple visits. Last time we covered Eastern Parts covering Lower and Upper Dibang Valley, Lohit, Anjaw and Changlang districts, this time we covered western and part of central covering, West Kameng, Tawang, Lower Subansiri, Upper Subansiri, West Siang, East Siang and Upper Siang.
The 5 major ancient trade points between Tibet and Arunachal was through Kenzamane (Zemithang), Bumla (Tawang), Kapangla Pass (Gelling), Lolla Pass (Mechuka), Dumla Pass (Monigong) and Kibithu. Except Bumla (where civilians are allowed with passes from DC and Army) all the other borders are closed for civilians. Our main intention was to travel as close as possible to these points to trace the historical McMahan line. We covered Kibithu in last trip, so tried to touch upon the rest of the points.


text:
All Orthopedics
Business of Orthopedics
Shoulder/Elbow
Total Joint Reconstruction
Orthopedics Topics
Experts discuss what to expect after ankle surgery
Patients can expect to return to many of their activities after ankle fusion and total ankle replacement.
Orthopedics Today, May 2005
Part I: [How top physicians make the call]
Ankle arthritis is a disease of relatively young and active patients, yet treatments are often time-limited. The emergence of improved joint replacement designs for the ankle has stemmed a renewed enthusiasm to find an alternative to fusion for disabling ankle pain.
In part two of this round table, some experts on ankle arthritis discuss their approach to this challenging clinical problem.
Charles Saltzman, MD
Beat Hintermann, MD
Orthopaedic University Clinic
Sandro Giannini, MD
Clinical Orthopaedics
Department, Sixth Division
University of Bologna,
Rizzoli Orthopaedic Insitute
Mark Myerson, MD
President, American Orthopaedic Foot &
Ankle Society Director, Institute for Foot and Ankle Reconstruction at Mercy Hospital
Michel Bonnin, MD
Orthopaedic Surgeon
Clinique Sainte Anne
Michael Coughlin, MD
Clinical Professor of Orthopedic Surgery
Oregon Health Sciences University,
Saltzman: What should patients expect to be able to do after an ankle fusion or replacement? Are there any restrictions on patient to pursue activity after these surgeries? Are their activity restrictions different?
Hintermann: Successful ankle fusion may allow the patient most activities. However, some activities such as running and jumping, where active plantar flexion and/or dorsiflexion are needed, may be limited despite of shoe modifications. Besides relieving pain, successful total ankle replacement, in contrast, may restore some motion, allowing patients to return to certain physical activities that they were not able to perform prior to implantation. Consequently, the physical demands of patients may increase, and successful primary replacements may fail because the replaced ankle is subjected to too much stress. This is probably one of the biggest concerns I have with total ankle replacement in young patients with high demands.
Sagittal plane motion of a total ankle replacement requires excellent fluoroscopic imaging. In this example, the Salto Implant shows about 22° of dorsiflexion and 25° of plantar flexion.
COURTESY OF MICHEL BONNIN
When comparing fusion with replacement of the ankle, the activity restrictions may be basically similar. There is, however, a totally conversely self-limiting mechanism. The patient with a fused ankle will limit his or her activities to what he or she is able to perform with the help of shoe modifications. For instance, he or she will avoid uphill walking because difficulties with the fixed foot to adapt the ground contact. The patient with a successfully replaced ankle, in contrast, will not feel the restriction of the performed surgery, and thus he or she may tend to subject the replaced ankle to too much stress.
Giannini: Patients should expect to be able to return to a nearly normal life. They can walk, ascend and descend stairs, and perform pretty well all the daily living motor tasks. Light sports like swimming, golf and cycling can also be performed. Certainly they should avoid all more demanding sport activities. When the remaining motion at the other foot joints allows 20º to 25° flexion and no signs of arthritis are evident, ankle arthrodesis still allows patients to perform sports even with high impact, which certainly is not the case when total ankle replacement is performed. Perhaps, when flexion between the forefoot and the shank is achieved and fusion was indicated, more demanding activity can also be performed.
Coughlin: After an ankle fusion I believe that a patient can return to heavy-duty labor, can expect to play sports such as basketball, can jog within the constraints of their arthrodesis and basically proceed with activities of their choice. I do educate them to the fact that increased activity may lead to degenerative arthritis of adjacent joints. Following a total ankle arthroplasty my recommendations are for a patient to be much more careful. Inadvertent fracture of a medial or lateral malleolus, or excess activities may lead to subsidence or failure of the ankle arthroplasty. I think that the patient who has a total ankle arthroplasty must be more judicious in their choice of activities. Thus the activity restrictions following surgery are very different following a total ankle arthroplasty in my hands vs. an ankle arthrodesis.
Myerson: Following ankle replacement, I allow patients to walk, hike, bike, swim, play doubles tennis and cross country ski. My biggest concern following ankle replacement is repetitive impact activities that are likely to lead to implant subsidence.
To some extent their ability to perform these activities is limited not by the prosthesis but by their age and activities prior to implantation. Although impact activities are tolerated and permitted following ankle arthrodesis, with the limitation of ankle dorsiflexion, less physical or sporting activity is likely.
Saltzman: How natural is ankle motion after replacement? What factors play into restoring motion?
Hintermann: Independent of the complexity of the deformity instability or malalignment, the main goal of total ankle arthroplasty remains the restoration of a normal, well-balanced, stable, and aligned ankle and hindfoot, where the ankle prosthesis is implanted to replace destroyed surfaces. It does not make sense to replace an ankle that never worked normally (for example, in clubfoot deformity), or where muscular function is lacking (for example, post-polio foot deformity or a paralytic foot).
Recently, Valderrabano and co-workers investigated, in vitro, the range of motion, movement transfer, and talar movement in the normal ankle, the fused ankle, and the replaced ankle (with three different ankle prostheses: STAR, Hintegra and Agility). Motion at the ankle joint complex was restricted less by each of the three ankle prostheses than by ankle fusion. The prostheses also changed the movement transfer within the ankle joint complex less than ankle fusion, especially during dorsiflexion/plantar flexion of the foot. The two-component ankle (Agility) restricted talar motion within the ankle mortise, whereas the three-component ankles (Hintegra and STAR) seemed to allow talar motion comparable to that in the normal ankle. Using an anatomically shaped talar component (Hintegra) evidenced motion closer to that of the normal ankle than did the use of a non-anatomically shaped talar component (STAR). They concluded that a successful design for total ankle arthroplasty should be shaped as anatomically as possible and should provide a physiological range of motion at the ankle joint, full transmission of movement transfer between foot and lower leg, and unconstrained talar motion within the ankle mortise.
What I have learned over the years is that restoration of the original center of rotation of the talus is essential to get motion close to the normal ankle. Using an anatomically shaped talar component (that is a conical shape with medially a smaller radius than laterally) is also essential to get unconstrained motion. The use of a cylindrically shaped talar component, as is the case for most of the recent designs, potentially overstresses the medial ankle ligaments particularly on posterior aspect that, in turn, provokes painful limitation of dorsiflexion. Ossifications may typically result from this chronic overload of ligaments.
Giannini: Many factors play into restoring ankle motion after surgical treatments, the first being a marked arc of motion before surgery. In many cases limited motion and rigidity affect significantly the status of the soft tissues, which can likely cause limited motion also after surgery. It is important, therefore, to use a prosthesis that can be set to be compatible with the soft tissues retained.
Bonnin: ROM of the ankle is generally improved after TAR but never returns to normal. In our series, the overall ROM as measured from dynamic radiographs improved from 15.2° ± 10° preoperatively to 28.3° ± 7° at follow up (P<.05). Clinical measurements are 22.6° ± 12° and 32.9° ± 13° respectively (P<.05), vs. an average of 46° ± 19° on the controlateral side.
In my experience, the quality of the functional result depends mainly on the capacity of recovering good dorsiflexion: The quality of life is better with a fusion in neutral position than with a stiff TAR in equinus position.
The factors influencing ROM are as follows: (1) the preop ROM; (3) the surgical technique; (2) the way you manage the postop period; and (3) the etiology.
In a case of very stiff ankle preoperatively (especially if stiff in equinus) even if a very aggressive release is done during surgery, the ankle remains stiff postoperatively. In these cases, the challenge is to obtain 50 to 10° of dorsiflexion. At the end of the procedure with the testing components, if the dorsiflexion of the ankle doesn't reach 10° easily (observed on the lateral side of the foot) we must consider few tricks to improve the mobility: Achilles lengthening, tenolysis of posterior tibial tendon, checking with an image intensifier that the AP positioning of the talar component is correct and lastly doing a new distal tibial cut a few millimeters.
In the postop period it is critical to maintain immobilization in maximal dorsiflexion otherwise the ankle develops equinus contracture because of the tonicity of the gastrocnemius muscles.
In our series the dorsiflexion measured on dynamic XR is better in the RA group (14.6° ± 17°) than in the OA group (9.7° ± 5.6°) (P<.05), although Achilles' tendon lengthening was less frequent (17% in RA vs. 45% in OA) and preoperative equinus contracture more frequent in the RA group (mean preoperative dorsiflexion was -3.5° ± 10° in the RA group vs. 0° ± 8.2° in the OA group).
Saltzman: Does premature adjacent joint arthritis develop after ankle replacements?
The Hintegra Total Ankle Prosthesis is a nonconstrained, three-component system. This new version uses pegs, thus screw fixation of the talar component is optional. It is manufactured by Newdeal SA in Lyon, France, with permission.
COURTESY OF BEAT HINTERMANN
Hintermann: Based on recent reports, there is evidence that ankle replacement protects, to a certain extent, the adjacent joints from further degenerative disease. Personally I was in the beginning too aggressive with contemporary subtalar and/or talonavicular fusion while performing total ankle arthroplasty due to the fear that the observed degenerative changes in these joints may be a source of pain. I then changed my attitude and, today, I limit such additional fusions to severe osteoarthrtitic conditions, severe instability and/or deformities. Most surprisingly, there were less than 1% of my cases where I had to consider a fusion of the subtalar or talonavicular joint after replacement. I thus support the belief that ankle replacement effectively preserves the adjacent joints from degenerative disease. This has some practical relevance.
For example, if severe osteoarthritis developed in a young patient after a trauma, total ankle arthroplasty may allow him or her to regain some motion and to properly bear the affected ankle, which, in turn, may protect the foot from further degenerative joint disease. When the replaced ankle wears out and revision of the prosthesis is no longer possible, ankle arthrodesis remains an option for salvage. The patient, nevertheless, may have benefited greatly from this intermediate solution, which allowed continued participation in some activities (including professional activities) during a significant period of his or her life that would not have been possible with a primary ankle arthrodesis. The intermediate total ankle arthroplasty may additionally have preserved his or her foot from the development of secondary osteoarthritis. Further clinical research is needed, however, to understand the pathologic changes taking place in the neighboring joints of a replaced and fused ankle, respectively, and how they can be influenced.
Bonnin: Arthritis of adjacent joints can be observed after TAR. However, this is mainly in the case of an undiagnosed, preexisting arthritis. This is true particularly in post-traumatic ankle — fracture of the talus — and in rheumatoid cases. In these patients I recommend a careful evaluation of the subtalar and midtarsal joints before considering a TAR. A preop CT scan, MRI or bone scan is often useful. In case of pantalar arthritis a triple arthrodesis can be done before the TAR.
Myerson: I have not identified this problem and believe that the contrary probably occurs. The range of motion after joint replacement is not considerable, and averages about 25º, but with this limited range of motion, this seems sufficient to offload the adjacent joints (subtalar and talonavicular), limiting the development of arthritis.
Saltzman: After ankle fusion is the development of adjacent joint arthritis inevitable? If it occurs, how do you treat it?
Giannini: After ankle fusion, the development of arthritis at the adjacent joints is very likely, though it progresses very slowly. This is true particularly when arthrodesis is at ankle neutral (90°) and rear-foot in slight valgus position. In these cases, the use of insoles, drugs and physical activities can be indicated. In more severe cases, subtalar and mid-tarsal arthrodesis can be considered or even conversion of the arthrodesis into ankle replacement in special cases.
Bonnin: Development of subtalar, mid tarsal or Lisfranc degeneration after ankle fusion is a challenging problem. The risk of this phenomenon can be limited with optimal positioning of the arthrodesis (no equinus) but it seems to be inevitable on long-term evaluations. The risk is particularly high in rheumatoid arthritis and it is the reason why I try to never fuse a rheumatoid ankle.
Treatment is difficult. The widely used attitude in these cases is to fuse the involved joints. The risk of this attitude is to transfer the problem on other joints and to increase the difficulty: When ankle, subtalar and midtarsal joints are fused what is the solution if the Lisfranc joint is involved? In the case of malpositionned arthrodesis, considering a reorientation osteotomy can be a viable option. In two complex cases I have done "desarthrodesis-prosthesis" of the ankle joint with quite satisfactory results.
Coughlin: It has been shown in several studies that following an ankle arthrodesis that adjacent joints will develop arthritis. Some arthritis obviously precedes the ankle arthrodesis. In the case where that has not occurred, there is no question that an ankle arthrodesis puts more stress on adjacent joints. While I do believe that adjacent joint arthritis is inevitable, with an appropriate position of the ankle fusion I believe that this arthritis progresses much more slowly. When it occurs, all the conservative methods such as anti-inflammatory medications and bracing are choices. In more severe cases a hindfoot arthrodesis may be necessary.
Saltzman: How long do total ankles last? When they fail why do they fail?
Hintermann: The question of how long the current ankles last cannot be answered with certainty. Based on most recent reports, a 10-year survivorship of more than 80% is realistic. Although the outcome of ankle replacement may further improve in the future because of improved implants, more reliable instrumentation and increased experience, it may never reach a success over time similar to that after hip or knee replacement. There are several reasons for this as follows:
(1) The ankle is a part of a functional unit, and any pathology involves other joints as well, particularly the subtalar joint.
(2) Malalignment and instability of the talus within the mortise are extremely difficult to be sufficiently addressed, as, again, the neighboring joints might be involved in the pathologic process.
(3) The bone stock may be critical with respect to load resistance and vascularity.
(4) Generally younger patients present with this pathology, thus not only their life expectation but also their activity level are higher.
Probably the biggest source of failures is the use of non-anatomic implants that do not use the whole resection surface for bony support, which may lead to subsidence of component. Non-anatomical surfaces, particularly on the talar side, may provoke ligament stress and thereby intrinsic forces that increase the shear forces at the bone-implant interface, particularly if malalignment has not been properly corrected, and/or if implants, particularly on talar side, have not been properly implanted. The created intrinsic forces may to lead component loosening and polyethylene wear. A final concern in total ankle arthroplasty is the vascularity of the talus below the inserted component over time, particularly in post-traumatic cases were some osteonecrosis may have occurred before component insertion.
Painful post-traumatic osteoarthritis 19 years after an ankle fracture with progressive anterior extrusion of the talus (female, 45 years old) (A-B). While performing ankle replacement, attention was paid to restore the center of rotation of talus, thereby balancing the ligaments in the sagittal plane (C-D, intraoperative view). Minimal bone resection was necessary (E) to insert the implants and tension the ligaments (F).
Bonnin: The survival rate of TAR with long follow-up is variable in the different series of the literature. H. Kitaoka with the Mayo Clinic cemented cylindrical TAR reported 64% at nine years. Kofoed with a cemented STAR reported 72% to 75% at nine years and Wood with a non-cemented STAR reported 88% at 3.8 years. For Kofoed the use of noncemented components improved the longevity and Wood emphasized the improvement due to dual coatings of Ti and calcium phosphate.
In terms of survival rate, the results of the Salto prosthesis seems slightly better than those reported for other three components with a survival rate at last review of 95% to 98%. However, the first implantation was done in January 1997 and we need longer-term evaluation.
Failures in TAR leading to revision can be due to loosening, instability, poly wear or residual pain.
Coughlin: A total ankle may fail for a number of reasons. If it is malaligned at surgery this is probably the most common cause of failure. When it is appropriately aligned it may fail due to subsidence or loosening of the components either at the tibial component interface or the talar component interface. The polyethylene may have early wear. A major concern in my mind is the possibility of polyethylene wear as we have seen in more proximal total joints. A total ankle's longevity is variable. In a more sedentary older patient, I believe that the longevity is decidedly better than in a younger, heavier, more active patient. That is why a frank discussion about the pros and cons of ankle arthroplasty is most important prior to surgery.
Myerson: I can only base this on my own limited experience of eight years of implantation, and that which has been reported in the literature. This is a common question posed by patients but is difficult to answer. Furthermore, I explain to patients that this is the wrong question to ask, since the longevity of the implant does not correlate with the perceived success, nor their satisfaction with the joint replacement.
There seem to be two phases by which one can determine the success of the surgery: the initial year when the position and alignment of the implant, and syndesmosis arthrodesis are important. Early failure occurs commonly when associated with deformity of the foot, which has not been adequately corrected. The later success is determined by the absence of osteophyte formation and subsidence.
Saltzman: Is it easy to convert a failed TAR to a fusion or revision replacement?
Giannini: It is definitely not difficult to convert failed replacement to a fusion, particularly in a few of the current designs, and revision replacement is very rare at the ankle. In the former case, the leg shortening needs to be discussed with the patient. In the latter case, bone allografts are essential and longer immobilization is necessary (four to six weeks). The bone stock maintenance, with technical difficulties and use of bone graft, revision replacement can also be considered. Revision replacement with proximal fixation stems should be considered.
Bonnin: The conversion of a TAR into fusion can be difficult if the design required major bone resections, if it was cemented or in case of migration of the components with osteolysis. In these difficult cases revision is a challenging technical problem requiring a pantalar arthrodesis. The use of a calcaneo-tibial intramedullary nail or external fixator can be a salvage solution, used in association with massive bone grafting.
Fusion is easier if it was a "third generation" TAR revised before any migration or osteolysis. In these cases, the gap created by the prosthesis is simply filled with iliac crest bone graft and fixation with screws respecting the subtalar joint is generally possible. Fusion is then easy to obtain.
Revision TAR with TAR is an unusual procedure. In my experience it is limited to simple cases such as changing an oversized component or exchanging a mobile component. In case of loosening, instability or osteolysis I prefer revising with fusion.
Coughlin: It is not as difficult as one thinks. Both the Agility and STAR ankle can often be successfully salvaged with a fusion. Likewise many times a failed ankle arthroplasty can be salvaged with a thicker polyethylene component or a revision of either the talar or the tibial components or both.
Myerson: Conversion of a failed replacement to an arthrodesis is a difficult surgery to perform but can be performed without inclusion of the subtalar joint. With the availability of intramedullary fixation for arthrodesis of the tibiotalar and subtalar joints, too many are performed with unnecessary inclusion of the subtalar joint. Arthrodesis must be performed with a structural bone graft, bone stimulation and rigid fixation. Revision ankle replacement is a frustrating and difficult endeavor. The same principles of joint replacement apply to the revision as to the primary procedure, but due to bone loss, instability and deformity, are more daunting procedures.
Dr. Bonnin has a financial interest in a product mentioned in this round table.
Anderson T, Montgomery F, Carlsson A. Uncemented S.T.A.R. total ankle prosthesis. Three to eight-year follow-up of fifty-one consecutive ankles. J Bone Joint Surg Am . 2003;85:1321-1329.
Bonnin M, Judet T, Colombier JA, et al. Mid-term results of the Salto Total Ankle Prosthesis. Clin Orthop . 2000.
Hintermann B. (2005) Total ankle replacement . Springer Vienna.
Hintermann B, Valderrabano V, Dereymaeker G, Dick W: The HINTEGRA Ankle. Rational and short-term results of 122 consecutive ankles. Clin Orthop . 2003.
Kofoed H. Cylindrical cemented ankle arthroplasty: a prospective series with long-term follow-up. Foot Ankle Int . 1995;16:474-479.
Kofoed H, Sorensen TS. Ankle arthroplasty for rheumatoid arthritis and osteoarthritis: prospective long-term study of cemented replacements. J Bone Joint Surg Br . 1998;80:328-332.
Valderrabano V, Hintermann B, Nigg BM, et al. Kinematic changes after fusion and total replacement of the ankle: part 1: range of motion. Foot Ankle Int . 2003;24:881-887.
Valderrabano V, Hintermann B, Nigg BM, Stefanyshyn D, Stergiou P. Kinematic changes after fusion and total replacement of the ankle: part 2: movement transfer. Foot Ankle Int . 2003;24:888-896.
Valderrabano V, Hintermann B, Nigg BM, Stefanyshyn D, Stergiou P. Kinematic changes after fusion and total replacement of the ankle: part 3: talar movement. Foot Ankle Int . 2003;24:897-900.
Valderrabano V, Hintermann B, Dick W. Scandinavian total ankle replacement: a 3.7 year average follow-up of 65 patients. Clin Orthop . In press.
Wood PL, Deakin S. Total ankle replacement. The results in 200 ankles. J Bone Joint Surg Br . 2003;85:334-341.

redpajama_set_name: RedPajamaCommonCrawl


Spicy octopus doesn't tend to be an everyday meal but sometimes you just hanker to present a entree that isn't at all obvious. After all, who doesn't want to break up the monotony of the nighttime dining ritual by coming up with a seafood dish that is out of the ordinary, to say the least?
So, roll up your sleeves and bring on your ingenuity to create what will be a meal to remember by following the explicit directions of chef David Maclellan of James Republic to make his grilled spicy octopus, served with roasted cauliflower and Meyer lemon confit.
2 smashed cloves of garlic.
Heavily salt the octopus for 12 to 16 hours. Rinse under cold water. In a 2 quart pot 3/4 full of water add the onions, carrots, celery, garlic, thyme, coriander seeds, bay leaves, white wine and add the octopus. Bring to a boil and then turn down to a gentle simmer and cook for about 1 hour or until tender.
Remove from the water. Add to the marinade for 24 hours, then season with s&p and char on the grill, then dice into ½ inch pieces.
1 head of white cauliflower (trimmed to small florets, save the remainder for puree).
½ C castel ventrano olives.
½ C. rinsed watercress leaves.
½ C extra virgin Olive oil.
1 bunch of Italian flat leaf parsley (chiffonade).
Toss the cauliflower with the olive oil and salt and pepper, and roast in a 400 degree oven for 8 minutes. Take the left over cauliflower stem, and sauté with the shallots and 1 tbl of the butter, then add thyme. When the cauliflower is tender add the cream, bring to a boil. Place the cauliflower mixture in a blender, puree until smooth, while blending add the remaining butter, season with s&p and reserve.
Slice the lemon 1/16th of an inch thick. In a sauce pot, bring the remaining ingredients up to a boil, simmer for 3 minutes and poor over the slices of lemon, let sit for 2 hours.
After all that prep (and worth every minute) serve this spicy octopus dish in a warm pan with the marcona almonds, olives, roasted cauliflower, diced octopus, chopped Meyer lemon, watercress, and chiffonade of parsley added. Toss the mixture and season with salt and pepper, then spoon some cauliflower puree before scooping the octopus mixture on top.


text:
William R. Stewart
Soul Urge (Heart Desire) Number 7
Soul Urge #7
William R. Stewart is a male celebrity.
He was born on Saturday October 29th 1864, in Unknown.
William R. Stewart loves knowledge, study, and insight. He values the gifts of his mind, which he uses to great advantage to penetrate the mysteries of life. William studies things in-depth. He searches beneath the surface of things, and abhors shallow judgments or opinions.
Stewart has a natural gift for analysis and research. Once William R. Stewart has grasped the facts of a subject, his creativity and abstract approach lifts his thinking beyond the rudimentary to the philosophical. William has a theoretical mind, but rather than indulge in fantasies or idle thought, he prefers to base his theories upon scientific facts.
He enjoys mental and physical puzzles - figuring them out, taking them apart, and putting them back together.
Some people may perceive William as cool or aloof. He is somewhat introverted; Stewart may feel slightly removed and even a little different. The fantasy of the hermit or monk engaged in a life of study and meditation appeals to him.
In relationships, William R. Stewart tends to keep things business-like and impersonal. He prefers to talk about the facts of a given situation, rather than the cloudier issues of emotions and personal feelings. William distrusts feelings - both his own and those of others. The whole emotional realm strikes him as unreliable, and a bit unnecessary.
William R. Stewart's inability to fully understand the emotional aspect of life is his Achilles heel. William is so rational that the unpredictability of the heart frightens and surprises him.
His challenge is to trust. William R. Stewart needs to share his heart with someone. This is a courageous step for him, but one that results in enormous growth and satisfaction.
The advice here to Stewart is to make a true connection with another human being. Without it, William may marry out of convenience or to fulfill social expectations, but it will not lead him out of loneliness. The more removed he is from people, the more William R. Stewart risks isolation, bitterness, and a cynical attitude toward life.
This choice represents a true crossroads in William's development. By sharing himself with others (without compromising his independence and need for privacy) William can cultivate his enormous charm and share his understanding of life. William R. Stewart is a natural teacher and advisor. And the wealth of knowledge he will accumulate in life is meant to be shared with others.
This is not to say that Stewart must compromise on his need for privacy or time spent alone to contemplate life. These are natural aspects of Stewart's personality, which are essential to his growth. These characteristics should not be threatening to William's spouse, but must be understood as fundamental to his being.
William R. Stewart is blessed with a great reserve of intuition, which can be cultivated by regular meditation and contemplation. His "inner voice" is his greatest guide and friend.
William is idealistic and has high expectations for himself. Stewart must learn to balance his serious nature with regular doses of fun.
His intelligence and cultivation make William R. Stewart charming and distinguished in appearance. As he gets older and more comfortable with his identity, people are naturally attracted to him. They see William's wisdom, his deep understanding of life, and the refinement Stewart radiates.
You and William
About William's Soul Urge (Heart's Desire) number
William R. Stewart's Soul Urge number represents his inner self. The Soul Urge number, also called Heart's Desire, shows William's underlying urge - his true motivation.
It reveals the general intention behind many of Stewart's actions. Consequently, it dramatically influences the choices William R. Stewart makes in life.
Read more about our interpretation of William R. Stewart's soul urge (heart's desire) number . . .
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William R. Stewart Numerology -- Soul Urge (Heart's Desire) Number 7 | © Copyright 2009-2020 Celebrities Galore and Master Numerologist Hans Decoz