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Arthroereisis (also referred to as arthrosis) is the limitation of excessive movement across a joint. Subtalar arthroereisis (STA) or extraosseous talotarsal stabilization (EOTTS) is designed to correct the excessive talar displacement and calcaneal eversion by placing an implant in the sinus tarsi, a canal located between the talus and the calcaneus.
Flexible flatfoot is a common disorder, anatomically described as excessive or abnormal pronation during weight bearing due to anterior and medial displacement of the talus. Flexible flatfoot may be congenital in nature, a result of cerebral palsy and other neuromuscular disorders, or may be acquired in adulthood due to posterior tibial tendon dysfunction, which in turn may be caused by trauma, overuse, and inflammatory disorders, among others. Symptoms include dull, aching and throbbing cramping pain, which in children may be described as growing pains. Conservative treatments include orthotics or shoe modifications. Additional symptoms include refusal to participate in athletics or walking long distances. Surgical approaches for painful flatfoot deformities include tendon transfers, osteotomy, and arthrodesis. Arthroereisis with a variety of implant designs has also been investigated.
STA has been performed for more than 50 years, with a variety of implants, designs, and compositions. The Maxwell-Brancheau Arthroereisis® (MBA) implant is the most frequently reported , although other devices such as the HyProCure®, STA-PEG® implant device and a Kalix® are also reported in the medical literature. The MBA implant is described as a reversible and easy to insert device with the additional advantage that it does not require bone cement. In children, insertion of the MBA implant is frequently offered as a stand-alone procedure, while adults often require adjunctive surgical procedures on bone and soft tissue to correct additional deformities.
Regulatory Status:
A number of implants have received marketing clearance through the U.S. Food and Drug Administration's (FDA) 510(k) pathway. For example, the HyProCure® Subtalar Implant System/Extra Osseos Fixation Device (GraMedica) received marketing clearance in 2004 (K042030, the SubFix™ arthroereisis implant (Memometal Technologies, Bruz, France) received FDA marketing clearance in 2010 (K093820) and the Arthrex ProStop Plus™ (Arthrex, Naples, FL) received marketing clearance in 2008 (K071456). The MBA implant (now owned by Integra LifeSciences Corp., Plainsboro, NJ) received FDA 510(k) marketing clearance in 1996, because it was substantially equivalent to products on the market prior to device regulation. According to the FDA summary, the primary indication for the subtalar MBA device is "as a spacer for stabilization of the subtalar joint. It is designed to block the anterior and inferior displacement of the talus, thus allowing normal subtalar joint motion but blocking excessive pronation and the resulting sequela". (1) The MBA Resorb Implant® received 510(k) marketing clearance in 2005 (K051611). This implant employs the same basic mechanical features as the predicate MBA implant, but is composed of a material (poly l-lactic acid) that is resorbed by the body. Predicate devices include the Osteomed Talar-Fit™ (K031155), Nexa Orthopedics Subtalar Peg (K032902 and K033046), Arthroereisis Implant Talus of Vilex (TOV, K041289), Instrateck (K080280), and Wright Medical Smith Sta-Peg (K792670).
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Subtalar arthroereisis (STA) using a subtalar implant or extraosseous talotarsal stabilization (EOTTS) is considered experimental, investigational and unproven for all indications.
NOTE: This policy does not address subtalar arthrodesis. See the Pricing Section for more coding information.
Policy Guidelines
Since there is no specific CPT code for subtalar arthroereisis, the following codes may be used by providers, which has been cited by the American Podiatric Medical Association, February 2010 Coding Alert:
Subtalar arthroereisis should not be coded as 28725 (subtalar arthrodesis), which describes joint fusion. Other arthrodesis or arthroscopy codes that should not be used are:
A literature search of the MedLine database, focusing on subtalar arthroereisis (STA) generally and the Maxwell-Brancheau Arthroereisis (MBA®) implant specifically, identified minimal published studies, primarily consisting of single institution case series and individual case reports. The largest case series by Nelson and colleagues, in 2004, consisted of 37 patients (67 feet) who underwent the MBA implant with an average of 18.4 months of follow up. (2) While this study reported various improvements in anatomic measurements, there were no data on improvement in symptoms.
Children with cerebral palsy and other neuromuscular disorders are another population of patients with flat feet. Vedantam and colleagues reported, in 1998, on a case series of 78 children (140 feet) with neuromuscular disease who underwent STA with an STA-PEG®. (3) The stem of this implant is placed into the calcaneus with the collar abutting the inferior surface of the lateral aspect of the talus, thus limiting motion. All but five of the children had additional procedures to balance the foot. Satisfactory results were reported in 96.4% of patients, although the contribution of the STA-PEG cannot be isolated.
In summary, data in the published medical literature is inadequate to permit scientific conclusions. One limitation of the published data is the lack of long-term outcomes, particularly important since the procedure is often performed in growing children.
2007-2008 Update
A search of the MedLine database for the period of September 2005 through July 2007 found no evidence to prompt a change in the policy statement. Several retrospective case series were published. One of these reported in 2006, significant improvements in pain and function in 78% of patients (23 patients, 28 feet) with use of a subtalar implant as a component of reconstructive foot and ankle surgery. (4) However, since results were not compared with controls receiving reconstructive surgery without STA, the contribution of the implants to these outcomes is unclear. In addition, the authors reported an overall complication rate of 46% with surgical removal of 39% of the implants due to sinus tarsi pain. The authors also commented that postoperative sinus tarsi pain was unpredictable. No prospective controlled studies were identified.
Subtalar implants are not supported by evidence in the peer-reviewed medical literature that:
2010 Update
A search of peer reviewed literature through March 2010 identified several studies and reviews regarding STA procedures and implants.
In one radiographic study of bioabsorbable STA, found poor outcomes in 3 of 6 patients met the inclusion criteria and consented to additional imaging with an average follow-up of 14 months (range, 12–50 months). (5) Two patients requested implant removal; a third had persistent pain but refused explantation. Radiographic measurement using magnetic resonance imaging (MRI) or computed tomography (CT) found that these three patients had smaller tarsal canal widths than the diameter of the inserted interference screw. The authors noted that the implant length also had to be reduced prior to implantation. They concluded that the current width and length of commercially available implants may need to be modified, and that more research and long-term clinical study are needed.
Scher and colleagues described two cases of extensive implant reaction in two children two years after STA-PEG procedures and tendo-Achilles lengthening were performed for painful flatfeet. (6) The patients had minimal subtalar motion and pain at the sinus tarsi. Radiographs demonstrated surgical defects in the calcaneus. After failure of conservative management, implants were removed with good relief of pain. The authors do not recommend arthroereisis in the treatment of painful flexible flatfoot in children.
Three case series with small numbers of patients reported outcomes of a combination of surgical interventions, in which STA was one component; thus, the contribution of the arthroereisis is not clear. In a United States study, Adelman and colleagues reported on a retrospective analysis of ten patients. (7) The authors described this as a pilot study, and they reported on changes in seven radiographic measurements. In a study from Spain, Chicchinelli et al., also reported on radiographic outcomes in a retrospective analysis of 20 pediatric patients (28 feet) treated with STA combined with gastrocnemius (muscle) recession, or with STA combined with gastrocnemius recession and medial column reconstruction. (8) The authors reported that gastrocnemius recession had a notable effect on correction of transverse plane deformity when used as an adjunct to STA; however, medial column reconstruction had a negative impact on the degree of correction in the transverse plane when used as an adjunct to STA and gastrocnemius recession. In a European study, Lucaccini et al. analyzed clinical and radiographic results of 14 patients (16 feet) with hallux valgus in abnormal pronation syndrome treated with distal osteotomy of the first metatarsal bone and STA performed in one stage. (9) These case series do not allow comparison with nonsurgical interventions or with other surgical interventions.
Conclusion: Due to the lack of new published clinical trials showing that STA is as beneficial as established alternatives, this technology is still considered experimental, investigational and unproven.
2012 Update
Periodic literature searches of the MedLine database on STA have identified minimal published studies, primarily consisting of single institution case series and individual case reports. The most recent literature update, using the MedLine database, was performed for the period of 2010 through October 2012. Following is a summary of the key literature to date.
There are no controlled trials of subtalar arthroereisis compared to alternative treatments. The evidence base consists entirely of single-arm case series that report on success rates following this procedure. Interpretation of the current case series evidence is limited by the use of adjunctive procedures in addition to STA, creating difficulties in determining the extent to which each modality contributed to the outcomes. The evidence base is also limited by the lack of long-term follow-up, which may be particularly important for a procedure performed in children.
In 2011, Metcalfe et al. published a systematic review of the literature on STA for pediatric flexible flatfoot. (10) Seventy-six case series or case reports (no controlled trials) were identified. Ten of the studies (756 feet) provided clinician-based assessment of the surgical result graded from "excellent to poor" with follow-up between 36 and 240 months. Six studies (212 feet) included estimates of overall patient satisfaction using non-validated outcome measures, while 1 study (16 feet) found significant improvement using a validated foot-specific patient outcome measure. Data from 15 studies that reported radiographic values were combined for analysis. Although 8 of 9 radiographic parameters showed statistically significant improvements following arthroereisis procedures, the relationship between radiographic and clinical outcomes is uncertain. The procedure was associated with a number of complications including sinus tarsi pain, device extrusion, and undercorrection. Complication rates ranged from 4.8% to 18.6%, with unplanned removal rates between 7.1% and 19.3% across all device types. The influence of adjunctive procedures on outcomes was not addressed in this review.
One case series that was not confounded by adjunctive procedures and that had a relatively long follow-up was published by Graham et al. in 2012. (11) This study reported mean 51-month follow-up of talotarsal stabilization in 117 feet using the HyProCure device. Patients who received adjunctive procedures affecting the talotarsal joint were excluded from the analysis. Adult patients who met the inclusion/exclusion criteria were invited to participate in the study. Eighty-three patients gave consent to participate, and 78 completed the Maryland Foot Score Questionnaire; 5 patients who had 7 implants (6%) removed did not complete the questionnaire. There were 16 revision surgeries with HyProCure; 9 involved repositioning of a partially displaced device or a change in size of the device. Of the patients who retained the device, 52% reported complete alleviation of foot pain, 69% had no limitations on their foot functional abilities, and 80% of cases reported complete satisfaction with the appearance of their feet. This case series is notable for its assessment of functional outcomes at medium-term follow-up in patients who did not have adjunct procedures.
In a 2010 study, Scharer and colleagues conducted a retrospective radiographic evaluation of 39 patients (68 feet) who had received the MBA implant for the treatment of painful pediatric flatfoot deformities. (12) The average age of the patients at the time of surgery was 12 years (range: 6-16 years). Additional procedures included 12 (18%) gastrocnemius recessions, 6 (9%) Achilles tendon lengthening, and 4 (6%) Kidner procedures. At an average 24-month follow-up (range: 6-61 months), there had been 10 (15%) complications requiring reoperation, including implant migration, undercorrection, overcorrection, and persistent pain. The implants were exchanged for either a larger or smaller implant. These case series do not allow comparison with nonsurgical interventions or with other surgical interventions.
An example of a case series with longer follow-up is a 2012 retrospective study by Brancheau et al., which reported mean 36-month follow-up (range 18 to 48 months) in 35 patients (60 feet) after use of the MBA implant with adjunct procedures. (13) The mean age of the patients was 14.3 years (range, 5 to 46 years). Significant changes were observed in radiographic measures (talocalcaneal angle, calcaneocuboid angle, first to second intermetatarsal angle, calcaneal inclination angle, and talar declination angle). Seventeen percent of patients reported that 9 implants (15%) were removed after the initial surgery. Of the 24 patients (68.6%) who answered a subjective questionnaire (in person or by telephone at a mean of 33 months postoperatively), 95.8% reported resolution of the chief presenting complaint, and 79.2% said they were 100% satisfied with their surgical outcome. The contribution of the MBA implant to these results cannot be determined by this study design.
Cook et al. conducted a retrospective case-control study to identify factors that may contribute to failure (explantation) of titanium arthroereisis implants. (14) All patients who required removal of a self-locking wedge-type subtalar arthroereisis (n=22) were compared in a 1:2 ratio (n=44) to patients with non-explanted arthroereisis who were treated during the same time period. Subjects were matched for preoperative radiographic measurements, age, gender, presenting diagnosis, and length of follow-up. Multivariate logistic regression showed no significant effect of age, gender, implant size, shape, and length of follow-up, implant position, surgeon experience, or concomitant procedures. Patients who required explantation had slightly greater odds of radiographic undercorrection (odds ratio [OR]: 1.175) or residual transverse plane-dominant deformities (OR: 1.096). The percentage of explantations in this retrospective analysis was not described.
Practice Guidelines and Position Statements
2009 Guidance from the United Kingdom's National Institute for Clinical Excellence (NICE) concluded that current evidence on the safety and efficacy of sinus tarsi implant insertion for mobile flatfoot is inadequate in quality and quantity. (15) Therefore this procedure should only be used with special arrangements for clinical governance, consent and audit, or research.
The American College of Foot and Ankle Surgeons (ACFAS) published practice guidelines for the diagnosis and treatment of adult and pediatric flatfoot in 2004 and 2005. (16, 17)
The ACFAS guideline on adult flatfoot states: "In the adult, arthroereisis is seldom implemented as an isolated procedure. Because of the long-term compensation and adaptation of the foot and adjunctive structures for flatfoot function, other ancillary procedures are usually used for appropriate stabilization. Long-term results of arthroereisis in the adult flexible flatfoot patient have not been established. Some surgeons advise against the subtalar arthroereisis procedure because of the risks associated with implantation of a foreign material, the potential need for further surgery to remove the implant, and the limited capacity of the implant to stabilize the medial column sag directly."
The ACFAS guideline on pediatric flatfoot states: "proponents of this procedure (arthroereisis) argue that it is a minimally invasive technique that does not distort the normal anatomy of the foot. Others have expressed concern about placing a permanent foreign body into a mobile segment of a child's foot. The indication for this procedure remains controversial in the surgical community."
The evidence in the published medical literature on STA is inadequate to permit scientific conclusions. The main limitation is the lack of controlled studies comparing use of the implants with other surgical procedures, alone or in combination. Other limitations of the published data is the lack of long-term outcomes, particularly important since the procedure is often performed in growing children, and the difficulty in separating the effect of this procedure from that of other adjunctive treatments. Therefore, STA is considered experimental, investigational and unproven.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member's benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.


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The sophisticated 12-ounce Konitz Café Latte Writing Mug lets you enjoy your favorite beverages in style. The words "Café Latte" appear throughout the body of the mug in a variety of font sizes. Choose from white text on a black background or black text on a white background. The Konitz Caffe Latte Mug is made of porcelain. For your convenience, it is dishwasher and microwave safe.
No reviews have been written for this product.

subset: commoncrawl


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nedinjapan's past comments
The movie Pearl harbor had a good reflection on Tokyo bombings, I think : http://www.imdb.com/title/tt0213149/?ref=nvsr_1
Posted in: Japan mourns victims of Tokyo firebombings
In my case, police followed me using my cellphone because my ex complained that I may have an affair. It was not even a criminal case. Police wearing plain clothes followed me on more than two occasions, at least. One was wearing sports clothes and pretending he was running. Another was sitting on the way checking on me. This is all done secretly all the time. Later when I got a girlfriend who brother was a police, she told me her brother would check her location using her cellphone if she was not home and at work. Unless a lawyer raises it, this is simply common activity and even has a name ...
Posted in: Use of GPS to track suspect ruled legal by Osaka court
@ReformedBasher The issue is not about bashing Japan but correcting its tarnished image by a group of rightist politicians whose vans broadcast hate speech openly in public. I am not Japanese neither Korean but my respect for Japan where I live helps me understand that Denials are destructive to the image of Japan. I wish Japan could get the respect of the international community the way Germany did, not through denial. Also remember most of the victims were from Korea and Japan left quite a different legacy in the two countries you are comparing.
Posted in: Japan shrugs off S Korean calls for 'sex slave' apology
If you have any doubts about Comfort Women, or are not educated on the issue, just do a Kensaku (search) in Youtube. Watch for example, https://www.youtube.com/watch?v=5yHHfYOGumI
https://www.youtube.com/watch?v=Mard9WrYn2I Words cannot describe the gravity of these crimes, and its denial is simply ridiculous. Can they ever "Grow Up"?
Posted in: Japan shrugs off S Korean calls for 'sex slave' apology
Fortunately with the age of information we live in, all the world can see and will see the documents of crimes committed by Japan in WWII forever. Comfort Women is just one of these. There are many others including the atrocities of Unit 731 cutting open people without anesthesia like in the horror movies. The barbaric acts of Japanese Imperial army will never be forgiven, as long as they are in denial and do not have the courage to accept their crimes and honestly apologize. May God judge you for raping all these women, a figure in hundred thousand or more ...
Posted in: Japan shrugs off S Korean calls for 'sex slave' apology
Just compare it with the situation of North Korea's kidnapping of 13 Japanese which will continue forever with the Japanese commenting like: Yurusenai! (can never be forgiven!) Well, Japan, your grandfathers including the grandfather of your prime minister, a War Criminal, have committed Yurusenai crimes in Korea, and this will continue. So get used to it!
Posted in: Japan shrugs off S Korean calls for 'sex slave' apology
Let me explain how he could do it. Most Japanese people cannot say no asseryively! So if someone tries hard enough and insists for a long time, he can almost always win. A few Japanese men have told me how they pick up a girl and insist and finally take her to hotel any evening they want to. They say it is enough to insist and refuse any excuse the woman makes. This guy used a sleeping pill only because he wanted to film them too. He could have insisted it was for a film audition! Probably because of his age he needed to drug them.
Posted in: Man arrested for drugging, raping over 100 women in fake clinical study
To avoid incidents like this, they need to Separate Road traffic watch from (criminal) Police force. I know some countries have already done that. Now, there is so much confusion in both the police force and people regarding some little traffic violations. People are so much scared of being treated as a criminal for this traffic violations, while some police treat ordinary people like criminals for not wearing a helmet. Even the police siren could make these young kids scare and response in an agitated way. Blame the system not the kids or the system abiding police.
Posted in: Two 15-year-old girls on minibike crash after police chase; one dead
She could have avoided all this if she had printed a disclaimer on the Kayak saying" Ime-ji desu" :-) They commonly use this disclaimer who tell people that a drwan picture is an image (whatever that means ...)!
Poor Japanese companies like Canon that have lost their China market because of this nonsense political moves. The root of all this is a deep sense of inferiority that causes them to over compensate. I have heard that Abe had a shrink to help him get over his mental breakdown. i wish the guy could also treat his deep rooted sense of loss and defeat that he is trying to compensate by honoring criminals.
Posted in: New internal affairs minister says she will visit Yasukuni Shrine
Oh, on another post I was just talking about the police perverts in Japan. Remmeber only a small percentage is ever reported and even a much smaller portin gets into media. You have a systematic problem with your police and it is better to accept it, JJ.
Posted in: Osaka police sergeant arrested for putting smartphone between woman's legs on train
Disillusioned, I agree with half of what you are saying but not the other half! With so many pervert police in Japan, people may be right to panick when they know police has has excuse to press on them hard. However, if as you say, police do that more frequently, I guess only the pervy cases will fly up the roof, not that people will not get used to them though :-)
There was a Japanese woman I had some relationship but it did not last. She was still emotionally suffering from her dad's suicide after his business went bankrupt when she was a tenager. She said yakuza came after her and made her work for years to pay for the debts her father had caused. In this case, I think suicide was not a courageous act.
Posted in: In some countries, including Japan, suicide is seen as a means to atone for a scandal or wrongdoing. What are your views on this?
Mercury at levels lower than what may cause death, damages the nervous system. Lower levels of intelligence and other intellectual problems, even personality disorders, could be more common among a population with higher mercury levels in their blood.
Article Unavailable
The title of this news is misleading. She is not taking the town to court, but a business, a museum. Apparently, they are very defensive and are afraid of being negatively presented so they overreact and this is a good chance for the activists to used law against them. I hope the court decision will show that rule of law still exists in Japan and you need to be tolerant of different views. It is sad to see many comments here are against spirit of democracy.
Posted in: Australian activist takes dolphin slaughter town to court
We should especially be grateful to American soldiers who lot their lives to save the world from a ruthless imperial power. The Japanese civilians were victims to the imperial system.
Posted in: Okinawa marks 69th anniversary of bloody World War II battle
I was only using some sarcastic fun to poke at this news. But don't you see? A big part of the Kawaii culture revolves around eroticizing childish looks. Pretty disgusting but true!
Posted in: Japan to ban possession of child porn, but manga, anime exempt
I think Japan should not accept to back on this even for an inch! They can take their case to the International Court of Justice and argue that child eroticism is part of Japanese culture and other countries should try to understand and respect that!
Posted in: Japan to ban possession of child porn, but manga, anime exempt
I have a comprise solution for Japan versus, Korea, China, ... Demolish the atomic bomb museums and forget Japan was ever bombed, and other countries in the region will forget your crimes. Stop crying over the atomic bomb victims and holding memorials for the two cities. We are tired of that already.... How does that work for you, Japan?
Posted in: 6 former 'comfort women' demand apology from Japan
Everybody knows what is happening at police stations and they still play this "game" of no, it is the costs, or criminals are too shy to confess in front of a camera ... Have you noticed that so many people in Japan act like they do not know what is happening, like they are stupid or something? This is a social value!
Posted in: Police may film interrogations under new proposals


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10 Adorable Cat Tats I Really Want
I've never really been a tattoo person. Sure I have a tiny heart on my hip that I got when I was 18, but I'm not exactly a regular at the tattoo parlor.
Recently, however, my cat of 16 years passed away, and I've become set on getting something to remember her by (as if I need to be reminded). When I read JaneA Kelley's article about channeling her grief for her dead cat into a piece of body art, I started considered getting a cat tattoo of my own. JaneA's is a little large for my taste (plus I don't think I have the pain threshold for such a large tattoo), so I started searching for a smaller version suited to my own personal style.
Surprisingly, there are a ton of cat tattoo options out there now. Long gone are the days of Tweetie Bird and Garfield cartoons. Instead, there are chic, artful tats perfect for me. Here are some of my favorites:
1. On the neck
The thought of inking the name of my significant other has never crossed my mind. Instead, I prefer to honor the relationship that really matters: the one I have with my cat. The cat in this photo may not agree with me, but I think this small outline is adorable and perfect for a first cat tattoo.
2. Two wrists, two cats
As the parent of multiple cats, I love that this tattoo honors both cats, instead of just one. Plus, look how much detail is in it!
3. Simple (homemade?)
If you don't want to sit through hours of someone drawing every last detail of your cats' faces, then these cartoonish outlines are the way to go.
4. What's that behind your ear?
This itty bitty solid tattoo is perfect for representing Pip, my black cat. Plus, it's a great place to put your tattoo if you don't want everyone to see it.
5. Say it like it is
If you don't want a picture of your cat, this three-letter tattoo will still get the point across. (The model in this photo also has the word "Meow" tattooed on the inside of her lower lip -- ouch!)
6. She wouldn't hold still posing
Even a partial outline of a cat is still adorable. Not sure about the placement, though. I don't really want to have to take off my shirt for people to see my ink.
7. You'll just feel a scratch
It wasn't until recently that I ever considered getting a tattoo. I was shopping in Petco when I saw the most gorgeous cat tattoo on someone's arm. This one might be a little painful, but worth it.
8. Your real cat might get jealous ...
I've never really consider leg tattoos before, but if I did, it would be this pair of cat faces. Also, it would be a nice distraction from any cellulite or varicose veins.
9. Who's hungry?
Cat tattoos don't have to be so serious. This one is hilarious.
10. Instant cat
And this one I NEED. What kind of crazy cat lady would I be without one?
The downside to getting a cat tattoo is I hear they are addictive. I currently have three cats, so what do I do to honor them when they inevitably pass (hate to even think about that)? At that rate, I could very well end up with a sleeve of cat tattoos. I also worry about what kind of repercussions it could have on my life. What if I were to end up at a job interview with a (gasp!) dog person. Plus, sometimes us cat ladies need to keep our true identities hidden from the rest of the world, since it's hard for non-cat-lovers to understand our fascination.
Do you have a cat tattoo? Do you still love it? Send me photos to feed my new obsession!
Read more about cat tattoos:


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Click on a thumbnail to go to Google Books.
War and Peace (1868)
by Léon Tolstoï
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I can't take any more of this overambitious crap. With more than 50 hours remaining on the audio book, I'm just going to cut my losses.
I'm never reading this book in 3 1/2 days again. If you want the easy time of it watch the film with Audrey Hepburn then read the last 100-150 pages of the book.
Very slowly reading this, I'm about 35% in. I only read my kindle on public transport which is why it's taking so long. This modern translation is much better than the Constance Garnett, I can fathom who is who and the dialogue reads more smoothly.
This one I also "read" long ago. Actually it was read to me by Alexander Scourby on long-playing records in 1969 because I was able to get "books for the blind" at the time. I still hear the prose in his deep, resonant voice. I was a big fan of Russian literature at the time, and this has never ceased. I was especially glad to counteract the Dostoyevskian Christianity I had been taught with Tolstoy's idea that the kingdom of God is within you.
Writing an original, cogent and halfway-intelligent review of War and Peace in English is as daunting a task as reading Tolstoy's opus magnum to begin with. Why, then, would I risk making a mockery of myself by awarding it only three stars? I'll explain, and thereby attempt to justify this near condemnation of a world-renowned work — a work, by the way, which Tolstoy himself says (in the Appendix) is not a novel, but which critics and the reading public in general call just that. And so, rather than skirt controversy on this minor point, I will, too.
Although I'd hesitate to call Tolstoy a stylist, there are (in over 1,200 pages of relatively small print) a number of instances in which he goes out on a literary limb. One such is on p. 524:
"Nikolai set out after the first troika; behind him the rest came rattling and screeching. At first they went at a slow trot along the narrow road. As they drove past the garden, shadows from the bare trees often lay across the road and obscured the bright light of the moon, but as soon as they drove beyond the fence, a plain of snow, sparkling like diamonds, with a dove-blue sheen, bathed in moonlight and motionless, opened out on all sides. Once, twice the front sleigh jolted over a bump; the next sleigh jolted in the same way, then the next, and, boldly breaking the frost-bound stillness, the sleighs strung out one after the other."
While I realize that being in the least bit critical of Leo Tolstoy's prose borders on iconoclasm, I nevertheless have to pose the question: am I the only reader in Christendom who looks at this and wonders about certain punctuation, not to mention about the possibility of a run-on sentence or two in this otherwise lyrical passage — so atypical of Tolstoy both in War and Peace and in Anna Karenina (the only other work of his I've read and reviewed both here and at Amazon)?
I give full credit, by the way, for an accurate translation (and transcription) of this work to Richard Pevear and Larissa Volokhonsky. I believe that they — much to their credit — would not have corrected any of Tolstoy's prose. And so, I can only conclude that Tolstoy himself is to blame for any weakness or sloppiness in his work. When I was a student of Russian language and literature at Columbia a few decades ago, Constance Garnett was considered the reigning queen in matters of English-language translations of the Russian classics. To me at the time, her work frequently read like that of a testosterone-spiked teenager out for a drunken spin on a Friday night. Not so with Pevear and Volokhonsky, who are studied and meticulous in their translation both of this work and of others I've read in the past.
Tolstoy is a first-rate story-teller, make no mistake about it. And he paints a rather deplorable picture of both the Russian aristocracy of the time and of the singularly solipsistic, narcissistic and megalomaniac Napoleón Bonaparte in particular. But he's simply sloppy in his prose, a fair portion of which is just not the handiwork of a brilliant and careful writer (e.g., Gustave Flaubert).
While I don't know that his generalized observations about the character and comportment of several European nationalities is a mark of genius, I did find his descriptions of Germans, Frenchmen, Englishmen, Italians and Russians (on p. 639) to be amusing, entertaining and — let's be frank — damned accurate!
All of the above notwithstanding, I'll give you that there are several passages in the novel (unfortunately, too lengthy to cite here in their entirety, but I'll quote the first and last sentences of each) that are particularly well-crafted and that I'd describe as quintessentially Tolstoy. The first begins at the bottom of p. 605 and concludes at the bottom of p. 606.
"Kings are the slaves of history … Their every action, which to them seems willed by themselves, in the historical sense is not willed, but happens in connection with the whole course of history and has been destined from before all ages."
A second comprises the entirety of Volume III, Part 2, Chapter 1 (pp. 682 – 682).
"Napoleon started the war with Russia because he could not help going to Dresden, could not help getting befuddled with honors, could not help putting on a Polish uniform, yielding to the heartening impression of a June morning, could not refrain from outbursts of anger in the presence of Kurakin and then of Balashov…Napoleon goes further, we retreat, and the very thing is achieved that was to defeat Napoleon."
A third (Vol. III, Part 2, XXVII) begins on p. 783 and ends on p. 785: "Many historians say that the battle of Borodino…fulfilled his [Napoleon's] role of seeming to command."
A fourth (Vol. III, Part 3, I) begins on p. 821 and finishes up on p. 823: "For human reason, absolute continuity…their reflections on the occasion of those deeds."
And then we have the Epilogue to War and Peace in which Tolstoy waxes quite philosophical (in Part 1, I-IV and the entire Part 2, which offers a lengthy monograph on freedom versus necessity) when he's not sounding downright balzacien (Part 1, V-XVI).
Prior to a most admirable Epilogue, however, we get the laconically poetic passage Pevear cites in his Introduction: "…drops dripped…whistled the saber, and again the horses scuffled and neighed…" (p. 1,055). Having once wrestled with my own metrical translation of Sergei Yesenin's poem, "A Letter to My Mother" for inclusion in my novel, Trompe-l'oeil, I can certainly appreciate not only Tolstoy's alliterative skill, but also Pevear's equally alliterative and artful translation.
But what of Tolstoy's — overwrought, in my opinion — metaphor on pp. 874-875, in which he compares the desertion of Moscow (just before the French invasion) with an abandoned beehive? Where was his writer's nose at that point?
These examples show not only the genius of the work, and of the man, but also its — and his — shortcomings. I just don't believe he was as good a writer (or at least an editor) as he was a thinker. After all, every writer has the opportunity to edit and polish his own work, and no one's pointing a gun at him to get on with the process.
And so, given what we know about Tolstoy's later years, I think the Latin citation (in footnote #9, on p. 1,237) is most appropriate — and herewith, I'll end my review except for one little piece of advice to you, a potential reader of War and Peace:
"Quos Deus vult perdere, prius dementat." *
And the advice? Do not try to read this book on the subway! One or the other will find you dead on the tracks.
Brooklyn, NY
[b:Trompe-l'oeil|10844205|Trompe-l'oeil|Russell Bittner|https://d202m5krfqbpi5.cloudfront.net/books/1327873786s/10844205.jpg|15758639]
* "Those whom God wants to destroy, he first drives mad."
[Note: This review refers mainly to the Pevear-Volokhonsky translation in comparison to other translations.]
The Russian language is the real hero of Tolstoy's masterpiece; it is his voice of truth. The English-speaking world is indebted to these two magnificent translators, Richard Pevear and Larissa Volokhonsky, for revealing more of its hidden riches than any who have tried to translate the book before.
Is contained in
The Works of Leo Tolstoi by Leo Tolstoi
Britannica Great Books 54 Volume Set by Robert Maynard Hutchins
I capolavori: Anna Karenina - Guerra e pace - La morte di Ivan Il'ič - Resurrezione - La sonata a Kreutzer e altri racconti by Lev Tolstoj
Die Romane Band I-X (Anna Karenina/ Krieg und Frieden/ Auferstehung) by Leo N. Tolstoi
War and Peace (1/2) by Leo Tolstoy
War and Peace (2/2) by Leo Tolstoy
War and Peace (1/3) by Leo Tolstoy
War and Peace (2/3) by Leo Tolstoy
War and Peace (3/3) by Leo Tolstoy
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Wikipedia in English (14)
Amazon.com Product Description (ISBN 0307266931, Hardcover)From Richard Pevear and Larissa Volokhonsky, the best-selling, award-winning translators of Anna Karenina and The Brothers Karamazov, comes a brilliant, engaging, and eminently readable translation of Leo Tolstoy's master epic.
War and Peace centers broadly on Napoleon's invasion of Russia in 1812 and follows three of the best-known characters in literature: Pierre Bezukhov, the illegitimate son of a count who is fighting for his inheritance and yearning for spiritual fulfillment; Prince Andrei Bolkonsky, who leaves behind his family to fight in the war against Napoleon; and Natasha Rostov, the beautiful young daughter of a nobleman, who intrigues both men. As Napoleon's army invades, Tolstoy vividly follows characters from diverse backgrounds—peasants and nobility, civilians and soldiers—as they struggle with the problems unique to their era, their history, and their culture. And as the novel progresses, these characters transcend their specificity, becoming some of the most moving—and human—figures in world literature.
Pevear and Volokhonsky have brought us this classic novel in a translation remarkable for its fidelity to Tolstoy's style and cadence and for its energetic, accessible prose. With stunning grace and precision, this new version of War and Peace is set to become the definitive English edition.
(retrieved from Amazon Mon, 30 Sep 2013 13:24:30 -0400)
From Pevear and Volokhonsky, the bestselling, award-winning translators of "Anna Karenina" and "The Brothers Karamazov," comes a brilliant, engaging, and eminently readable translation of Tolstoy's master epic.
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The Starkville Academy Volunteers get to experience two treats when it comes to golf this week.
The Class 5A North State track and field championship wasn't settled until the last lap around the track when Jalan Catledge found his stride helping the Starkville Yellowjackets take the title.
It was an end of an era Saturday afternoon as the baseball coaching career of Danny Carlisle with the Starkville Yellowjackets came to a close.
The words of Bo Bell from Tuesday night keep coming back to my mind.
"There will never be another Danny Carlisle."
MABEN – The East Webster Lady Wolverines showed that Lesley Hudson was hittable.
Being comfortable and familiar with your surroundings helps out in any sport.
NEW HOPE – In a game where a pitching clinic was put on, one swing of the bat provided the fireworks.
The Starkville Academy baseball team got back to what it does best.
It can be found all over the third round of the Mississippi High School Activities Association Class 5A baseball series.
Three weeks ago Mississippi State basketball was dealt a significant blow when freshman Rodney Hood announced he would request his release in an effort to find a new home to play his college basketbal


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Zak Billmeier grew up in southern Vermont and coastal Maine. After graduating from Mary Washington College with a Geography degree he still isn't sure quite what to do with, he eventually settled in the mountains of Central Virginia. He spends his free time chasing his daughter around, taking pictures, gardening and cooking. Zak traces the roots of his interest in electronic gadgets to the Casio wristwatch with a built-in calculator he received as a gift one year as a child. He joined Crutchfield's car A/V team in 2007.
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Pioneer's advanced app mode gives you touchscreen control over select apps in certain Pioneer A/V receivers. It puts the apps right where they're most useful—in your dash on your receiver's big screen. It's a great way to add functionality like navigation, Internet radio, and traffic updates, all from your iPhone®.
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Ormet Reducing Operations at Burnside Refinery COMPANY CONTINUES TO EXPLORE STRATEGIC ALTERNATIVES Business Wire HANNIBAL, Ohio -- September 11, 2012 Ormet Corporation ("Ormet") announced today it is issuing WARN notices to 250 employees at its Burnside, Louisiana alumina refinery primarily due to the already reduced operating level at Ormet's Hannibal, Ohio aluminum smelting operation. The Company continues to actively pursue alternatives with the State of Ohio and AEP to mitigate the impact on Ormet of the recent PUCO rulings in the AEP Electric Security Plan (ESP) rate case finalized on August 8, 2012. The sizable impact of this ruling and the dramatic increase of the cost of electricity in Ohio over the past several years, in addition to the current aluminum market, have forced Ormet to significantly downsize its operations while exploring strategic alternatives. "We are still hopeful that we can all find short and longer term solutions to the substantial increase in our power costs and save these jobs," said Mike Tanchuk, Ormet's CEO. Separately, Ormet also announced that it has retained Evercore Partners to assist the Company as it continues to explore strategic alternatives. ABOUT ORMET: Headquartered in Hannibal, Ohio, Ormet Corporation is a major U.S. producer of aluminum. Ormet employs approximately 1,000 people from across Monroe County, Southeastern Ohio, and parts of West Virginia. Its aluminum smelter has an annual aluminum production capacity of approximately 271,000 metric tons. Ormet also operates an alumina refinery in Burnside, Louisiana producing approximately 540,000 metric tons of alumina which is a primary raw material in the production of aluminum. The Burnside refinery employs approximately 250 people. For more information, visit Ormet website at www.ormet.com This press release contains forward-looking statements within the meaning of the federal securities laws. Such statements are based on current expectations, and the actual results and the timing of certain events could differ materially from those projected in or contemplated by these forward-looking statements due to a number of factors. Readers are cautioned that Ormet's business is, and the forward-looking statements contained in this press release are, subject to numerous significant risks and uncertainties. These risks and uncertainties include, among others, those discussed in Ormet 15c2-11 information and disclosure statements for the year ended December 31, 2011 and the quarter ended March 31, 2012 (copies of which are available at Ormet's website at www.ormet.com), and risks associated with Ormet's ability to operate with current electricity rates and low metal prices. Contact: Ormet Corporation James B. Riley, 740-483-2602
Ormet Reducing Operations at Burnside Refinery
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A TV spot for Google's new device for streaming Web content to a TV set showcases how Chromecast can transfer life on small online screens to the living room's big screen. The 72andSunny production makes it all appear to be an enjoyable shared experience.
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Registration FAQs
2015 information will be posted soon
Scanning of Name Badges
In order to receive a letter of attendance for the conference, it is necessary to have your name badge scanned EVERY DAY while at the conference.
Confirmation of Attendance
In order to receive documentation stating that you attended FMF, you need to scan your name badge (or have a staff member scan it for you) each day that you attend FMF. All scanned registrants will receive a letter confirming attendance at FMF 2014 by January 1, 2015. Please note that these documents are not available for pickup on-site.


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Hotel La Fenière - La Bouilladisse
8 Rue Jean Pourchier - Rn 96 - La Bouilladisse1-877-662-6988
Welcome to La Fenière!
Leave room for your swimwear and towel as this hotel features an outdoor pool and a seasonal outdoor pool, a great way to unwind. This hotel has its own restaurant serving lunch and dinner where you will find a selection of items to try.
Free Wi-Fi is provided. Other amenities include a garden.
We stayed during the period between Christmas and the new year. The highly rated ...Venere Guest, USA
These reviews have been left by customers who actually stayed at this hotel
Check Availability at Hotel La Fenière
Breakfast at Hotel La Fenière
A buffet breakfast is served between 7:00 AM and 10:00 AM for a fee.
Hotel Facilities at La Fenière
- Outdoor swimming pool
- Internet/Email services
- Restaurant/Dining
- Room service - limited hour
- Garden
- Pets accepted
- Free parking
Know before you go
Check-in: between 5 PM and 8 PM.
Check-out: before noon.
Please contact the property ahead of time if you are planning to arrive after 8 PM.
PolicyExtra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
City tax and/or any other fees charged by the hotel
The following fees and deposits are charged by the property at time of service, check-in, or check-out.
- Fee for buffet breakfast: EUR 8.00 per person (approximately)
- Rollaway bed fee: EUR 10.00 per night
The above list may not be comprehensive. Fees and deposits may not include tax and are subject to change.
National ratingThis hotel has received its official star rating from the French Tourism Development Agency, ATOUT France.
La Fenière Hotel reviews
- December 2012
- Venere Guest
- Family with older children
We stayed during the period between Christmas and the new year. The highly rated restaurant was closed and other choices in town were very limited. We had no warning of this. It's well over 10 minutes from Aix, at least the way we came. Quite convenient to Cassis, which we visited the next day. Hard to find at night. We mistakenly entered a doctor's office under the sign; reception is off the street in back, and it was dark. The room was clean and comfortable. We awoke to see that the town is quite beautifully situated in the mountains.
- September 2012
- Venere Guest
- Couple
- France
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- December 2013
- Venere Guest
- Couple
- France
La Fenière Hotel reviews by TripAdvisor
Room Details
Book your pet-friendly accommodation at the 12-room La Fenière. Televisions in each room offer entertainment at the end of a long day. Business travelers will have access to free (wired) high-speed Internet access as well as desks and phones during their La Bouilladisse visit. Private bathrooms are outfitted with hair dryers and complimentary toiletries. Additional comforts include air conditioning.
Accommodation Services
- Air conditioning
- Telephone
- Hairdryer in each room
- Desk
- High speed Internet access
How to reach La Fenière HotelBy car
Autoroute A52 en venant de Lyon: prendre direction Toulon Nice, puis Toulon Aubagne: sortie 33 La Bouilladisse Pas De Trets. En venant de Toulon ou Marseille prendre direction Aix en Provence : sortie 33 La Boilladisse Pas De Trets.
Distances from Hotel La FenièreSainte-Victoire Golf - 7.5 km / 4.6 mi
Allauch-Marseille Golf - 11.5 km / 7.2 mi
Marcel Pagnol House - 11.7 km / 7.3 mi
Santons Maryse Di Landro Museum - 12 km / 7.4 mi
French Foreign Legion Museum - 12.1 km / 7.5 mi
Chateau de la Buzine - 13.3 km / 8.3 mi
Salette Golf - 13.6 km / 8.4 mi
Montagne Sainte Victoire - 15 km / 9.3 mi
University of Aix-Marseille III - 16.1 km / 10 mi
Golf de la Sainte Baume - 16.4 km / 10.2 mi
Jardins d'Albertas - 16.6 km / 10.3 mi
Le Dome - 17.7 km / 11 mi
Granet Museum - 18.3 km / 11.3 mi
Place des Quatre-Dauphins - 18.3 km / 11.4 mi
Paul Cezanne University - 18.4 km / 11.4 mi
The preferred airport for La Fenière is Marseille (MRS-Marseille - Provence) - 30.2 km / 18.8 mi.
Distances are calculated in a straight line from the property's location to the point of interest or airport and may not reflect actual travel distance.
Distances are displayed to the nearest 0.1 km and mile.
Transportation services Hotel La Fenière
- Free parking
We have the accommodation you need, all over the world
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SHELTON — A car crashed through the front window of a nail salon Tuesday, police said.
No one was injured in the accident, which happened about 2:30 p.m. at Modern Nails, 10 Huntington Plaza.
The driver, Elaine McPadden, 82, of Shelton told officers she was pulling into a parking spot when her foot slipped off the brake pedal and hit the gas, police said. The black Cadillac smashed the window, and the front end of the car ended up in the salon.


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From the Publisher"The book is beautifully presented and richly illustrated with over 100 black and white photographs. Music and Image in Classical Athens provides a valuable contribution to the discussion of the social significance of music in Ancient Greece. With a thorough examination of a wide range of visual evidence, Bundrick constructs a coherent narrative about the significance of musical images."
-Sohie Gibson, Bryn Mawr Classical Review
"The book provides fascinating evidence for a cultural shift in Athens in the fifth century, one that permeated its society and infiltrated its economy and vase production."
-Bradford Lee Eden, University of California, Santa Barbara
"Bundrick's text is clear and her discussions lucid; she cites hundreds of vase depictions by musical category. Since classicists and ancient art historians are not usually versed in ancient music, Bundrick's book should be a must-read for every student of ancient Athens from undergraduate to the senior scholar."
-John G. Younger, Kansas University, Classical World
"This is an original and useful book and a fine example of how to use visual evidence to answer questions on which literary sources are silent. Naturally, Bundrick quotes poets, historians, and philosophers where relevant; all the quotations are given in English, and any Greek terms are transliterated, making the book accessible to a broader audience...[A]nyone working on Athenian iconography, ancient music, or the festival competitions will find this work useful."
-Anne Mahoney, Tufts University, The Classical Outlook
"It is one of those rare books that truly will be of use to the beginning student and the experienced scholar alike...Bundrick has a gift for clear, economical exposition, and a masterful ability to edit her copious sources in such a way that the reader feels neither overwhelmed nor deprived of the full picture in all its necessary detail." —Timothy Power, Rutgers University, The Phoenix: Journal of the Classical Association of Canada


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text: North Georgia Outdoor Range [Archive] - Glock Talk Glock Talk > The Main Room > WhereULive > The Georgia Club > North Georgia Outdoor Range PDA View Full Version : North Georgia Outdoor Range lcp06-03-2008, 19:38I spend time in the Blue Ridge/Ellijay area and was wondering if anyone can give me some idea where I can find an outdoor pistol/rifle range in that area. TenMillimeter06-04-2008, 06:46USFS Sumac Creek range is in the general area off of 411, but still a little bit of a drive: http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&ll=34.939704,-84.745445&spn=0.193912,0.319977&z=12&om=1&msid=101369465628231192183.0004408a7004201d2472b USFS link: http://www.fs.fed.us/conf/rec/shooting.htm lcp06-04-2008, 08:38That is still a bit of a drive. However, I do appreciate the links. You would think that such a rural area would have more outdoor ranges. Fannin county has only one but it is for law enforcement only. FillYerHands06-10-2008, 11:08Sounds like time to rent a front end loader and a 100-yard measuring tape. Voila, your own range. Send us an invite! major06-11-2008, 05:09There's an outdoor range (free) on highway 156 west of Calhoun. There's also one in Adairsville. lcp06-13-2008, 16:45I wish that I had that much room. The issue would be the neighbors. It seems to me that a commercial outdoor range in Fannin county could be a success. Even though a rural area an outdoor range would let hunters sight in rifles etc. Jenell06-22-2008, 08:30There's an outdoor range (free) on highway 156 west of Calhoun. There's also one in Adairsville. I was thinking of those too. Wish I could think of the names. detroit19207-14-2008, 21:13I was thinking of those too. Wish I could think of the names. http://georgiawildlife.dnr.state.ga.us/content/displaycontent.asp?txtDocument=442&txtPage=2 Region I- Armuchee- 706.295.6041 Shooting Range: Johns Mountain WMA (Chestnut Mountain Shooting Range) Location: Floyd County Facilities: 100-yard range Directions: I-75, take exit 320 (Lafayette-Reseca exit). Turn left on Hwy 136 and go approximately 5 miles, turn right where the 136 connector runs into Hwy 136. Go approximately 0.25 miles and the range is on the right. Range Hours: May 1- August 31: 9:00 am 8:00 pm; September 1- April 30: 9:00 am-5:00 pm; SUNDAY- CLOSED Shooting Range: Cohutta WMA (Sumac Creek Shooting Range) Location: Murray County Facilities: 100-yard range Directions: Hwy 411 North out of Eton. Turn right on Hwy 2. Go to the end of the pavement and pass the Cohutta WMA entrance sign on right. Continue onto the top of the hill and the range road will be on the right. Range Hours: Sunrise to sunset daily :wavey: Jenell07-15-2008, 15:28Good link Detroit! detroit19207-15-2008, 16:38Good link Detroit! Thank you, some buddies from Sigforum and I try to go up to Chestnut MT. once a month or so for an unorganized shoot. It has both benches for rifles and a counter type area for pistols. It even has a handicapped (lower counter) spot. 100 yards, an OK access road, no range officer, "modern" outhouse, and a couple of benches for spectators, not bad for $5 for parking. vBulletin® v3.8.7, Copyright ©2000-2015, vBulletin Solutions, Inc.


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Frozen (Choral Suite) - SATB Divisi
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Frozen (Choral Suite) - SATB Divisi composed by Christine Hals, Christophe Beck, and Frode Fjellheim. Edited by Roger Emerson. For Choral (SATB Divisi). Disney Choral. 16 pages. Published by Hal Leonard (HL.127011).
Two haunting choral songs used in the Disney animated feature Frozen capture the stark beauty of the frozen north. Adapted from the actual choral settings used in the movie, these accompanied editions are wonderful selections that will expand your singers''understanding of Scandinavian music. Includes Heimr Árnadalr, Vuelie and The Great Thaw ("Vuelie" Reprise).
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Frozen (Choral Suite) - SATB Divisi
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- Filed Under
Despite his philanthropy and clean criminal record, former NBA player Jalen Rose is going to jail as a statement to the community, a judge said Wednesday.
"There lies the answer to drunk driving," Judge Kimberly Small told a packed courtroom in 48th District Court in Bloomfield Hills. "Send a message that there will be serious consequences."
On Tuesday, Rose will report to the Oakland County Jail to begin serving a 20-day sentence for first-time drunken driving. He will likely spend his days in a one-person cell and could shave a few days off for good behavior, officials said. ...


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Orthopedic Applications of Stem-Cell Therapy
Mesenchymal stem-cell therapy is considered investigational for all orthopedic applications, including use in repair or regeneration of musculoskeletal tissue.
Allograft bone products containing viable stem cells, including but not limited to demineralized bone matrix (DBM) with stem cells, is considered investigational for all orthopedic applications.
Recombinant and Autologous Platelet-Derived Growth Factors as a Primary Treatment of Wound Healing and Other Miscellaneous Conditions
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
Note: This policy does not address unprocessed allograft bone.
Mesenchymal stem cells (MSCs) have the capability to differentiate into a variety of tissue types, including various musculoskeletal tissues. Potential uses of MSCs for orthopedic applications include treatment of damaged bone, cartilage, ligaments, tendons and intervertebral discs.
MSCs are multipotent cells (also called stromal multipotent cells) that possess the ability to differentiate into various tissues including organs, trabecular bone, tendon, articular cartilage, ligaments, muscle, and fat. MSCs are associated with the blood vessels within bone marrow, synovium, fat, and muscle, where they can be mobilized for endogenous repair as occurs with healing of bone fractures. Bone-marrow aspirate is considered to be the most accessible source and, thus, the most common place to isolate MSCs for treatment of musculoskeletal disease. However, harvesting MSCs from bone marrow requires an additional procedure that may result in donor-site morbidity. In addition, the number of MSCs in bone marrow is low, and the number and differentiation capacity of bone marrow‒derived MSCs decreases with age, limiting their efficiency when isolated from older patients.
Tissues such as muscle, cartilage, tendon, ligaments, and vertebral discs show limited capacity for endogenous repair. Therefore, tissue engineering techniques are being developed to improve the efficiency of repair or regeneration of damaged musculoskeletal tissues. Tissue engineering focuses on the integration of biomaterials with MSCs and/or bioactive molecules such as growth factors. In vivo, the fate of stem cells is regulated by signals in the local 3-dimensional microenvironment from the extracellular matrix and neighboring cells. It is believed that the success of tissue engineering with MSCs will also require an appropriate 3-dimensional scaffold or matrix, culture conditions for tissue-specific induction, and implantation techniques that provide appropriate biomechanical forces and mechanical stimulation. The ability to induce cell division and differentiation without adverse effects, such as the formation of neoplasms, remains a significant concern. Given that each tissue type requires different culture conditions, induction factors (signaling proteins, cytokines, growth factors), and implantation techniques, each preparation must be individually examined.
The U.S. Food and Drug Administration (FDA) has stated:
"A major challenge posed by SC [stem-cell] therapy is the need to ensure their efficacy and safety. Cells manufactured in large quantities outside their natural environment in the human body can become ineffective or dangerous and produce significant adverse effects, such as tumors, severe immune reactions, or growth of unwanted tissue."(1)
Regulatory Status
Concentrated autologous MSCs do not require approval by FDA.
Demineralized bone matrix (DBM), which is processed allograft bone, is considered minimally processed tissue and does not require FDA approval. At least 4 commercially available DBM products are reported to contain viable stem cells:
Other products contain DBM and are designed to be mixed with bone marrow aspirate. Some of the products that are currently available are:
Other commercially available products are intended to be mixed with bone marrow aspirate and have received 510(k) clearance, such as:
No products using engineered or expanded MSCs have been approved by FDA for orthopedic applications.
In 2008, FDA determined that the mesenchymal stem cells sold by Regenerative Sciences for use in the Regenexx™ procedure would be considered drugs or biological products and thus require submission of a New Drug Application (NDA) or Biologics Licensing Application (BLA) to FDA. (2) To date, no NDA or BLA has been approved by FDA for this product. As of 2013, the expanded stem-cell procedure is only offered in the Cayman Islands. Regenexx™ network facilities in the U.S. provide same-day stem-cell and blood platelet procedures, which do not require FDA approval. Available online at http://www.regenexx.com/common-questions/regenexx-fda-clarification\. (Last accessed May 8, 2014.)
Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
The Regenexx™ procedure is currently performed in one location (Regenerative Sciences, Centeno Schultz Clinic, Bloomfield, Colorado).
This policy was created in 2010 and updated periodically using the MEDLINE database. The most recent literature update was performed through March 3, 2014.
At the time this policy was created, the literature consisted almost entirely of review articles describing the potential of stem-cell therapy for orthopedic applications in humans, along with basic science experiments on sources of mesenchymal stem cells (MSCs), regulation of cell growth and differentiation, and development of scaffolds. (3) Authors of these reviews indicated that the technology was in an early stage of development. In literature searches of the MEDLINE database, use of cultured MSCs in humans was identified in only a few centers in the U.S., Europe, and Asia. Since the policy was created, the evidence base has been steadily increasing, although there is a lack of high-quality randomized controlled trials (RCTs) and nearly all of the studies to date have been performed outside of the U.S.
Cartilage Defects
The source of MSCs may have an impact on outcomes, but this is not well understood and the available literature uses multiple different sources of MSC. Because of the uncertainty over whether these products are equivalent, the evidence will be grouped by source of MSC.
One systematic review was published in 2013 that included multiple sources of MSC. In 2013, Filardo et al. conducted a systematic review of mesenchymal stem cells for the treatment of cartilage lesions. (4) They identified 72 preclinical papers and 18 clinical reports. Of the 18 clinical reports, none were randomized, 5 were comparative, 6 were case series, and 7 were case reports. In 2 clinical studies, the source of MSCs was adipose tissue, in 5, bone marrow concentrate, and in 11, the source was bone marrow-derived. Following is a summary of the key literature to date, focusing on comparative studies.
Cartilage Defects: MSCs Expanded from Bone Marrow
In December 2013 (after the systematic review by Filardo et al. was published), Wong et al. reported an RCT of cultured MSCs in 56 patients with osteoarthritis who underwent medial opening-wedge high tibial osteotomy and microfracture of a cartilage lesion. (5) Bone marrow was harvested at the time of microfracture and the MSCs were isolated and cultured. After three weeks, the cells were assessed for viability and delivered to the clinic, where patients received an intra-articular injection of MSCs suspended in hyaluronic acid (HA), or for controls, intra-articular injection of HA alone. The primary outcome was the International Knee Documentation Committee (IKDC) score at six months, one year, and two years. Secondary outcomes were the Tegner and Lysholm scores through two years and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system by MRI at one year. All patients completed the two year follow-up. After adjusting for age, baseline scores, and time of evaluation, the group treated with MSCs showed significantly better scores on the IKDC (mean difference, 7.65 on 0-100 scale; p=0.001), Lysholm (mean difference, 7.61 on 0-100 scale; p=0.02), and Tegner (mean difference, 0.64 on a 0-10 scale; p=0.02). Blinded analysis of MRI results found higher MOCART scores in the MSC group. The group treated with MSCs had a higher proportion of patients who had complete cartilage coverage of their lesions (32% vs. 0%), greater than 50% cartilage cover (36% vs. 14%) and complete integration of the regenerated cartilage (61% vs. 14%). This study is ongoing and recruiting additional patients.
Wakitani et al. first reported use of expanded MSCs for repair of cartilage defects in 2002. (6) Cells from bone marrow aspirate of 12 patients with osteoarthritic knees were culture expanded, embedded in collagen gel, transplanted into the articular cartilage defect, and covered with autologous periosteum at the time of high tibial osteotomy. Clinical improvement was not found to be different between the experimental group and a group of 12 control patients who underwent high tibial osteotomy alone. Wakitani et al. have since published several cases of patients treated for isolated cartilage defects, with clinical improvement reported at up to 27 months. (7) However, most of the defects appear to have been filled with fibrocartilage. A 2011 report from Wakitani et al. was a follow-up safety study of 31 of the 41 patients (3 patients had died, 5 had undergone total knee arthroplasty) who had received MSCs for articular cartilage repair in their clinics between 1998 and 2008. (8) At a mean of 75 months (range, 5-137) since the index procedure, no tumors or infections were identified. Function was not reported.
Another study from Asia evaluated the efficacy of bone marrow-derived MSCs compared with autologous chondrocyte implantation (ACI) in 36 matched patient pairs. (9) Thirty-six consecutive patients with at least 1 symptomatic chondral lesion on the femoral condyle, trochlea, or patella were matched with 36 cases of ACI performed earlier, based on lesion sites and 10-year age intervals. Autologous MSCs were cultured from 30 mL of bone marrow from the iliac crest, tested to confirm that the cultured cells were MSCs, and implanted beneath a periosteal patch. Concomitant procedures included patella realignment, high -tibial osteotomy, partial meniscectomy, and anterior cruciate ligament reconstruction. Clinical outcomes, measured pre-operatively and at 3, 6, 12, 18, and 24 months after operation using the International Cartilage Repair Society Cartilage Injury Evaluation Package, showed improvement in patients' scores over the 2-year follow-up in both groups, with no significant difference between groups for any of the outcome measures except for Physical Role Functioning on the 36-Item Short-Form Health Survey, which showed a greater improvement over time in the MSC group.
A 2010 publication from Centeno et al. of Regenerative Sciences describes the use of percutaneously injected culture-expanded MSCs from the iliac spine in 226 patients. (10) Following harvesting, cells were cultured with autologous platelet lysate and re-injected under fluoroscopic guidance into peripheral joints (n=213) or intervertebral discs (n=13). Follow-up for adverse events at a mean of 10.6 months showed 10 cases of probable procedure-related complications (injections or stem-cell related), all of which were considered to be self-limited or treated with simple therapeutic measures. Serial magnetic resonance imaging (MRIs) from a subset of patients showed no evidence of tumor formation at a median follow-up of 15 months. The efficacy of these procedures was not reported. This procedure is no longer offered in the U.S.
Cartilage Defects: MSCs Concentrated from Bone Marrow
In 2009, Giannini et al. reported a one-step procedure for transplanting bone marrow-derived cells for Type II (>1.5 cm2, <5 mm deep) osteochondral lesions of the talus in 48 patients. (11) A total of 60 -mL-bone marrow aspirate was collected from the iliac crest. The bone marrow-derived cells were concentrated in the operating room and implanted with a scaffold (collagen powder or HA membrane) and platelet gel. In a 2010 publication, Giannini et al. reported results of a retrospective analysis based on the evolution of the investigator's technique at the time of treatment. Outcomes following arthroscopic application of the MSC concentrate (n=25) were similar to open (n=10) or arthroscopic (n=46) ACI. (12) ACI with a biodegradable scaffold is not commercially available in the U.S. (see Related Policies).
Cartilage Defects: Adipose-Derived MSCs
In 2013, Kim et al. reported a retrospective comparison of outcomes from 35 patients (37 ankles), who were older than 50 years of age, had focal osteochondral lesions of the talus, and were treated with microfracture alone between May 2008 and September 2010. (13) The comparison group was 30 patients (31 ankles) who received MSC injection along with marrow stimulation between October 2010 and December 2011. MSCs were harvested from the fat pad of the buttock of the patients 1 day before surgery, concentrated, and injected after the arthroscopic procedure. With an average 22 month follow-up (range, 12-44 months), patients treated with MSCs showed greater improvements in visual analog scale score, American Orthopaedic Foot and Ankle Society Ankle‒Hindfoot Scale, Tegner Activity Scale, and the Roles and Maudsley score .
The same group reported a retrospective analysis of the injection of adipose-derived MSCs from the infrapatellar fat pad and platelet-rich plasma (PRP) into arthroscopically-débrided knees of 25 patients with osteoarthritis of the knee. (14) Results were compared with a randomly selected group of patients who had previously undergone arthroscopic débridement and PRP injections without stem cells. Although there was a trend for greater improvement in the MSC group, at final follow-up, there was no significant difference between the MSC and control groups in clinical outcomes (Lysholm, Tegner, visual analog score). Use of PRP is discussed in a separate policy. (See Related Policies).
Cartilage Defects: MSCs from Peripheral Blood
A 2013 report from Asia described a small RCT with autologous peripheral blood MSCs for focal articular cartilage lesions. (15) Fifty patients with grade 3 and 4 lesions of the knee joint underwent arthroscopic subchondral drilling followed by 5 weekly injections of HA. Half of the patients were randomly allocated to receive injections of peripheral blood stem cells or no further treatment. There were baseline differences in age between the groups, with a mean age of 38 years for the treatment group compared with 42 for the control group. The peripheral blood stem cells were harvested after stimulation with recombinant human granulocyte colony-stimulating factor, divided in vials, and cryopreserved. At 6 months after surgery, HA and MSCs were re-administered over 3 weekly injections. At 18 months after surgery, second look arthroscopy on 16 patients in each group showed significantly higher histological scores (by about 10%) for the MSC group (1,066 vs. 957 by independent observers) while blinded evaluation of MRI showed a higher morphologic score (9.9 vs. 8.5). There was no difference in IKDC scores between the 2 groups at 24 months after surgery. It is uncertain how differences in patient age at baseline may have affected the response to subchondral drilling.
Section Summary
The evidence base on MSCs for cartilage repair is increasing, although nearly all studies to date have been performed in Asia with a variety of methods of MSC preparation. Only 2 small randomized studies have been identified. Both of these studies reported an improvement in histological and morphologic outcomes. One of these studies also reported an improvement in functional outcomes. The method of preparation used in this positive study was to obtain MSCs from bone marrow at the time of microfracture, culture (expand) over a period of 3 weeks, and inject in the knee in a carrier of HA. The second randomized trial, using MSCs from peripheral blood, found improvement in histological and morphologic outcomes, but not functional outcomes, following stimulation with recombinant human granulocyte colony-stimulating factor. Other nonrandomized comparative studies reported no benefit compared with ACI, but have reported a benefit compared with microfracture alone.
Fusion and Non-union
There is limited evidence on the use of allografts with stem cells for fusion of the extremities or spine or for the treatment of non-union. One retrospective series from 2009 was identified on the use of Trinity Evolution Matrix MSC bone allograft for revision surgery of the foot and ankle. (16) Twenty-three patients were included who had undergone revision foot and/or ankle surgery for residual malunion, non-union, or significant segmental bone loss. Patients were followed to the point of radiographic and clinical union, which occurred at a median of 72.5 days for 21 of the 23 patients (91.3%).
In 2014, Vangsness et al. reported an industry-sponsored phase 1/2 randomized, double-blind, multicenter study (NCT00225095, NCT00702741) of cultured allogeneic MSCs (Chondrogen™, Osiris Therapeutics) injected into the knee after partial meniscectomy. (17) The 55 patients in this U.S. study were randomized to intra-articular injection of either 50x106 allogeneic MSCs, 150x106 allogeneic MSCs in HA, or HA vehicle control at seven to ten days after meniscectomy. The cultured MSCs were derived from bone-marrow aspirates from unrelated donors. At two year follow-up, 3 patients in the low-dose MSC group had significantly increased meniscal volume measured by MRI (with an a priori determined threshold of at least 15%) compared with none in the control group and none in the high-dose MSC group. There was no significant difference between the groups in the Lysholm Knee Scale. On subgroup analysis, patients with osteoarthritis who received MSCs had a significantly greater reduction in pain at two years compared with patients who received HA alone. This appears to be a post hoc analysis and should be considered preliminary. No serious adverse events were thought to be related to the investigational treatment.
Two randomized comparative trials from Asia have been identified that evaluated the use of MSCs for osteonecrosis of the femoral head.
Osteonecrosis: MSCs Expanded from Bone Marrow
In 2012, Zhao et al. reported a randomized trial that included 100 patients (104 hips) with early stage femoral head osteonecrosis treated with core decompression and expanded bone marrow MSCs versus core decompression alone. (18) At 60 months after surgery, 2 of the 53 hips (3.7%) treated with MSCs progressed and underwent vascularized bone grafting, compared with 10 of 44 hips (23%) in the decompression group who progressed and underwent either vascularized bone grafting (n=5) or total hip replacement (n=5). The MSC group also had improved Harris Hip Scores compared with the control group on independent evaluation (data presented graphically). The volume of the lesion was also reduced by treatment with MSCs.
Osteonecrosis: MSCs Concentrated from Bone Marrow
Another small trial randomized 40 patients (51 hips) with early stage femoral head osteonecrosis to core decompression plus concentrated bone marrow MSCs or core decompression alone. (19) Blinding of assessments in this small trial was not described. Harris Hip Score was significantly improved in the MSC group (scores of 83.65 and 82.42) compared with core decompression (scores of 76.68 and 77.39). Kaplan-Meier analysis showed improved hip survival in the MSC group (mean, 51.9 weeks) compared with the core decompression group (mean, 46.7 weeks). There were no significant differences between the groups in the radiographic assessment or MRI results.
Osteonecrosis: Conclusions
Two small studies from Asia have compared core decompression alone versus core decompression with MSCs in patients with osteonecrosis of the femoral head. Both studies reported improvement in the Harris Hip Score in patients treated with MSCs, although it was not reported whether the patients or investigators were blinded to the treatment group. Hip survival was significantly improved following treatment with either expanded or concentrated MSCs. The effect appears to be larger with expanded MSCs compared with concentrated MSCs. Additional studies with a larger number of patients are needed to permit greater certainty regarding the effect of this treatment on health outcomes.
Ongoing and Unpublished Clinical Trials
A search of online site: ClinicalTrials.gov in March 2014 identified a number of trials on use of MSCs for orthopedic indications from both within and outside the U.S. The following is a sample of some of the larger studies:
The use of mesenchymal stem cells (MSCs) for orthopedic conditions is an active area of research. Despite continued research into the methods of harvesting and delivering treatment, there are uncertainties regarding the optimal source of cells and the delivery method. Current available evidence on procedures using autologous bone-marrow-derived MSCs for orthopedic indications in humans consists of a few small randomized and non-randomized comparative trials with insufficient data to evaluate health outcomes. In addition, expanded MSCs for orthopedic applications are not Food and Drug Administration (FDA) approved (concentrated autologous MSCs do not require FDA approval). Due the lack of evidence that clinical outcomes are improved and the lack of regulatory approval, use of stem cells for orthopedic applications is considered investigational.
Practice Guidelines and Position Statements
The American Association of Orthopaedic Surgeons states that stem-cell procedures in orthopedics are still at an experimental stage; most musculoskeletal treatments using stem cells are performed at research centers as part of controlled, clinical trials, and results of studies in animal models provide proof-of-concept that in the future, similar methods could be used to treat osteoarthritis, nonunion of fractures, and bone defects in humans.(20)
In 2006, the Mesenchymal and Tissue Stem-Cell Committee of the International Society for Cellular Therapy proposed a minimal set of criteria to standardize the characterization of multipotent mesenchymal stem cells. (21) The proposed criteria for human MSCs included plastic-adherence when maintained in standard culture conditions; a phenotype of expression of CD105, CD73, and CD90 with a lack surface expression of CD45, CD34, CD14 or CD11b, CD79 alpha or CD19, and HLA-DR surface molecules; and the capability of differentiating into osteoblasts, adipocytes, and chondrocytes using standard in vitro tissue culture-differentiating conditions.
Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.
Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous
Bone marrow harvesting for transplantation
Bone marrow or blood-derived peripheral stem cell transplantation; autologous
New policy; add to Therapy section.Policy created with literature review through January 2011; considered investigational. ICD-10 codes included in policy.
Replace policy. Policy updated with literature review through February 2012; reference 6 added and references reordered; policy statement unchanged.
Update Related Policies: remove 7.01.48, it was archived.
Update Related Policies – add 2.02.18.
Update Coding Section – ICD-10 codes are now effective 10/01/2014.
Clarification only. Statement within the Benefit Application section stating, "Therefore, requests may be made for an out-of-network facility" was removed, as this conflicts with the FDA statements in the rest of the policy. No other changes.
Replace policy. New policy statement added that allograft bone containing viable stem cells is considered investigational. New policy guideline added that policy does not address unprocessed allograft bone. Regulatory status section updated regarding allograft bone. Rationale updated based on a literature review through March 2013. References 4, and 11-15 added; others renumbered or removed. Policy statement changed as noted.
Update Related Policies. Change title to 2.02.18.
Annual Review. Policy updated with literature review through March 3, 2014; references 5, 13, and 17 added; policy statements unchanged. ICD-10 codes removed in line with code mapping project and implementation delay.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).


text:
Fairfax, Virginia - Even though the Friends of NRA Banquet season is rolling to a close, there are still plenty of opportunities to attend. Just like those who made it to the last night's dinner at the Waterford in Fairfax.
Under the steady hand of newly appointed Eastern Virginia Field Rep. David Wells, the night was began as guests made their way around the auctions and games that frequent every Friends event.
"There wasn't a Fairfax Friends event last year," said Wells. "It's great to see the crowd's enthusiasm."
Volunteers from the community along with NRA Headquarters staff explained the rules, took the tickets and passed out prizes throughout the night. Friendly barbs along the lines of "that's a terrible choice" and "don't even bother I already won" were thrown about with great frequency.
"Our people enjoy giving each other a hard time," said Wells. "As long as they're in a good mood for the auction, then I'll be in a good mood too."
Though we don't have final numbers yet, Wells and the staff were encouraged by the raw count. In time, we'll share those numbers and more about the Friends of NRA return to Fairfax.
friends banquets | virginia | friends of nra
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