Total Ankle Arthroplasty: Comparing Perioperative Outcomes When Performed at an Orthopaedic Specialty Hospital Versus an Academic Teaching Hospital.

BACKGROUND: The number of total ankle arthroplasties (TAAs) performed in the United States has risen significantly in recent years, as has utilization of orthopaedic specialty hospital (OSH) to treat healthy patients undergoing elective surgery. The purpose of this study was to compare postoperative outcomes following TAA at an OSH when compared with a matching population of patients undergoing TAA at an academic teaching hospital (ATH). METHODS: We identified all TAA from January 2014 to December 2014 at the OSH and January 2010 to January 2016 at the ATH. Each OSH patient was manually matched with a corresponding ATH patient by clinical variables. Outcomes analyzed were length of stay (LOS), 30-day readmissions, mortality, reoperation, and inpatient rehabilitation utilization. RESULTS: There were 40 TAA patients in each group. OSH and ATH patients were similar in age, body mass index, age-adjusted Charlson Comorbidity Index, and gender. Average LOS for TAA at the OSH was 1.28 ± 0.51 compared with 2.03 ± 0.89 (P < .001) at the ATH. There were no OSH patients readmitted within 30 days, compared with 2 ATH patients readmitted (5.0%; P = .15). Two OSH patients (5.0%) and 2 ATH patients (5.0%; P = 1.00) required reoperation. There were no mortalities in either group. There were no OSH patients requiring transfer. CONCLUSIONS: Primary TAA performed at an OSH had significantly shorter LOS when compared with a matched patient treated at an ATH with no significant difference in readmission or reoperation rates and may offer a potential source of significant health care savings. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.

Bilateral Posterior Tibial Tendon and Flexor Digitorum Longus Dislocations.

The authors present a case of a previously healthy and athletic 17-year-old female who presented with a 3.5-year history of medial left ankle pain after sustaining an inversion injury while playing basketball. Prior to presentation, she had failed prior immobilization and physical therapy for a presumed ankles sprain. Physical examination revealed a dislocated posterior tibial tendon (PTT) that was temporarily reducible, but would spontaneously dislocate immediately after reduction. She had pain and snapping of the PTT with resisted ankle plantar flexion and resisted inversion as well as 4/5 strength in ankle inversion. The diagnosis of dislocated PTT was confirmed on magnetic resonance imaging (MRI). The patient underwent suture anchor repair of the medial retinaculum of the left ankle. At the time of surgery both the PTT and flexor digitorum longus (FDL) were dislocated. Three months postoperatively, the patient represented with PTT dislocation of the right (nonoperative) ankle confirmed by MRI. After failure of immobilization, physical therapy, and oral anti-inflammatory medications, the patient underwent suture anchor repair of the medial retinaculum of the right ankle. At 6 months postoperatively, the patient has 5/5 strength inversion bilaterally, no subluxation of either PTT, and has returned to all activities without limitation. The authors present this unique case of bilateral PTT dislocation and concurrent PTT/FDL dislocation along with review of the literature for PTT dislocation. The authors highlight the common misdaiganosis of this injury and highlight the successful results of surgical intervention. LEVELS OF EVIDENCE: Level V: Case report.

Rituximab-induced depletion of anti-PLA2R autoantibodies predicts response in membranous nephropathy.

Autoantibodies to the M-type phospholipase A(2) receptor (PLA(2)R) are sensitive and specific for idiopathic membranous nephropathy. The anti-B cell agent rituximab is a promising therapy for this disease, but biomarkers of early response to treatment currently do not exist. Here, we investigated whether levels of anti-PLA(2)R correlate with the immunological activity of membranous nephropathy, potentially exhibiting a more rapid response to treatment than clinical parameters such as proteinuria. We measured the amount of anti-PLA(2)R using Western blot immunoassay in serial serum samples from a total of 35 patients treated with rituximab for membranous nephropathy in two distinct cohorts. Pretreatment samples from 25 of 35 (71%) patients contained anti-PLA(2)R, and these autoantibodies declined or disappeared in 17 (68%) of these patients within 12 months after rituximab. Those who demonstrated this immunologic response fared better clinically: 59% and 88% attained complete or partial remission by 12 and 24 months, respectively, compared with 0% and 33% among those with persistent anti-PLA(2)R levels. Changes in antibody levels preceded changes in proteinuria. One subject who relapsed during follow-up had a concomitant return of anti-PLA(2)R. In summary, measuring anti-PLA(2)R levels by immunoassay may be a method to follow and predict response to treatment with rituximab in membranous nephropathy.