News From ACFAS

The ACFAS Research Committee has selected the Clinical and Scientific Research Grant recipient for 2008: Paul J. Kim, DPM, of Midwestern University. Dr. Kim received $19,400 for his study: Physiological Response to Surgical Microdebridement in Patients with Achilles Tendinopathy.

The Clinical and Scientific Research Grant provides financial assistance, through the generous support of the Divisions, for research within the podiatric surgical arena that could otherwise not be funded. The purpose of this grant is to fund research with either direct or indirect impact on issues of interest to members of ACFAS and to educate members in the implementation of EBM for the advancement of their clinical practice and patient needs. This research may be clinical or laboratory-based, with clearly defined research goals meeting all the criteria for grant submission.

In just a few minutes you can enhance your knowledge with the latest research from journals you probably don’t regularly read. With this month’s edition of the ACFAS online Scientific Literature Review you’ll read about these studies and many more:

• advantages of MDCT vs. conventional radiography in patients with acute ankle and foot trauma

• the importance of the evaluation and arthroscopic treatment of intra-articular talar lesions for successful outcomes when treating lateral ankle instability

• use of infrared imaging as a quick and non-invasive method to determine the
presence of acute compartment syndrome in the lower extremity following trauma.

This month’s abstracts were produced by residents at St. John North Shores Hospital, Harrison Twp., Michigan.

Of the six hands-on workshops to be offered at ACFAS' Annual Scientific Conference March 4-8, two are now filled to capacity. The four-hour workshops provide an intensive learning experience led by expert faculty.

Register online now to reserve one of the remaining spaces in these popular sessions.

Online registration for the Conference will close on Saturday, Feb. 14. Click on the Web link below for more information on the workshops and the conference, to be held at the Gaylord National Resort and Conference Center in Washington, D.C.

Foot and Ankle Surgery

Surgical Repair of Acute and Chronic Tibialis Anterior Tendon Ruptures

Ruptures in the tibialis anterior tendon are unusual but can cause a significant loss of ankle dorsiflexion. Researchers in this study tracked 19 tibialis anterior tendon ruptures that were surgically repaired in 18 patients aged 21 to 78. Patients were reassessed clinically with the American Orthopaedic Foot and Ankle Society hindfoot score at an average of 53.3 months after surgery. Following surgery, the average hindfoot score improved significantly from 55.5 points preoperatively to 93.6 points postoperatively. Ankle dorsiflexion strength was graded clinically as 5/5 in 15 of the 19 cases. Three patients regained 4/5 ankle dorsiflexion strength, and one patient had 3/5 strength with a poor clinical result. The researchers concluded that surgical restoration of the function of the tibialis anterior muscle can be beneficial irrespective of age, sex, medical comorbidity, or delay in diagnosis. However, early surgical treatment may be less complicated than delayed treatment, and an intercalated free tendon graft and/or gastrocnemius recession may be needed to ensure that the repair is sufficiently tensioned and balanced.



Surgical Implants Coated With One of 'Nature's Antibiotics' Could Prevent Infection

University of British Columbia (UBC) researchers have discovered that coating medical devices with short tethered cationic antimicrobial peptides can protect them against fungi and bacteria and could perhaps prevent infection and rejection in surgical implants. "The rapid progress of biomedical technology and an aging population places increasing demands on medical implants to treat serious tissue disorders and replace organ function," says Robert Hancock with UBC's Department of Microbiology and Immunology in a press release. "These cationic peptides are currently being developed as soluble antibiotics for administration to patients to combat infection. We have developed a new method for finding a variety of effective peptides that can bind to a surface and still kill harmful bacteria and fungus." Hancock says that the peptides are active when bound to surfaces. The study was published in the Jan. 30 edition of Chemistry & Biology.



Local Doctor's Exclusive Fix for Chronically Injured Ankles Gets Raves

Patients have rave reviews for the ankle surgery procedure developed by Dr. Robert Lim of Naperville, Ill., which has been successful enough that one longtime gymnast with both ankles weakened by years of injuries has returned to the uneven parallel bars. Lim is claiming a 100 percent success rate with his Lim procedure, and athletes and other doctors praise him as well, but there is one omission: he has never published results in a medical journal. The Lim procedure involves creating an artificial ligament by anchoring suture material from the fibula with tiny screws to the talus, where collagen or scar tissue can form along the new ligament. "It's such a different procedure, not a lot of doctors even know it exists," says Lim, who says he has treated 252 patients successfully. "Older doctors who don't know me think it can't work because it's so radically different. But I rely on the happiness of my patients." While other doctors congratulate him and are interested in his procedure, they say they cannot be sure if it works unless a peer-reviewed study is published in a publication such as the Journal of Foot & Ankle Surgery. "Ultimately, we want to see a randomized controlled study comparing a new procedure to the gold standard," says Dr. Sean Grambart, DPM, FACFAS, of the University of Illinois at Champaign-Urbana, a board certified foot and ankle surgeon. "It always makes me a little leery when you hear 100 percent effective, especially with no scientific background." Lim says that he has put a study together but is holding off on publishing it while he discusses marketing possibilities with orthopedic manufacturers.



AOFAS Study on Orthopaedic Foot and Ankle Surgery Pain Finds Correlation Between Anticipation of Pain Pre-Surgery and Actual Occurrence Post-Surgery

A recent study has found that patients' expectations of post-operative pain is linked to the actual occurrence of pain following foot and ankle surgery. Researchers led by Loretta B. Chou, MD, an orthopaedic foot and ankle surgeon in the Department of Orthopaedic Surgery at the Stanford University Medical Center, examined 98 patients who underwent a variety of orthopaedic operations. The patients were given a Short-Form McGill Pain Questionnaire before and after surgery to evaluate their levels of pain. The questionnaire has 15 pain descriptors in the Present Pain Intensity index as well as a visual analogue scale for pain. The study suggests that the pre-surgical expectations of pain could contribute to its subsequent incidence. Pain severity was highest following foot and ankle surgery at the 3-Day Post-Operative Pain assessment, but most patients felt little or no pain after six weeks post-surgery. This early pain was found to be more severe than that anticipated by the patients. "While we cannot isolate the exact cause, optimistic patients suffered much less postoperative pain than their pessimistic counterparts," Chou observed. She added that in subsequent follow-up studies, "one study focuses on ankle fractures and the other, removal of painful hardware from the foot and ankle."

Practice Management

Reducing Tax Liabilities: Don't Wait Until April 15th to Protect Your Income

Physicians seeking to reduce their tax liabilities should begin work as soon as possible rather than waiting until just before tax time, although ordinary accountants may not know about some of the measures that are of help to physicians. For example, one of the strategies to protect a practice's accounts receivable from malpractice liability and other business risks can also be used to cut down on the practice's income tax burden as well. Physicians should also look into "income sharing" with their families via a family limited partnership or limited liability company, taking advantage of new tax rules adopted by Congress in 2006. A third thing to look into is cash-value life insurance, as growth of policy cash balances is not taxable and almost every state protects these from creditors, though there can be great variation from state to state on how much is protected. Fourth, physicians should look into hiring investment managers whose portfolio management seeks to reduce income and capital gains taxes; with individually managed accounts, or IMAs, which can invest in the same securities as a mutual fund, the manager works individually with the investor to take advantage of losses and manage taxes. Finally, physicians should look into using a Charitable Remainder Trust, or CRT, which can make annual or more frequent payments to the doctor or to the doctor and a family member until the doctor's death, after which the remaining money goes to the doctor's chosen charity. CRTs come with a number of advantages in terms of taxes and investment return.



How to Save Money by Improving Your Inventory Management

Medical practices can cut costs by improving their inventory management, specifically by keeping track of medical and office supplies and how often they are used and making improvements to the ordering system. "I tell my clients that effective inventory management is an important part of a practice's overall fiscal fitness program," says Kenneth Hertz, a principal in the Medical Group Management Association (MGMA) Health Care Consulting Group. Family practices' median expenditure on drugs, administrative supplies, and medical and surgical supplies is 8.53 percent of annual collections, according to an MGMA survey. A key part of good inventory management is finding the best price for supplies, which involves comparison shopping as well as trying to develop a strong relationship with a chosen vendor. Pharmaceutical manufacturers may also offer discounts for online orders, enabling practices to bypass the middleman and save even more money through the online discount. Word of mouth is the best way to find good vendors, and specialty email lists can be a useful source as well. Tracking inventory is best accomplished by concentrating on speed and ease of use, which can be accomplished with paper, a spreadsheet program, or specialty inventory management software that is often a component of medical accounting software.



At The Same Table: Alternative Liability Resolution

A growing number of doctors are looking at ways to resolve disputes outside the court system, such as mediation or other voluntary methods, but it may not be the solution to all the liability problems doctors face. "The goal is to bring both sides together to discuss the issue. We can talk about money and all those things [in court], but you lose sight of the human element in a lawsuit," says rheumatologist Mark A. Lopatin, MD, one of the Pennsylvania doctors at Abington Memorial Hospital who have taken an interest in alternative dispute resolution. The Pennsylvania Medical Society, Montgomery County Medical Society, and Montgomery Bar Association are backing the pilot program at Abington, which was spurred by a 2004 Supreme Court decision that encouraged health practices to consider mediation. Mediators differ from arbitrators in that they do not make final decisions and both parties can still go to court, but former Montgomery Bar Association President Robert F. Morris Jr. says the court system can be a tough one for plaintiffs and defendants alike. "The courts work well in just compensation for most patients. ... But it's a difficult thing to relive an injury through the court system, and if we can avoid all that and still reach a fair result, the public is well-served." Legal experts say that mediation and other voluntary programs are gaining attention from plaintiffs and defendants, especially as the patient safety movement evolves and tort reform is challenged. Still, though there is anecdotal evidence of benefits from alternative resolution methods, American Medical Association Board of Trustees member Robert M. Wah, MD, warns that "it is not conclusive, and what we need to have is clear evidence."



Nuts and Bolts of E-Prescribing

Under the Medicare Improvements for Patients and Providers Act of 2008, physicians who use e-prescribing (eRX) systems have access to incentives that are separate from those offered under the Physicians Quality Reporting Initiative. The incentive program was rolled out on Jan. 1, 2009, and the Centers for Medicare and Medicaid Services will prohibit faxed prescriptions beginning Jan. 1, 2012. To qualify for the new incentive program and meet the definition of "successful e-prescriber," physicians must report one eRX measure in half of reportable cases this year and have an approved eRX system in place, among other things. Once the 2012 deadline arrives, physicians who do not meet the successful e-prescriber standards will be penalized, with a reduction in payments for covered Medicare Part B fee schedule services. Research shows that just 17 percent of physicians had eRX systems in 2007, mainly due to workflow, usability, cost, and implementation challenges. Physicians now have access to a vast number of eRX products, ranging from stand-alone systems to those that integrate with electronic medical records systems. Regardless of the chosen system, implementation will be successful only if physicians embrace the technology.

Health Policy and Reimbursement

AMA Sues Insurers for Underpaying Docs

The American Medical Association and the medical associations of several states— including New York, New Jersey, and Connecticut—are suing Aetna Inc. and Cigna Corp., accusing them of rigging the physician reimbursement system and underpayment. The suits, filed in federal court in New Jersey on Feb. 9., claim that Aetna and Cigna used skewed data from Ingenix, a subsidiary of UnitedHealth Group, to underpay doctors, forcing excessive costs for patients. New York's state attorney general, Andrew Cuomo, recently reached a settlement under which the Ingenix database will be shut down. "We can no longer ignore the improper business practices of health insurers who decide to play by their own rules without regard to patients, or the legitimate costs required to care for them," says American Medical Association President Dr. Nancy H. Nielsen in a statement.



Obama Lifts Restrictions On Kids' Health Coverage

President Obama has lifted a directive instituted under the Bush administration that limited the State Children's Health Insurance Program's (SCHIP's) scope by penalizing states that enrolled middle-class children without proving that nearly all poorer children were enrolled first. "These requirements have limited coverage under several state plans that otherwise would have covered additional, uninsured children," Obama wrote to the Department of Health and Human Services, adding, "As a result, tens of thousand of children have been denied health care coverage." The restrictions also required that children be uninsured for a year before they could enroll, and at least 95 percent of SCHIP- or Medicaid-eligible children had to be enrolled in those programs already before states could start to cover higher income children. "The way I see it, providing coverage to 11 million children through CHIP is a down payment on my commitment to cover every single American," Obama said at the bill-signing ceremony.



Feds May Make Health Insurance Easier After Layoff

The federal government's stimulus plan makes it easier for people to retain health insurance if they lose their job. The law would expand COBRA, which currently allows unemployed individuals to keep health insurance from their former job for up to 18 months if they pay for it in full. The modified COBRA would provide recently unemployed workers with a 65 percent subsidy to help pay their COBRA coverage for up to 12 months. Individuals who lose a job they had for 10 years would be allowed to stay on COBRA at their own expense up to age 65, if they do not get another job with insurance first. People ages 55 and up would also be allowed to do so irrespective of the 10-year requirement. But companies that have less than 20 employees do not qualify for COBRA, so people who lose their jobs from such firms would likely be incorporated into Medicaid. States that get extra money under the initiative would have to reduce some of the cuts they recently made to the program.



Taking a Financial History: Determining the Health of Your Patient's Credit Rating

Physician practices and hospitals increasingly are turning to credit checks as patients' out-of-pocket costs rise with the growing popularity of high-deductible health plans. Companies that provide credit information to healthcare providers typically categorize individuals as more or less likely to pay their medical bills so that collection efforts can be targeted to those better able to make payments. These firms also identify patients eligible for government assistance, charity care, or self-pay discounts and let providers know when payment plans are necessary. While some services focus on traditional credit histories, others provide information about income, home values, and medical bill payment history. Rebecca Kuehn of the Federal Trade Commission says these credit checks are legal if providers offer payment plans or deferred bill payment. However, Jeff Denning of Practice Performance Management says primary care physicians might find credit checks to be too costly and time consuming. Moreover, physicians might worry about ethical issues, as the American Medical Association says a patient's ability to pay cannot be a factor in treatment decisions.

Technology and Device Trends

New Technique Helps Painful Joint Disease

Swiss researchers led by Martin Stolz of the University of Basel have come up with a way to fast-track the diagnosis of people with osteoarthritis. An experimental "atomic force microscope" is designed to be minimally invasive. Its use entails tapping the surface of a joint with a tiny tip that responds to stiffness. Though there are presently no treatments to stop or check the loss of cartilage associated with osteoarthritis, early detection could give up to six month's warning to someone prone to the disease, allowing the patient to take appropriate measures, such as losing weight or exercising more, to help conserve tissue. The study appears in the journal Nature Nanotechnology.



University of California Engineers Develop Novel Method for Accelerating Bone Growth

Researchers at the University of California, San Diego, have published findings in the Proceedings of the National Academy of Sciences outlining how bone growth can be accelerated through the use of nanotubes and stem cells, which could lead to quicker and improved recovery for patients undergoing orthopedic surgery. The researchers used a nano-bio technology of placing mesenchymal stem cells on ultra-thin titanium oxide nanotubes to convert the conversion paths into osteoblasts, or bone-building cells. "What we anticipate through our research is that if the surgeon uses titanium oxide nanotubes with stem cells, the bone healing could be accelerated and a patient may be able to walk in one month instead of being on crutches for three months," said Sungho Jin, a materials science professor. "Our in-vitro and in-vivo data indicate that such advantages can occur by using the titanium oxide nanotube treated implants, which can reduce the loosening of bones." The exact change in nanotube diameter can be controlled to induce selective differentiation of stem cells into osteoblast cells. Nanotubes with a larger diameter cause cells growing on their surface to elongate dramatically more than those with a small diameter; the larger-diameter nanotube promotes quicker and stronger bone growth. Though other groups have reported the use of nano topography to induce preferred differentiation, the studies were for the most part done on polymer surfaces, which are not desirable orthopedic implant materials," said Jin.



A Low-Dimensional Sagittal-Plane Forward-Dynamic Model for Asymmetric Gait and Its Application to Study the Gait of Transtibial Prosthesis Users

Researchers have presented a model designed to help practitioners make informed design and selection decisions regarding transtibial prosthetic components while providing a basis for making the alignment process systematic. The researchers sought to extend a recently developed low-dimensional modeling approach for normal human gait to the modeling of asymmetric gait. The asymmetric model is applied to analyze the gait dynamics of a transtibial prosthesis user, specifically the variations in joint torque and joint power costs that occur with changes in sagittal-plane alignment of the prosthesis, mass distribution of the prosthesis, and roll-over shape of the prosthetic foot being used. The model predicts an increase in cost with addition of mass and a more distal location of the mass and the existence of an alignment at which costs are minimized. The predictions also suggest guidelines for the selection of prosthetic feet and suitable alignments.



Abstract News © Copyright 2009 INFORMATION, INC.

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