News From ACFAS

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It's not too late to come explore the brilliant minds, ideas and beaches at the ACFAS 2011 Annual Scientific Conference in Fort Lauderdale, Fla., March 9-12. On-site registration will be open from March 8 to March 11.

Plan your personal program of education, debate and sunshine today at the ACFAS 2011 website!

Is your Joint Commission-accredited hospital ready for MS.01.01.01? Revisions to Medical Staff Standard MS.01.01.01, formerly known as MS.1.20, go into effect March 31. The change addresses the Medical Staff’s self-governance and its accountability to the governing body for the quality and safety of patient care.

According to the Commission, the revised standard recognizes that while a hospital’s governing body is ultimately responsible for the quality and safety of care, the Governing Body, Medical Staff and Administration must collaborate to achieve this goal. Standard MS.01.01.01 provides the framework for constructing, writing and implementing Medical Staff Bylaws, which describe the Medical Staff’s organizational responsibilities and how the Medical Staff and Governing Body will work together.

ACFAS is an active member of the Joint Commission’s Liaison Network and Ambulatory advisory group (PTAC). Visit the Commission’s website to learn more.
The United States Bone and Joint Decade’s (USBJD) Young Investigator Initiative is a grant mentoring program to help early-career clinical and basic investigators learn to secure funding and other survival skills for pursuing an academic career by working with experienced researchers.

Investigators selected for the program attend two workshops, 12 to 18 months apart, and work with faculty in between to develop their grant applications. The deadline to apply for the next cycle starting with the Fall 2011 Workshop is July 15, 2011.

This program is open to junior faculty, senior fellows or postdoctoral researchers nominated by their department or division chairs, and to senior fellows or residents who are conducting research and have or will have a faculty appointment. For more information visit the USBJD website.
“Deformity correction is a very complex problem,” begins podcast moderator Byron L. Hutchinson, DPM, FACFAS, “and often we undertake it for joint preservation and joint salvage.”

You can explore approaches to this challenging topic with ACFAS’ latest free podcast. Listen in as fellow foot and ankle surgeons consider aspects including history, assessment, planning, techniques, potential complications and more.

Tune in whenever you are ready to hear the new podcast or browse the entire library at ACFAS e-Learning.

Foot and Ankle Surgery

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Researchers investigated whether a period of 2–3 weeks of immobilization in a cast, followed by early mobilization, could provide better functional results than longer periods of immobilization in cases of subtalar dislocation. Eight patients with uncomplicated medial subtalar dislocations were involved in the study. Immediate reduction under sedation and cast immobilization was provided in all cases. The rehabilitation protocol consisted of two completed weeks of immobilization and thereafter ankle range-of-motion exercises and partial weight-bearing mobilization. Patients were followed up for a mean period of three years. All patients achieved almost normal ankle range of motion and good clinical outcome (mean AOFAS score of 92.25). No radiographic evidence of arthritis or avascular necrosis of the talus was detected. Two patients complained of mild pain of the hindfoot. All patients returned to daily routine activities in about two months from injury.



Researchers evaluated the effectiveness of the fibula-pro-tibia plating technique—the insertion of one or more screws through the plate across the tibio-fibular space to the fibula—in managing difficult diaphyseal tibial non-unions. Thirty patients with diaphyseal non-union of tibia were managed with this technique. The time between injury and index operation ranged between six and 24 months. Sixteen patients had three surgical procedures before the index operation, ten had two procedures, and four patients had one. The duration of follow-up ranged between 10 and 38 months. The mean healing time was 3.5 months. Complications included two cases of delayed union, which required regrafting after four months, and two cases of infected nonunion, which resolved completely after achieving union and removing the plates. There was no negative effect from this fixation technique on ankle joint motion.



Researchers evaluated the clinical outcomes of arthroscopic microfracture of symptomatic cystic type osteochondral lesions of the talus (OLT), seeking to verify the efficacy of enhanced ankle MRI for predicting the nature of cystic osteochondral lesions. Twenty-two patients with cystic type OLTs were assessed. All underwent arthroscopic debridement and microfracture with a minimum of 18-month follow-up. At a median follow-up of 32 months, AOFAS scores improved from a median of 69 preoperative to 90 postoperative and VAS scores improved from a mean of 7.0 ± 1.8 to a mean of 1.7 ± 1.9. The overall patient satisfaction rate was 86 percent. Gadolinium-enhanced MRI scans performed on 21 feet all showed enhancement of varying intensities (from low to high) for the cystic OLTs, implying a vasculogenic potential.

Practice Management

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Hospitals are increasingly outsourcing administrative duties to companies with hundreds of physicians under contract as goals for quality, patient safety, and throughput become more critical to maximizing reimbursement. Companies that provide these services are increasingly gaining market share by being able to bundle subspecialties. Statistically, about two-thirds of civilian hospitals outsource some of their physician staffing needs to some other entity, according to Lynn Massingale, executive chairman of TeamHealth in Knoxville, TN, which works in 45 states and more than 500 hospitals to provide emergency medicine, hospital medicine, and anesthesiology physician services. The company grades its physicians on the same measures, and their compensation as well as their continuing employment is at least partly dependent on meeting those goals, incentivizing their physicians to work together for smooth transitions from the emergency department, reduce admission wait times for a bed, work together with the rest of the clinical staff, and effectively communicate.



A newly-released study on unwanted variation in elective surgical procedures suggest that many preventable errors are taking place because physicians are not listening to their patients. The report, from the Dartmouth Atlas Project, concludes that if physicians educated and listened to their patients more thoroughly, unwanted variation would decline. Researchers took an in-depth look at medical conditions involving decisions for elective care in cases where the statistics don't recommend a single course of action. The study found that much of the difference is attributable to physicians' preferences, not differences in patient populations. But in cases of elective procedures, giving a patient an undesired treatment is as much an error as wrong-site surgery, said Michael Barry, a co-author of the study. The study can be found here.



For small practices looking to recruit more physicians, recruiters suggest connecting with physicians who most likely want to work in one's area at one's type of practice. One way of establishing such connections is to have medical students and residents rotate through a practice, while state medical societies and similar entities also can be tapped for potential recruits. Experts note that networking is a much more valuable practice for finding not just doctors interested in working for a smaller practice, but also those who could be persuaded to do so. Upon making a contact, a physician or other recruiter should emphasize the positive attributes of a small practice, such as greater flexibility and independence and a significant link with patients. The structure and presentation of the compensation package can be critical, and compensation can be established using benchmarking data from various medical societies or consultancies. Hospitals can offer recruitment assistance to further their mission of physician alignment, and it is more probable that large institutions will have physician recruiters on staff. If a practice chooses to work with a search firm, experts advise contracting with multiple firms.



An orthopedic surgeon in Massachusetts has agreed to pay $500,000 to settle a wrong-site surgery malpractice suit brought by a patient on whom he had performed wrong-ankle surgery. The procedure was a tendon transfer to treat recurring pain in the patient's right ankle caused by inflammation of her posterior tendon. The orthopedic surgeon performed the surgery on the woman's left ankle, even though the right side had been marked. When the mistake was discovered after surgery, the woman elected to have physical therapy instead of surgery to treat her right-ankle pain. The defendant surgeon continued to provide her post-operative care. In the lawsuit, the patient claimed that the doctor was negligent in performing surgery on the wrong ankle, which required her to use a walking boot for five weeks, have surgical hardware removed, and undergo physical therapy and 10 months of rehabilitation.

Health Policy and Reimbursement

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Medicare's reimbursement system knowingly hurts patient care by underpaying doctors in 200 counties in 32 states a total of $3.2 billion, including $500 million in California alone, according to a lawsuit filed by seven California counties and physicians, who want to force the agency to fix the system. The suit contends that the federal fee schedule underpays physicians in certain counties by classifying those regions as rural, lower-cost counties, when they are in fact expensive places to provide care, often in areas that are now urbanized. The physicians' lawyer, Dario De Ghetaldi, says the geographic practice cost index results in physicians and other healthcare providers being paid between 12 percent and 24 percent less than their colleagues in neighboring, demographically similar counties for providing exactly the same services.



CMS has imposed new limits on the maximum number of medical records a recovery audit contractor may request from physicians and non-physician practitioners for complex reviews. Changes include:

* To qualify as a single entity for such requests, a practice must have only one tax identification number. If the practice has more than one location, the first three digits of the ZIP codes at all locations must be the same to qualify as one entity.

* The number of records that RACs may request from each entity in a 45-day period depends on the number of physicians or other practitioners at each entity. RACs may request a limit of 50 records from a group of 50 or more practitioners, up to 40 records for a group of 25-49, up to 25 records from a group of 6-24, and up to 10 records from a group of five or fewer.

* If a practice receives a request for more documents than the guidelines would allow, it may request the RAC to modify the limit and provide documentation of its size.

* CMS may give an RAC permission to exceed the limits. Impacted practices will be notified of the change in writing.

The CMS release can be found here.



RAND Health, a division of the not-for-profit RAND Corp., has released a report analyzing proposed models of payment reform and the current state of performance measurement. The report, commissioned by the National Quality Forum, identifies 90 payment reform programs that are either planned or currently in place in some capacity. It then classifies those programs into 19 payment models, including global payment, medical home and accountable care organization shared savings. The report can be accessed here.

Medicine, Drugs and Devices

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Choosing an electronic health record (EHR) can be an overwhelming process, but practices that allow physicians and nurses to actively participate in the selection process can incorporate a system that makes daily work flow more efficient. In the office, EHRs can simplify insurance verification, automate appointment reminders, and make it easy for staff to inform patients about account balances. On the clinical side, EHRs can help nurses identify patients with preset alerts or color codes and better enable physicians to see patients in the order they were scheduled. They provide flowsheets to review vital signs and patients' progress in terms of weight loss and blood pressure control, and systems with prescription writer tools make it easy to update and refill medication and match medication with the appropriate ICD-9 code when it is ordered. Additionally, lab and diagnostic test results are forwarded from a document management tool to the patient's chart and can be made available to patients through an online portal.



Researchers investigated whether venotonic drugs had an effect in clinical outcome of patients with ankle sprain. Eighty-one patients with type II and III ankle sprain were screened and randomly assigned for receiving standard conservative treatment alone (control group, 39 patients) or with oral intake of a venotonic drug (micronized purified flavonoid fraction, Daflon 1,000 mg × 3) for 20 days (study group, 42 patients). Measurement of the circumference of ankle region in two different locations and assessment of pain intensity with the Visual Analogue Score were performed at the time of patients’ admission and during the 7th and 20th posttraumatic day. There were no significant differences between the two groups regarding the values of perimeter of ankle joint or pain intensity at all the examined time points.



Purdue University researchers are developing a robotic system that can recognize hand gestures during a surgical procedure. The system would be used to control a robotic scrub nurse or to tell a computer to show medical images of the patient, both of which could help reduce the length of procedures and the risk of infection, says Purdue professor Juan Pablo Wachs. The system uses algorithms and a camera to identify hand gestures as commands to instruct the robot or computer. The gesture algorithms are based on anthropometry, which involves predicting the position of the hands based on the position of the head. The researchers also are developing ways to anticipate what images the surgeon will need to see next and what instruments will be needed, says Wachs.