News From ACFAS

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Listen to the latest ACFAS free podcast, Controversies in Trauma, and be privy to multiple viewpoints concerning whether or not to perform surgery on some of the most frequently-discussed traumatic foot and ankle injuries. The panel featured in this podcast is not afraid to debate one another's stance, and as you listen, you will find that in most cases, there are multiple solutions. Main topics discussed include:

• Jones Fractures
• Midsubstance Achilles Tendon Fractures
• Lisfranc Injuries
• Syndesmotic Ankle Injury
• Orthobiologics and Intramedullary Fixation on First Procedure

Visit acfas.org/education and click on eLearning and Podcasts to listen to this and other ACFAS podcasts. Do you feel like there’s not enough time in a day to read all the latest news in the world of surgical science? You're not alone. Check out our Scientific Literature Reviews at acfas.org/SLR to find summarized varieties of published articles including clinical studies, case reports, methodology and technical reports, clinical "pearls," literature reviews and more. A new batch is published monthly on the website by podiatric residents, so you know that what you read will be relevant to your day-to-day work. Here's a sneak peek at some of what March 2013 has to offer. Be sure to view the full listings at acfas.org/SLR.

• Role of Body Mass Index in Acute Charcot Neuroarthropathy, from the journal Foot and Ankle Surgery, reviewed by Ciara Nicholson, DPM
• The Pediatric Bohler’s Angle and Crucial Angle of Gissane: A Case Series, from the Journal of Orthopaedic Surgery and Research, reviewed by Wendell D. Wallace, DPM

Foot and Ankle Surgery

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An evaluation was held to ascertain the occurrence of injuries to the flexor and peroneal retinacula in hindfoot fractures as detected by ankle computed tomography (CT), with study patients identified through review of CT records at a single institution. Hindfoot fractures undergoing CT exhibited flexor retinacular trauma in 23.7 percent of cases and peroneal retinacular trauma in 10.2 percent. Partial tearing of the posterior tibial tendon was observed in 4.2 percent of cases, while the tendon was partially entrapped between fracture fragments in 16.1 percent. The peroneal tendon was seldom injured, being entrapped in 1.7 percent of cases. Pilon, distal tibial shaft, malleolar, talar and calcaneal fractures were all related to retinacular injuries. CT findings correlated well with surgical findings. There were zero false-positive CT findings, and only a single false-negative finding, a posterior tibial tendon entrapped at surgery, but in a normal position on the CT.


According to a four-year prospective study, adolescents with hypermobility in their joints – or double jointedness – are almost twice as likely as their normal-jointed counterparts are to develop musculoskeletal pain in their shoulders, knees, ankles and feet as they enter adulthood. The study found that 44.8 percent of teens in the study reported joint pain within the past month that lasted at least a day. The study was published in Arthritis & Rheumatism.


Pregnant women appear to be at an especially high risk for permanent structural and functional lower-limb changes due to a combination of greater weight on the joints with potentially greater laxity during pregnancy. A study of 49 women was held to determine whether arch height loss continues after pregnancy, with static and dynamic arch measurements obtained in the first trimester and at 19 weeks postpartum. Linear mixed models were employed to see whether outcome measures significantly changed overall or by parity. The researchers observed a significant decrease in arch height and rigidity indices with concomitant increases in foot length and arch drop. The first pregnancy accounted for the reduction in arch rigidity and the increases in foot length and arch drop, and no changes were spotted in the center of pressure excursion index.

Practice Management

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The Affordable Care Act (ACA) will fuel a number of changes in the healthcare industry over the next few years. One of those areas includes physicians' websites, which will need to be more detailed in the future to comply with the law. Additionally, websites will become a critical aspect of the doctor-patient relationship and method of communication. Experts say physician websites will require regular updates and must have features like integration with electronic medical records and health education information. The websites should also include personalization to attract new patients and integration of social media websites like Twitter of Facebook.


According to a survey of primary care physicians at Veterans Affairs (VA) hospitals, too much information is causing doctors to miss test results in offices heavily reliant on electronic health records (EHRs). The survey polled 5,001 primary care practitioners (PCPs) working at VA hospitals and found that 29.8 percent reported missing information that delayed patient treatment. The PCPs reported receiving 63 alerts a day, with 86.9 percent deeming them excessive and 69.6 percent saying they received more than they could handle.


Medical practices frequently embark on a lease renewal process or seek new space without a plan or strategy in place, which can result in wasted time and/or money. Because building and property owners will naturally look for advantages in their lease agreements, physicians or their practice managers must allow sufficient time for the process of finding the right space and negotiating a new or renewed lease, and carefully define their requirements as they consider all possible alternatives for reaching their desired objectives.

The complexity of the process dictates that permitting enough time to complete the build-out and other aspects of the project becomes a management necessity, and it can take as long as two years to properly lease and build out standard space of 10,000 square feet for a healthcare facility in an existing building. Some practices employ a management company and/or a specialist broker to help with these tasks, and in either case, success in a space search or lease renewal relies on careful planning and project plan implementation. Required plan elements include scheduling all of the organization's anticipated resources, developing an accurate and intense cost estimation method and establishing solid site selection goals such as size, location, price and whether the property will be a lease or a purchase.

Issues that should be addressed before commencing a site search or lease renewal negotiation include whether the practice has to maintain a certain image above all else, or whether price is the most critical factor; determining accessibility needs; whether parking is a priority; the importance of access to public transportation; and whether specific requirements as to where the practice is sited exist that override the other preferences. Practices should shun becoming over-infatuated with a specific property, because location, infrastructure and cost are crucial to operating a successful medical facility. It may be alternately necessary to negotiate on more than one site concurrently.

If a lease is involved, the practice should study all lease documents carefully to avoid concealed costs associated with operating expenses, taxes, landlord's services and the tenant's end-of-term requirements. If necessary, the practice should seek assistance from a lawyer specializing in real estate or a commercial real estate expert for issues such as exiting a lease that favors the landlord or the property developer, or pinpointing the right space that satisfies all requirements.

Health Policy and Reimbursement

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Physicians caring for Medicare patients say their practices will have difficulty keeping up with government mandates and growing demand for services when a 2 percent cut goes into effect on April 1st. While physicians have yet to feel the effects of sequestration, but the American Medical Association and other organized medicine groups say the cuts will become evident soon, narrowing practices' margins and interfering with reforms to improve health care. For physicians, receiving adequate pay for Medicare services has been an ongoing problem. The Medicare pay system has increased doctors' rates by only 4 percent since 2001, but the cost of operating a practice has increased by more than 20 percent, according to American Medical Association President Jeremy A. Lazarus, MD. "At the same time that Medicare physician payment rates have been frozen, physicians need to make investments in their practices to help design, lead and adopt new models of care delivery that can increase quality and reduce costs now and in the future," says Lazarus.


In light of sequestration, the Centers for Medicare & Medicaid Services has announced that the 2 percent reduction in Medicare will extend to meaningful use payments under the EHR Incentive Program. Electronic health record (EHR) advocates are concerned that adoption will slow significantly as providers see less benefit to investing their resources in the meaningful use program without the hope of adequate reimbursement. Providers may need to reexamine their health IT budgets, their plans and their goals to adjust to the cuts.


The Agency for Healthcare Research and Quality (AHRQ) has furnished a list of patient safety strategies that can improve healthcare quality through immediate implementation. Among the strategies are preoperative checklists, proper hand hygiene and barrier precautions to prevent healthcare-associated infections. AHRQ issued the study as an updated follow-up to its 2001 analysis of patient-safety practices. The study involved the review of 41 safety practices, culled from an initial list of over 100. A panel of healthcare stakeholders identified 10 of those practices as "strongly encouraged" for adoption, including prevention bundles for central line-associated bloodstream infections and ventilator-associated pneumonia. An additional 12, such as medication reconciliation, team training, practices to reduce radiation exposure and computerized provider order entry, were classified "encouraged" for adoption. The wide adoption of the top 10 strategies could lead to meaningful safety gains and better patient outcomes, AHRQ officials say. The report authors' reviews of the top 10 strategies were published in a special supplement in the Annals of Internal Medicine.


A new report from the National Commission on Physician Payment Reform recommends the elimination of standalone, fee-for-service payment to medical practices, followed by a five-year transition to a system founded on quality and value by testing new payment models. The commission determined that the fee-for service payment model as well as problems related to Medicare, such as sustainable growth-rate formula to pay physicians and the operation of the Relative Value Scale Update Committee (RUC), have created systemic issues. Still, the report concedes that "because fee-for-service will remain an important mode of payment into the future, even as the nation shifts toward fixed-payment models, it will be necessary to continue recalibrating fee-for-service payments to encourage behavior that improves quality and cost-effectiveness and penalize behavior that misuses or overuses care." The repeal of the SGR was another of the commission's recommendations, with the repeal's cost covered by cost reductions from the Medicare program as a whole. The elimination of higher payments for facility-based services that could be carried out in less expensive settings also was suggested. To improve the RUC, the report suggests that the committee "should continue to make changes to become more representative of the medical profession as a whole and to make its decision-making more transparent."

Medicine, Drugs and Devices

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A new study published in Medicine and Science in Sports and Exercise draws a connection between running barefoot or wearing minimalist "barefoot" shoes and the risk of foot injury. Thirty-six adults who ran between 15 and 30 miles per week while wearing normal running shoes were enlisted in the study. Baseline magnetic resonance imagery (MRI) scans were taken of their feet and lower legs to check for current injuries or problems. Half of the group was then assigned to continue running as before with the same footwear, while the other half was assigned to run wearing barefoot-style shoes, gradually increasing the mileage that they ran in them. A follow-up MRI was administered to both groups of runners after 10 weeks, and although there was no sign of injuries to or changes in the lower-leg tissues, more than 50 percent of the runners wearing the minimalist shoes showed early evidence of bone injuries in their feet. Most of the runners in this subgroup developed bone marrow edema that was rated at least level 2, indicating early bone injury.


The Food and Drug Administration's panel of health experts has voted against the continued use of the osteoporosis drug calcitonin salmon. The panel noted that there is little evidence that the drug is effective at treating brittle bones and that it may increase the risk of cancer. However, panel members who voted to continue using calcitonin salmon said that the drug should still be made available for osteoporosis patients who cannot take bisphosphonates such as Fosamax. The FDA typically follows the advice of its panels, though it is not required to do so.


A class of untreatable, often fatal bacteria is proliferating throughout U.S. hospitals, creating a nightmare scenario through their resistance to antibiotics, their high mortality rate and their ability to share their resistance genes with other bacteria. Centers for Disease Control and Prevention Director Thomas Frieden warns that failure to contain the spread of carbapenem-resistant Enterobacteriaceae (CRE) will soon make treatment of even common infections impossible. He says immune-compromised people who are hospitalized for a prolonged period or are living in a nursing home are particularly prone to CRE infection. Twelve years ago, just 1.2 percent of the common family of bacteria, Enterobacteriaceae, were resistant to carbapenem antibiotics, but that figure had increased to 4.2 percent by 2011. The CDC has outlined a six-step plan for hospitals. Among the practices hospitals should implement to contain CRE infections is finding out which, if any, of their patients have CRE; using precautions such as gloves and gowns to prevent contagion; removing catheters and other invasive devices as soon as possible; and having patients reconsider using antibiotics.