News From ACFAS

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This fall, “1st MTPJ A-Z Workshop and Seminar,” 2010’s regional CME success, will once again bring ACFAS’ top-rated continuing education to a city near you. Make your plans now to advance your surgical skills and knowledge through this contemporary, hands-on course.

ACFAS has teamed with Regional Divisions 1, 8, and 12 to bring this program to three convenient locations:

• Manhattan Beach Marriott, Manhattan Beach, Calif., Sept. 9–10
• Boston Marriott Burlington, Burlington, Mass., Oct. 21–22
• Best Western Lehigh Valley Hotel and Conference Center, Bethlehem, Pa., Dec. 2–3

Keep your eye on the ACFAS website for complete information and online registration, coming soon!
You may not have time to read all the research you’d like to, but in just a few minutes you can catch up with ACFAS’ Scientific Literature Review Monthly. Some of the latest reviews prepared for active foot and ankle surgeons by podiatric residents are:

Complications of Talus Fractures in Children, from the Journal of Pediatric Orthopaedics.
Reviewed by Mario Voloshin, DPM, New York Hospital Queens.

Single Stage Surgical Treatment of Infected Nonunion of the Distal Tibia, from the Journal of Orthopedic Trauma.
Reviewed by Pasquale Cancelliere, DPM, Beth Israel Deaconess Medical Center.

Browse new entries or the entire archive at Scientific Literature Reviews Monthly.

Foot and Ankle Surgery

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Researchers compared the mechanical stability of angle-stable locking construct with four screws with conventional five screw locking in intramedullary nailed distal tibia fractures under cyclic loading. Ten pairs of fresh-frozen human cadaveric tibiae were intramedullary nailed and assigned to either an angle-stable locking construct consisting of four screws or conventional five-screw locking. Bending stiffness of the angle-stable and the conventional fixation was 644.3 N/° and 416.5 N/°, respectively (P = 0.075, power 0.434). Torsional stiffness of the angle-stable locking (1.91 Nm/°) was significantly higher compared with the conventional one (1.13 Nm/°; P = 0.001, power 0.981). Torsional play of the angle-stable fixation (0.08°) was significantly smaller compared with the conventional one (0.46°; P = 0.002, power 0.965). The angle-stable locking revealed significantly less torsional deformation in the fracture gap after one cycle (0.74°) than the conventional one (1.75°; P = 0.005, power 0.915) and also after 1000 cycles (angle-stable: 1.56°; conventional: 2.51°; P = 0.042, power 0.562). Modes of failure were fracture of the distal fragment, loosening of distal locking screws, nail breakage, and their combination, equally distributed between the groups (P = 0.325).



Researchers assessed the effectiveness of percutaneous bicortical screw fixation for correcting displaced intraarticular zone I and displaced zone II fractures of the proximal fifth metatarsal bone through a study of 23 fractures. All fractures healed uneventfully following bicortical fixation, with a mean healing time of 6.3 weeks. The average AOFAS score was 94. All the patients reported no pain at rest or during athletic activity. The implant was removed in all cases at a mean of 23.2 weeks. There was no refracture in any of the cases.



Researchers assessed whether excision of the plantaris tendon would relieve symptoms of Achilles tendinopathy. Three patients with pain and stiffness at the mid-portion of the Achilles tendon were treated by excision of the plantaris tendon. Preoperatively, these patients experienced recognizable tenderness on palpation of the medial side of the mid-portion of the Achilles tendon with localized nodular thickening at 4–7 cm proximal to the insertion. The plantaris tendon was bluntly retrieved and excised with a tendon stripper through a 4-cm incision in the proximal calf. The researchers report a good-to-excellent outcome of this novel procedure in the three patients.

Practice Management

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There are various strategies medical practices can implement to remain solvent amid slowing cash flows. Experts advise practices to hold three to six months of cash in reserve to address any shortfalls, but many physicians say the tightness of money makes such a strategy unworkable. Tapping into personal reserves or deferring salary is a frequently used tactic. Meanwhile, medical practices can get in touch with a bank for a secured or unsecured line of credit, preferably before difficulties arise. Experts recommend that practices have access to a line of credit that can cover at least three to six months of operating costs. If short-term cash-flow shortfalls often happen at the start of the year, a practice can leave some money in the practice from the final months of the previous year to cover next year's bills. Experts advise practices to perform an audit to see where cash is going out and whether it is coming in suitably. If the shortfall occurs, the National CPA Health Care Advisors Association's Marc Lion suggests that the practice should examine its billing, collection, and denial management procedures. The practice can do this in-house or use the services of an outside consultant or accountant.



Small physician practices are lagging behind larger practices and hospitals in the adoption and employment of electronic health record (EHR) systems, and a study published in the Journal of the American Medical Informatics Association aims to better understand the obstacles that small practices face. Anxiety about future obsolescence is a significant barrier to small practices' EHR takeup. University of Massachusetts Medical School professor Sowmya Rao notes that small practices "only have so much money they can invest, they want to make sure what they get meets their needs and will not go obsolete in the near future." Helping healthcare providers, specifically small practices, become meaningful EHR users is the goal of regional extension centers (RECs) established by funding allocated under the HITECH Act. Harvard School of Public Health professor Ashish Jha says RECs must "develop real expertise in the needs of small practices."

Health Policy and Reimbursement

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Accountable care organizations (ACOs) will likely face start-up and first-year costs 6-14 times higher than HHS has estimated, according to a study released by the American Hospital Association. The study analyzed previous research of start-up and first-year costs of accountable care and similar organizations. ACOs need to develop 23 different capabilities across four categories: network development and management; care coordination, quality improvement and utilization management; clinical information systems; and data analytics, in their initial year. “The shared savings rate with ACOs should be adjusted to reflect these costs in order to encourage and enable participation in this important program,” says president and CEO of the AHA, Richard Umbdenstock. The study was completed before the ACO rule was released on March 31 and does not include the costs of meeting the requirements of the Medicare Shared Savings Program.



Facing strong criticism of the proposed regulation for accountable care organizations (ACOs), the White House has announced new options to lure hesitant doctors and hospitals. The Department of Health and Human Services announced a new "Pioneer" ACO model, which officials promised "will provide a faster path for mature ACOs" and save Medicare as much as $430 million over three years. One incentive being offered is the opportunity to pocket more of the expected savings in exchange for taking on greater financial risk. These ACOs also will be able to work with private insurers and eventually Medicaid. For less mature health systems, the Centers for Medicare & Medicaid Services (CMS) announced it is considering helping cash-strapped provider groups form ACOs by giving them some of their share of anticipated savings upfront. CMS is requesting comments on the idea by June 17. In another step, CMS will offer four free educational sessions for providers interested in finding out more about starting an ACO.



The American Medical Association (AMA) detailed a plan to replace Medicare's sustainable growth rate (SGR) formula at a House Energy and Commerce health subcommittee hearing on May 5. In addition to repealing the SGR, the AMA plan calls for implementing a five-year period of positive Medicare payments based on practice costs, and testing and migrating to multiple payment models designed to augment the coordination, quality, and suitability of care while addressing cost concerns. "A new system should allow physicians to choose from a menu of new payment models, including shared savings, gainsharing and payment bundling programs across providers and episodes of care," said AMA President Cecil B. Wilson.

Medicine, Drugs and Devices

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By a narrow margin, the Food and Drug Administration's (FDA) Orthopaedic and Rehabilitation Devices Panel voted to recommend approval of an investigational bone graft device that regrows bones in the foot and ankle using a growth factor protein. A human platelet-derived growth factor (PDGF) known as rh-PDGF-BB regrows a bony mass between two bones, and it functions as a scaffold that supports the new growth; BioMimetic said the product, called Augment, would spare patients from undergoing a uncomfortable and invasive bone harvest procedure required for autograft. A number of panelists as well as the FDA questioned whether the protein used in the product may induce the growth of tumors, but the panel ultimately voted that its benefits offset the risks.



The Centers for Medicare & Medicaid Services will soon issue the first bonus payments for Medicare providers who have demonstrated meaningful use of electronic health records. However, physicians and other individual "eligible providers" won't receive their payments until they have billed Medicare for at least $24,000 in allowed charges this year, according to CMS.



Researchers evaluated the efficacy of treatment of arthrogrypotic foot deformities with the Taylor Spatial Frame, focusing on seven patients, or 10 feet, treated over a five-year period. All patients reached the preoperative correction goal and their frames were removed at 16.1 weeks, on average. Four patients developed pin tract infections, one patient had iatrogenic regenerate translation that was reduced by a residual program, one patient had recurrence of equines, and another exhibited partial recurrence of forefoot supination; two hindfoot varus deformities were corrected by calcaneal osteotomy at the time of Butt frame extraction.