News From ACFAS

Last week College staff joined 100+ other healthcare association and state government representatives for the annual Joint Commission (JC) Liaison Network Forum. A topic of particular interest to DPMs is a new attempt by JC to work with the Centers for Medicare and Medicaid Services (CMS) to update the Conditions of Participation (CoP), some of which have not been reviewed since 1986. With Donald Berwick, MD, assuming the helm of CMS recently, all parties appear optimistic that the CoPs and the related JC standards can be examined and modified to reflect current practice, which could assist ACFAS members in achieving additional recognition and parity in key areas.

For questions about the conference, contact ACFAS Director of Health Policy, Practice Advocacy and Research Kristin Hellquist.

Research is essential to the medical profession and ACFAS is at the forefront of research for foot and ankle surgeons. If you’re involved in a study, submit your manuscript or poster to be considered for presentation at the ACFAS Annual Scientific Conference, March 9–12, 2011, in Fort Lauderdale, Fla. Follow the links below for full guidelines and applications:

• Manuscript submission NEW deadline: August 15, 2010
• Poster submission deadline: October 1, 2010

“Somewhere between arthrotomy or arthroscopy and total ankle replacement or fusion is where this procedure has a home,” says moderator Byron L. Hutchinson, DPM, FACFAS, in the new ACFAS podcast, “Chronic Ankle Pain: Arthrodiastasis.” Although ankle arthrodiastasis may seem controversial to some, the three experienced surgeons on the panel quickly find consensus on indications, goals, techniques, technology and protocols in surgery and recovery.

Visit ACFAS e-Learning today to download this bonus podcast, the second for July, and listen in on the comprehensive discussion of how this procedure can benefit sufferers of chronic ankle pain.

“It’s really about making the patient as pain-free as possible,” concludes panelist Bradley M. Lamm, DPM, FACFAS. “I think we’re doing all we can in all aspects to try to salvage that ankle joint.”

Catch up on research in journals you may not usually read with ACFAS’ Scientific Literature Reviews. Article abstracts are prepared for the interests of foot and ankle surgeons by podiatric residents. Current abstracts include:

Lower Extremity Arterial Injury Patterns and Reconstructive Outcomes in Patients with Severe Lower Extremity Trauma: A 26-Year Review, from the Journal of the American College of Surgeons.
Reviewed by Judianne Walker, DPM, Maricopa Medical Center.

Read this and many more reviews on the ACFAS website.

Foot and Ankle Surgery

Cartilage Lesions in Anterior Bony Impingement of the Ankle

Researchers investigated the correlations between spur severity, clinical characteristics, and articular cartilage lesions in patients with anterior bony impingement. The study included 57 ankles in 57 patients who had undergone a spur resection for anterior impingement, excluding spurs in patients with osteoarthritis with joint space narrowing. The duration of pain, degree of sports activity, and presence of mechanical instability showed no relation to spur severity. Of the ankles, 28 (49.1 percent) were grade 1, one (1.8 percent) was grade 2, and 28 (49.1 percent) were grade 3. Cartilage lesions were present in 46 ankles (80.7 percent). Spur severity was correlated with the degree of cartilage lesions (Spearman ρ = 0.30). Grade 3 ankles had more spur fragmentation than grade 1 or 2 ankles. The mean length of the tibial spurs with tram-track lesions or spur fragmentation was longer than that without these lesions.



Ultrasound-Guided Subsartorial Approach Found Effective for Saphenous Nerve Block

An ultrasound-guided subsartorial approach to saphenous nerve blockade is a moderately effective means to anesthetize the anteromedial lower extremity, researchers suggest. They also concluded that the success rate for this procedure is based on stringent criteria with an endpoint of postoperative analgesia. During a four-month period, researchers reviewed the medical records of all patients receiving a subsartorial saphenous nerve block for lower extremity surgery. Patient demographics and data were recorded, including block characteristics, intraoperative anesthetic management, pre-block, post-block, and postoperative pain scores as well as postoperative analgesic dosing. Preoperative block success was defined by minimal intraoperative analgesic administration and a pain score of 0 in the postanesthesia care unit not requiring analgesic supplementation. Postoperative block success was defined by reduction of pain score to 0 without need for additional analgesic dosing. A total of 39 consecutive patients were identified as receiving an ultrasound-guided subsartorial saphenous nerve block. Overall, this ultrasound-guided technique was found to have a 77 percent success rate.



Treatment of Severe Fractures of the Calcaneus by Reconstruction Arthrodesis Using the Vira System

The surgical applicability and clinical results of the minimally invasive Vira system in treatment for severe calcaneus fractures was studied. The Vira system comprises a fixation implant and a specific jig for the reduction of the fracture and placement of the holed nail and two screws for fixation to the talus. The study involved 37 patients with acute intra-articular calcaneus fractures treated by reconstruction and primary fusion with the Vira system, 33 of whom were analyzed over a period of two years. All patients were prospectively assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scale, plain radiographs, and computed tomography scan studies. The median AOFAS score one year following surgery was 75.43 points. The result was deemed good and very good in 31 cases, and mild in five cases and poor in one case. Eighty-one percent of the patients could wear normal shoes, while the footprint and the alignment of the heel were considered normal in all cases, although seven patients exhibited a mild valgus deviation.

Practice Management

Many Doctors Don't Report Incompetent Colleagues

A third of doctors who knew of peers who were incompetent or impaired did not turn them in, according to a study published in The Journal of the American Medical Association. Researchers evaluated responses from 1,891 doctors in a variety of specialties. The survey found that 17 percent of physicians had direct knowledge of a colleague in their practice or hospital whom they believed was impaired or incompetent.



Physician-Patient E-mail Improves Quality, Study Finds

A new study published in Health Affairs suggests that physician-patient e-mailing may improve the quality of care. Researchers at Kaiser Permanente followed 35,423 patients with diabetes, hypertension, or both over a two–month period. Those that used e–mail to communicate with their doctors saw a statistically significant improvement in measures from the Healthcare Effectiveness Data and Information Set. The study was a follow–up to a previous one, which found that e–mail communication could reduce the need for office visits by up to 10 percent and reduce the telephone calls to a practice by 14 percent.



What Final Meaningful Use Rules on EMRs Mean for Doctors, Hospitals

The U.S. Centers for Medicare and Medicaid Services (CMS) has issued its final version of meaningful use rules, which the government will employ to qualify electronic medical record (EMR) deployments for billions of dollars in incentives. CMS decreased the number of quality measures from 90 to 44, and doctors only have to report electronically on three. CMS does little to push the electronic exchange of EMRs between hospitals and among states in the final rules, and there remains a rigid 2015 deadline for implementing EMRs as mandated by the Health Information Technology for Economic and Clinical Health Act of 2009.

According to the final rules, reimbursement payments for Medicare providers may commence no sooner than October 2010 for qualifying hospitals, and no sooner than January 2011 for eligible health care professionals; the rules permit providers to start EMR deployment in 2012, 2013, or 2014, and still have two full years to implement stage one standards, says GE Healthcare IT's Mark Segal. Health care providers only have to record 90 days of EMR data to disclose to CMS in order to be eligible for reimbursement, rather than 12 months as required in the preliminary rules; also, Segal says CMS amended the percentage of patients that had to be sent electronic reminders for care management, from 50 percent of all patients 50 years old or over to 20 percent of all patients 65 and over.

Health Policy and Reimbursement

Domestic Medical Travel is Taking Off for Surgery Deals

Gillette, Wyo., resident John McNally's employer offered to pay his travel expenses if he was willing to have his knee-replacement surgery in Fort Collins, Colo., a five-hour drive from his home. The Colorado surgery center had a track record of success with such operations, and it charged significantly less than the hospital in Gillette. Despite feeling "every bump" on the ride back, McNally was so pleased with the operation's outcome that he returned to Colorado to have the other knee replaced a few months later. A growing number of employers and insurers are offering financial incentives to encourage patients to consider "domestic medical travel," to take advantage of high-quality care at lower prices. The strategy is helping employers reduce their costs 20 percent to 40 percent. Employers with domestic travel programs say they can save money by negotiating a single rate, including fees for surgeons, anesthesiologists, and all medical care up until the patient is discharged. Domestic medical travel could revolutionize the health care industry by creating "a truly national competition," according to Health Capital Group consultant Jim Unland. Employers and insurers have sent patients to "centers of excellence" for organ transplants and other complex procedures for years, but domestic medical travel is starting to be used in other types of medical care, including back and cardiac-bypass surgeries, and even relatively minor treatments like knee cartilage repairs. Domestic medical travel does face some challenges. For example, it could backfire if employers and insurers focus solely on costs, instead of quality, and while most programs are voluntary, major financial incentives could blur the line between choice and necessity.



Senate Moves to Extend Unemployment Benefits, Still Lacking COBRA Subsidy

The Senate broke a stalemate on Tuesday over extending unemployment benefits for Americans who have been out of work for six months or more, voting to override Republican objections that the bill’s costs would add to the federal deficit. Democrats, however, abandoned plans to extend subsidies that pay up to 65 percent of COBRA health insurance premiums for unemployed workers.



Washington State Supreme Court Strikes Down Medical Liability Reform

The Washington state Supreme Court has struck down another part of a 2006 medical professional liability reform that was intended to curb medical malpractice lawsuits. The law required health providers be given a 90-day notice before a medical malpractice suit could be filed, which the court held was unconstitutional. Steve Suchil, American Insurance Association assistant vice president of state affairs for the Western region, says the AIA is "very disappointed" because the court is "removing a pretty useful tool" aimed at lowering the cost of medical professional liability insurance. Before the 2006 reforms, "there was a real concern about the cost of litigation," Suchil notes. At the time, reform proponents said a growing number of physicians were closing their practices or moving out of state in the interest of finding more affordable medical liability coverage. The state had been listed by the American Medical Association as one in a "medical malpractice crisis" at the time. In September 2009, the court also struck down another piece of the 2006 law - requiring a certificate of merit from a medical expert before suing - as unconstitutional. "These were the biggest part[s] of the reform," Suchil says. "These were pretty reasonable reforms."

Technology and Device Trends

Hindfoot Correction and Stabilization by Pins in Plaster After Surgical Release of Talipes Equino Varus Feet in Older Children

Congenital talipes equino varus is one of the most common congenital abnormalities affecting the lower limb and can be challenging to manage. Hindfoot deformity is considered the most difficult to treat because the calcaneus is often small and thus difficult to control during casting after surgical release in severe or relapsed cases. Researchers used three pins to control and maintain the hind foot correction during casting in 47 cases (59 feet) using a modified, coronal plane, transverse calcaneal pin. The pin is inserted from medial to lateral through the calcaneus to correct the varus mal-positioning of the calcaneus in the sagittal plane and to provide a better control on the small sized, hindfoot during casting. The results were favorable after the application of this transverse pin.



Trials Set to Begin for Stem Cell Osteoarthritis Treatment

A stem cell therapy for osteoarthritis is to be tested on patients for the first time in the United Kingdom. The year-long trial could be the first step towards a new treatment that avoids the need for joint replacement surgery. The trial, funded by the charity Arthritis Research UK, will use stem cells extracted from bone marrow to repair worn knee cartilage.



Time-Resolved MR Angiography Useful for the Diagnosis of Traumatic Lateral Plantar Artery Pseudoaneurysm

The researchers present a case of traumatic pseudoaneurysm of the lateral plantar artery following a foot laceration. Diagnosis was made by the use of high-resolution, time-resolved contrast-enhanced 3D magnetic resonance angiography, also referred to as TRICKS (time-resolved imaging of contrast kinetics). They found that this technique provided high spatial resolution for the arterial anatomy as well as temporal resolution, which allowed better delineation of the hemodynamic characteristics of the pseudoaneurysm.



Abstract News © Copyright 2010 INFORMATION, INC.

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