News From ACFAS

ACFAS Fellows who meet criteria for election to the Board of Directors are encouraged to submit a nomination application by October 1. Two 3-year director terms are open for nomination this year. The Nominating Committee will announce recommended candidates to the membership no later than November 10. Candidate information and ballots will be mailed to all voting members no later than December 24. Ballots must be returned to the ACFAS office by January 24, 2011. New officers and directors will take office during the ACFAS 2011 Annual Scientific Conference on March 9–12, 2011, in Fort Lauderdale, Fla.

For complete details on the recommended criteria for candidates and the nomination application, visit the ACFAS website, or contact Executive Director Chris Mahaffey at 773-693-9300, x 1305, or mahaffey@acfas.org. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Mary E. Crawford, DPM, FACFAS, at 425-330-9639 or dockmary@aol.com.

The ACFAS Practice Management Committee is investigating coding and billing resources for members of the College. Please take our very short survey so we can better serve you!

The September/October issue of the Journal of Foot & Ankle Surgery will mail soon, but ACFAS members can use their free access to read it now! The new issue features an instructional course on high fibular fracture in association with triplane fracture, and nine case reports available only online, including:

• An unusual etiology for adult-acquired flatfoot
• Hourglass ganglion cyst of the foot
• Surgical repair of abductor hallucis muscle herniation

… and many more. Don't wait to read the original research, literature reviews, tips, quips and pearls, and online-only case reports. Log on to the ACFAS website and follow the links in the right menu for seamless access to the new issue of JFAS.


FootHealthFacts.org is now on Facebook! Become a fan of the leading foot and ankle health information page on the social network and share it with your patients and community. Fans will be the first to read the latest consumer health information from ACFAS and have a direct link to FootHealthFacts.org, where they can find a foot and ankle surgeon in their area or read a variety of comprehensive resources on foot and ankle conditions.

Just log on to your Facebook account and “like” Foot Health Facts to become a fan and join the conversation!

Quickly catch up on the latest research with ACFAS’ Scientific Literature Reviews. In just a few minutes you can browse research abstracts prepared by podiatric residents from journals you might not usually read. Current abstracts include:

Takedown of Ankle Fusion and Conversion to Total Ankle Replacement, from Clinical Orthopaedics and Related Research.
Reviewed by JoAnn Marie Zotis, DPM, OCPM/UHHS Richmond Medical Center.

Access new entries or the entire archive anytime at Scientific Literature Reviews.

Foot and Ankle Surgery

Is Obesity Protective Against Wound Healing Complications in Pilon Surgery?

A traumatized, limited soft tissue envelope contributes to wound healing complications in the open treatment of pilon fractures. Obese patients have larger soft tissue envelopes around the ankle, theoretically providing a greater area for energy distribution and more accommodation to implants. Researchers examined whether ankle dimensions in obese patients are larger than in lean patients and if the increased soft tissue envelope volume translates into fewer wound complications. A consecutive series of 176 pilon fractures treated from March 2002 to December 2007 were retrospectively reviewed. Patients with body mass index (BMI) >30 were compared to those with BMI <30 for CT-derived ankle dimensions and wound complications. Thirty-one fractures in obese patients were compared to 83 in lean patients. The average ratio of bone area to soft tissue area at the tibial plafond was 0.35 for the obese group and 0.38 for the lean group. There were 8 major wound-healing complications. Four occurred in the obese group (13 percent) and 4 in the lean group (5 percent). The researchers concluded that obesity does not appear to be protective of wound-healing complications, but rather there is a trend toward the opposite.



Outcome of the Functional Treatment of First-Time Ankle Inversion Injury

Avulsion fractures of the lateral malleoli in ankle inversion injuries are often undetected on routine radiographs and, as a result, managed as ankle sprain. Researchers compared the outcomes of functional treatment between the first-time severe ligament injury and avulsion fracture of the lateral ankle investigated how the anterior talofibular ligament (ATFL) view and the calcaneofibular ligament (CFL) view affects the diagnosis of the avulsion fracture and outcome of functional treatment of the ankle inversion injury. A total of 276 consecutive patients with a first-time severe ankle inversion injury were classified into a ligament injury group (group I) or an avulsion fracture group (group II) on the basis of physical examination and radiographs. The patients with a negative finding on routine radiographs and a positive finding on the ATFL or CFL were classified as group IIA. A total of 202 (73.2 percent) patients were in group I and 74 (26.8 percent) were in group II. In all, 50 patients in group II showed negative standard radiographs and a positive ATFL or CFL view. Clinical and radiographic results of group II were inferior to those of group I at the one-year follow-up. The outcome of group IIA was comparable to that of group I.



The Modified Oblique Keller Capsular Interpositional Arthroplasty for Hallux Rigidus

Researchers compared a cohort of 10 patients (10 toes) who had undergone the modified Keller arthroplasty with a group of 12 patients (12 toes) who had undergone a first metatarsophalangeal joint arthrodesis for hallux rigidus at an average of 63 and 68 months, respectively. Clinical outcome differences existed between the groups, with AOFAS scores being significantly higher for the arthroplasty group than for the arthrodesis group. The arthroplasty group had a mean of 54° of passive and 30° of active range of motion of the first metatarsophalangeal joint. The plantar pressure data revealed significantly higher pressures in the arthrodesis group under the great toe but not under the second metatarsal head.

Practice Management

Tips for Hiring New Staff

There are several key steps medical practices should take when hiring new staff, such as accurately defining the job description based on duties and desired skills and attributes. Potential hires should be informed of other issues not covered in the job description, such as salary increases, promotion opportunities, and vacation time. During the interview, it may be worthwhile to ask questions that are unexpected and for which the prospect would not have a prepared answer, such as what they liked or did not like about their previous job or boss. Another approach is to ask the prospect about a likely scenario in the office and how he or she would handle it. Promising candidates should participate in at least two interviews and be given quizzes to test their ability to proofread, write, or do math problems. If an applicant is deemed acceptable, he or she can come in for a test day to interact with other staff members who can subsequently give feedback. Experts also advise practices to check references, confirm past employment, and conduct background checks based on such things as credit, motor vehicle, and criminal record checks.



Do Orthopedic Physician-Owners Perform More Surgery?

Orthopedic surgeons with ownership interests in ASCs or specialty hospitals are more likely to perform common outpatient procedures than physician non-owners, according to research published in the August issue of Archives of Surgery. For the study, researchers analyzed 5 years of claims data from a large private insurer in Idaho. Patients of physician-owners were found to be 54 percent to 129 percent more likely to undergo carpal tunnel repair, 33 percent to 100 percent more likely to have their rotator cuffs repaired, and 27 percent to 78 percent more likely to undergo arthroscopic surgery when compared to patients of surgeon non-owners.



Imaging at the Doctor's: Good Thing or Transparent Ploy?

For years, doctors with patients who needed an MRI or another medical imaging procedure had to send their patients to outside imaging centers. However, a growing number of doctors are bringing medical imaging machines into their own practices, which doctors say enable them to work more closely with medical imaging technicians and provide their patients with immediate results. However, critics say these self-referrals allow physicians to fatten their profits, and result in excess tests and higher Medicare spending, and should be banned.

Under the healthcare overhaul, doctors who refer Medicare and Medicaid patients to in-house imaging machines must disclose in writing that they own the equipment, and will also have to tell patients that they can get the services elsewhere and provide them with a list of 10 alternative sites within 25 miles. These rules go into effect in 2011.

Health Policy and Reimbursement

10-Year Medicare Physician Pay Fix Would Cost $330 Billion, CBO Says

In an August 25 letter to Sen. Mike Crapo (R-Idaho), the Congressional Budget Office (CBO) estimates that adoption of a 10-year Medicare payment fix for physicians would cost $330 billion. Under current law, payment rates for physicians' services will be reduced in December to about 21 percent below their 2009 level, with additional rate reductions taking effect in future years. CBO estimates that the cost of freezing Medicare physician payment rates at the 2009 level for six months during the second half of calendar year 2010 and allowing for an inflation update for 2011 through 2019 would be $278 billion. But CBO said that estimate did not include the enactment of legislation modifying physician payment rates in 2010. The legislation increased physician payment rates by 2.2 percent for June through November of 2010, with an estimated cost of $6.3 billion over the 2010-2011 period.

Congress, meanwhile, is expected in a lame-duck session to address Medicare physician payments that would otherwise decrease by 21 percent in 2011, according to Hart Health Strategies.



MGMA Urges Changes to CMS' e-Scripts Plans

CMS has been urged by the Medical Group Management Association (MGMA) to amend the penalties scheduled for its e-prescribing incentives initiative. The CMS deployed the eRX program last year, offering a 1 percent bonus payment starting in 2011 for doctors or group practices that would qualify as "successful electronic prescribers" as defined in the Medicare Improvements for Patients and Providers Act of 2008; but in 2012 the program will impose penalties on providers who are unsuccessful e-prescribers. The MGMA concurred with the CMS that low-volume prescribers should not receive penalties, but suggested in a comments letter that the agency "exercise additional flexibility in assigning penalties." The CMS additionally says that the receipt of an incentive payment under Medicare's electronic health records incentive program will not obviate the application of the penalty to providers under the separately administered eRX program, and avoiding the penalty will entail the physician or group practice meeting "the relevant eRX penalty criteria for being a successful electronic prescriber."



The Medical Loss Ratio Requirements Are Being Carefully Crafted

In the new health care law, section 2718 requires health insurers to spend a specified minimum amount on "activities that improve health care quality," writes Timothy Jost, consumer representative for the National Association of Insurance Commissioners (NAIC). Section 2718, Jost writes, "allows for various deductions from the premium revenues counted in the denominator, excluding some taxes, regulatory fees, and risk adjustment payments." The provision also allows the U.S. Department of Health and Human Services to "adjust" required ratios on an individual state basis during a transitional period, which may help prevent market destabilization, and also requires the implementation of regulations that take the situation of newer, smaller, and varied plans into account. Section 2718 also delegates to the NAIC the task of establishing definitions and methodologies for the section's implementation.



Tighter Medical Privacy Rules Sought

The Obama administration is rewriting new rules on medical privacy after an outpouring of criticism from consumer groups and lawmakers, who say the rules do not adequately protect the rights of patients. Under temporary rules issued by HHS Secretary Kathleen Sebelius, healthcare providers and health insurance plans would have to notify patients of a privacy breach only if they found that the violation posed “a significant risk of financial, reputational, or other harm to the individual." No notification is required if a hospital or an insurer believes, after a risk assessment, that the patient will not be harmed, the rules said. Critics have denounced the rules on the grounds that they fall short of offering patients the fullest protections possible, arguing that risk is in the eye of the beholder.

Hospitals and insurance companies, seeking to maintain greater control over patient notification, generally support the rules. After analyzing comments from the public, Sebelius developed final rules and submitted them to the White House Office of Management and Budget for approval in May. At the urging of the White House, however, she withdrew the rules to allow for further consideration.

Technology and Device Trends

A Surgeon's Hands or a Robot's?

Since it was first approved by the FDA in 1999, robotic surgery has quickly grown, and can now be used in dozens of procedures. Supporters of robotic surgery say it is less invasive and more accurate. However, that does not guarantee that the outcomes are better. Some doctors believe that additional research is needed to prove that certain robotic procedures are better than traditional options, and recent reports of problematic robotic surgeries have led to concern about whether all doctors who use the devices have received sufficient training.



Prenatally Diagnosed Clubfeet: Comparing Ultrasonographic Severity With Objective Clinical Outcomes

Researchers set out to lower the false positive (FP) rate for prenatally detected clubfeet and predict clinical severity through use of a new prenatal sonographic classification system. All pregnant patients referred to the fetal care center at the researchers' institution were retrospectively identified, and 113 fetuses were identified in toto. Follow-up data was available for 107 fetuses, 17 of whom were terminated or died not long after birth. A unique sonographic severity scale for clubfoot was assigned by a radiologist specializing in prenatal obstetric sonography (US) to each fetus according to specific anatomic features, and the prenatal sonographic scores were then evaluated with respect to final postnatal clinical diagnosis and to clinical severity. Of the 83 remaining fetuses with a prenatal diagnosis of at least one clubfoot, 67 had a clubfoot documented at birth, while a foot categorized as "mild" on prenatal US was significantly less likely to be a true clubfoot at birth than when a "moderate" or "severe" diagnosis was assigned. The FP rate fell to 3/42 if mild clubfoot patients were excluded from the analysis. The sonographic scoring system yielded improved prenatal identification of a true clubfoot and a reduction in the FP rate, while it is less probable that an isolated mild clubfoot diagnosed on a prenatal sonogram will be a clubfoot at birth.



U.S. Judge Rules Against Obama's Stem Cell Policy

Chief Judge Royce C. Lamberth of Federal District Court for the District of Columbia has blocked President Obama’s 2009 executive order that expanded embryonic stem cell research, saying it violated a ban on federal money being used to destroy embryos. The ruling has come as a shock to scientists at the NIH and at universities across the country, which had viewed the Obama administration’s new policy and the grants provided under it as settled law.



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