News From ACFAS

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The 2011 ACFAS Clinical and Scientific Research Grant has been awarded to Naohiro Shibuya, DPM, MS, FACFAS; Daniel Jupiter, PhD; and Javier La Fontaine, DPM, MS, FACFAS, for their project, “Assessment of Risk Factors Associated with Symptomatic and Non-symptomatic Flatfoot Deformity.”

“I’m very excited to have yet another substantial entry in our growing list of research studies funded under this grant,” says ACFAS President Glenn M. Weinraub, DPM, FACFAS. “The art of podiatric foot and ankle surgery is always evolving with advances in treatments, techniques and technologies. Having good, unbiased research to guide us can only help us be better surgeons and improve patient outcomes.”

For more information on the grant and to view past winners, visit acfas.org/grant (member login required). Are you an avid researcher? The College is recruiting investigative sites for a new multi-center retrospective study on predictive variables associated with successful and unsuccessful outcomes when performing subtalar joint arthroereisis in adults and children. Subjects and sites will be compensated for their time. If you’d like to participate, please complete and return the application on the ACFAS website.

Criteria for site selection include:

• Required one-year contractual commitment by the investigative site.
• Primary investigator at each site in good standing with ACFAS.
• Volume and variety of patients treated for symptomatic non-neuromuscular flatfoot with subtalar arthroereisis during the past 10 years.
• Past participation in multi-center studies.
• Professional reputation for scholarly activity.

Keeping up with the latest trends can be difficult at the speed with which research and technology is growing and changing. Stay ahead of the curve with Scientific Literature Reviews Monthly on the ACFAS website. In just a few minutes you can read abstracts prepared by podiatric residents from journals you may not regularly see. The latest edition includes:

Extracorporeal Shock Wave Therapy for Nonunion of the Tibia, from the Journal of Orthopaedic Trauma.
Reviewed by C. Keith McSpadden, DPM, The Western Pennsylvania Hospital.

Foot and Ankle Reconstruction: Pedicled Muscle Flaps versus Free Flaps and the Role of Diabetes, from Plastic and Reconstructive Surgery.
Reviewed by Matthew J. Hentges, DPM, The Western Pennsylvania Hospital.

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

Futurescan™

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Healthcare, especially healthcare financing, is changing day by day. To help provide some basic education on current trends in the U.S. healthcare industry, ACFAS is sharing abstracted articles from the American Hospital Association's publication, Futurescan™ 2011: Healthcare Trends and Implications 2011–2016, in this special eight-week section.

Hospitals have rapidly embraced and adapted social media services over the past several years. Although they have mainly been used to supplement traditional print and electronic public relations and marketing communications initiatives, hospital managers outside of marketing envision additional applications for social media.

One such application is the ability to post updates and supply information rapidly and accurately during crisis situations, while brand monitoring and customer service can be enhanced via blogs, networking sites, and other social media that provide education about and support for those with specific medical conditions. Educating and attracting patients is another emerging use for social media, with one example being the Twittercast, involving the real-time documentation and discussion of surgical procedures.

It is anticipated that established services such as Facebook and Twitter will continue to expand and become a common form of communication in hospitals, so executives should ascertain if staff are already using social media tools; hospitals should have usage guidelines established and be considering tools such as Socialcast.com to provide this type of service. Meanwhile, healthcare consumers seeking advice will increasingly reach out to trusted online social networks, and hospital leaders should set processes and procedures to effect real-time monitoring of their organizational/institutional image. Finally, hospital staff will expect collaborative and research-related social media tools to be available and accessible in the workplace, so hospital leaders must cultivate a willingness to use social media.

Foot and Ankle Surgery

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Sanders' subtype C calcaneal fracture line exits close to the tarsal canal; therefore, researchers hypothesized that this fracture pattern may induce more subtalar arthrosis and complaints. Eleven feet with and 14 feet without the C line were compared in this study.

Patients' demographics, radiological findings, AOFAS and Maryland scores were evaluated. No significant differences were detected between the two groups in terms of their demographics. The mean preoperative Bohler's angle was significantly lower for group one but postoperateive Bohler's angle did not differ. Although not statistically significant, the mean AOFAS (81.9 vs. 84.3) and Maryland (87.8 vs. 92.0) scores were lower for those with the C line, and the median subtalar arthrosis grade was higher for those with the C-line (score 2) than for without (score 1.5). The worse results may be associated with C-line fracture patterns despite satisfactory reduction.


Research was conducted to evaluate the effectiveness of syndesmosis-only fixation for Weber type-C fractures. Twelve patients with Weber type-C fracture were treated with anatomical reduction and syndesmosis-only fixation. Patients were kept non-weight-bearing for six weeks, followed by screw extraction at an average of eight weeks. The postoperative functional outcome score was 75 at a mean follow-up of 13 months, and excellent to good results were observed in 83 percent of the patients, using an objective ankle scoring system (Olerud and Molander scale) and by radiographic assessment of the ankle mortise. Ankle mortise was reduced in all patients, and all but one fibular fracture united without fixation loss. One patient had late diastasis following removal of the syndesmotic screw.

Practice Management

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Federal antitrust rules are squeezing private physician practices out of innovative healthcare delivery models such as accountable care organizations. Hospitals are aggressively hiring more doctors and acquiring practices, and physicians, already pressured by insurance payments declining as practice costs rise, see themselves as having no other option but to sign on, or risk being shut out by the local health system. Powerful insurers, meanwhile, have grown to such size that it is tough for physicians to get paid reasonable rates. The American Medical Association says that Federal Trade Commission antitrust regulations are needlessly restrictive and ultimately prohibitive to physician-led delivery models; for most doctors, the risk is too high that partnering clinically so they may negotiate with payers on an innovative delivery model will lead to an antitrust violation.


Integrating an electronic health records (EHR) system with a practice management (PM) system can enable healthcare providers to become even more efficient. At Hillside Medical Office in Wichita, KS, a coder working in the PM system can click on a patient chart in the EHR and view actual physician notes to determine if the encounter was properly coded; and billing staff in the PM system's accounts receivables module can click over to any needed clinical information in the EHR. Front desk staff or clinicians answering patient phone calls can click to the patient chart during the call and answer questions, rather than search for the paper chart. BayView OB/GYN in Petoskey, MI, says aside from billing charges, clinicians and support staff can access any other part of its PM system from EHR, such as schedules, insurance information, account balance and coding. They can check on past or current appointments, or non-shows, from one system, and registration staff can save time by shooting out test orders from the EHR. However, there will be a learning curve when attempting to maximize EHR and PM efficiency. Healthcare providers report a decline in costs in certain areas, but physician IT consultant Steven Lazarus says the efficiencies have paid for an EHR-PM integration in one year for a money-losing, 15-physician cardiology group.

Health Policy and Reimbursement

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The Medicare Payment Advisory Commission (MedPAC) has passed a recommendation that would replace the sustainable growth rate (SGR) formula and its automatic cuts to doctors' payments. MedPac's alternative keeps rates steady for primary care physicians over the next decade and cuts payments to specialists. Physician groups quickly registered their disapproval, arguing that the new plan is unfair to both specialists and primary care doctors. The proposal will reach Congress later in October. If Congress does not act on the MedPAC plan or come up with an alternative before January 1, a 30 percent across-the-board cut in Medicare payments mandated by the SGR will go into effect.


Dr. Donald Berwick, the head of the federal Centers for Medicare and Medicaid Services (CMS), is pushing hospitals across the country to take steps to reduce errors, unnecessary care, and other forms of waste in the Medicare and Medicaid programs. Several healthcare systems have already partnered with CMS to redesign their systems in order to improve the quality of the healthcare they give and the efficiency with which it is delivered. Dr. Berwick has also launched a new campaign to reduce hospital-acquired infections and other problems by 40 percent by 2013, and to reduce hospital admissions by 20 percent. Meanwhile, Dr. Berwick--who will have to leave his position at the end of the year because of the manner in which he was appointed by President Obama--expressed concern about federal lawmakers' focus on cutting spending, saying that it could hurt efforts to reduce healthcare costs by improving quality.


Nearly a decade after the National Committee on Vital and Health Statistics recommended that the United States adopt ICD-10, the healthcare community is still extremely uncertain about its potential impact. "Even the mere mention of ICD-10 runs shivers up peoples' spines," says Bill Bernstein, chairman of the healthcare division at law firm Manatt, Phelps & Phillips, which works with states and providers on health IT and related public policy issues. Some describe the years since the recommendation was promulgated as the ICD-10's "reign of fear."


The Supreme Court justices opened their new term on Oct. 3 by hearing a major healthcare case that tests whether judges can stop states from cutting their payments to doctors and hospitals who serve low-income patients. The case will likely impact how much money is available to pay for medical care for more than 50 million Americans who depend on Medicaid. The program has been a cooperative effort and jointly funded by the federal government and the states, but states are facing huge budget deficits and looking for savings. For example, the California Legislature has voted a series of cuts in its payments to providers of Medi-Cal. The providers went to court in San Francisco arguing that the state was violating federal law by imposing the cuts, warning that the reduced payments were so low that patients would be denied the care they needed. Federal district and appeals court judges responded by issuing orders blocking the cuts from going into effect. Lawyers for California, backed by other 31 states, appealed to the Supreme Court, and were joined by the Obama administration. They argue that disputes over Medicaid funding should be resolved by healthcare administrators and not by judges.

Medicine, Drugs and Devices

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Three months of vigorous exercise can decrease body fat and increase bone formation and insulin sensitivity in obese children, according to Norman Pollock, PhD, of Georgia Health Sciences University in Augusta and colleagues. Pollock says the aerobic exercise intervention resulted in significant dose-response benefits on total and visceral adiposity. The exercise did not appear to alter fasting glucose, but other measures of insulin sensitivity showed improvements, as demonstrated by an upward trend on the Matsuda index. There was also an upward trend in the markers of bone formation osteocalcin and procollagen type 1 amino propeptide.

Unlike the bone formation markers, there was no dose response effect of exercise in the marker of bone resorption carboxyterminal telopeptide region of type I collagen (ICTP) or carboxyterminal collagen crosslinks (CTX). Multiple linear regression analyses adjusting for age, race, and sex showed that changes in bone formation were positively associated with changes in insulin sensitivity and negatively correlated with changes in visceral adipose tissue.

The researchers then examined whether insulin sensitivity mediated the relationship between visceral fat and bone formation, and by how much. The researchers observed a relationship between bone formation and central adiposity, which Pollock concludes should be investigated further to determine if the link can be explained by glucose homeostasis.