News From ACFAS

The bickering continues in Washington, the Medicare buy-in proposal is out, but Senate Democrats appear to be inching closer to the votes they need to pass a major health reform bill. The key now appears to be whether the Democrats can bring in conservative Sen. Ben Nelson (D-Neb.) while not losing support of liberal party members. Even if the Senate passes a bill before Christmas, the critical reconciliation process is unlikely to begin before the new year.

ACFAS supports the ongoing efforts of physician advocates to support necessary measures to avert the physician Medicare payment cuts that go into effect January 1, 2010. Right now, the temporary one-year "fix" for the payment update is embedded in the overall health reform legislation. It is likely that an interim action will be taken by Congress to avoid the payment cuts so that physicians are not penalized by what may be a lengthy reconciliation process.

Register now to save 15 percent or more on the premier education event of 2010 — the ACFAS Annual Scientific Conference, February 22–26, in Las Vegas.

Early bird conference registration ends December 21, 2009. You can also take advantage of the Mandalay Bay reduced room rate of $189, plus airfares that will again drop after the holidays.

Preregistration is trending to an all-time high! Reserve your seat and room now. Visit acfas.org/lasvegas or call 800-421-2237 for information and immediate registration.

Candidate profiles and ballots for the 2010 ACFAS Board of Directors election were mailed to the preferred addresses of ACFAS voting members on December 11. Ballots must be returned to the ACFAS office by mail or fax no later than 5 p.m. CST on January 12, 2010. Voting members are Fellow, Associate, Life and Emeritus members. More information on nominations and elections is available on the ACFAS web site.

Three Fellows were recommended by the Nominating Committee for two three-year terms. Voting members may vote for one or two candidates. The nominees are:

• Richard Derner, DPM, FACFAS
• Sean Grambart, DPM, FACFAS
• Roya Mirmiran, DPM, FACFAS

Decide the future of your College! Return your ballot by January 12.

Foot and Ankle Surgery

Structural Bone Graft Can Be Used to Convert Failed Ankle Arthroplasty to Fusion

Researchers at the 25th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society presented research showing that patients with failed total ankle replacements converted to ankle or extended hindfoot fusions can benefit from large structural bone grafts, which have shown high union rates. The functional improvement is modest, though, says Mark J. Berkowitz, MD, stressing the importance of preserving the subtalar joint as much as possible to improve function and limit complications. In a group of 24 patients who had failed total ankle replacements converted to fusion with structural allografts, all patients eventually achieved union though there were two nonunions, two soft-tissue complications, and three subtalar nonunions. The subtalar nonunions were a concern for Berkowitz, who said surgeons should use a single anterior approach and IM nails in these instances.



Diabetic Foot, Ankle Patients Have Fivefold Greater Risk for Postoperative Infection

Patients with diabetes mellitus have a significantly greater risk for developing a severe postoperative infection than those without diabetes, according to research presented at the 25th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society. In a review of the charts of 1,000 consecutive surgical cases, the researchers found that peripheral neuropathy was the strongest predictor of infection in people with and without diabetes. They found an overall infection rate of 4.8 percent—a 2.8 percent infection rate for the control group and a 13.2 percent infection rate for the study group.



Segmental Analysis of Motor Conduction Velocity in Distal Tracts of Tibial Nerve: A Coaxial Needle Electrode Study

A recent study aimed to describe a new method of segmental analysis of motor nerve conduction velocity (mCV) in the tibial nerve (Tn) tract distal to the upper margin of the tarsal tunnel. The study recorded compound muscle action potentials (CMAPs) using a coaxial needle electrode from the flexor hallucis brecis muscle to test the medial plantar nerver, as well as from the flexor digiti quinti brevis and the first dorsal interosseous muscles to test the superficial and deep branches of the lateral plantar nerve. CMAPs were obtained by stimulating at three sites located above and below the tarsal tunnel and at the sole of the foot. The study found that in normal subjects the mean mCV in the proximal tract was 44.5+/-4.7, 43.5+/-5.9 and 42.6+/-4.2m/s for the MPn, sLPn and dLPn, respectively, and the corresponding values in the intermediate tract were 40.7+/-5.6, 39.4+/-5.6 and 40.9+/-5.8m/s. The researchers conclude that segmental analysis of mCV in the distal tibial nerve can be performed when CMAPs are recorded using a coaxial needle electrode, which prevents the simultaneous recording of activity in nearby muscle groups. The findings are important because conventional neurophysiological examiniation for suspected entrapments in distal Tn are usually unable to discriminate between a lesion inside the tarsal tunnel or distal to the it. The technique proposed by the researchers could help better define the lesion site.



Restoration of Strength Despite Low Stress and Abnormal Imaging After Achilles Injury

A group of researchers performed a study to ascertain how useful clinical imaging is in anticipating the mechanical properties of Achilles tendons following an acute injury. They created a central tendon defect in one Achilles tendon of rabbits, which were then killed--some immediately after surgery, some four to eight weeks following surgery. The researchers carried out magnetic resonance imaging (MRI), ultrasonography (US), calcaneal bone mineral densitometry, and mechanical testing to failure by applying a dual-cryofixation assembly on experimental and contralateral tendons. Analysis via MRI and US showed that all dimensions of the injured tendons after two weeks and more were greater than those of the contralateral tendons. The tendons of rabbits that were killed four to eight weeks after surgery exhibited a greater average T1-weighted optical density (OD) than those in rabbits that were killed immediately after surgery. At both four weeks and eight weeks, mechanical stress was demonstrably lower in the experimental tendons compared to the contralateral tendons. Mean peak load to failure was substantially reduced immediately after surgery versus four and eight weeks afterward, and there was correspondence between lower mechanical stress and both high T1-weighted OD and proton density OD. There also was correlation between T1-weighted OD and reduced peak load in the experimental tendons. The investigators concluded from these findings that an enlarged tendon of lower stress tolerated normal peak loads four weeks after injury, which supports the notion that progressive loading is possible four weeks following a rupture to the Achilles tendon.

Practice Management

EHR Customer Satisfaction Scores Drop, Says KLAS

KLAS, a HIT “market watcher,” has released a survey finding that satisfaction scores for electronic health record (EHR) products dropped for the second straight year. The biggest drop was in products for larger practices (25-100 physicians). The software satisfaction score for that market was down 3 to 4 percent, which a KLAS spokesperson described as “huge for an overall market segment.” KLAS believes that demand for HIT may be increasing at such a high rate that vendors may be falling short on installation and support services.



Cash Flow Squeeze: 2012 IRS Rule Will Withhold Some Medicare Pay

Physician advocates are concerned about a provision in a 2005 tax bill that will result in a 3 percent withholding of payments to physicians who see Medicare patients. Under the law, the withholding would be refunded when physicians file tax returns for the year. With increasingly slim profit margins, the withholding could have a serious impact on smaller practices with a large number of Medicare patients. The provision is not directed specifically at healthcare providers, but applies to any contractor doing work for federal, state and local governments. Medicaid is not included because services are provided based on patient financial need. Physician groups are working to repeal the provision before it goes into effect.



Patient ID Theft Rises

Medical identity theft is on the rise and expected to worsen as more uninsured people use the coverage of a friend, relative or even a stranger to get care. A significant portion of the fraud is committed by people who pay medical workers for patients' information. . For example, a clerk at a medical clinic in Florida downloaded personal information and provided it to her cousin who then used it to file over $2 million in Medicare claims.



How to Handle Insurer Requests for More Information on Patients' Pre-existing Conditions

The case of David Sacco, MD, raises the issue of whether insurance forms physicians are asked to complete as part of claims payment can be used to retroactively refuse coverage to patients. Sacco notes that these forms often include a list of ICD-9 codes affiliated with recent treatment of a patient, and then ask if he is aware of that patient having previously received treatment for the same conditions. The forms contain a warning that incorrect information may be deemed "fraud." Healthcare attorney Steven I. Kern notes that "since the inquiry seems to be related to payment for services, it's likely that the carrier has a right to this information before determining if the services are covered and payment is due to the physician."

Health Policy and Reimbursement

Small Practices Face Big Challenges

A recent study published in the Journal of the American Medical Association raises concerns about the ability of solo and small physician practices to collect enough data to make meaningful conclusions about the quality of care they provide. This is a concern for those providers as Medicare moves towards more payment incentives based on quality reporting. The study found that 65 percent of primary care practices are too small to draw such conclusions, and that even aggregating data over 3 years did not provide enough data for more than 50 percent of the groups with fewer than six physicians.



State Podiatrists Sue On Insurer Changes

The New Jersey Podiatric Medical Society (NJPMS) has filed suit against Horizon Blue Cross/Blue Shield of New Jersey and one of the insurer's contractors, CareCore National, challenging Horizon's recent decision to stop reimbursements to its participating podiatrists for certain diagnostic tests that fall under the scope of podiatric medicine, as defined by the state's Board of Medical Examiners. As part of Horizon's expanded relationship with CareCore, which provides radiology and other imaging services to Horizon customers, patients would be required to have these screenings at hospitals or general imaging centers, instead of with their local podiatrists. NJPMS president Steven Maffei, DPM, notes that the New Jersey Legislature entrusted the state Board of Medical Examiners, not health care insurers, with the authority to define the scope of practice. "Acceptable diagnostic testing for the ankle and foot is clearly within the practice of podiatry," says Maffei.



Another Medical School Reports Doctors’ Industry Ties

Northwestern University's medical school has become the latest to publicly report financial ties between doctors and the drug and medical device industries. The medical school recently announced that online faculty profiles now include doctors' service on boards of directors, consulting work, investment interests, royalties, lectures, and participation in scientific advisory boards. A few months ago, Stanford University's medical school announced that it would start disclosing faculty members receiving more than $5,000 per year from drug and device manufacturers, and the Cleveland Clinic started posting its doctors' financial ties online last year. This comes as Washington is pushing for greater transparency in the medical industry.

Technology and Device Trends

FDA Safety Alert: Don't Use Steris System 1

The U.S. Food and Drug Administration (FDA) warns in a safety alert that it has received reports of malfunctions in the Steris System 1 (SS1) tabletop liquid chemical reprocessor, and that an alternative means for sterilizing and disinfecting instruments should be sought out. Such malfunctions could lead to patients getting infected, while the FDA also says that it has gotten "reports of injuries, mostly burns from exposure to the sterilant solution, to health care facility staff operating the device." In May 2008, the FDA sent Steris a letter that it would need approval from the agency to sell an updated version of the SS1 because it had modified the device without the FDA's go-ahead. Steris said in January 2009 that it would adhere to an agreement with the FDA and halt new SS1 sales, except those in which the device is sold in the United States "on a replacement basis only." Steris additionally promised to work with customers to migrate them to lawfully marketed replacements for the SS1, but the FDA sent the safety alert because it "isn't satisfied that the firm has been working effectively to transition its customers to replacements for the SS1," based on a recent inspection of Steris and meetings with the company. Furthermore, the agency says Steris has been reassuring clients that there is no need for a change in their clinical practice and that the firm is continuing to design or redesign new SS1 accessories.



Multiplanar Imaging Shown to be Reliable for Assessing Parameters of Flatfoot

Weight-bearing, multiplanar axial imaging provides reliable measures of flatfoot deformity, according to research presented at the 25th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society. The study also found that patients with flatfoot and lateral hindfoot pain have increased subtalar arthrosis and calcaneofibular impingement, which can be better visualized with the 3-D imaging modality compared to conventional radiographs.



Surgical Treatment of Osteochondral Lesions of the Talus by Open-Field Autologuous Chondrocyte Implantation

The ideal treatment of osteochondral lesions of the talus is still controversial. This study examines the 10-year clinical results of autologous chondrocyte implantation in the treatment of osteochondral lesions of the talus. Researchers found that the results of autologous chondrocyte implantation in the ankle joint are comparable with those in the knee as demonstrated by the significant clinical improvement, hyaline cartilage repair and the durability of the results.



Abstract News © Copyright 2009 INFORMATION, INC.

---

You have received this newsletter as a service of the American College of Foot and Ankle Surgeons. To change your email address, please click here. If you wish to unsubscribe click here.