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This Week's Headlines

News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Medicine, Drugs and Devices

News From ACFAS

Register Now for Early Bird Savings

Early bird rates for the ACFAS 2011 Annual Scientific Conference have been extended through Jan. 11, 2011! Register today to save $65 or more on your ticket to:
  • Trusted, respected speakers
  • Cutting edge clinical and practice management topics
  • Lively debates and hands-on workshops
  • Up to 34 CME hours
Make your plans now to explore the brilliant minds, ideas and beaches in Fort Lauderdale, Fla., March 9–12. Just call 800-421-2237 or visit the conference home page at

Physician Challenges in the News

HealthLeaders Media recently offered its top physician challenges for 2011. Foot and ankle surgeons need to understand these issues in order to move their practices forward and optimize their expertise in the healthcare continuum. The greatest concerns are:
  • Fixing Medicare reimbursement for physicians (don’t expect Congress to find a permanent solution anytime soon).
  • Electronic health records (EHRs) and the definition of “meaningful use” will continue to be a hot issue for private practice and acute settings. Registration began Jan. 3 for eligible providers in the Medicare and Medicaid EHR Incentive Programs.
  • The shortage of primary care physicians will challenge the implementation of new healthcare models.
  • Accountable care organizations (ACOs) are the new model designed to cut costs and improve quality. They are the darling of the Obama healthcare plan and how they really work will be scrutinized closely. Look for this to further strain relationships between doctors and hospitals.
The full article is available here. Earns Bronze Award

ACFAS’ consumer website,, has been honored with a Bronze Award for Website Excellence in Association TRENDS’ 2010 All-Media Contest. The website was chosen among more than 470 entries in this annual association publications contest which recognizes the most creative and effective communication vehicles developed in the past year. offers visitors an extensive library of foot and ankle health topics searchable by alphabetical index or by selecting their area of concern on the “Where do you hurt?” interactive foot diagram. The website continues to break monthly visitor records, with over 3 million unique visitors in 2010.
Online Education at Your Service

Stop by ACFAS e-Learning any time to refresh your knowledge with the latest additions to the online library:
  • Podcast: Imaging
    An exploration of different imaging technologies and their relative strengths as diagnostic tools.
  • Scientific Session Video: Ethical Issues in Surgical Decisions
    All physicians encounter ethical dilemmas in practice that require them to make difficult decisions. Panelists discuss specific cases, and an ethicist weighs in on the decisions made.
ACFAS members can earn continuing education contact hours at no cost with selected materials on the website. Visit often to browse the resources at your fingertips in video, podcast, and DVD at

Foot and Ankle Surgery

Direction of the Oblique Medial Malleolar Osteotomy for Exposure of the Talus

A medial malleolar osteotomy is often indicated for operative exposure of posteromedial osteochondral defects and fractures of the talus. To obtain a congruent joint surface after refixation, the oblique osteotomy should be directed perpendicularly to the articular surface of the tibia at the intersection between the tibial plafond and medial malleolus. Researchers sought to determine this perpendicular direction in relation to the longitudinal tibial axis for use during surgery.

Using anteroposterior mortise radiographs and coronal computed tomography (CT) scans of 46 ankles (45 patients) with an osteochondral lesion of the talus, the researchers measured the intersection angle between the tibial plafond and medial malleolus. The bisector of this angle indicated the osteotomy perpendicular to the tibial articular surface. This osteotomy was measured relative to the longitudinal tibial axis on radiographs. Intraclass correlation coefficients (ICC) were calculated to assess reliability.

The mean osteotomy was 57.2 ± 3.2° relative to the tibial plafond on radiographs and 56.5 ± 2.8 on CT scans. This osteotomy corresponded to 30.4 ± 3.7° relative to the longitudinal tibial axis. The intraobserver (ICC, 0.90–0.93) and interobserver (ICC, 0.65–0.91) reliability of these measurements were good to excellent.

The researchers concluded that medial malleolar osteotomy directed at a mean 30° relative to the tibial axis enters the joint perpendicularly to the tibial cartilage, and will likely result in a congruent joint surface after reduction.

From the article of the same title
Archives of Orthopaedic and Trauma Surgery (12/10) van Bergen, Christiaan J. A.; Tuijthof, Gabriëlle J. M.; Sierevelt, Inger N.; et al.
Web Link - Publication Homepage: Link to Full Text Unavailable | Return to Headlines

Joshi's External Stabilization System (JESS) Application for Correction of Resistant Club-Foot

Researchers assessed the effectiveness of Joshi's external stabilization system (JESS) method of differential distraction as a therapeutic technique for resistant clubfeet and the morbidity and complications of the method so that ways to overcome them could be suggested. They conducted the prospective study in a tertiary care facility involving 11 patients with 15 old, recurrent, and resistant cases of clubfoot deformities that underwent JESS.

Three patients out of four bilateral cases were operated concurrently for both feet, while one foot with severe deformity was operated on for the other patient. The procedure entailed the insertion of K-wires and the creation of holds and linkage between the holds. In all hospitalized patients, fractional calcaneo-metatarsal distraction was performed from the third post-operative day at the rate of 0.25 mm/hrs. Differential distraction on medial side was executed at twice the rate of that on the lateral side. In non-hospitalized patients distraction was performed at the rate of 1 mm/daily on medial side and 0.5 mm/daily on lateral side. Calcaneo-metatarsal distraction was used to achieve correction of forefoot adduction at tarso-metatarsal joints, stretching the socket for head of talus and reduction of calcaneocuboid joint.

The researchers conclude that JESS yields satisfactory cosmetic and functional improvement for resistant clubfeet, while ankle movements are particularly better in terms of dorsiflexion than that facilitated by open surgery.

From the article of the same title
Internet Journal of Orthopedic Surgery (12/11/10) Vol. 18, No. 1, Manjappa, C. N.

Plantar Enthesopathy: Thickening of the Enthesis Is Correlated With Energy Dissipation of the Plantar Fat Pad During Walking

Researchers performed a study to determine whether plantar fat pad mechanics account for variance in the thickness of the fascial enthesis in subjects who have and do not have plantar enthesopathy. The researchers focused on nine patients exhibiting unilateral plantar enthesopathy and nine asymptomatic, individually matched controls.

High-resolution ultrasound was employed to measure the thickness of the enthesis of the symptomatic, asymptomatic, and a matched control limb, while compressive strain of the plantar fat pad during walking was calculated from dynamic lateral radiographs acquired with a multifunction fluoroscopy unit. Peak compressive stress was concurrently captured using a pressure platform, and principal viscoelastic parameters were estimated from subsequent stress-strain curves. The symptomatic fascial enthesis exhibited significantly greater thickening than the asymptomatic enthesis, which was subsequently thicker than the enthesis of control limbs. No significant difference in the mean thickness, peak stress, peak strain, or secant modulus of the plantar fat pad between limbs was observed, but the energy dissipated by the fat pad during loading and unloading was substantially lower in the symptomatic limb in comparison to asymptomatic and control limbs.

The researchers drew a correlation between the energy-dissipating properties of the plantar fat pad and the sonographic appearance of the enthesis in symptomatic limbs, supporting a previously unidentified connection between the mechanical behavior of the plantar fat pad and enthesopathy.

From the article of the same title
American Journal of Sports Medicine (12/01/10) Vol. 38, No. 12, P. 2522 Wearing, Scott C.; Smeathers, James E.; Urry, Stephen R.; et al.

Practice Management

4 Crucial Steps for Auditing Your Accounts Receivable

Maintaining accounts receivable can help improve the billing process. Daria Semanyshyn of Advanced Medical Practice Management outlines four steps for auditing a practice's A/R and spotting problems early.

* Run monthly A/R reports and maintain a spreadsheet that recaps monthly charges and payments, month-end aging buckets, average days in A/R, and 90-day A/R.

* Enforce follow-up procedures. After identifying problems in the A/R trends, the billing or A/R manager should have an established policy to follow and record the error. Such policies should include making notes in your billing system describing the action to correct the claim.

* Unpaid claims should be reviewed every month to make sure practice staff are following up on correcting and appealing claims.

* Make a list of the top 20 reasons a claim is denied, which can help the A/R supervisor determine the causes of denials and rejections.

From the article of the same title
Becker's ASC Review (12/10) Fields, Rachel

Addressing Common Inefficiencies in Office Practice

Inefficiency is costly in terms of time, effort, productivity, and patient satisfaction. It is important to search out common inefficiencies and address them. To get a sense of how your practice is doing in terms of efficiency, try these simple tests:

* Call your office around 9 a.m. on a Monday and try to make an appointment.
* Dial into your automated phone system and then try to speak to a human.
* Ask your clinical staff how much time they spend tracking down test results after the patient has been roomed.
* Check your watch when you enter your office each morning and again when you enter your first patient room.

From the article of the same title
Family Practice Management (12/10) Young, Jill
Web Link - May Require Paid Subscription | Return to Headlines

HITECH Compliance is About Business Process, Not Technology

A successful EHR migration will allow for accelerated revenue while meeting federal compliance standards. The migration should focus on:

* Analyzing and mapping business processes before a vendor is selected and the technology installed.

* Written responses from vendors; a detailed list of requirements is likely to reduce the number of vendors down to those that are most serious about the business. Vendors that do respond should be asked to verify conformance, presenting a blank copy of their software to be subjected to real-world user tests.

* After a vendor has been selected, the healthcare organization should have user representatives from key employee sectors regularly meet with the vendor to develop requests, prioritize future development, and simplify future upgrades.

From the article of the same title
Physicians News Digest (12/13/10) Nelson, Ron

Health Policy and Reimbursement

CMS: History & Physical Can Be Performed on Day of Surgery

Ambulatory surgery centers may perform a history and physical (H&P) on a patient the same day that patient is scheduled for surgery, according to new CMS guidance. The existing H&P requirement for ASCs, as written, had been causing confusion among state surveyors, who reportedly didn't know whether the requirement that H&Ps be performed "not more than 30 days before the date of the scheduled surgery" allowed the assessments to be conducted on the actual day of surgery. The letter clarifies 3 major points:

* The comprehensive H&P may be performed on the same day as the surgical procedure, and may be performed in the ASC. However, the H&P must be performed before the patient is prepped and brought into the OR.

* If the H&P is performed on the day of the surgical procedure in the ASC, the H&P assessment may be combined with some, but not all, of the elements of the pre-surgical assessments. Specifically, it cannot be combined with the anesthesia/procedure risk assessment, which must be performed after the H&P by a physician.

* A comprehensive medical H&P assessment is required regardless of the type of surgical procedure.

From the article of the same title
Outpatient Surgery (12/25/10) Tsikitas, Irene

Inpatient or Outpatient? The Battle to Control Costs

Over the past year, a central front in the war to control medical costs has been short-stay, or one-day, admissions to hospitals. Observation status, created by Medicare, has existed for years, but was infrequently used by hospitals until last year, after a crackdown by Medicare auditors, who in a three-state demonstration project demanded hospitals repay about $1 billion. Hospitals around the country are now policing admissions much more closely, pushing many more patients into observation to avoid Medicare audits and denials.

Private insurers such as Blue Cross, following Medicare's lead, are now denying many more admissions that they believe are suitable for observation. Doctors see this as second-guessing by insurers and an erosion of the doctor's role in healthcare.

From the article of the same title
Philadelphia Inquirer (12/26/10) Vitez, Michael

Interest-Based Mediation of Medical Malpractice Lawsuits: A Route to Improved Patient Safety?

Using mediation to resolve medical malpractice lawsuits could reduce costs and ensure that procedures are changed in hospitals to prevent recurrences of the error that led to the lawsuit, according to new research. The researchers looked at 31 cases from 11 nonprofit hospitals in New York City in 2006 and 2007 that went to mediation. About 70 percent of the cases settled either during or after mediation, for amounts from $35,000 to $1.7 million. Mediation offers several advantages:

* The outcome is under the parties’ control.
* Plaintiffs can receive payment soon after the harm instead of waiting years.
* Defendants do not have to pay outside lawyers to try the case.
* Members of the medical staff do not have to prepare for discovery and a trial.
* Even if mediation doesn’t resolve the case, it may create enough momentum to lead to a settlement.

Yet the study found that major challenges remain for mediation to gain greater acceptance in malpractice suits. Key among them is lack of physician involvement. In none of the cases studied did a doctor take part in the mediation, which, according to the researchers, deprives them and their patients of the opportunity for healing, understanding, forgiveness, and repair of broken relationships and failed communication.

From the article of the same title
Journal of Health Politics, Policy and Law (10/01/10) Vol. 35, No. 5, P. 797 Hyman, Chris Stern; Liebman, Carol B.; Schechter, Clyde B.

Medicine, Drugs and Devices

EHR Deployment May Cost $120,000 Per Doctor

The deployment of electronic health record (EHR) platforms in doctor offices may cost up to $120,000 per physician, according to a new study. The figure includes not only hardware, software, and other technology expenses, but also accounts for disruptions in productivity and loss of revenue as doctors adjust to using EHRs. The poll of 200 physician practices throughout the country by IT services company CDW Healthcare found that doctors expect their volume of patient encounters to fall by 10 percent in the first 12 months after deploying an EHR. This lost revenue averages around $100,000 annually.

However, once physicians get used to workflow changes and other obstacles involved with moving to EHR systems, they will experience a 15 percent average increase in patient volume, which translates to around $150,000 in additional revenue, according to the researchers. The sooner physicians clear the hurdle of using new EHRs, the faster the productivity gain is. Proper training for using the software is critical, and physicians should be prepared for any adjustments they need to make in workflow processes, or be prepared to have software modified to address their workflow needs.

From the article of the same title
InformationWeek (12/13/10) McGee, Marianne Kolbasuk

FDA Places Experimental Pain Drugs on Hold

Johnson & Johnson has suspended studies of its experimental pain drug fulranumab because of recent warnings from the US Food and Drug Administration (FDA) that it and other nerve growth factor inhibitors might be associated with a bone disorder that could lead to total joint replacements. Meanwhile, Regeneron Pharmaceuticals says FDA has placed its osteoarthritis pain drug, REGN475/SAR164877, on hold after a patient in another firm's trial developed avascular necrosis of a joint. Both J&J and Regeneron's drugs are designed to inhibit the pain-related protein NGF, and earlier in 2010 a Pfizer NGF-inhibitor, tanezumab, was put on hold after some patients required joint replacement surgery. Not long after the problems were disclosed in the Pfizer study, AstraZeneca voluntarily stopped an early stage study of its NGF-inhibitor, MEDI-578.

From the article of the same title
Reuters (12/28/10) Clarke, Toni

Geolocation Services: Have Your Patients Put You on the Map?

While texting from a practice's waiting room is a common occurrence, some patients may actually be telling their friends and social networks where they are. A technology called geolocation allows mobile smartphone users to "check in" at various businesses and locations to let their virtual friends know where they are, using their smartphone's GPS features. The technology not only allow users to post their location, but to provide reviews, observations, and critiques. While experts generally think that checking in a practice is not something physicians should encourage, that does not mean it is not possible to benefit from this technology.

Some applications allow business owners to claim the listing as their business, which allows them to correct information and add details. Anthony LaFauce, director of digital strategy at healthcare public relations firm SpectrumScience, says he has seen pharmacies using geolocation applications to promote services like flu shots, and that physicians could do similar promotions. Such services could also help patients find a new doctor. Patients could also set up geolocation services to remind them of their doctor's advice, such as staying away from fast food locations.

From the article of the same title
American Medical News (12/20/10) Dolan, Pamela Lewis

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January 5, 2011