News From ACFAS

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Take a break from chilly weather to explore brilliant minds, ideas and beaches at the ACFAS 2011 Annual Scientific Conference in Fort Lauderdale, Fla. — and enjoy exclusive discounts when you act now! Offers expire soon:

• February 11 — hotel rooms are limited. Reserve your room by Feb. 11 to receive the special ACFAS rate.
• February 15 — register online to save 10 percent. After Feb. 15, registration will be available on-site.

Don’t delay! Visit acfas.org/ftlauderdale today to make your plans for ACFAS 2011, March 9–12, in the Sunshine State.
ACFAS is working on mobile apps for content on both acfas.org and FootHealthFacts.org. Tell us what you’d like to see on our apps! Send us a note at thisweek@acfas.org.
Any surgical procedure carries with it the possibility of complications. “Forefoot Complications,” the latest free podcast at ACFAS e-Learning, explores options and recommendations for specific problems and pathologies in forefoot surgery.

“Complications happen for a few reasons,” says panelist Donald E. Buddecke, DPM, FACFAS, “a bad day for the surgeon, a noncompliant patient, or just bad luck.”

Listen in as experienced surgeons share best practices for dealing with complications they’ve actually encountered. And, visit ACFAS e-Learning any time to browse the entire library of information on the diagnosis and treatment of foot and ankle conditions, at your fingertips.
Get quick reads on recent research with ACFAS’ Scientific Literature Reviews. Podiatric residents have prepared concise reviews of articles from journals you may not commonly read. Current abstracts include:

The Results of Early Primary Open Reduction and Internal Fixation for Treatment of OTA 43. C Type Tibial Pilon Fractures: A Cohort Study, from the Journal of Orthopaedic Trauma.
Reviewed by Christopher J. Fatti, DPM, Yale/DVA New England Surgical Residency Program.

Morton Neuroma: MR Imaging after Resection — Postoperative MR and Histologic Findings in Asymptomatic and Symptomatic Intermetatarsal Spaces, from Radiology.
Reviewed by Sara Karamloo, DPM, Yale/DVA New England Surgical Residency Program.

Find a variety of abstracts to feed your interests at Scientific Literature Reviews.

Foot and Ankle Surgery

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Researchers investigated the functional outcomes specific to percutaneous tendo-Achilles lengthening (PTAL) when performed in tandem with triple arthrodesis and subtalar fusion. A retrospective review of 107 patients who underwent 117 procedures was performed. The most common procedure in the study population was triple arthrodesis (91 percent). Fifty-eight percent of the patients reported moderate improvement in motion postoperatively, but 80 percent reported some degree of persistent stiffness. While 38 percent of patients reported postoperative weakness, 66 percent and 61 percent stated that ascending and descending stairs, respectively, was easier.



Researchers evaluated patients who underwent surgical reduction of diaphyseal (Weber C) fibular fracture, fixated with one-third tubular plates. They excluded all OTA type 44-C3 fractures. Thirty-nine patients with an OTA type 44-C1 or C2 fracture completed a one-year follow-up. Union rate was 97 percent, while overall complication rate was 10 percent. There was one wound infection and two patients who required revision open reduction and internal fixation. There was no wound necrosis, malunion or post-traumatic osteoarthrosis.



The Nationwide Inpatient Sample from 2003–2007 was reviewed to evaluate socioeconomic status (SES) and other hospital variables associated with major amputation in patients with critical limb ischemia (CLI). Amputation was performed in 24.2 percent of CLI patients overall. Lower-income patients were more likely to be treated at institutions with low volume of revascularization, while patients treated at facilities with higher revascularization volume were admitted electively, assessed with diagnostic imaging and had likelihood of undergoing lower extremity revascularization. The regression analysis showed that minority patients, those with lower SES, and Medicaid patients were more likely to undergo amputation for CLI.



Researchers investigated whether stability-based criteria are useful in selecting between nonoperative and operative treatment of ankle fractures, through retrospective analysis of 160 ankle fractures in skeletally mature patients to acquire an epidemiological profile in a population of approximately 130,000. They found that the overall incidence of ankle fractures was 154/100,000.

Nonoperatively treated patients exhibited greater displacement of the distal fibula following treatment, but less pain and better Olerud–Molander and Visual Analogue Scale functional scores. Female gender, older age, unstable fracture, and co-morbidity were independent factors for worse outcome, and none of the nonoperatively treated patients required operative fixation during followup.

The researchers concluded that stability-based fracture classification was a simple and practical technique in decision-making for ankle fracture treatment, and that lateral malleolar fractures could be successfully treated without surgery as long as the ankle mortise was stable; pain or functional scores were not affected by displacement of the distal fibula.

Practice Management

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Twenty percent of medical claims are processed inaccurately by commercial health insurers, according to the American Medical Association's (AMA) National Health Insurer Report Card. The administrative costs of ensuring proper insurance payments takes a heavy financial toll on physicians and can consume up to 14 percent of their earned revenue, according to AMA President Cecil Wilson. AMA offers an interactive library of resources and tools for improving claims submission and efficiency.



One Medical Group aims to provide a new nationwide template for primary care by offering the same personalized health care services as concierge medical practices at a substantially lower cost of $150 to $250 annually. One Medical physicians see a maximum of 16 patients per day and the practice accepts a diversity of insurance plans, including Medicare. The practice keeps overhead low by implementing automated systems wherever possible. It offers a website and a new iPhone application through which patients can set up appointments, refill prescriptions, and in certain instances originate new ones.



Medical professionals, because of their high net worth, are often targets for lawsuits where plaintiffs and lawyers stand to profit from a winning verdict. The average medical malpractice verdict in the United States is $3.9 million, but average liability policies cover only $1 million. Doctors need to protect their assets by buying as much liability insurance as they can afford and then making sure the remaining assets not covered by liability insurance are not exposed by having the appropriate riders and umbrella policies in place. They should review umbrella policies carefully, as they will cover only certain situations to specific limits. In the face of a legal battle, making plaintiffs and lawyers aware that ones' assets are well protected may also help reduce legal fees--as even if they win a lawsuit, they will not be able to collect.

Health Policy and Reimbursement

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U.S. Federal District Court Judge Roger Vinson has ruled that the individual health insurance mandate requiring Americans to purchase coverage is unconstitutional. Vinson indicated that the mandate is so connected to the other elements of the Affordable Care Act that the entire law must be declared unconstitutional and redesigned by Congress. The opinion states that Congress exceeded its regulatory powers under the Commerce Clause of the U.S. Constitution. It is likely the ruling will be appealed, but the judge did not enjoin or suspend the law while that process is completed, which could take two years.



Maryland is considering legislation to bar gifts from companies to healthcare providers in the wake of allegations that a Towson cardiologist was "indirectly influenced" to perform unnecessary stent procedures by device maker Abbott Laboratories. Vermont and Massachusetts recently enacted similar laws, considered the most restrictive in the nation, that significantly limit the items sales representatives can offer to physicians, prohibiting trinkets, trips and most meals. They also require public disclosure of certain financial transactions.



The Senate has amended a bill to reauthorize and modernize the Federal Aviation Administration (FAA) with a provision that eliminates the new 1099 requirement in the Affordable Care Act (ACA). Under ACA, all businesses, including medical practices, must file a 1099 with the IRS beginning in 2012 if they purchase $600 or more worth of goods or services in a given year from any vendor. Right now, businesses need to file it only for services provided by unincorporated businesses, such as sole proprietors. The repeal of the new 1099 reporting duty will not be final until Congress passes the FAA bill. According to an aide to Senate Majority Leader Harry Reid (D-NV), the Senate could vote on the FAA measure as early as mid-February.



The U.S. Supreme Court has consented to hear California's appeal of a lower court's ruling blocking certain pay cuts for the California Medicaid program, Medi-Cal. The review of the state's appeal hinges on the issue of whether private parties are entitled to sue in federal court to enforce federal Medicaid law. New California Gov. Jerry Brown (D) has proposed slashing 10 percent off payments to doctors and other health professionals in his initial budget plan. Doctors have said low rates have caused California to face shortfalls of physicians willing to accept Medicaid. Doctors also have been confronted with higher overhead and declining pay from insurers. The state's proposal to reduce physician rates was recently rejected by CMS. A federal precedent could be established should the plaintiffs win the case, while the cuts deployed by California prior to the injunction would constitute a violation of federal law. Health professionals already impacted by those reductions could then seek refunds from the state.

Medicine, Drugs and Devices

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A dearth of injectable generic drugs for certain serious illnesses is forcing some hospitals to scramble to locate the treatments or search for alternative medicines. The supply of these drugs has restricted in recent years as the generic-pharmaceutical industry has consolidated, with many of the drugs now manufactured by one or two major companies. In many instances, patents have long lapsed and the original brand-name drug is no longer being manufactured. The FDA recorded an all-time high of 178 drug shortages in 2010, up from 157 the previous year and 55 five years ago.



NIH's Undiagnosed Diseases Program has solved its first mystery by determining why calcium deposits were building up in the extremities of five affected siblings. The researchers found the cause to be a mutation in a gene that prevents calcium from accumulating in blood vessels by producing extracellular adenosine. An osteoporosis drug, bisphosphonate, could be the simplest treatment for the disease because it reduces levels of the enzyme alkaline phosphatase, which are increased in people with the gene mutation. Washington University bone endocrinologist Dwight Towler says the breakthrough is very important because it can help scientists understand calcification signals in different parts of the body.