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This Week's Headlines

News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Technology and Device Trends

News From ACFAS

Scientific Conference Kicks Off

Today over 1,100 DPMs from 48 states and 10 foreign countries are converging on the ACFAS 2009 Annual Scientific Conference in Washington, DC.

The biggest and best conclave of foot and ankle surgery expertise, wisdom, and products will be rolled out, including 48 sessions, a record 108 posters, 36 manuscript presentations, and an 80,000 square foot exhibit hall.

Inside the exhibit hall attendees will:
  • Visit 200 companies to see the latest advantages in medical devices, supplies, and services.
  • Pick up a copy of the new Forefoot Disorders Clinical Practice Guideline (Booth 603)
  • Scan their badges for CME verification and online transcripts
  • Enjoy complete lunch and refreshment breaks included in the registration fee
  • Pick up a copy of the new ACFAS Privileging Toolkit at the ACFAS Booth
  • See demos of new e-Learning courses to be launched next month at
If you weren't able to attend this year’s conference, plan ahead now for the 2010 Scientific Conference on February 23-26 in exciting Las Vegas.

Prefer ACFAS programs closer to home?

Get involved in your regional ACFAS Division, which works to help students, residents and members in your part of the country. Thirteen of 14 divisions will be holding meetings this week at the Annual Scientific Conference.
If you’re attending the conference, please join colleagues from your region at your Division meeting. Check the conference program for the time and place.

For a complete list of ACFAS Regional Divisions, click on the Web link below. ACFAS regional divisions offer educational programs, provide scholarships to students and residents, support young members, and sponsor ACFAS-led research projects.
Teacher Extraordinaire George Gumann Gets Award

George Gumann, DPM, FACFAS, will be honored with the College's Distinguished Service Award on March 6 at the Annual Scientific Conference. Gumann will be recognized for his 20-year contribution as one of the College's most prolific and highly rated CME faculty members.

"I can't think of anybody who deserves this more than George," said John Stienstra, DPM, FACFAS. Gumann is a superb teacher, he added.

"George puts a lot of thought into his preparation and is able to express thoughts and concepts well to listeners, so that they're able to understand him and apply the learning to their practices," Stienstra said.

He also has a proven ability to identify genuine scientific advances, as opposed to trends that may be a passing fashion.

Speaking of fashion, Stienstra warns that conference-goers will be able to spot Gumann because of his bent for suits in colors such as shocking pink, electric blue and neon green. Be sure and congratulate him, Stienstra says--but bring your sunglasses.

Foot and Ankle Surgery

Fracture of an Ossified Tibialis Anterior Tendon

Doctors have successfully managed fractures of ossified tibialis anterior tendon by excising the ossified tendon and transferring the extensor hallucis longus tendon. A 64-year-old man presented his injury two weeks after falling down while mountain hiking, with his ankle fully plantarflexed. There were two tender and bony hard masses found on the course of the tibialis anterior tendon, and operative exploration found that there was complete rupture of the tendon through a bony mass. After the mass was excised, there was too much of a gap between the torn ends of the tendon for them to be directly repaired. Instead, extensor hallucis longus tendon was retrieved near the metatarsophalangeal joint, then passed through the insertion of the anterior tibial tendon and sutured in place. One year after surgery, radiographs and ultrasonography found no recurrence of calcification or ossification, and the patient had good mobility in his tibialis anterior muscle.

From the article of the same title
Ortho Supersite (02/01/2009) Lee, Woo-Chun; Moon, Jeong-Seok; Kim, Ji-Yeong

Management of the Ingrown Toenail

In many cases, ingrown toenails can be effectively treated via unilateral matricectomy, but contralateral ingrown toenail may take root over time as the remaining portion of the nail plate repositions itself. The nail plate's functional and cosmetic roles can be maintained by bilateral partial matricectomy, which should be considered in extreme or recurring cases. Effective alternative treatments include partial matricectomy through electrocautery, radiofrequency and carbon dioxide laser ablation, and the benefits of these methods include less bleeding, a lessening of postoperative pain and immediate sterilization of infected tissue. The carbon dioxide laser also limits thermal damage to adjacent tissues, while drawbacks include a prolonged period for reepithelization and healing of the tissues by secondary intention and as many as six seeks of local wound care. Complete cauterization can be ensured by staining the nail matrix with methylene blue before performing a partial matricectomy with the carbon dioxide laser. If the matricectomy is incomplete, then a nail spicule can regrow along the new lateral nail fold, resulting in inflammation that can often require another procedure. Physicians should prescribe an oral antibiotic that deals with common skin flora if infection of the lateral nail fold is suspected, while excessive electrocautery or radiofrequency ablation to the nail matrix may damage the adjacent and underlying fascia or periosteum. If the healing of the toe is not going well several weeks following the procedure, then debridement, oral antibiotics and radiographic assessment may be necessary.

From the article of the same title
American Family Physician (02/09) Vol. 79, No. 4, Heidelbaugh, Joel J.; Lee, Hobart

The Effect of Ankle Taping on Detection of Inversion-Eversion Movements in Participants With Recurrent Ankle Sprain

A group of researchers tested the hypothesis that ankle taping improves the detection of inversion and eversion movements through controlled laboratory study. The research involved measuring the 70 percent threshold for movement detection in 16 participants suffering from recurrent ankle sprain with the ankle taped or untaped. The threshold for movement detection was analyzed at three velocities—0.1 degrees per second, 0.5 degrees per second, and 2.5 degrees per second—in two directions. It was determined that the ability to detect movement in the inversion-eversion plane in subjects with recurrent ankle sprain was significantly inhibited with taping. Although the findings imply that the effectiveness of taping is unlikely to be explained by an improved ability to detect inversion or eversion movements, clinicians should continue taping to lower the chances of recurrent spraining since the method is efficacious in reducing the occurrence of sprain.

From the article of the same title
American Journal of Sports Medicine (02/01/09) Refshauge, Kathryn M.; Raymond, Jacqueline; Kilbreath, Sharon L.

U.S. Preventive Services Task Force Recommends Dual Energy X-ray Absorptiometry for Osteoporosis Diagnosis

Approximately 8 million women and 2 million men in the United States suffer from osteoporosis. Injuries and mortality linked to the disease can be prevented with early screening and treatment. The U.S. Preventive Services Task Force recommends using dual energy x-ray absorptiometry to screen all women 65 years and older as well as women ages 60 to 64 who have increased fracture risk. Other organizations recommend screening all men 70 years and older. For persons with osteoporosis diagnosed by dual energy x-ray absorptiometry or previous fragility fracture, effective first-line treatment consists of fall prevention and adequate intake of calcium (at least 1,200 mg per day) and vitamin D (at least 700 to 800 IU per day) as well as treatment with a bisphosphonate. Raloxifene, calcitonin, teriparatide, or hormone therapy are also recommended for some patients.

From "Diagnosis and Treatment of Osteoporosis"
American Family Physician (02/09) Vol. 79, No. 3, P. 193; Sweet, Mary Gayle; Sweet, Jon M.; Jeremiah, Michael P.

Practice Management

Slowing the Growth of Health Care Costs--Lessons from Regional Variation

By taking cues from regions of the United States where healthcare spending growth rates are manageable, insurers and hospitals might, with the right physician leadership, succeed at "bending the cost curve." Between 1992 and 2006, Medicare spending in Miami; East Long Island, N.Y.; Boston; San Francisco; and Salem, Ore. rose by 3.5 percent each year. Noticeable variations occurred between regions. Three regions—Boston, San Francisco, and East Long Island—began with nearly equivalent per capita spending, but their spending increased at different rates: 4.0 percent in East Long Island, 3 percent in Boston, and 2.4 percent in San Francisco. By 2006, East Long Island required about $1 billion more in Medicare spending each year than San Francisco. Technological and health differences were ruled out as explanations for the discrepancy. Researchers found that physicians, however, played a large role in the differences. For example, physicians in high-spending areas were more likely to offer discretionary procedures, such as referrals to ultra-specialists. The researchers concluded that physicians can play an active role in bring down the costs of healthcare in the future. Physicians can help patients understand when conservative treatment is likely to be as safe as more intensive and higher-cost paths. Physicians also have the credibility to argue against the need for further growth in oversupplied regions and can support changes within the healthcare system to help patients and communities get the best care at the lowest cost.

From the article of the same title
New England Journal of Medicine (02/26/09) Vol. 360, No. 9, P. 849; Fisher, Elliott S.; Bynum, Julie P.; Skinner, Jonathan S.

Health Policy and Reimbursement

Administration Proposes Medicare Cuts, Tax Increases Pay for New Healthcare Plan

President Barack Obama plans to fund the revamping of the U.S. healthcare system with $634 billion generated from higher tax revenues from wealthy Americans and cuts in Medicare spending over the next decade. The money will be used to help provide health coverage to more than 47 million uninsured Americans. The president's budget plan proposes that the top income tax rate for couples with incomes of more than $250,000 a year be raised from 35 percent to 39.3 percent. The plan also would limit tax deductions for the wealthy. These tax changes are expected to generate about $318 billion over the next 10 years. At the same time, about $316 billion will be cut from Medicare by decreasing some payments to private insurance plans that focus on the elderly. Also under consideration is a higher premium for Medicare prescription drug coverage for upper-income beneficiaries.

From "Medicare Cuts, Tax Hike on Wealthy to Pay for Healthcare Plan"
Los Angeles Times (02/25/09) Levey, Noam

Obama Names Nurse to Head Healthcare Access Agency

Mary Wakefield, a nurse who heads the University of North Dakota Center for Rural Health, has been chosen by President Barack Obama to head the Health Resources and Services Administration, the agency of the U.S. Health and Human Services Department in charge of improving access to healthcare in the United States. As such, she will be charged with overseeing the $2.5 billion allocated in the economic stimulus bill for training healthcare professionals and improving the U.S. healthcare infrastructure. The agency's primary responsibility is to improve access to healthcare services for people without medical insurance and healthcare systems in rural communities.

From the article of the same title
Reuters (02/20/09)

CMS Predicts Reduction in National Health Expenditures in 2009 due to Recession

A report issued by the Centers for Medicare & Medicaid Services (CMS) projects that growth in U.S. national health expenditures (NHE) in the United States will significantly overtake economic growth in 2008 and 2009 because of the recession. NHE growth is expected to be 6.1 percent in 2008 as health spending increases from $2.2 trillion in 2007 to $2.4 trillion, while 2008 gross domestic product (GDP) growth is expected to be 3.5 percent. Health spending is projected to rise 5.5 percent while GDP is expected to decline 0.2 percent in 2009. NHE growth is expected to decrease to 4.6 percent in 2010, primarily due to a projected decline in Medicare spending growth principally attributable to a 21 percent cut to Medicare physician payment rates required under the Sustainable Growth Rate (SGR) formula called for in 2010 under current law. Spending on physician and clinical services is expected to grow 6.2 percent in 2008, compared to a 2007 growth rate of 6.5 percent. A deceleration in hospital spending growth is forecast from 7.2 percent in 2008 to 5.7 percent in 2009, resulting from reduced growth in use affiliated with the recession and projected slower income growth. A slowdown in prescription drug spending growth to 3.5 percent is expected in 2008, followed by an acceleration to 4 percent in 2009 as projected double-digit increases in Medicare and Medicaid growth compensate for continuing recession-related deceleration in private prescription drug spending growth.

From "Growth in National Health Expenditures Expected to Slow in 2009 as a Result of Recession"
Centers for Medicare & Medicaid Services (02/24/09)

Technology and Device Trends

Total Ankle Arthroplasty Device Shows 98 Percent Mid- to Long-term Survivorship

A study of 293 patients who underwent total ankle arthroplasty (TAA) using the Hintegra prosthesis was undertaken by Beat Hintermann, MD, and Alexej Barg, MD, between October 2002 and April 2008. Prior to the operation, most of the patients were diagnosed with post-traumatic osteoarthritis, and at the time of the TAA 29.2 percent had associated problems and needed additional surgery. It was indicated by mid- to long-term follow-up that patients had less pain, improved motion, increased function and an 83.9 percent patient satisfaction rate following TAA. "The Hintegra ankle has evolved to a safe procedure," stated Hintermann during his presentation at the American Academy of Orthopedic Surgeons 76th Annual Meeting. "It has a steep learning curve. It provides reliable mid- to long-term results, despite a high amount of accompanying problems, and its anatomic design and biomechanical features allow us to successfully resurface the osteoarthritic ankle as part of complex hindfoot reconstruction. I believe that it provides frontal plane stability." A 98 percent survivorship at five years using the prosthesis was indicated by the study. Hintermann said the results demonstrate "that TAA has become a viable alternative to ankle arthrodesis even for younger patients and more difficult conditions, as is often the case in post-traumatic osteoarthritis."

From the article of the same title
Ortho Supersite (02/26/2009) Brockenbrough, Gina

Researchers Make Nerve Cells From New 'Stem' Cells

UCLA researchers reported on Feb. 24 that they had cultured nerve cells out of ordinary skin cells. Induced pluripotent stem (iPS) cells were employed to create motor neurons, and scientists hope that iPS cells might offer a substitute for embryonic stem cells and a shortcut to customized medical therapy for various diseases. The researchers noted that the ability to create new motor neurons might help treat diseases such as amyotrophic lateral sclerosis. "IPS-derived cells appeared to follow a normal developmental progression associated with motor neuron formation," the researchers wrote in Stem Cells. They added that the cells resemble neurons taken from embryonic stem cells. UCLA scientist William Lowry and colleagues used the iPS technique to revert skin fibroblasts back to an embryonic state, and then converted them into motor neurons. The next phase will involve attaching their neurons to muscle cells to see if they can induce contraction.

From the article of the same title
Reuters (UK) (02/24/09) Fox, Maggie

Study Utilizes First-Pass IV Gadofosveset-Enhanced MR Angiography to Image Pedal Arteries

A study of first-pass IV gadofosveset–enhanced MR angiography to visualize pedal arteries in patients with peripheral arterial occlusive disease found that it provided good diagnostic utility in 83.9 percent of segments, with no venous contamination in 96.8 percent of segments. The angiography used a dedicated foot coil and cuff compression, assessing arterial segments for visibility, stenosis or occlusion, and contamination. Switzerland's University Hospital Basel researchers concluded that "Gadofosveset-enhanced MR angiography of the pedal arteries in patients with peripheral arterial occlusive disease has arterial visibility equal to that of digital subtraction angiography and facilitates depiction of clinically significant stenosis and occlusion."

From "Pedal Angiography in Peripheral Arterial Occlusive Disease"
American Journal of Roentgenology (02/01/2009) P. 775; Kos, Sebastian; Reisinger, Clemens; Aschwanden, Markus

Effect of Extracorporeal Shock Wave Therapy on Cultured Tenocytes

There is little documentation on how human normal or pathologic tendon tissue is affected by shock waves, and a group of researchers theorized that inflammatory cytokine and MMP production would be down-regulated by shock wave stimulation. In an experiment using diseased Achilles tendon tissue and healthy flexor hallucis longus tissue, the researchers applied extracorporeal shock wave therapy (ESWT) to cultured cells at various dosages. Cells that received 1,000 and 2,000 shocks experienced a dose-dependent decline in viability versus the normal control, while cells that received 500 shocks exhibited a 23.4 percent increase in cell count. A greater concentration of MMP 1, 2 and 13 was recorded in diseased tenocytes compared with normal cells, while the diseased tenocytes also had higher IL-6 levels. Normal cells exhibited a rise in IL-1 levels following shock wave treatment, while MMP-1 and MMP-13 levels fell significantly in diseased tenocytes after treatment. The researchers concluded that human tendinopathy-affected cells exhibited higher levels of ILs and MMPs in comparison to normal cells, and ESWT reduced the expression of several ILs and MMPs.

From the article of the same title
Foot & Ankle International (02/09) Vol. 30, No. 2, Han, Seung Hwan; Lee, Jin Woo; Guyton, Gregory P.

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March 4, 2009