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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

ACFAS Issues H&P Privileging Position Statement

The granting of H&P privileges should be uniformly applied to surgeons regardless of medical degree, pursuant to clear-cut Joint Commission standards and CMS regulations, according to a new ACFAS position statement adopted by the Board of Directors on March 4, 2009.

The one-page position statement summarizes numerous Joint Commission and CMS standards, regulations, and statements since 2000 for use by ACFAS members during hospital privileging procedures. The new statement, also approved by the College’s Professional Relations Committee, is in response to continual questions raised and hurdles encountered by ACFAS members in some hospitals.

The new position statement is available by clicking the Web link below. Questions may be directed to ACFAS Director of Health Policy Laura J. Walsh, JD at or 773-693-9300 x1322.
March’s Scientific Abstracts Online Now Available

Find out whether a local anesthetic block or conscious sedation controlled pain better in patients undergoing a closed reduction in ankle fracture-dislocations.

Learn which factors affected the outcomes of patients receiving arthroscopic treatment for osteochondral lesions of the ankle.

Podiatric residents have summarized these research studies and others from non-podiatric journals you may not see regularly. It's all in Scientific Literature Reviews, a free feature on

Click on the Web link below to see the latest five reviews, from the Journal of Bone and Joint Surgery (American), the Journal of Arthroscopic and Related Surgery and others.

What's New in Fixation?

Which works better...stainless steel or titanium screws? Cannulated or non-cannulated? What are the advantages and drawbacks to using lapidus plates? And when do you take a risk to try out a new product?

In the latest ACFAS eLearning podcast, "Fixation Debate," Donald Buddecke, DPM, leads Eric Barp, DPM, Sean Grambart, DPM, and Christopher Lamy, DPM, in a discussion about the many options in surgical hardware which have become available in the past few years.

As always, podcasts are free and available 24/7 by clicking on the Web link below.

Foot and Ankle Surgery

Researchers Unravel Mystery Behind Clubfoot

Researchers at St. Louis Children's Hospital say they have identified the gene behind clubfoot, a condition that afflicts one in every 1,000 babies. "We're able to find a new gene that's never been implicated in human disease before," says Christina Gurnett, MD, PhD, a neurologist at Washington University in St. Louis. "When you make mutations of this gene, you alter the way the foot forms." The finding opens the door to potential treatment options. "Figuring out the cause is the first step to bettering treatment options and working on preventative strategies," says Matthew Dobbs, MD, Associate Professor of Orthopedic Surgery at St. Louis Children's Hospital.

From the article of the same title (03/11/09)

Ankle Exercises Build Seniors' Strength, Balance

Research from Portugal indicates that elderly people's strength and balance can be improved by a series of ankle and foot flexing exercises. Fernando Ribeiro and colleagues at the University of Porto note that targeting muscle groups in the legs that play a critical role in helping maintain balance may offer an inexpensive technique to boost mobility and prevent falls among senior citizens. The study involved Ribeiro's team randomly assigning 48 institutionalized elderly individuals to an ankle exercise group or a control group, and the former group performed three 15-minute exercise sessions a week for six weeks. The sessions entailed five minutes of warm-up, five minutes of ankle extension and flexion exercises using elastic bands for resistance, and five minutes of cool down. The bands became increasingly resistant as the participants' strength grew. Although no significant differences in ankle strength or mobility were observed in the control group after six weeks, the exercise group exhibited significant strength improvements in the ankle dorsiflexors as well as the plantar flexors. Exercise group participants also did better on two tests that measured functional mobility and balance. One test measured how far a person can reach forward while keeping their feet in the same position, and the other timed how long it took them to get up from a chair, walk three meters, turn around, walk back, and sit down again. "In our opinion, this low-technology, progressive resistive exercise program can be implemented in almost all elderly institutions under the supervision of a rehabilitation team," conclude the researchers.

From the article of the same title
Reuters Health Information Services (03/06/09)

Study Finds Largest Bilateral Osteochondral Talar Lesions Are the Most Symptomatic

Richard D. Ferkel, MD, of Van Nuys, Calif., presented a retrospective chart review at the American Orthopaedic Foot and Ankle Society 2009 Specialty Day Meeting in Las Vegas that offered new insights about the preponderance and nature of bilateral osteochondral lesions of the talus. "Ten percent of patients with osteochondral lesions of the talus have bilateral involvement," he stated. Ferkel presented data for 48 bilateral lesion patients whose charts were accessible from his database of 526 patients with osteochondral talar lesions accumulated over 23 years. It was the investigators' goal to better quantify the prevalence of bilateral lesions, which has ranged in the literature from 10 percent to 25 percent, as well as identify the most symptomatic lesions while also ascertaining which lesions were treated operatively and why. Fifty-nine of 96 bilateral lesions the investigators identified were symptomatic, and Ferkel noted that "there was a significantly higher group of patients that were symptomatic the larger the surface area was." Investigators categorized patients into those who had bilateral surgery, unilateral surgery, or no surgery to evaluate who sought treatment of their lesions, and uncovered higher surgical rates among patients in the unilateral surgical group. "The surface area [of the lesion] was dramatically higher on the side that had surgery," said Ferkel. Although trauma was associated with less than half of the lesions in the most common medial location, the majority of the symptomatic lesions tended to be caused by trauma. Ferkel told the moderator that the researchers did not investigate ankle alignment as a causative factor in the study.

From the article of the same title
Ortho Supersite (03/06/2009) Rapp, Susan M.

Practice Management

Wal-Mart Plans to Market Digital Health Records System

Wal-Mart Stores wants to make electronic health records accessible and affordable for mainstream small-office doctors and jump-start adoption by such practitioners through a package deal of hardware, software, installation, maintenance and training. The offering combines Wal-Mart's Sam's Club division with Dell and eClinicalWorks, with Dell offering either a desktop or a tablet PC and eClinicalWorks providing the electronic record and practice management software, for billing and patient registration, as a service over the Internet. The Sam's Club offering will be less than $25,000 for the first doctor in a practice, and around $10,000 for each additional physician; following installation and training, continuing annual costs for maintenance and support will be $4,000 to $6,500 a year, according to Wal-Mart. The offer is coming as the Obama administration is attempting to spur the takeup of digital medical records with $19 billion of incentives in the economic stimulus package. Sam's Club's 47 million members include some 200,000 health care providers, and Sam's Club executive Todd Matherly says research indicates that health information technology is becoming more affordable and interest is growing among small physician practices. Most health experts concur that digital records can reduce costs and improve care through proper use, but the cost and complexity of the technology has made many doctors in small practices reluctant to invest.

From the article of the same title
New York Times (03/11/09) Lohr, Steve

Mass. Bill Aims to Reverse Court Expansion of Physician Liability

Massachusetts doctors are trying to reverse several decisions by the state Supreme Judicial Court that allegedly expand their liability unfairly by appealing to the state Legislature. Two years ago, the court determined that physicians are liable not only to patients, but to anyone else "foreseeably" placed at risk when doctors fail to warn patients about potential side effects of prescribed drugs. The ruling allowed a mother whose son was hit by a car to sue the doctor who prescribed drugs to the driver, who lost consciousness behind the wheel. Last year, justices ruled in another case that physicians may be held liable if their actions lowered a patient's chances for survival, even if the patient already had a recovery probability of less than 50 percent. Massachusetts Medical Society President Bruce S. Auerbach, MD, warned that the rulings establish dangerous precedents that "open a huge waterfront for plaintiff attorneys and drop the bar to an unconscionably low level" for proving medical negligence. In February Auerbach's organization helped file legislation mandating that plaintiffs would have to have a direct relationship with a physician defendant and demonstrate that any alleged negligence caused injury that would not have happened otherwise. Physicians are worried that they could be targeted by a wave of lawsuits while liability insurance rates would skyrocket without such protection. Auerbach also noted that the added risk "could potentially discourage doctors from taking care of more complex patients."

From the article of the same title
American Medical News (03/09/08) Sorrel, Amy Lynn

Health Policy and Reimbursement

No Verdict on Pay-for-Performance U.S. Health Plans

Pay-for-performance plans, which dictate that doctors, hospitals and other providers receive more money if they satisfy certain objectives, have not noticeably improved the quality of medical care and may in fact be hindering doctor-patient relationships, according to researchers. A RAND study of a pay-for-performance program started in 2003 involving seven major California health plans and 225 physician groups concluded that the program appears to be accelerating the adoption of information technology such as electronic medical records without significantly enhancing quality. "Physician groups are responding to pay-for-performance programs by making practice changes and altering how they compensate physicians to reward quality, but health plans and purchasers say that those investments are not yet translating into substantial gains in quality," said RAND policy researcher Cheryl Damberg. "The true benefits of these programs may take more time to be realized and it is likely that investments in other quality efforts will be needed in addition to performance-based pay." The majority of the medical groups polled in the study said that the program's financial incentives were insufficient to spark significant change among most physicians, and suggested that the incentives had to be two to five times higher to stimulate quality improvements. A separate study of doctors in California and England by University of Manchester researchers has determined that there is resentment of pay-performance plans by physicians, who feel that the programs infringe on the doctor-patient relationship. British doctors felt that the concentration on computer systems and data collection displaced communication with patients, while U.S. physicians said the structure of the audit and payment systems sometimes warped the care process.

From the article of the same title
Reuters (03/10/09) Steenhuysen, Julie

CMS Striving for a Fair Audit Program, Official Says

The Centers for Medicare & Medicaid Services (CMS) is still promoting its Recovery Audit Contractor (RAC) program despite controversy caused by the program, which pays incentive fees to third-party auditors that identify and correct improper payments paid to healthcare providers in fee-for-service Medicare. "The success of this program is important," said Lt. Terrence Lew, a health insurance specialist with the CMS Division of Recovery Audit Operations’ Financial Services Group, during a Practicing Physicians Advisory Council (PPAC) meeting. "We heard loud and clear that providers were upset with the burdens placed upon them," and "we don’t want to overwhelm providers." Lew said that CMS would encourage auditors to "be reasonable" with providers and noted that the agency has already made some changes to minimize the burden on doctors, such as limiting the number of medical record requests during a RAC review. But the new limits are still burdensome, noted PPAC member Fredrica Smith, an internist and rheumatologist in Los Alamos, N.M., saying that a small group practice would have difficulty in producing 20 medical records in 45 days. The panel made several recommendations to ease burdens for doctors, including requiring RAC auditors to reimburse providers for copies of medical records prior to the start of a RAC audit. HHS is required to make the program permanent on a national basis by Jan. 1, 2010.

From the article of the same title
Modern Healthcare (03/09/09) Lubell, Jennifer

The Bigger Picture: Love Lost

The Love Settlement was passed to rectify what were deemed to be unfair payer practices by stipulating transparency in fee schedules, compliance with realistic medical necessity standards, time limits for credentialing reviews, and the required establishment of an external review for disputed claims by certain Blue Cross Blue Shield Plans. This means that plaintiffs can, for a fee, submit payers disputes to the Billing Dispute External Review Board, provided that they meet certain criteria. Physicians Practice's Pamela Moore, PhD, writes that the settlement is a step forward, but warns that there are deep flaws in the external review process. "The reviews will focus on the denied claims, not the policy behind the denials," she notes. "And it's the policy that is really at stake in physician complaints about payers." Moore writes that payers are still following the practice of concocting rules to suit themselves, and then revising them whenever it is to their advantage. A doctor following the appeal process "will pay for the privilege of the second level of appeal and the adjudicator will just say, 'Yes, you were denied properly based on the policy,'" says consultant Suzanne Madden. "They missed the boat on what physicians can actually appeal with this." The appeal's restrictions and its price point are especially galling in view of the problems most doctors have in drawing a distinction between the causes of denials. "In fairness, I don't see why payers should let physicians set the rules about why and when and how much they should get paid," writes Moore. "But there should be some opportunity for discussion, some third-party determination of what makes sense for all parties when a policy becomes contentious. Otherwise the kinds of disputes that led to the Love Settlement in the first place will just continue."

From the article of the same title
Physicians Practice (03/09) Moore, Pamela

Technology and Device Trends

Immune Reaction To Metal Debris Leads to Early Failure of Joint Implants

Rush University Medical Center researchers have won the annual William H. Harris, MD Award for scientific merit for their study identifying a key immunological defense reaction to joint replacement device metals. These immunological reactions lead to loosening of components in the device, bringing about early failure. "As soon as joint replacement devices are implanted, they begin to corrode and wear away, releasing particles and ions that ultimately signal danger to the body's immune system," says co-author Nadim Hallab, MD. This study is the first to show that debris and ions from implants can trigger a certain inflammatory pathway. The study is currently available online and is expected to appear in the Journal of Orthopaedic Research's June issue.

From the article of the same title
Ortho Supersite (03/10/2009)

Brace Yourself: Ankle Braces Hurt Knees

Athletes tend to wear different types of ankle braces after subtalar joint inversions. They think that this will prevent rolled ankles and further injury. However, exercising with braces can put athletes at risk for other injuries and knee problems, according to studies. Many studies have been done examining the athletic performance effects of wearing ankle braces, and while most have shown that braces can help prevent ankle sprains, a few have demonstrated the stress braces can put on an athlete's knee joint. Research by Kandy Venesky of Indiana University, appearing in The Journal of Athletic Training, showed that wearing ankle braces increased the twisting forces about the knee by 10 percent, boosting the risk of knee ligament injury. Research from the University of Kansas Medical Center confirmed the findings, showing that wearing ankle braces significantly increased torque at the knee joint during trunk rotation movement while standing on one leg, the same motion that occurs during a one-leg landing. To prevent knee injury, a training program that reinforces proper landing technique and strengthens necessary ligaments and muscles is essential, says Dr. Phil Wagner, director of SPARTA Performance Science in Menlo Park, Calif. The use of ankle tape rather than a brace may also be appropriate. The tape can provide lateral support without significantly inhibiting essential range of motion in the ankle joint, keeping the torque off knees.

From the article of the same title
San Jose Mercury News (CA) (03/06/09) Wagner, Phil

Fractures of the Distal Tibia Treated With Polyaxial Locking Plating

Researchers evaluated various factors in 32 adult patients with very short metaphyseal fragments in fractures of the distal tibia treated with a polyaxial locking system. Every fracture healed, with 14 weeks being the average time to union. Six patients reported occasional local disturbance over the medial malleolus, and there were two cases of postoperative superficial infections and evidence of delayed wound healing. Using the American Orthopaedic Foot and Ankle Society ankle score of 100 total possible points, the average functional score was 87.3 points. The researchers concluded that polyaxial locking plates, which offer more fixation versatility, may be a reasonable treatment option for distal tibia fractures with very short metaphyseal segments.

From the article of the same title
Clinical Orthopaedics and Related Research (03/01/09) Vol. 467, No. 3, Gao, Hong; Zhang, Chang-Qing; Luo, Cong-Feng

FDA and Eight Academic and Research Institutions to Collaborate Under Nanotechnology Initiative

The FDA and the Alliance for NanoHealth (ANH) have agreed to enter into a joint effort to speed the development of promising new medical products in the field of nanotechnology. Under a Memorandum of Understanding, the new initiative will focus on research designed to improve understanding of how nanoparticles behave and affect biologic systems, and developing processes that will mitigate risks associated with nanoengineered products. All outcomes of the cooperative will be available for public access.

From the article of the same title (03/10/09)

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March 18, 2009