News From ACFAS

Foot and ankle surgery thrives on research! If you're involved in a study that would benefit the profession, enter your manuscript now for the 2010 Annual Scientific Conference Competition.

You can enter in the individual or institutional category, and winners will divide $10,000 in prize money provided by a generous grant from the Podiatry Foundation of Pittsburgh.

Submit your manuscript electronically by Aug. 3, 2009 to be considered for review.

Learn more about how to submit a manuscript.




While the May/June issue of the Journal of Foot & Ankle Surgery is making its way to your mailbox, you can read the articles online.

This issue features seven research articles, including "The Effect of Hindfoot Realignment in Triple Arthrodesis" and "The Utility and Effectiveness of Bone Morphogenetic Protein in Foot and Ankle Surgery." You'll also find case reports, reviews and tips, quips and pearls.



When you can follow up with pantalar arthrodesis patients 37 years later, what do you learn about the procedure's effectiveness?

How does an arthroscopic method of repair for the lateral ankle ligament complex compare to the Brostrom-Gould procedure?

Find out quickly and easily in this month's Scientific Literature Reviews. Research from the Journal of Bone & Joint Surgery (American) and Foot & Ankle International is featured in the May abstracts, prepared by podiatric residents.

Don't be in the dark on research when it's so easy to keep up to date.

Foot and Ankle Surgery

Sprained Ankle Rehab Complicated by Delayed Muscle Response, BYU-Michigan Study Finds

Researchers from Brigham Young University and the University of Michigan say that the lateral muscles of the leg play a key part in how quickly the ankle responds to a misstep, which in turn is key to the long-term strength of the ankle afterward. "The lateral muscles of the leg are key to ankle injury," says Brigham Young researcher Ty Hopkins, PhD, ATC. "They are key because they resist the movement that is involved in injury itself and position the foot during movement."

The researchers had people walk down a runway with trapdoors to nudge their ankles, then compared the muscle response in people with a history of weak ankles versus that in a control group with no such history. The control group's muscles responded within 55 milliseconds, while the response time was up to 90 milliseconds in the group with a history of ankle trouble—enough time to make a difference in whether the ankle is sprained—and the control group's muscles responded more strongly as well.

This research focused on the peroneus longus muscle, which moves the foot in the direction opposite an ankle injury. According to Hopkins, "The peroneus longus by itself probably isn't a very good protector simply because of its size, even if it contracted really well. We are working on other projects now to look at the system of muscles involved with stabilizing the ankle." The research is presented in the May issue of The American Journal of Sports Medicine.



Complication Rates Following Open Reduction and Internal Fixation of Ankle Fractures

Researchers at the University of California at Los Angeles Department of Orthopaedic Surgery analyzed patient data in the California discharge database to clarify risks related to open reduction and internal fixation of ankle fractures. Overall, the rate of short-term complications such as pulmonary embolism, mortality, wound infection, amputation, and revision was low, as was the intermediate-term rate of reoperation.

Notable risk factors predicting short-term complications were open injury, diabetes, and peripheral vascular disease. Meanwhile, fracture type was an important predictor of reoperation for ankle fusion or replacement, with a higher intermediate-term reoperation rate seen in patients with trimalleolar fractures and open fractures. The researchers found no significant effect from hospital volume on the rate of short-term or intermediate-term complications.



Improved Surveillance for Surgical Site Infections After Orthopedic Implantation Procedures: Extending Applications for Automated Data

Focused surveillance, using automated inpatient diagnosis codes and pharmacy data, can be more sensitive than routine surveillance in detecting surgical site infections after arthroplasty, researchers report. The study was conducted at eight hospitals and involved a review of medical records from 696 total hip arthroplasty procedures and 1,009 total knee arthroplasty procedures.

An inpatient diagnosis code for infection within a year after the operation had a substantially higher sensitivity compared with routine surveillance, and adding antimicrobial exposure of greater than seven days after the procedure increased the sensitivity. The researchers suggest that this screening could be efficiently added to traditional methods.

Health Policy and Reimbursement

New Effort Reopens a Medical Minefield

The Federal government’s plan to spend $1.1 billion in stimulus funds on comparative effectiveness studies of common diseases has come under fire from some stakeholders, including medical device companies and some providers who say they are concerned about “cookbook medicine” and possible rationing of care. However, the effort has significant support from medical researchers, patient groups and insurers. In late June, after public hearings, the Institutes of Medicine will issue a report recommending priorities for study.



Trends In Medicaid Physician Fees, 2003-2008

Researchers from the Urban Institute found that Medicaid reimbursement rates to physicians increased by a total of 15.1% between 2003 and 2008. This failed by a significant margin to keep up with inflation (which increased by 20.3 percent) or the cost of providing medical care (which increased by 28.1%) during that same time period. Primary care reimbursement rates rose by 20% while payment for non-primary care services grew by just 8.7%.



State Seeks to Revamp Way Doctors, Hospitals Are Paid

A 10-member Massachusetts commission created in 2008 by the legislature to look at ways to slow the rapid growth in health care costs in the state is preparing to propose a radical change in the way health insurers pay providers in Massachusetts. The proposal, which is supported by Governor Deval Patrick, would replace the current “fee for service” payment system with a global per-patient annual payment which would be adjusted for patient risk and include “stop loss” protection for providers. The details have yet to be worked out but there is wide consensus in the State that there is an urgent need for action.

Technology and Device Trends

Promising Results Seen With Minimally Invasive Repair of Achilles Tendon Ruptures

Eric M. Bluman, MD, PhD, talked about the results of minimally invasive repair methods and spotlighted the outcomes of repairs using a minimally invasive Achilles tendon suture device at the American Orthopedic Foot and Ankle Society's 24th Annual Meeting. Bluman uses the Achillon device to aid in rupture repairs, and the method entails a 2-cm vertical incision that permits direct visualization of tendon apposition while also maintaining all the sutures deep to the peritenon. Bluman said he has applied the technique to numerous patients, 11 of whom have a minimum 12-month follow-up and are "all back to their pre-rupture activity level."

Dynamometry revealed no significant difference between the uninjured side and the contralateral limb, nor did Bluman see any wound problems, infections, re-ruptures, sural nerve injuries, or adhesions. He noted that no infections or sural nerve injuries were detected in a study by the Achillon's inventor on 83 patients whose tendons were repaired with the device. Bluman said that there have been reports of higher sural nerve damage rates in people who have been treated with completely percutaneous methods, and added that "there is an inability to directly visualize tendon apposition as well."



Botox Injections May Ease Diabetic Foot Pain

Injecting Botox in the skin at the top of the foot can relieve diabetes patients of chronic foot pain caused by nerve damage, according to researchers led by Dr. Chaur-Jong Hu of Taipei Medical University in Taiwan. The treatment was tested on 18 patients with type 2 diabetes who had nerve-related pain in both feet. The patients randomly received injections of Botox or saline, and 12 weeks later received the opposite treatment. The injections were administered into the skin rather than into muscles at a dozen sites across the top of the foot.

The average pain score on a scale from 1 to 10 was 6.36 at the start of the study, and at 12 weeks the pain score fell by 2.53 points for people who received the Botox treatment, while the score for the saline recipients fell by only 0.53 points. Also, 44 percent of the subjects had a reduction of at least three points in their pain score within 12 weeks following the Botox treatment.

Intradermal Botox injections were determined by Hu's team to be "an effective and safe method of relieving diabetic neuropathic pain in the feet." However, the team found that "the detailed underlying mechanisms, optimal dosage, and precise course of therapy require further evaluation."



Magnetic Resonance Angiography in Clubfoot and Vertical Talus: A Feasibility Study

Congenital vascular alterations of the normal adult arterial pattern have been linked to numerous congenital limb deformities, including clubfoot and vertical talus. Absence of the anterior tibial artery and dorsalis pedis artery has been observed in most patients with clubfoot, as has absence of the posterior tibial artery in all patients with vertical talus.

In this study, researchers used magnetic resonance (MR) angiography to define the lower extremity vascular anatomy of two patients with left-sided vertical talus and right-sided clubfoot and one patient with bilateral vertical talus and cartilage-derived morphogenetic protein-1 (CDMP-1) gene mutation. Of the former two, the MR angiography showed that one had bilateral posterior tibial artery deficiencies and the other had bilateral anterior tibial artery deficiencies, while the patient with bilateral vertical talus and CDMP-1 mutation had normal arterial structure bilaterally.

Though clubfoot and vertical talus have distinctly different clinical phenotypes, the association of each with arterial abnormalities suggests a common etiology during development. The researchers concluded that the presence of normal arterial structure in the patient with vertical talus and CDMP-1 mutation suggests that other nonvascular etiologies may be responsible for some cases of foot deformities.



Voyage of the Microrobots

A potential medical revolution could be facilitated with the advent of tiny robots that can access small spaces in the human body without the need for invasive surgery, once the technical challenges of producing, powering and steering such microrobots are overcome. A group of researchers details proposed solutions to these problems in Applied Physics Letters.

The researchers have assembled a swimming bacterium-scale robot. The device is comprised of an artificial, helical flagellum mated to a magnetic "head." The flagellum turns when placed in a weak, oscillating magnetic field generated by three pairs of orthogonal pairs of electromagnetic coils so that the microrobot is propelled through liquid at speeds of 1 to 2 micrometers per second. The robots are etched out of thin semiconductor films deposited on a substrate, but future microrobots will require more sophisticated fabrication techniques.

External magnetic actuation makes incorporating actuators and power supplies into the robots' bodies unnecessary, and it should give doctors a direct method for controlling and steering the machines inside patients. Steering microrobots deep inside the body would require very high magnetic-field gradients, which could heat and damage tissues. For this reason and others, many groups are exploring on-board actuation and powering methods, with a recent trend being the utilization of living cells as actuators driven by chemical energy. Cellular "motors" give the system compactness, affordability and speed, while the cellular propulsion or actuation component could serve multiple roles.

Working out techniques for detecting, localizing and communicating with microrobots within the body and constructing and integrating on-board diagnostic and therapeutic instruments are additional challenges. Armies of microrobots will be required to treat large areas of the body, improve the success of medical operations and deliver a sufficient dosage of drugs to their targets, necessitating a programming and control methodology.



Abstract News © Copyright 2009 INFORMATION, INC.

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