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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

The Latest On the “Doc Fix”

Sources in the know are saying this morning that both political parties are unhappy about the prospects for a Medicare “doc fix,” which would avert a 21 percent reduction in Medicare payments to physicians that is scheduled to go in effect on June 1.

Democrats realize they have to scale back their package to win votes. Ideas being discussed in Washington include offering only a one-month extension to these expiring programs, which just pushes resolution of this issue out another month.

The Senate Health, Education, Labor and Pensions Chairman Tom Harkin, D-Iowa, has stated an extension of the Medicare doctor fix through only the end of 2010 could save $57 billion in cost in the bill's financial score, while others in Congress acknowledge delaying a permanent solution creates more expenses down the road.

Questions? E-mail ACFAS Director of Health Policy, Practice Advocacy and Research Kristin Hellquist.
Point Your Patients to ACFAS Consumer Podcasts

Looking for more valuable foot health information to share with your patients? Two new patient education podcasts, “Diabetes and Your Feet” and “Hallux Rigidus,” are now available on, ACFAS' official consumer website.

Each podcast features a panel of physicians who answer the most common questions patients have on these health issues. Additional podcasts on other foot and ankle health topics can be found by visiting
Short Takes on Research for Busy Surgeons

ACFAS’ Scientific Literature Reviews offer you the chance to quickly catch up on articles from journals you may not usually read. Current research is abstracted especially for the interests of foot and ankle surgeons by podiatric residents. New abstracts for May include:

Treatment of Chronic Lateral Ankle Instability: A Modified Broström
Technique Using Three Suture Anchors
, from the Journal of Orthopaedic Surgery and Research.
Reviewed by Jennifer Gerteisen, DPM, St. John Hospital.

Extraskeletal Osteochondroma of the Foot, from the Journal of the Chinese Medical Association.
Reviewed by Jill Greenley, DPM, St. John Hospital.

Hyaluronic Acid as a Treatment for Ankle Osteoarthritis, from Current Reviews in Musculoskeletal Medicine.
Reviewed by Kelsey L. Harvey, DPM, St. John Hospital.

Read these reviews and many more on the ACFAS website.

Foot and Ankle Surgery

Evaluation of the Ankle Function Following Reconstruction of the Donor Defect With a Split Fibular Bone After a Vascularized Fibular Flap Transfer

Researchers conducted a study to validate their hypothesis that the reconstruction of the missing segment of the fibula using a redundant split fibular graft after a vascularized fibular flap transfer may have a better result on ankle function. Of 24 patients who received a free fibula flap for mandible reconstruction, 14 patients underwent the conventional method of donor site closure, in which the redundant fibular bone was discarded (Group I). Ten patients underwent longitudinal osteotomy of the redundant non-vascularized fibular portion to bridge the donor site defect (Group II). The research showed that the muscle peak torque of the donor leg was significantly lower at ankle plantar flexion, eversion, and inversion in Group I as well as at dorsiflexion, plantar flexion, and inversion in Group II against the contralateral non-operated leg. The muscle power was significantly greater when performing ankle eversion in those who underwent split fibular bone reconstruction. The researchers concluded that the reconstruction of the donor site with a split fibular bone graft led only a slight improvement in ankle eversion.

From the article of the same title
Archives of Orthopaedic and Trauma Surgery (06/10) Vol. 130, No. 6, P. 781; Hsieh, C. H.; Cheung, S. M.; Sun, C. K.; et al.

Percutaneous Gallagher Nail Stabilisation for Fragility Ankle Fracture

Researchers treated nine osteoporotic fragility fractures of the ankle in the elderly by closed reduction and percutaneous ankle stabilization using a transarticular Gallagher nail introduced via the calcaneum and directed through the talar dome into the tibia. All the fractures maintained satisfactory alignment and healed without delay. Pain-free transfer with assistance was possible in all patients by eight weeks post-operatively. Nails were removed in eight patients, and six patients returned to pre-fracture mobility status. Union was achieved in eight cases. No wound complications occurred.

From the article of the same title
European Journal of Orthopaedic Surgery and Traumatology (05/10) O’Daly, Brendan J. ; Harty, James A. ; O’Malley, Natasha

Soft Tissue and Bone Penetration Abilities of Daptomycin in Diabetic Patients With Bacterial Foot Infections

In the attempt to overcome increasing glycopeptide- and methicillin-resistant soft tissue infections, daptomycin is considered as an attractive alternative to the class of glycopeptides. Researchers evaluated daptomycin's ability to penetrate into inflamed subcutaneous adipose tissue and bone in diabetic patients presenting with severe bacterial foot infection. Serial sampling of specimens at steady-state was performed from zero to eight hours post-dose in five patients and from eight to 16 hours after study drug administration in another group of four patients. In all subjects, daptomycin was administered intravenously once daily at a dosage of 6 mg/kg body weight for four consecutive days at minimum. The researchers found that equilibrium between free tissue and plasma concentrations was achieved approximately two hours post-infusion. Under steady-state conditions, the degree of tissue penetration was assessed by the calculation of the ratio of free (f) AUC of daptomycin in plasma to the fAUC in tissues. The mean ratios of the fAUC0-16 tissue to the fAUC0-16 plasma were 1.44, 0.98 and 1.08 for healthy tissue, inflamed subcutaneous adipose tissue and bone, respectively. The corresponding ratios of the fAUCs from zero to 24 hours were 1.54, 1.06 and 1.17, respectively. The researchers concluded that daptomycin given at intravenous doses of 6 mg/kg body weight once daily may be considered an effective treatment regimen in diabetic patients suffering from bacterial foot infection and osteomyelitis.

From the article of the same title
Journal of Antimicrobial Chemotherapy (06/01/10) Vol. 65, No. 6, P. 1252; Traunmüller, F.; Schintler, M. V.; Metzler, J.; et al.

Practice Management

FDA Urges Docs to Report Misleading Drug Ads

The Food and Drug Administration recently announced that it is seeking assistance from doctors in identifying misleading drug advertisements as part of the FDA's most recent effort to police marketing by the pharmaceutical industry. The agency's Bad Ad Program is urging doctors to report ads and sales pitches that violate FDA rules. "The Bad Ad Program will help healthcare providers recognize misleading prescription drug promotion and provide them with an easy way to report this activity to the agency," says Thomas Abrams, FDA drug advertising division director.

From the article of the same title
Associated Press (05/11/10) Perrone, Matthew

Scrubbing In: It's Critical to Speak Patient's Language

In many places across the country, English is often a patient's second language. Before surgical procedures, some physicians use books that describe the purpose of the procedure, how it will take place, and what are the risks and benefits. Translation in the medical field is a necessity, particularly as more than 34 million foreign-born people live in the United States. Medical schools are incorporating classes and strategies on how to get past the language barrier, including practicing using professional interpreters.

When interpreters are not available, many hospitals use special language phones that can connect a physician or nurse to a translator, with options for dozens of languages. These phones take a few minutes to hook up, but significantly improve the patient's care. Proper translation can put patients at ease with upcoming procedures by answering any questions or uncertainties they may have.

From the article of the same title
Philadelphia Inquirer (05/10/10) Sobel, Rachel K.

The 12-Step Way to Reduce Practice Expenses: Part 2, Operational Efficiencies

Medical practices can save a lot of money even with small reductions in their operational costs, first by reviewing their office lease and other lease agreements, including maintenance contracts and repair costs. Office supply costs are another area of potential expense reduction, and group purchasing can yield volume-discount prices. The practice should optimize the ordering and handling of supplies, while further operational efficiencies can be realized by scrutinizing the cost-effectiveness of outside services. In addition, the practice should seek ways to economize on postage and telephone costs. The final three steps for lowering practice expenses include assessing the practice's advertising for waste and ineffectiveness; tracking down and removing causes of patient refunds; and tightening controls on petty cash and eliminating problems that incur extra bank charges. The 12-Step Way To Reduce Practice Expenses: Part 1, Staffing Efficiencies can be viewed here.

From the article of the same title
Family Practice Management (06/10) Vol. 17, No. 3, P. 30; Tinsley, Reed
Web Link - May Require Paid Subscription | Return to Headlines

Health Policy and Reimbursement

HHS Preparing Surveys to Gauge Patient Response to EHRs and PHRs

The Department of Health and Human Services is preparing two surveys that aim to gather information about patients' preferences and satisfaction with electronic health records and personal health records in order to improve nationwide HIT adoption efforts. To learn more about the value of PHR adoption, HHS plans to survey about 500 Medicare beneficiaries who are enrolled in the Medicare PHR Choice Pilot, which launched in January 2009 in Arizona and Utah. The program encouraged fee-for-service beneficiaries to enroll in one of several available PHR services to track their own health and healthcare services. HHS hasn't yet indicated if they plan to expand the pilot project, but the results of the survey could determine whether Medicare adopts a national PHR program.

The second survey will be designed to assess the gap between patients' and providers' perceptions about how EHR systems affect the delivery of care. It will focus particularly on primary care practices, and the goal is to understand how having an EHR in a primary care office affects consumers' satisfaction with their care, their communication with their doctors, and the coordination of care. HHS plans to gather information about EHR preferences through three projects: A survey that will collect information directly from 840 patients, a screening and recruitment form for staff at primary care practices, and a focus group of about 20 patients from primary care practices.

Both survey proposals are open for comments and suggestions for 30 days.

From "Agency Information Collection Request. 30-Day Public Comment Request"
Federal Register (05/14/10)

Insurance Regulators Wrestle With Definition of 'Unreasonable' Rate Increases

State and federal officials are grappling with the definition of "unreasonable" premium rate hikes, a perplexing issue that Congress has handed insurance regulators. The National Association of Insurance Commissioners (NAIC) issued a letter to the Department of Health and Human Services suggesting nearly a dozen options for flagging a "potentially unreasonable" premium increase. Those options included average increases above a certain percentage, those that top the consumer price index by a specific percentage, rates that cause an insurer to lose money but gain market share, and those targeting the coverage of excessive administrative costs. Among the numerous determinants of premium increases identified by insurers are how much insurers must pay doctors, hospitals, and drug companies; the length of customer policy retention is another factor that must be weighed, as policies become more costly as clients get older or fall ill. America's Health Insurance Plans has discouraged NAIC's adoption of an "arbitrary" definition, and spurred regulators to assess whether a rate is "reasonable," based on variables such as an insurer's ability to pay estimated claims costs.

From the article of the same title
Kaiser Health News (05/17/10) Appleby, Julie

No, You Can't Keep Your Health Plan

American Enterprise Institute fellow Scott Gottlieb writes that starting in 2011, health plans will have a regulated "floor" on their medical loss ratios, with insurers only able to spend 20 percent of their premiums on running their plans if they supply policies directly to consumers or to small employers, or 15 percent if they supply policies to large employers. Individual policies come with higher marketing, medical, and start-up costs, and fewer new policies will be offered if insurers cannot spend more of their revenue to launch policies. Reducing the actual cost of products is one of the few remaining expense management strategies, and in healthcare this translates into pressuring providers to take lower fees and reduce their employment of expensive services such as radiology.

Doctors, meanwhile, will have to contend with elevated operating costs, as the Obama health plan carries more expenses, such as a mandate to purchase information technology systems and keep more records. A 2007 survey by the Medical Group Management Association found that overhead costs already eat up over 60 percent of the revenue produced by an average medical practice, while Medicare reimbursement is declining simultaneously.

From the article of the same title
Wall Street Journal (05/18/10) Gottlieb, Scott
Web Link - May Require Paid Subscription | Return to Headlines

Technology and Device Trends

Domo Arigato, Doctor Roboto

Doctor robots, devices that allow a doctor to examine patients from a remote location, are being employed by several hospitals across the nation for a variety of purposes, including stroke treatment, emergency room call, critical care coverage, hospital capacity management, and specialty training and collaboration. The robots allow patients to interact with the doctor via live videofeed. In addition to improved efficiency for doctors, who can conduct night and weekend rounds from their home, clinic, or office, the robots can also improve patient and family satisfaction. In a study led by Louis Kavoussi, chairman of urology at the North Shore LIJ Health System in New York and an early user of a doctor robot, half the patients preferred a "tele-rounding" visit by their own doctor to a "real" visit by another physician. More than 80 percent of the patients felt that the robot increased physician accessibility.

From the article of the same title
HealthLeaders Media (05/18/10) Shaw, Gienna

Misalignment of Total Ankle Components Can Induce High Joint Contact Pressures

A major cause of the limited longevity of total ankle replacements is premature polyethylene component wear, which can be brought about by high joint contact pressures. Researchers implemented a computational model to validate their hypothesis that intercomponent positioning deviating from the manufacturer's recommendations can result in pressure distributions that may lead to wear of the polyethylene insert. They also investigated the hypothesis that a modern mobile-bearing design may be able to better compensate for misalignments compared with an early two-component design. Two finite element models of total ankle replacement prostheses were built to quantify peak and average contact pressures on the polyethylene insert surfaces. The models were configured to replicate three potential misalignments: version of the tibial component, version of the talar component, and relative component rotation of the two-component design. The researchers found that with the use of the manufacturer's guidelines for positioning of the two-component design, the predicted average joint contact pressures exceeded the yield stress of polyethylene (18 to 20 MPa), while pressure magnitudes increased as implant alignment was systematically deviated from this reference position. The three-component design showed lower-magnitude contact pressures in the standard position (<10 MPa) and was generally less sensitive to misalignment. The researchers concluded that in the tested implants, a highly congruent mobile-bearing total ankle replacement design yields more evenly distributed and lower-magnitude joint contact pressures than a less congruent design.

From the article of the same title
Journal of Bone and Joint Surgery (American) (05/01/10) Vol. 92, No. 5, P. 1179
Web Link - May Require Paid Subscription | Return to Headlines

Multidisciplinary Team of Researchers Developing Glass to Treat Damaged Bone

An international multidisciplinary team of researchers is developing glass that can treat patients with damaged bone. The goal is to place in the body a glass “scaffold” with chemical ingredients that match those of natural bone to promote transport of blood and nutrients through interconnected pores and allows new cells to grow, without causing infection or a systemic reaction. When attached to injured or diseased bone, the glass spurs the bone to regenerate and is then absorbed into the body. Researchers are working on bioglass that can be formed readily into complex shapes. The technology, which will be tested in the near future in human clinical trials, could be particularly useful for patients with osteoporosis.

From the article of the same title
ASM International eNews (05/11/10)

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May 26, 2010