News From ACFAS

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The deadline to review/verify your 2012 ACFAS Annual Scientific Conference CME record online has been extended to June 5, 2012.

If you have not already done so, please log on to the ACFAS CME website to verify your attendance and CME credit hours.

Remember: AFTER June 5, 2012 the online edit function will no longer be available to Conference attendees; CME credit hours recorded for ACFAS 2012 as of June 5 will be entered on your ACFAS education record.

If you have any questions regarding the online CME transcript service, please contact Maggie Hjelm, Jane Battisson, or Marilyn Wallace in the ACFAS Education Department or phone 800-421-2237.

Visit the ACFAS CME website today to confirm the accuracy of your 2012 ACFAS Annual Conference CME hours!
If you are involved in a study that would benefit the advancement of the profession, submit your manuscript for presentation consideration at the 2013 Annual Scientific Conference in Las Vegas, February 11-14, 2013.

Winners of the ACFAS Manuscript Awards of Excellence divide $10,000 in prize money from a generous grant from the Podiatry Foundation of Pittsburgh.

To read detailed information on manuscript requirements and policies and to submit your manuscript, visit acfas.org/lasvegas. The deadline to submit manuscripts is August 15, 2012. Educate your surgical patients with the information they need before their surgery with the new Perioperative Patient Education CD.

The new educational CD is filled with over 11 handouts on the most common surgical procedures, including Achilles Tendon Disorders, bunions, chronic ankle instability, flatfoot, fracture repair, hallux rigidus, hammertoe, tailor’s bunion and ankle anthroscopy.

Each handout has been peer-reviewed, providing clear, concise and ample information that may be tailored to the patient’s specific needs and situation, such as:

• Risks and benefits of surgery
• Details on preparing for surgery
• Description of the procedure
• Post-op instructions
• Patient consent form

To see a complete list of topics and to order your new patient education CD tool for only $95, visit acfas.org/perioperativecd.

Foot and Ankle Surgery

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Researchers assessed the safety of percutaneous Achilles tenotomy as part of the Ponseti serial casting protocol for treatment of pediatric clubfoot when executed as an "office procedure" without sedation or general anesthesia during the final stage of the serial casting protocol. The study included all infants managed in the outpatient clinic between 2006 and 2010, and tenotomy was indicated when the forefoot was completely corrected and if the hind-foot exhibited rigid equinus. Tenotomy was carried out by a single scalpel stab in the outpatient clinic, using topical and local anesthesia. The cast was then applied and kept on for three weeks, and infants were sent home after one hour of supervision. The researchers specifically focused on perioperative complications, recovery unit notes, and hospital readmission. Fifty-six infants, or 83 feet, were included in the current study, and 27 had bilateral clubfoot. Three infants had complex clubfoot while familial risk was known in six patients. Forty-one infants were indicated for Achilles tenotomy, which was performed after an average of five casts. There were no negative events related to local anesthesia and/or the procedure itself, and there was no delay in discharge in any of the operated infants. One infant was evaluated in the emergency room three days following the procedure due to unfounded parental concern of swelling inside the cast. Retenotomy was carried out in seven patients, or 12 feet, while two had complex clubfoot. All of these infants but for one had moderate to poor compliance with the treatment protocol.


A study was conducted to test the hypothesis that lateral minimally invasive plate osteosynthesis (MIPO) would be comparable with medial MIPO with respect to clinical and radiographic results for treatment of distal tibial fractures. Twenty-four patients with a distal tibia fracture were treated using MIPO between June 2005 and February 2009, with half fixated by medial MIPO and the other half by lateral MIPO. The groups were compared with regard to time to union, and clinical outcomes were evaluated using the IOWA ankle-rating system and the range of ankle motion at last follow-up. Average operation time and postoperative complications were assessed by chart review, while radiographic results were rated according to tibial angulation and shortening at last follow-up. Radiological evidence of bony union was seen in all study subjects. There was no significant difference between the two groups in terms of average union time, mean IOWA score, range of ankle motion, operation time, or angulation and shortening. Angular deformity greater than 5 degrees or tibial shortening greater than 10 mm was not observed in any patient at the last follow-up. Skin irritation was seen in one case in the medial MIPO group and limited motion due to entrapment of the tibialis anterior muscle was observed in one patient in the lateral MIPO group.


A study was held to examine how the hemodynamic parameter ankle-brachial pressure index (ABI) correlates with the run-off resistance (ROR) evaluated on magnetic resonance angiograms (MRA) in patients with peripheral arterial disease (PAD) Fontaine Stage I and II and its potential as a reliable reporting system in clinical routine. Contrast-enhanced MRA was administered to 321 PAD patients using a 1.5T MR scanner with moving bed method, and the ROR and resting ABI were determined in each patient's leg and correlation analysis was carried out using the Pearson test. The researchers identified a significant negative correlation between ROR and resting ABI, while patients younger than median age who had higher ABI values exhibited an even more substantial correlation.

Practice Management

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New research from the Johns Hopkins Center for Injury Research and Policy published this month in Public Health Reports indicates that International Classification of Diseases (ICD)-10 coding points to a 42 percent increase in fatal falls among those 65 and older between 1999 and 2007. The higher death rate is not due to a greater incidence of serious falls, but rather because coding for death classification was updated from ICD-9 to ICD-10 in 1999, which calls for more detail about the underlying cause of death. Johns Hopkins professor Susan Baker reports that since the migration to ICD-10 cause-of-death coding, "there has been increasing attention to educating doctors and medical examiners to let them know there's a correct way to code death, and [in these cases] that there was a fall that led to it. This calls attention to the fact that falls are an extremely important cause of morbidity and mortality in the elderly, and now we're starting to see what the real numbers are. They are far and away the leading cause of death in the elderly." Baker's research revealed a 698 percent increase in mortality coding under the category "other falls on the same level." There is a greater incidence of same-level falls among seniors, and these falls do not result in immediately life-threatening injuries. Rather, they prompt a trip to the doctor or hospital, diagnosis of a fractured or broken hip, and frequent complications from surgery or pneumonia weeks or months later. The research cited deaths classified as falls among seniors involving wheelchairs or furniture as exhibiting the second highest increase in coding. Baker says the increase in falls among the elderly population should not only stress the value of accurate coding, but also prompt clinicians to monitor much more closely for this risk in their patients and take greater precautions.


A few simple tweaks can really change the bottom line for physician offices, and therefore their paychecks. Practices often hemorrhage money from staffing, considering a single physician clinic that sees an average of 30 patients per day (without any ancillary services) only needs three team members other than the physician to run the office, assuming everyone is properly trained and motivated and the right systems are in place. Such offices are likely to have upwards of seven staff members (check in receptionist, check out receptionist, billing specialist, lab tech, two medical assistants and an office manager), but they can cut their staff nearly in half by cross-training everyone and if there is a willingness to work as a team and jump in whenever needed.

For example, the office manager should spend most of his or her time on billing, but should also back up the receptionist on the phones and check in/checkout, fill in for the medical assistant when help is needed on the clinical side, and serve as the liaison between the physician and the staff for routine issues. A practice will need to set general rules for lunch breaks and time of arrival prior to the first patient. Moreover, offices must promote teamwork, and interruptions should be minimal during clinic hours. Practices should look to add a mid-level nurse practitioner/physician assistant at around 40 patients per day.


There is a greater risk of medical error as a result of "prevalent, pervasive and variable" medical resident fatigue, according to a study in the American Medical Association's Archives of Surgery journal. Analysis of the sleep and awake times of 27 orthopaedic surgery residents over a two-week period determined that the subjects were at less than 80 percent mental effectiveness and were fatigued 48 percent of their awake time and at less than 70 percent mental effectiveness 27 percent of their waking hours. Residents averaged 5.3 hours of daily sleep in total, with day-shift participants averaging 5.7 hours of daily sleep and night-shift participants averaging 5.1 hours. The researchers observed a lower likelihood of fatigue among residents in outpatient rotations such as foot and ankle service, as well as an underrepresentation of such residents in the study. The study authors suggested that hospitals can identify "specific periods, rotations, and individuals that could benefit from targeted interventions and overall risk reduction" by using the fatigue-measuring tools employed in the analysis.

Health Policy and Reimbursement

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Medical billing is expected to be streamlined and expedited under a bundled payment agreement between BlueCross BlueShield of Tennessee, Vanderbilt Medical Group, Tennessee Orthopaedic Alliance, and two similar practices in Knoxville and Memphis. Under the new system, which will launch in October, Tennessee Orthopaedic and orthopaedic surgeons at Vanderbilt Medical Group each will be paid a set amount for the entire episode of care for most total knee and hip replacements, including care delivered up to 90 days following the procedure. Advocates say it spurs physicians, hospitals, and other providers to concentrate on overall care and cooperate closely as a group, while critics worry that doctors or hospitals could skimp on required care to get financial incentives. Health Care Incentives Improvement Institute executive director Francois de Brantes says hip and knee replacements can run $27,000 for a commercially insured patient compared to $20,000 for a Medicare patient since implant vendors charge private-sector plans more than they do government payers.

The participants in the new system have determined which aspects of care to cover in their bundled price, such as surgery and the hospital stay. "By establishing which measures ensure optimal results across an entire episode of care, and defining them as best practices, we can raise the quality of care for all of our patients in a consistent and sustainable way," notes Tennessee Orthopaedic surgeon William B. Kurtz. BlueCross says it will share information about variations in care, general costs, and efficiencies with participating surgeons to refine best practices that it believes lead to better results.


Federal auditors have found that the Center for Medicare & Medicaid Services (CMS) failed to collect about 80 percent of the $416 million that was specifically identified as Medicare overpayments in prior audits. Furthermore, auditors said the CMS couldn't prove that the 20 percent said to be collected was actually received. In response, the CMS said that just over half of the overpayments identified by the U.S. Department of Health and Human Services' Office of the Inspector General was included in audits that were released after the statute of limitations had expired for reopening the claims, making collections impossible under current laws and regulations. The agency, however, pledged to strengthen its systems.


A study that was recently published in the Journal of Clinical Hypertension has found that placing restrictions on meetings between doctors and drug company sales representatives can have a number of negative ramifications. Researchers who performed the study found that doctors who had very little access to sales reps had the lowest adoption rates for Merck's drug Januvia, and that it took them 1.4 and 4.6 times longer to begin writing prescriptions for the drug compared with doctors who had low or medium access to sales reps after Januvia was introduced. In addition, the study found that doctors who had very low access to sales reps were four times slower than doctors who had low access in reducing their usage of GlaxoSmithKline's Avandia following warnings in 2007 about cardiovascular events. Finally, the study found that there was significantly less change in doctors' prescribing habits following the 2008 release of controversial and disappointing test results for Merck's Vytorin. According to the researchers who performed the study, the findings show that limiting doctors' access to sales reps can reduce appropriate responses to both negative and positive information about drugs, though they added that specialists were more responsive than primary care doctors to new information. This lower level of responsiveness among primary care physicians is significant, researchers said, because these doctors are the first physicians that many patients see when they need medical treatment.

Medicine, Drugs and Devices

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The nonprofit Health Care Cost Institute has launched a new database containing more than 3 billion medical claims from 33 million individuals that researchers can peruse to see how much doctors and hospitals actually charge insurers for their services. The nation's three largest insurers -- Aetna, Humana and UnitedHealthcare -- who combined write policies for 20 percent of Americans under 65 who are insured by an employer, provided the data, which has been scrubbed of personally identifiable information. Until now, researchers have had to gather data from much smaller employer surveys, or rely on federal Medicare statistics, which reflect claims only from those who are 65 or older.


The Federal Communications Commission has voted unanimously to allocate wireless spectrum for medical body area networks, a new type of wireless medical device that would reduce the number of wires tethering a patient to a hospital bed and increase the role of patient monitoring at home. The allocation is expected to limit interference from other sources, such as a Wi-Fi network, and allow hospitals and other healthcare providers to increase the number of patients who are monitored in a hospital, ease patient transport, better control infection and encourage patient mobility.


A new study published online by the Archives of Internal Medicine draws a connection between widely used osteoporosis medications such as Actonel and Fosamax and rare but serious atypical thigh fractures, and it notes that the risk of fracture climbs with persistent administration of the drugs. The study was performed by physicians at the University Hospitals of Geneva, who analyzed the records of 477 patients 50 years and older treated at the hospital for certain types of leg fractures between 1999 and 2010. All but seven of the 39 patients who had atypical thigh fractures had taken a bisphosphonate drug, and eleven of those 39 patients had atypical breaks in both thighs. The researchers say the study's conclusions support the recommendation that patients should reconsider taking bisphosponate drugs after three to five years of use. "Otherwise, it is possibly causing more harm than benefit," says study co-author and orthopaedic surgeon Robin Peter. He also suggests that physicians consider halting bisphosphonate treatment in any patient who has had one atypical thigh fracture and complains about pain in the other thigh. Two years ago, the Food and Drug Administration said bisphosphonate drug labels would bear a warning about the risk of atypical thigh fractures, while in 2011 an FDA-convened expert panel voiced concern about such injuries.