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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

Practice Alert: HIPAA Changes in the 2009 Stimulus Package

The 2009 federal Stimulus Package signed into law in February includes significant revisions to HIPAA. ACFAS has developed a practice alert outlining the changes at the web link below.

These changes present an opportunity to review your HIPAA compliance program with practice staff.
Do Your Patients Need DVT Prophylaxis?

Although the literature indicates that foot and ankle surgery is not a major risk factor for deep vein thrombosis (DVT), in the latest ACFAS podcast a panel of experts agrees that foot and ankle surgeons must take this into consideration before performing surgery.

Moderator Troy J. Boffeli, DPM is joined by Allen M. Jacobs, DPM, D. Scot Malay, DPM, and John Etcheverry, DPM as they discuss risk factors, the main things you need to know about your patient's history, and cases in which DVT has become an issue for them.

Tune in to this important topic using the web link, below.

Gain New Perspectives with Fall Surgical Skills Courses

If you ask three experts, you'll likely get three different perspectives on the best way to approach a specific surgical dilemma. The hands-on ACFAS Surgical Skills Courses provide the knowledge to make the decisions, and the techniques to carry them out.

The October 10-11 Flatfoot Surgical Skills Course, to be held in the Denver area, features updates and fresh insights to this popular topic. The course blends lectures, videos and high-energy discussions with many hours of hands-on lab time that mimics the live operating room.

Choose either November 14 or 15 to attend the one-day Complex Reconstruction Surgical Skills Course in Las Vegas. Extensive lab time in this fast-paced course will enable you to choose from an array of first ray, rearfoot, and tendon techniques that go beyond the basics.

Space is limited at these sites. Reserve your seat by registering online, using the web link below.

Foot and Ankle Surgery

Recovery of Ankle Dorsiflexion Weakness Following Lumbar Decompressive Surgery

This retrospective study evaluates the recovery of ankle dorsiflexion (ADF) weakness following decompressive surgery in order to identify factors indicative of a better outcome. In a study of 56 consecutive patients with ADF weakness secondary to nerve root compression who underwent lumbar decompressive surgery, the researchers found that decompressive surgery was associated with an early improvement in ADF weakness, and that only small improvements take place beyond six weeks following surgery. The degree of deficit at presentation was predictive of the extent of recovery.

From the article of the same title
Journal of Clinical Neuroscience (08/01/09) Vol. 16, No. 8, P. 1024; Ghahreman, Ali; Ferch, Richard D.; Rao, Preshanth

Intraneural Injection With Low-Current Stimulation During Popliteal Sciatic Nerve Block

Prevention of an intraneural injection of a local anesthetic during peripheral nerve blockade is considered important to avoid neurologic injury, but the needle-nerve relationship during low-current electrical nerve localization is not well understood. Researchers in this study postulated that intraneural needletip location is common during low-current stimulation popliteal sciatic nerve blockade. Twenty-four consecutive ASA class I-III patients scheduled for foot or ankle surgery under popliteal sciatic nerve block using a combined ultrasound and nerve stimulator-guided technique were prospectively studied. The researchers concluded that the absence of motor response to nerve stimulation during popliteal sciatic nerve block does not exclude intraneural needle placement and may lead to additional unnecessary attempts at nerve localization and that low-current stimulation was associated with a high frequency of intraneural needle placement.

From the article of the same title
Anesthesia & Analgesia (08/09)

New Thrombosis Study Findings Have Been Published by P.D. Stein and Colleagues

Ankle exercise increases venous blood velocity while supine, but the effect of ankle exercise on venous blood velocity while sitting is not known. Researchers tested the hypothesis that venous blood velocity can be increased while sitting by repetitive dorsiflexion of the foot. Time-averaged peak velocity (TAPV) in the popliteal vein of 20 healthy male volunteers was measured by pulsed Doppler ultrasound at rest and during ankle exercise in the supine and sitting positions.

Right popliteal vein TAPV while supine at rest was 11 cm/second and with ankle exercise it increased to 24 cm/second. With sitting at rest, right popliteal vein blood TAPV decreased from 11 cm/second to 3 cm/second. With ankle exercise while sitting, right popliteal vein TAPV increased to 18 cm/second, according to P.D. Stein and colleagues. The researchers concluded: "In both the supine and sitting positions, ankle exercise increased venous blood velocity, thereby transiently reducing a tendency toward venous stasis. Such ankle exercise might be useful in the prevention of stasis-induced deep venous thrombosis."

From the article of the same title
Health Risk Factor Week (08/04/09)

Paget's Disease of Bone - Becoming a Rarity?

Paget's disease is a chronic bone disorder of unknown cause, and recent studies have reported an unexplained reduction in both prevalence and disease severity. The authors undertook a radiographic survey to determine the current prevalence of Paget's disease in New Zealand (previously recognized as a high prevalence area). Paget's disease was detected in 2.6 percent of radiographs and had already been diagnosed in 63 percent of radiographs. Those cases that were newly recognized were found to be significantly older with less active disease. These results confirm the secular trend of Paget's disease presenting later in life and in milder form, suggesting that there are important environmental determinants. Given the secular trend and limitations to life expectancy, the authors predict that Paget's disease will become increasingly rare.

From the article of the same title
Rheumatology (07/16/09) Bastin, Sonja; Bird, Helen; Gamble, Gregory; et al.

Prevention of Surgical Site Infections: Improving Compliance With the Surgical Care Improvement Project Measures

Surgical site infections (SSIs) are the second most common adverse event that hospitalized patients face, although between 40 percent and 60 percent of these infections may be preventable. Hospital patients with SSIs are five times more likely to be readmitted, 60 percent more likely to be admitted to an intensive care unit, and twice as likely to die than patients who do not develop SSIs. The Surgical Care Improvement Project seeks to improve the use of prophylaxis practices known to reduce these infections.

Administering an antibiotic at the correct time could be the most important SSI prevention measure, studies have found, with infection rates progressively increasing with greater time before or after the initial surgical incision. Clindamycin, metronidazole, most cephalosporins, and penicillins should be given within an hour of the first incision, but up to two hours before the incision for vancomycin and fluoroquinolones. Additional evidence shows that antibiotics should be discontinued within 24 hours of the end of surgery, and glycemic control is also of value for patients undergoing surgery. To carry out these and other measures, a hospital team is needed to both establish goals and assess intra-hospital progress on certain measures.

From the article of the same title
Medscape (07/14/09) Olsen, Keith M.

Practice Management

Beyond Co-Pay: Surprise Bill at the Doctor's

Physician practices and clinics increasingly are asking patients to pay upfront all out of pocket expenses, and/or require patients to agree to a deposit or payment plan in advance for outpatient surgeries and expensive tests. For elective surgeries, many practices insist on full payment beforehand. NaviNet Inc., a “real time communications network” that links doctors and insurers, surveyed 650 doctors, and more than half indicated that they are trying to collect more out-of-pocket cost at the time of service. According to McKinsey & Co., once a patient leaves the office, physicians typically collect about half of what is owed. If the patient is uninsured, that figure drops to between just 10 percent and 20 percent when patients of what is owed.

From the article of the same title
Wall Street Journal (08/05/09) Mathews, Anna Wilde

Survey Rates Physicians' Bedside Manner

Consumer Checkbook, a not-for-profit that provides consumer information on a range of services, recently surveyed 100,000 patients in three cities (Denver, Kansas City, and Memphis) about satisfaction with their interactions with their specific physicians. The surveys looked at patient opinion on how well their physicians listen and explain, how easy it is to make an appointment, and how they are treated by practice staff. The project used US Agency for Healthcare Research and Quality-developed survey questions and was done in collaboration with major national and regional plans in order to facilitate selection of patients for each physician. The survey did not include DPMs. The reports are now available to patients, free online.

From the article of the same title
Business Insurance (07/24/09) Wojcik, Joanne

Health Policy and Reimbursement

In Health Fight, Government and Insurers Are Cast as Villains

The August Congressional recess is unfolding in a charged atmosphere as interest groups on all sides engaged in heated rhetoric. Proponents of the Democrats health system reform plan are focusing on health insurers as an evil force. The liberal sent members a video featuring snakes slithering and a voiceover saying, “they prey on our weaknesses, trying to separate the healthy from the sick … let's take on the real predators - health insurance companies.” On the other side of the fence, the conservative Club for Growth is running an ad campaign that includes the following voice over - “$22,750. In England, government health officials decided that's how much six months of life is worth.”

From the article of the same title
Wall Street Journal (08/10/09) Bendavid, Naftali

Expanding Preventive Care May Add to Costs, CBO Says

A Congressional Budget Office report released last week cast a shadow over proponents of preventive care (eg, cancer screening, cholesterol management, vaccines, wellness programs) who contend that covering such care as part of a “public option” would save the government money. The CBO cited a 2009 New England Journal of Medicine Study which found that less than “20% of preventive services that were examined save money, while the rest add to costs.”

From the article of the same title
Washington Post (08/08/09) Montgomery, Lori

Digital Health: Struggle or a Pipedream

CNNMoney looked at how three healthcare systems are trying to create electronic health records - with varying degrees of success. The difference between electronic medical records and electronic health records is interoperability- the ability to share information between different providers. This is something easier said than done. The report highlights efforts of a network of 16 community-based hospitals in North Carolina to implement the EHR and noted that it took four years of drafting legal documents to get clear where the data would “live,” who would access it, etc. They decided that the data would reside in the patient's home hospital, not in a central data warehouse. Memorial Hospital, a 99 bed facility in rural Wyoming, went live in “one fell swoop.” Officials noted that one of the biggest changes was getting providers and staff to adjust to the system, since none had worked with an EHR before.

From the article of the same title
CNNMoney (07/31/09)

Technology and Device Trends

Higher Nonunion Rates Seen With Locked Plates for Hallux MTP Fusion

A recent study indicates a trend toward higher nonunion rates in patients with hallux metatarsophalangeal (MTP) arthrodesis who were treated with locking plates compared to non-locking constructs. The study was presented by Kenneth J. Hunt, MD, at the 25th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society in Vancouver, British Columbia, Canada. The study also showed higher nonunion rates overall for patients with rheumatoid arthritis.

From the article of the same title
Ortho Supersite (07/29/2009) Brockenbrough, Gina

Scientists Closer to Making Implantable Bone Material for Orthopedics

Researchers are closer to understanding how to grow replacement bones using stem cell technology. Scientists from Imperial College London compared the bone-like material grown from three different, commonly used, clinically relevant cell types and discovered significant differences between the qualities of bone-like material that these can form. Among these discoveries was that bone-like materials that were grown from bone cells in mouse skull and mouse bone marrow stem cells successfully mimicked many of the hallmarks of real bone, including stiffness. The researchers also found that the bone-like material grown from mouse embryonic stem cells was much less stiff and complex in its mineral composition when compared to the other materials.

From "Comparative Materials Differences Revealed in Engineered Bone as a Function of Cell-specific Differentiation"
Nature Materials (07/09) Gentleman, Eileen; Swain, Robin J.; Evans, Nicholas D.

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August 12, 2009