News From ACFAS

When ACFAS convenes its 2011 Annual Scientific Conference in sunny Fort Lauderdale, March 9–12, be assured the masses of students that once swarmed the beaches are long gone.

These days, a decidedly more elegant clientele stays in the luxury hotels that line the scenic beachfront, shops at the city’s upscale boutiques, dines at first-rate restaurants, and attends meetings at the modern convention center.

Influenced by the sun and waves, Fort Lauderdale is the “Venice of America” with more than 300 miles of sparkling Intracoastal waterways. The weather is always brilliant in this tropical city of many treasures. Arrive early or stay later for deep sea diving, fishing, snorkeling, golf, a Caribbean cruise, or just ooh-ing and aahhh-ing.

Oh yes … and embrace the brilliant minds and ideas at the No. 1 rated foot and ankle surgical conference at the beautiful Fort Lauderdale Convention Center. Save the dates now! The complete program and registration information will be on your desk and online by Oct. 15.

ACFAS members are invited to weigh in on the Centers for Medicare & Medicaid Services (CMS) possible physician self-referral rule exceptions that would allow physicians to accept items and services of value to use toward implementing electronic health records and electronic prescribing systems, according to a notice in the Sept. 10 Federal Register (75 Fed. Reg. 55330). In the notice, CMS requested comments on the necessity of such exceptions as well as ways to improve existing exceptions. Comments are due November 9, 2010.

The physician self-referral law, also known as the Stark law, prohibits physicians from referring Medicare and Medicaid patients to entities in which they have financial relationships, either through a direct investment or through family. The exceptions involving EHRs and e-prescribing were mandated in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. No. 108-173) to allow for certain arrangements in which physicians could receive non-monetary help toward implementing EHRs and eRx. For more information, download the Federal Register notice (in PDF).

Submit your current research for display in the ACFAS 2011 Annual Scientific Conference Poster Exhibit. Applications and abstracts are due October 1, 2010.

Apply for support for your research proposal with a 2010 ACFAS Clinical and Scientific Research Grant. Fellows and Associate Members can receive up to $20,000 for research in podiatric surgery of interest to members of the College. Applications are due October 15, 2010.

For applications and more information, visit the ACFAS website.

The ACFAS Practice Management Committee is investigating coding and billing resources for members of the College. Please take our very short survey so we can better serve you!

Catch up on research in journals you may not usually read with ACFAS’ Scientific Literature Reviews. Article abstracts are tailored for the interests of foot and ankle surgeons by podiatric residents. New abstracts for September include:

Extraarticular Lateral Hindfoot Impingment With Posterior Tibial Tendon Tear: MRI Correlation, from the American Journal of Roentgenology.
Reviewed by Elizabeth Cherry, DPM, OCPM/UHHS Richmond Medical Center.

Comparison of 4.5 and 5.5 mm Cannulated Stainless Steel Screws for Fifth Metatarsal Jones Fracture Fixation, from Foot & Ankle International.
Reviewed by Ashma S. Davidson, DPM, OCPM/UHHS Richmond Medical Center.

Browse the latest entries or the entire archive any time at Scientific Literature Reviews.

Foot and Ankle Surgery

Ankle Strength and Functional Limitations in Children and Adolescents With Type I Osteogenesis Imperfecta

Researchers sought to determine whether children with type I osteogenesis imperfecta (OI) exhibit ankle plantar flexor weakness and whether this correlates with physical function. Twenty children and adolescents with type I OI and 20 age-matched controls participated in an evaluation session. Ankle plantar flexor weakness was more evident in the OI group compared with the control group. Heel-rise strength correlated with ankle isometric plantar flexion strength. Limitations in Pediatric Outcome Data Collection Instrument subscales—sports and physical function and pain/comfort—were also present in the OI group. The researchers concluded that ankle plantar flexor weakness is present in children and adolescents with type I OI and correlates with function.



Early Results of Arthroscopic Lateral Ankle Ligament Reconstruction Promising

All ankle instability symptoms improved in an initial series of patients who underwent a new arthroscopically assisted lateral ankle ligament reconstruction, according to the surgeon who developed the technique. To reinforce the original repair, however, five of eight patients needed another suture subsequently passed through the fibular periosteum and into the inferior extensor retinaculum, reported Peter G. Mangone, MD, at the 2010 Summer Meeting of the American Orthopaedic Foot and Ankle Society. Mangone said when he started performing the procedure, he placed just one bioabsorbable bone anchor, which worked well, but the use of two, which is indicated for patients suited for an open Brostrom procedure, has shown even better results. He and a colleague have successfully completed 12 additional cases using the new method he described, but results were too short-term to present.

The procedure involves the placement of one or two resorbable bone anchors in the distal anterior inferior fibula with the suture also exiting in that area. The second anchor is placed slightly dorsal to that or cephalad, with the suture for the first anchor passing through the inferior extensor retinaculum and the capsule. The other goes through the anterior talofibular ligament area of the capsule on the anterior extensor retinaculum. To pass sutures through the ligament complex, Mangone recommended using a sharp-tipped suture passer or microsuture device with an outside-in or inside-out technique. Finally, the distractor is removed and the ankle is placed in slight dorsiflexion to tie down the lateral ligament.



Mechanical Properties of the Achilles Tendon Aponeurosis Are Altered in Athletes With Achilles Tendinopathy

Researchers compared Achilles tendon–aponeurosis strain between male athletes with and without Achilles tendinopathy. Fifteen healthy men and 14 men with midportion Achilles tendinopathy who were all running over 20 km per week participated in the study. Each participant was tested in a single session that involved maximal isometric plantar flexion efforts being performed on a calf-raise apparatus while synchronous real-time ultrasonography of the triceps surae aponeurosis was recorded. Achilles tendon–aponeurosis strain was calculated by dividing tendon displacement during plantar flexion by resting tendon length. Participants in the Achilles tendinopathy group had a higher incidence of Achilles tendon–aponeurosis complex strain, compared to the control group. However, there was no significant difference in maximal isometric plantar flexion force between those groups.

Practice Management

OSHA Should Regulate Work Hours for Doctors-in-Training, Groups Tell Labor Department

The Occupational Safety and Health Administration (OSHA) should take doctors-in-training under its purview, consumer and health advocacy groups said in a petition sent to the agency. Currently, the Accreditation Council for Graduate Medical Education (ACGME) is responsible for regulating and enforcing resident physician work hours. In July, it proposed new guidelines for work hours for resident doctors, but they still leave the majority of those doctors in danger, the groups said.

A survey published in the Journal of the American Medical Association found that six of seven surgical resident physicians had fallen asleep at the wheel while driving to and from work. Three of these six residents had been involved in car crashes. Resident physicians also are at high risk of developing clinical depression.

Other countries, such as Denmark, New Zealand and the United Kingdom, regulate resident physician work hours, and all of these countries limit shifts to less than 16 hours or fewer for all resident physicians and limit the work week to fewer hours than the ACGME is proposing. "Based on what we have learned from research evidence, we don't recommend that any physician stay awake for 24 hours or more, which is the case today," said the Committee of Interns and Residents/SEIU Healthcare President Farbod Raiszadeh. "OSHA must intervene so that physicians in training are no longer at risk for needle stick injuries, car crashes and other hazards that we know stem from chronic sleep deprivation."



Physicians Say White House Should Not Write Off Small Practices

The White House is advising physicians to accept a life as a hospital employee or member of a large group practice in the wake of healthcare reform, but some leaders of organized medicine are objecting to the government message. "We're not ready to write off the small practices," said J. Fred Ralston Jr., MD, president of the American College of Physicians. "We think there needs to be more than one delivery model." M. Todd Williamson, MD, spokesperson for the Coalition of State Medical and National Specialty Societies, which opposed the new healthcare reform law, said, "America is not a one-size-fits-all country."

Ralston and Williamson were responding to an article by two White House officials and one ex-official about the implications of healthcare reform for medicine that was published online August 23 in the Annals of Internal Medicine. The authors wrote, "The economic forces put in motion by the [Affordable Care] Act ... are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups." Physicians who embrace the changes and opportunities created by the law "are likely to deliver the greatest benefits to their patients, the health system, and themselves" and "will be rewarded in the future payment system."



Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings

Patient panels with greater proportions of underinsured, minority, and non-English speaking patients were associated with lower physician quality rankings, according to a new study. Physicians are increasingly becoming the focus of quality performance measurement, with many healthcare systems now using physician assessments as part of their re-credentialing process. “These programs use performance incentives including cash payments and public reports to motivate clinicians, practice groups, and health care systems to achieve specific health care quality goals,” according to the researchers.

An assumption underlying physician clinical performance assessment is that the measures represent physician performance. “However, the same physician may have higher or lower measured quality scores depending on the panel of patients he or she manages," say the researchers. "The association of patient panel characteristics with physician quality scores could lead to inaccurate physician clinical performance rankings that could have implications on how physicians are rewarded and on how resources are allocated within healthcare systems.”

Health Policy and Reimbursement

CMS Letter Identifies Methodologies States Must Use to Control Improper Coding

CMS has identified five National Correct Coding Initiative (NCCI) methodologies that state Medicaid programs must use for claims filed on or after Oct. 1. The five methodologies reflect the NCCI standards for Medicare, which were developed “to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment,” according to a letter from CMS to state Medicaid directors. The letter is part of a series intended to provide guidance on the health care reform law's requirements.

The five methodologies are procedure-to-procedure edits for practitioner and ambulatory surgical centers; procedure-to-procedure edits for outpatient hospital services incorporated into the Medicare outpatient code editor (OCE) for hospitals reimbursed through the hospital outpatient prospective payment system (OPPS); Medically Unlikely Edits (MUE) units-of-service edits for practitioner and ambulatory surgical center services; MUE units-of-service edits for outpatient hospital services for hospitals reimbursed through the OPPS and for critical access hospitals; and MUE units-of-service edits for supplier claims for durable medical equipment.



Health Insurers Plan Hikes

Health insurers say they plan to raise premiums for some Americans as a direct result of the health overhaul in coming weeks. Aetna, some BlueCross BlueShield plans, and other smaller carriers have asked for premium increases of between 1 percent and 9 percent to pay for extra benefits required under the law, according to filings with state regulators. Impacted will be policies for individuals and small businesses.



Researchers Peg Malpractice Costs at Over $55 Billion

Medical malpractice costs in the United States average about $55.6 billion annually, or 2.4 percent of annual healthcare spending, according to analysis published in the September issue of Health Affairs. The estimate includes defensive-medicine activities, which alone costs about $45.6 billion a year, the study found.

Tort reforms such as capping noneconomic damages could reduce liability costs, but are likely to have little effect on overall healthcare spending, the study found. Reform proposals such as moving away from fee-for-service reimbursement could have a greater impact.

Technology and Device Trends

Computer-Assisted and Robot-Assisted Technologies to Improve Bone-Cutting Accuracy When Integrated With a Freehand Process Using an Oscillating Saw

Freehand bone cutting with an oscillating saw during orthopaedic surgery can produce large cutting errors due to the complex hand-controlled positioning of the surgical tool. Researchers investigated the potential improvements in cutting accuracy when computer-assisted and robot-assisted technologies are applied to a freehand bone-cutting process when no jigs are available. They designed an experiment based on a geometrical model of the cutting process with use of a simulated bone of rectangular geometry. A series of 156 cuts were performed by six operators employing three technologically different procedures: freehand, navigated freehand, and robot-assisted cutting. The researchers found that the location of the cut plane averaged 2.8 mm after use of the navigated freehand process compared with 5.2 mm after use of the freehand process. Further improvements were obtained with use of the robot-assisted process, which provided an average location of 1.7 mm.



Injury Reduction Effectiveness of Assigning Running Shoes Based on Plantar Shape in Marine Corps Basic Training

Researchers investigated the effectiveness of assigning running shoes based on plantar shape in Marine Corps Basic Trainees. An experimental group of Marine Corps recruits (408 men, 314 women) were assigned motion control shoes for low arched, stability shoes for normal arched and cushioned shoes for high arched feet. All of the Marine corps recruits in a control group (408 men, 314 women) received stability shoes regardless of their foot type. Via Cox regression analysis, they found that there was little difference in risk of injury between two groups.



Novel Technique Uses YouTube Videos to Study Ankle Fracture Injury Mechanisms

A small case series suggests that the Lauge-Hansen classification system may not always predict certain fracture patterns accurately. The researchers in the study viewed over 1,000 video clips of potential ankle fractures posted on YouTube, with the goal of obtaining a clear visualization of the injury mechanism, including foot position and deforming force. Videos were included if the injury mechanism could be categorized by the Lauge-Hansen system and if there appeared to be a significant mechanism that would have likely caused a fracture. The researchers requested radiographs from the individuals in the videos, and classified the videos and radiographs using the Lauge-Hansen system. The deforming mechanisms in the study were supination external rotation, supination adduction (SAD), pronation external rotation (PER) or pronation abduction. Based on observation of the videos, the researchers report SAD-deforming trauma in eight participants and PER-deforming trauma in seven, with 12 true ankle fractures. All five fractures identified as SAD injuries on video were also SAD fractures based on radiographs. Only two of the seven fractures identified by video as PER injuries had PER pattern radiographic ankle fractures, according to the researchers. Five other cases had supination external rotation ankle fracture patterns. "Our series shows that when in vivo injury videos are matched to their corresponding x-rays, the Lauge-Hansen system is only 58 percent overall accurate in predicting fracture patterns from deforming injury mechanism as pertaining to SAD and PER injury mechanisms," the study authors write.



Abstract News © Copyright 2010 INFORMATION, INC.

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