News From ACFAS

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The College is recruiting investigative sites for a new multi-center retrospective study looking at predictive variables associated with successful and unsuccessful outcomes when performing subtalar joint arthroereisis in adults and children. Subjects and sites will be compensated for their time. If you are interested in participating in this important study, please complete and return the application on the ACFAS website.

The criteria for site selection include:

1. Required one-year contractual commitment by the investigative site.
2. Primary investigator at each site in good standing with the American College of Foot and Ankle Surgeons.
3. Volume (minimum of 40) and variety (children and adults) of patients treated for symptomatic non-neuromuscular flatfoot with subtalar arthroereisis during the past 10 years.
4. Past participation in multi-center studies.
5. Professional reputation for scholarly activity.

Discover knowledge, skills and San Antonio itself while you’re attending the ACFAS 2012 Annual Scientific Conference, March 1-4. San Antonio combines a friendly small-town appeal with a big-city mix of cultures, cuisines, architecture and art. Only a 10-minute cab ride from the airport, its downtown is built along the famous River Walk that connects restaurants, theaters, shopping, hotels and the Henry B. Gonzalez Convention Center, host to ACFAS 2012.

Whatever your favorite free-time activity, you’ll find it within easy walking distance. Wander one block off the River Walk to visit an artisan’s colony renowned for glass blowing. Join in the vibrant nightlife and enjoy a variety of live music. If you have extra time to spend in the area, you can golf on top-notch local courses, or explore the city’s many parks, theme parks, museums or historical neighborhoods.

Start making your plans to add to your medical and practice knowledge in the warm heart of Texas, and look for full program information soon at acfas.org/sanantonio. Visit "Articles in Press" at the Journal of Foot & Ankle Surgery's online home page to stay a step ahead of the crowd with the latest research in your profession. New articles are available as soon as their proofs have been approved — even before they're assigned to an issue.

It's quick and easy with your free member access:

• Go to acfas.org/jfas.
• Click on “Read current and past issues online” (member login required).
• When you reach the JFAS home page, scroll down to “Articles in Press.”

Enjoy tomorrow’s news today, including original research, case reports, and tips, quips and pearls.

Futurescan™

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Healthcare, especially healthcare financing, is changing day by day. To help provide some basic education on current trends in the U.S. healthcare industry, ACFAS is sharing abstracted articles from the American Hospital Association's publication, Futurescan™ 2011: Healthcare Trends and Implications 2011–2016, in this special eight-week section.

U.S. healthcare leaders have a responsibility as well as an enormous opportunity to remedy the United States' laggard pace with other nations in terms of implementing an electronic health information infrastructure, and there now exists a once-in-a-generation chance to deploy needed health reform enablers. The Obama administration's concentration on healthcare, coupled with enablers supplied via the Health Information Technology for Economic and Clinical Health (HITECH) Act, will focus industry attention on the adoption and effective use of health information technology (HIT).

HITECH gives enabling financial incentives and programmatic support to overcome many of the impediments obstructing the dissemination and effective use of electronic health records (EHRs) and personal health records. HITECH brings into alignment hospital and physician incentives to implement EHR systems, and hospital leaders should leverage these aligned incentives to partner with their medical staffs and community doctors in a shared strategy to interconnect and exchange patient information to improve care.

For HIT deployment to be successful, it is recommended that an experienced chief medical information officer be hired. Engaging physicians and medical staff not just as stakeholders, but as true partners in redefining the workflow and processes that will improve outcomes, also is essential. Feedback reports need to be provided using credible quality measures, while patient engagement through such things as online home monitoring and electronic visits will be critical to hospital efforts to lower 30-day readmission rates. Finally, health data should be seamlessly integrated across the continuum.

Foot and Ankle Surgery

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Extensor hallucis longus (EHL) strength has been identified as a primary predictor of L5 nerve root radiculopathy and deep peroneal nerve palsy, but assessment of EHL strength is commonly overlooked, mainly due to the lack of an objective and accurate method for evaluation, since manual muscle testing (MMT) has not been well utilized. Researchers assessed the reliability of evaluating manual muscle testing (MMT) in various toe positions. Forty healthy volunteers (80 toes) with good muscle strength were recruited. Each subject was examined with MMT at the metatarsophalangeal joint (MTPp) and interphalangeal joint (IPp) with various positions of the MTP joint (maximal extension: IPp-e, neutral position: IPp-n, maximal flexion: IPp-f) by two examiners.

Great toe extensor strength was highly maintained in MTP measurement. Correct detections in each position (MTPp, IPp-e, IPp-n, IPp-f) were 96.3 percent and 96.3 percent, 45.0 percent and 32.5 percent, 53.8 percent and 33.8 percent, and 50.0 percent and 61.5 percent for the first and second observer, respectively. The inter-observer variability for great toe extensor strength was highly maintained in MTP measurement (κ values = 1.00). The κ value of each position was 0.69, 0.35, and 0.28 for IPp-e, IPp-n, and IPp-f, respectively. There were no correlations between great toe length or angle in extension of the MTP and great toe extensor strength in each position.


Researchers evaluated the clinical outcome of osteochondral lesions of the talus treated with a fresh osteochondral allograft. A transfer of fresh osteochondral allograft was performed in 42 patients with a symptomatic, refractory osteochondral lesion of the talus. Complete postoperative follow-up was achieved for thirty-eight patients. The average duration of follow-up was 37.7 months. Graft failure occurred in four patients. With the inclusion of scores before revision for those with graft failure, the mean visual analog pain scale score improved from 8.2 to 3.3 points, and the mean AOFAS ankle-hindfoot score improved from 52 to 79 points. Patient satisfaction with the outcome was rated as excellent, very good, or good by 28 of the 38 patients and as fair or poor by 10 patients. Of the 15 MRI scans, most showed minimal graft subsidence, reasonable graft stability, and persistent articular congruence.


Researchers set out to determine whether or not the addition of computed tomography (CT) would improve the reliability of fracture classification and treatment decision in distal tibial physeal fractures. Five independent observers evaluated 50 distal tibial physeal fractures on two separate occasions for Salter Harris (SH) classification and treatment decision (surgical/nonsurgical) using plain radiographs (round 1) and combination of radiographs and CT (round 2). During round 1, observers were asked if they would order a CT, and during round 2, they were asked if the CT was useful. The results indicated that the addition of CT in complex distal tibial physeal fractures did not increase interobserver reliability to classify the fracture or the treatment decision. Surgeons reported that the CT was most useful to plan screw placement and changed their treatment decision in about 20 percent of the cases.

Practice Management

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Auditors estimate that Medicare overpaid physicians $28.8 million in 2008 and 2009 for ambulatory and outpatient services that were performed in hospitals instead of doctors' offices, according to two new government reports. The Centers for Medicare & Medicaid Services (CMS) said it would consider investigating the estimated $28.8 million in overpayments but noted that it must consider "return on investment" in such reviews. Physicians interviewed by the auditors explained that Medicare's billing system is extraordinarily complex, and either their staffs or billing agents may have been confused about the precise selection of a facility on claims forms. Some doctors also told the auditors that their billing agents were unaware that place-of-service can change the payments for services.


Medical groups cut spending by 2.2 percent last year, despite the fact that general operating costs have increased by more than 52.6 percent since 2001, according to the Medical Group Management Association (MGMA). MGMA's "Cost Survey for Multispecialty Practices: 2011 Report" found that total medical revenue in multispecialty practices not owned by hospitals or integrated delivery systems increased 45.9 percent since 2001 and 8.5 percent since 2009, likely because practice managers are scrutinizing their operating expanses more closely, according to the association. Drug supply costs fell 8.5 percent since 2010, though spending on medical and surgical supplies increased by 7.4 percent. Also since 2010, expenditures for total support staff have increased by 4.8 percent.


Hospitals and doctors currently use a system of about 18,000 codes to describe medical services in bills sent to insurers, but these codes lack a certain amount of nuance. A new federally mandated version of the system, known as International Classification of Diseases, 10th Revision (ICD-10), will expand the number of codes to about 14,000, adding codes that describe exactly what bone was broken or which artery received a stent, for example. The federal agencies that developed ICD-10 say the codes will provide more exact and up-to-date accounting of diagnoses and hospital inpatient procedures, which could improve payment methods and care guidelines. Healthcare providers and insurers, meanwhile, are preparing for possible problems that may arise when switching to ICD-10 on Oct. 1, 2013.

Health Policy and Reimbursement

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The Centers for Medicare & Medicaid Services (CMS) proposes adjusting 2015 payments for some physicians by using quality and efficiency measured in 2013, which has provoked criticism. CMS' argument is that not all of a doctor's claims may be processed until 2014, and that it needs "adequate lead time to collect performance data, assess performance, and construct and compute the value modifier during 2014 so that it can be applied to specific physicians starting Jan. 1, 2015, as required by statute." In an Aug. 29 comment letter, the American Medical Association expressed worry that doctors could see their payments cut based on premature or unfair performance measurements.


President Obama's deficit reduction plans strengthens the role of the Independent Payment Advisory Board (IPAB), charged under the healthcare reform law to recommend to Congress policies to control Medicare costs if spending exceeds a targeted growth rate. The board could soon have new tools at its disposal, like the ability to consider value-based benefit designs, when making recommendations. In the budget proposal, President Obama has included $320 billion in cuts to Medicare and Medicaid, and IPAB is considered key to helping achieve those cuts in such a way that minimizes the immediate effect on beneficiaries.

Medicine, Drugs and Devices

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A randomized control trial was performed to assess the short-term clinical effectiveness of in-shoe foot orthoses over a wait-and-see policy in the treatment of anterior knee pain (AKP) and evaluate the ability of foot posture measures to anticipate outcome. The trial involved 40 patients with clinically diagnosed AKP of greater than six-week duration, who had not been treated with orthoses in the previous five years. Foot orthoses produced a significant global improvement compared with the control group (p = 0.008, relative risk reduction = 8.47 percent, numbers needed to treat = 2). Significant differences also occurred in measures of function (standardized mean difference = 0.71). Within the intervention group, individuals who exhibited a change in midfoot width from weight bearing to non-weight bearing of >11.25 mm were more likely to report a successful outcome (correct classification 77.8 percent).


A report from the Department of Health and Human Services (HHS) makes new recommendations to support health text messaging and mobile health programs aimed at improving population and public health. The text messaging initiatives would deliver health information and resources to individuals via their mobile phones. The report recommends that, among other actions, HHS develop and host evidence-based health text message libraries that leverage HHS' information. According to the report, public health issues that could most benefit from a health text message library include diabetes and emergency response.


The Centers for Medicare & Medicaid Services (CMS) will create a database containing the health information of Medicare beneficiaries who receive treatment with providers participating in an accountable care organization. CMS said it will use the data collection to support policy activities and reimbursement for its programs to bundle payments and share savings. The database is scheduled to go live on Oct. 19.