News From ACFAS

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“PRP: State of the Art Today,” is the subject of the latest free podcast at ACFAS e-Learning. Platelet-rich plasma is a very popular topic in today’s treatment arena. Yet, as moderator Mark Hardy, DPM, FACFAS, notes: “The factors that determine the biological properties of PRP are, for the most part, unknown, and there is not a clear understanding of its clinical effects or its application.”

Hear four Fellows of the College discuss experiences with the use of PRP in practice, its effectiveness, its potential drawbacks, reasons for its current popularity and the many questions about it that should be explored through further research.

Visit ACFAS e-Learning whenever you are ready to learn more about this or the entire library of foot and ankle health topics, available in podcast, video and DVD. Visit the Journal of Foot & Ankle Surgery online today to get the first look at the November 2011 issue. Features include a new instructional course, “Metal-reinforced Cement Augmentation for Complex Talar Subsidence in Failed Total Ankle Arthroplasty,” and three audio add-ons that give you the chance to hear authors explain aspects of their research.

Use your free member access to listen to these concise online enhancements, and read original research, case reports, reviews, and quips, tips and pearls. Just visit acfas.org/jfas, click on “Read current and past issues online” and log in with your ACFAS member information. When you reach the JFAS home page at jfas.org, you don’t need to log in again — simply start reading or researching as you wish.

Check back often for more new content at the online home of JFAS! You may not have time to read all the research you’d like to, but in just a few minutes you can catch up with ACFAS’ Scientific Literature Review Monthly. Recent articles from peer-reviewed publications are abstracted for busy foot and ankle surgeons by podiatric residents. The latest entries are:

"Evaluation of the Syndesmotic-only Fixation for Weber-C Ankle Fractures with Syndesmotic Injury," from the Indian Journal of Orthopaedics.
Reviewed by Sara Karamloo, DPM, Yale-New Haven Hospital/CT DVA

"The Use of a Portable, Wearable Form of Pulsed Radio Frequency Electromagnetic Energy Device for the Healing of Recalcitrant Ulcers," from the International Wound Journal.
Reviewed by Sarah Edgar, DPM, Yale-New Haven Hospital/CT DVA

"Tuberculosis of the Foot and Ankle in Children," from the Journal of Orthopaedic Surgery.
Reviewed by Chanel Houston, DPM, Yale-New Haven Hospital/CT DVA

Browse new abstracts or the entire archive any time at Scientific Literature Reviews Monthly.

Foot and Ankle Surgery

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Researchers evaluated the outcomes following reconstruction of the chronic Achilles tendon ruptures with large gaps (>6 cm) using free semitendinosus tendon graft transfer. Eleven consecutive patients underwent the technique and were followed up prospectively for a mean of 25 ± 3 months. The average AOFAS and Achilles Tendon Rupture Score improved from 70 ± 5 and 32 ± 6 preoperatively, to 92 ± 5 and 89 ± 4 points post-operatively (P = 0.001). The range of dorsiflexion was significantly limited on the operated side (13 ± 4° vs. 17 ± 4°) (P = 0.04). All patients were able to stand on the tiptoe of injured leg, and no patient walked with a visible limp. Post-operative complications included one patient with symptomatic DVT and 2 patients with superficial infection treated nonoperatively.


A study was held to characterize the clinical effectiveness of ultrasound-guided (USG) ankle block in comparison with conventional anatomic landmark-guided (ALG) techniques through a six-year retrospective cohort study of all ankle blocks performed for foot surgery and demographic, intraoperative, and postoperative outcome data. The researchers identified 655 patients who received unilateral ankle block and 58 patients who received bilateral ankle block, and analyzed them separately. In patients to whom unilateral ankle block was administered, successful surgical anesthesia was more likely in the USG group (84 percent versus 66 percent). ALG group patients were more likely to need supplemental local anesthesia (10 percent versus 5 percent), unplanned general anesthesia (17 percent versus 7 percent), or supplemental fentanyl (18 percent versus 9 percent). The groups exhibited similar postanesthetic care unit pain scores, but patients in the ALG group were more likely to receive intravenous opioids (21 percent versus 12 percent), and they received a higher average opioid dose (10.6 mg versus 8.7 mg intravenous morphine, ALG versus USG). In patients receiving bilateral ankle block, successful surgical anesthesia also was more likely in the USG group (84 percent versus 57 percent), but this was not statistically significant given the small sample size.


A study was conducted to assess the validity of magnetic resonance imaging (MRI) T2-mapping sequence in the characterization of reparative tissue acquired by bone marrow derived cell transplantation (BMDCT) and its ability to correspond with clinical outcomes. BMDCT was performed on 20 patients with an osteochondral lesion of the talus, and they were evaluated at two years follow-up using MRI T2-mapping sequence. Twenty healthy volunteers were enlisted as a control group.

AOFAS score rose from 66.8 plus or minus 14.5 pre-operatively to 91.2 plus or minus 8.3 at two years follow-up. T2-relaxation time value of 35 to 45 ms was derived from healthy ankles assessment and assumed as normal hyaline cartilage value and utilized as a control. Regenerated tissue with a T2-relaxation time value comparable to hyaline cartilage was detected in all the cases treated, covering an average of 78 percent of the repaired lesion area. A high clinical score correlated directly to isointense signal in DPFSE fat sat, and percentage of regenerated hyaline cartilage, inversely to the percentage of regenerated fibrocartilage. Lesion's depth negatively related to the integrity of the repaired tissue's surface and to the percentage of regenerated hyaline cartilage.

Practice Management

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Research shows that the number of patients visiting physicians every month has been falling consistently. Furthermore, analysis shows that the number may not rise again due to a struggling economy, higher insurance deductibles, and efforts by health plans and other to reduce use that have altered patient patterns. Increasingly, patients only go in for office visits, or any other healthcare system interaction, when a problem can no longer be ignored.


A survey from Wolters Kluwer Health of American Medical Association members shows that both primary-care physicians and specialists use web browsers like Google and Yahoo as a source of information. The survey asked physicians how often they used certain sources to obtain information to diagnose, treat, and care for patients. In response, 68 percent said they frequently consult professional journals, 60 percent said they turn to colleagues, and just under half, 46 percent, said they used general web browsers.

The survey also asked whether improved access to medical information by patients has a positive impact on the doctor-patient relationship, and 53 percent of respondents said they believe it does. Only about a fifth of respondents believe increased access to information has been detrimental, and resulted in misinformation and incorrect self-diagnosis. The survey also found that doctors most want to see improvements in their ability to spend more time with patients, and that expense is a major barrier to the adoption of new health technologies.


Although a new Manhattan Research survey found that most U.S. adults have not accessed their electronic medical records and have no interest in doing so, other research has found that an uptick in the use of mobile devices and tools such as patient portals are driving a boost in patient engagement. A Southern Crescent Women's Healthcare office in Georgia that has had a patient portal since 2007 has seen about 43 percent of its patients utilize it, and office manager Jessica Mustain says the portal's convenience is what makes it so appealing. "Once [patients] become more engaged in taking care of their own health, we have more of a shared responsibility instead of me telling them what to do," notes Loyola University Health System's Keith Veselik.

University of California, San Diego, professor Josh Lee points to a digital divide when it comes to older and less affluent patients, and he encourages patients to engage with a patient portal by stressing the need for an e-mail address rather than a computer. The impetus for producing the portal was to get patients more involved in their care, and the only way to do that is to provide them with information.

Health Policy and Reimbursement

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The CMS has released a final rule with comment period updating Medicare payment policies and rates for hospital outpatient and ambulatory surgical center services. Payment rates for the outpatient prospective payment system will increase by 1.9 percent. Payments to ambulatory surgery centers will go up 1.6 percent and the rule establishes a quality-reporting program that includes four outcome measures and one for infection. Most provisions in the document are final and go into effect Jan. 1, but there are certain issues—such as interim values—which the CMS is accepting comments on, and it will respond to the feedback in next year's final rule.


The Office of the National Coordinator (ONC) for Health Information Technology has revised the expected launch time for a permanent program to accredit the organizations that will test and certify electronic health record (EHR) systems as capable of meeting Stage 2 criteria. The delay is necessary to align the EHR testing and certification program with the release of the final Stage 2 meaningful-use rules as well as to ensure there will be sufficient numbers of testing and certification bodies accredited under the permanent program to meet vendor demand, according to the ONC's notice. The ONC is tasked with establishing an EHR testing and certification program under the American Recovery and Reinvestment Act of 2009, which also created the EHR incentive payment programs under Medicare and Medicaid.

Medicine, Drugs and Devices

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Footwear equipped with global positioning system (GPS) devices for seniors with dementia are slated to hit the U.S. market in October, according to manufacturer GTX. The shoes will cost about $300 per pair and purchasers will be able to set up a monitoring service to find wearers suffering from Alzheimer's disease who wander off. George Mason University professor Andrew Carle says people in early-stage Alzheimer's are especially vulnerable to getting lost, and seniors often reject bracelet or pendant trackers out of disease-encouraged paranoia.

The GPS system is implanted in the heel of the shoe, and it lets family members or caregivers monitor the wearer and set up a "geofence" that would trigger an alert if the person wanders outside a certain area. GTX is developing the shoes with the Aetrex footwear company, and they say the market for such products is expanding, given the skyrocketing costs of Alzheimer's.


Sports medicine orthopaedist James Andrews of Gulf Breeze, Fla., believes that MRIs are being overused to diagnose injuries in athletes. Andrews tested this theory by scanning the shoulders of 31 healthy professional baseball players, and found that while the players had no injuries or pain, the MRIs showed abnormal shoulder cartilage in 90 percent of the athletes, and abnormal rotator cuff tendons in 87 percent. Now, Andrews and other prominent sports medicine specialists are standing up against what they believe is the widespread overuse of MRIs in their specialty. While MRIs can be invaluable, helping find serious problems like tumors or distinguishing between competing diagnoses, they can also be used by doctors who own MRI machines to make money. MRIs can also be used to please athletes, many of whom expect a scan.

However, scans can be easily misinterpreted and can cause misdiagnoses that result in unnecessary and even harmful treatments and surgeries. Frequently in sports medicine, where injuries are normally torn muscles, sprained tendons, or small cracks in bones, MRIs are often not needed and specialists can determine what is wrong using a careful medical history, a physical exam, and possibly an X-ray.