News From ACFAS

Healthcare providers who accept Medicare are nervous again. They are waiting for Congress to once again "fix" the payment system. Repealing the current payment formula would cost more than $280 billion over 10 years. The American Medical Association is calling for a 13-month reprieve that would give Congress time to work on a new payment system, and the Obama administration supports that approach. The AMA and White House would settle for adding the cost to the deficit. Most Republicans and many conservative Democrats want it paid for. Aides to the Senate Finance Committee chairman Sen. Max Baucus, D-Mont., say he's working toward the longest possible extension that will get the 60 votes needed to pass the Senate.

The Joint Commission recently reminded all hospital chief executive officers and medical staff presidents of pending revisions to its Medical Staff Standard MS.01.01.01 (formerly MS.1.20) regarding the credentialing and privileging of physicians and licensed independent practitioners, which will take effect March 31, 2011.

The revisions were recommended by an implementation task force of supportive organizations, including representatives from the American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, Federation of American Hospitals and National Association of Medical Staff Services.

To comply with the new standard, hospitals, their governing boards and their medical staffs will need to examine their current bylaws and related documents, determine if any changes need to be made, and make those changes by March 31. The commission’s website offers answers to frequently asked questions in PDF (64 KB).

The Council on Podiatric Medical Education has finalized revisions to the standards, requirements and procedures for approval of podiatric residencies. The new documents, CPME 320, “Standards and Requirements for Approval of Podiatric Medicine and Surgery Residencies,” and CPME 330, “Procedures for Approval of Podiatric Medicine and Surgery Residencies,” go into effect July 1, 2011.

All of the College’s comments on the revisions were integrated into the new documents, including:

1. Retaining the words “and Surgery” in the definition of residencies
2. Increasing the number of patient encounters
3. Increasing the number of H&P examinations

You can access the new documents on the CPME website. ACFAS encourages you to consider starting a new residency, adding a slot to an existing program, and/or offering assistance to nearby programs (e.g., lecturing, etc.).

The November 2010 issue of the Journal of Foot & Ankle Surgery is online now! Log in to hear its very first audio add-on, a conversation between Bradley M. Lamm, DPM, FACFAS, co-author of “Two-Stage Percutaneous Approach to Charcot Diabetic Foot Reconstruction,” and JFAS editor D. Scot Malay, DPM, MSCE, FACFAS. More interviews are planned for each issue in 2011.

“This new feature is for interested readers to hear authors talk about some of the more complex or perhaps controversial points of their papers,” says Malay. “It will be at your fingertips 24/7 online — and we’ll be adding more extras in the not-too-distant future.”

Use your free member access to JFAS to listen in:

• Go to the ACFAS web page for JFAS
• Click on “Read current and past issues online (member login required)" in the right menu and log in with your ACFAS ID and password
• When you reach the JFAS.org home page at Elsevier, click on the journal cover image for the current table of contents
• Under “Two-Stage Percutaneous Approach to Charcot Diabetic Foot Reconstruction,” click on “Add-Ons”

Foot and Ankle Surgery

Hallux Valgus Deformity Treated With the Extensor Hallucis Longus Tendon Transfer by Dynamic Correction

Researchers treated hallux valgus by transferring the extensor hallucis longus (EHL) tendon to reduce the likelihood of recurrence. Twenty-five patients (38 feet) underwent the procedure. The mean duration of follow-up was 38.2±3.2 months. The surgical procedure includes the release of the distal soft tissues, excision of the medial eminence, plication of the medial part of the capsule, and transfer of the EHL tendon, and reconstructing its insertion.

At follow-up, 35 feet (23 patients, 85 percent) were free from pain at the first metatarsophalangeal joint. In three feet (two patients), the pain was alleviated but persisted. The mean hallux valgus angle decreased significantly from a preoperative 38.3°±8.0° to 7.3°±2.0° at the time of the most recent follow-up, and the mean intermetatarsal angle decreased significantly from preoperative 12.5°±3.4° to postoperative 6.5°±2.4°. The mean AOFAS score according increased from 46.5 to 84.8 points.

The researchers concluded that hallux valgus can be corrected by transferring the EHL tendon medially and reconstructing its insertion. The technique can achieve stress balance of metatarsophalangeal joints and therefore prevent the recurrence of hallux valgus.



Plantar Fascia-Specific Stretching Versus Radial Shock-Wave Therapy as Initial Treatment of Plantar Fasciopathy

The effectiveness of plantar fascia-specific stretching over shock-wave therapy as an initial treatment for proximal plantar fasciopathy remains unclear. Researchers gauged the effectiveness of these two forms of treatment for patients who had unilateral plantar fasciopathy for a maximum duration of six weeks and who had not been treated previously. One hundred and two patients with acute plantar fasciopathy were randomly assigned to perform an eight-week plantar fascia-specific stretching program (Group I, n = 54) or to receive repetitive low-energy radial shock-wave therapy without local anesthesia, administered weekly for three weeks (Group II, n = 48). Patients were evaluated at baseline and at two, four, and 15 months after baseline.

At two months after baseline, the Foot Function Index sum score showed significantly greater changes for the patients managed with plantar fascia-specific stretching than for those managed with shock-wave therapy, as well as individually for item 2 of the index (pain during the first few steps of walking in the morning). Thirty-five patients (65%) in Group I versus 14 patients (29%) in Group II were satisfied with the treatment. These findings persisted at four months. At 15 months after baseline, no significant between-group difference was measured.

The researchers concluded that program of manual stretching exercises specific to the plantar fascia is superior to repetitive low-energy radial shock-wave therapy for the treatment of acute symptoms of proximal plantar fasciopathy.



You May Have Inherited Your Bad Feet

Foot disorders might be passed down from one generation to the next, according research presented at the American College of Rheumatology Annual Scientific Meeting. Researchers looked at the link between hallux valgus, pes cavus, and heredity as a part of the Framingham Foot Study—a study from 2002 through 2005 that examined common foot disorders and the functional limitations they cause in 2,179 participants—to evaluate whether these common foot conditions are inherited; 675 participants (31 percent) with hallux valgus and 154 participants (seven percent) with pes cavus were identified.

Using statistical genetics software, researchers found that hallux valgus was inherited in approximately 39 percent of the women and 38 percent of men in the study. They also found that 89 percent of the participants under the age of sixty inherited the condition. In the subjects with pes cavus, 68 percent of the women and 20 percent of the men were found to have inherited the condition. Of those under the age of 60 with pes cavus, 99 percent in women and 63 percent in men were inherited.

Practice Management

Electronic Alerts to Doctors Can Reduce Unnecessary Tests

The performance of unnecessary tests that yield false positives could be greatly reduced by targeting alerts in electronic medical systems, while physicians would pay closer attention to the messages they receive, according to a Kaiser Permanente study. The study, which entailed a randomized trial of 788,000 patients at eight clinics, discovered that an electronic alert sent to doctors the moment they ordered a blood test for senior patients cut unnecessary use of tests that often generate false positives for the elderly.

The study concentrated on the D-Dimer test used to detect blood clots. The test actually spots chronic inflammation, a sign that a patient may have a clot and therefore would need further testing. Rather than giving the D-Dimer test for clots, doctors who suspect an elderly patient may have a clot would instead order an ultrasound or computed tomography scan. Although the D-Dimer test costs less, results can take as long as two hours, potentially impacting patient treatment.



Family Health History: 'Best Kept Secret' in Care

Uncovering the family predisposition to certain diseases is better than costly genetic testing in predicting what illnesses you and your children are likely to face, according to research presented at a meeting of the American Society of Human Genetics. All that is required from patients is a little time questioning relatives, yet good family health trees are rare. A government survey estimated less than a third of families have one, and time-crunched doctors seldom push their patients to remedy that. The U.S. Surgeon General operates a free website that helps people create a family health history and share it electronically with relatives and their doctors.



Physician Professionalism and Changes in Physician-Industry Relationships From 2004 to 2009

Fewer physicians say they have financial relationships with drug companies than five years ago, but 8 out of 10 practicing physicians still accepted free drug samples, gifts, or payments from industry for their services in 2009, report researchers. The study recorded big drops in the percentage of respondents who say they were reimbursed for traveling to meetings sponsored by drug companies, from 35 percent to 18 percent. Participation in company speakers bureaus also fell, from 16 percent to 8 percent.

Health Policy and Reimbursement

AMA Establishes 13 Principles for Development, Implementation of ACOs

The American Medical Association (AMA) has adopted 13 guiding principles for the development and operation of accountable care organizations (ACOs). The new principles emphasize that ACOs must be physician-led, place patients' interests first, ensure voluntary physician and patient participation, and enable independent physicians to participate.



Doctor's Offices Doing More Surgeries

Out of about 80 million outpatient surgeries last year, more than 12 million were performed in doctor's offices. That figure is expected to continue growing along with advances in anesthetics and minimally invasive procedures that make office surgery possible, but some doctors warn that safeguards for patients have been slow to keep up with the increasing number of procedures. Only 25 states currently have rules, statutes or other guidelines for office-based surgeries.



Justices Reluctant to Let Medical Residents Skip Taxes

Several Supreme Court justices appeared reluctant to overturn an IRS requirement that medical residents pay Social Security taxes. Arguing before the court on behalf of the Mayo Clinic, lawyer Theodore Olson urged the court to reject the IRS rule as arbitrary, arguing that - like other students - medical residents attend lectures, perform laboratory work, and are focused primarily on learning. Full-time students who work are generally exempt from Social Security taxes, but law clerks and tradesman apprentices are not. In a 2005 rule, the IRS said medical residents are full-time employees and not students. The case came before the Supreme Court after a lower court upheld the IRS rule. A decision is expected by next June.



Nearly 59 Million Lack Health Insurance: CDC

Nearly 59 million Americans went without health insurance coverage for at least part of 2010, according to the CDC. Four million more Americans went without insurance in the first part of 2010 than during the same time in 2008. The healthcare reform bill passed in March promises to get health insurance coverage to 32 million Americans who currently lack coverage.

Medicine, Drugs and Devices

Pfizer Arthritis Drug Succeeds in Late Stage Trial

An experimental drug for rheumatoid arthritis being developed by Pfizer significantly reduced symptoms and improved physical function, according to data from a late-stage clinical trial. Tasocitinib met two of three primary goals of the 611-patient Phase III study at two tested doses compared with a placebo; on the third primary goal, tasocitinib demonstrated a numerically higher measure of disease remission at three months than placebo, but the measure did not reach statistical significance. Tasocitinib belongs to a new class of oral drugs known as JAK inhibitors that impacts the signaling of proteins involved in inflammatory and autoimmune diseases. "This is the first oral medication for rheumatoid arthritis that has had a successful Phase III study this century," said Roy Fleischmann, the study's primary investigator.



Special Mobility Shoes Benefit People With Osteoarthritis

The use of special mobility shoes can help ease knee pain and slow the progression of osteoarthritis (OA), according to research presented at the American College of Rheumatology Annual Scientific Meeting. Researchers used a special camera system and a force plate to determine gait in 16 participants diagnosed with knee OA while they walked in their own shoes, in mobility shoes, and barefoot. After this initial evaluation, participants were instructed to wear the mobility shoes a minimum of six hours per day, six days a week for six months. To determine the progression of each participant, researchers performed the same gait analysis that was performed at the beginning of the study at six, 12, and 24 weeks.

Researchers determined that mobility shoes, in comparison to conventional shoes, led to significantly decreased knee loads in the participants. Additionally, they found that longer-term use of the mobility shoes led to improved outcomes, noting a reduction in knee load that increased from 3.7 percent at the beginning of the study to 9.4 percent after six weeks and to 18 percent at 24 weeks. After 24 weeks of wearing mobility shoes, participants experienced an adaptation in their gait (with a knee load reduction of 11 percent) even when wearing conventional shoes, leading researchers to conclude that the use of mobility shoes could create beneficial neuromuscular and behavioral changes in how people with OA walk.



Total Ankle Replacement in Association With Hindfoot Fusion

Researchers report the clinical and radiological outcome of total ankle replacement performed in conjunction with hindfoot fusion or in isolation. Between May 2003 and June 2008, 60 ankles were treated with total ankle replacement with either subtalar or triple fusion. The results were compared with a control group of 288 ankles treated with total ankle replacement alone.

After the mean follow-up of 39.5 months, the ankles with hindfoot fusion showed significant improvement in the mean visual analogue score for pain, the mean AOFAS score, and the mean of a modified version of this score. The mean visual analogue pain score and mean modified AOFAS score were not significantly different between the hindfoot fusion and the control groups, but the hindfoot fusion group had a significantly lower mean range of movement and a higher rate of posterior focal osteolysis.

The researchers concluded that subtalar or triple fusion is feasible and has minimal adverse effects on ankles treated with total ankle replacement up to midterm follow-up. The clinical outcome of total ankle replacement when combined with hindfoot fusion is comparable to that of ankle replacement alone. Therefore, hindfoot fusion should be performed in conjunction with total ankle replacement when indicated.



Abstract News © Copyright 2010 INFORMATION, INC.

---

You have received this newsletter as a service of the American College of Foot and Ankle Surgeons. To change your email address, please click here. If you wish to unsubscribe click here.