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This Week's Headlines

News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Medicine, Drugs and Devices

News From ACFAS

Medicare Pay Cut Delayed Yet Again

Late on Nov. 30 President Obama signed H.R. 5712, which will delay a pending 23 percent cut in Medicare physician reimbursement until Dec. 31, according to online news sources. The new legislation also gives physicians a temporary 2.2 percent reimbursement increase.

The next deadline is Jan. 1, when a scheduled 25 percent pay cut is supposed to take effect. Since the 111th Congress ends on Jan. 3, watch for this issue to be postponed yet again when the politically divided 112th Congress takes office.
Latest ACFAS e-Learning Podcast: CRPS

CRPS, or Chronic Regional Pain Syndrome, is still incompletely understood in the medical community. As podcast moderator Christopher D. Lotufo, DPM, FACFAS, notes, “Although there have been a number of studies and articles published on this subject, there is so much to learn regarding how to properly manage CRPS.”

Listen in as Lotufo interviews Lawrence M. Fallat, DPM, FACFAS, on the changing definitions, treatment options, successes, failures and risks he’s encountered in many years of helping patients afflicted with this difficult condition.

Stop by today to explore the new podcast and the entire archive of resources at ACFAS e-Learning.
Reach More Patients with FOOTNOTES

Share the latest foot and ankle health information with your patients and community by downloading the Winter 2010 issue of FOOTNOTES patient newsletter. Inside this issue, readers can learn about:
  • Foot fractures and osteoporosis
  • Keeping your feet fit in the New Year
  • Staying safe while having fun with winter sports
FOOTNOTES is a free member benefit you can customize with your practice’s information. Start spreading your news by downloading your issue today at

Foot and Ankle Surgery

Comparison of the Outcomes of Distraction Osteogenesis for First and Fourth Brachymetatarsia

Researchers compared the outcomes of patients who underwent distraction osteogenesis for the treatment of first and/or fourth brachymetatarsia. Data from 48 patients (64 feet, 74 metatarsals) were reviewed. The indications for surgery included a metatarsal that was at least 10 mm shorter than the adjacent metatarsal and that had an unacceptable cosmetic appearance. The study group comprised 32 first brachymetatarsia in 19 patients (Group A) and 42 fourth brachymetatarsia in 29 patients (Group B). The average duration of follow-up was 58.1 months in Group A and 56.1 in Group B.

All patients were satisfied with the final length of the metatarsal and all had achieved bone union at the time of the last follow-up. The mean lengthening gain was 17.2 mm (42.9%) in Group A and 16.3 mm (37.3%) in Group B. The mean healing index was 71.0 days/cm in Group A and 67.3 days/cm in Group B. The mean AOFAS score was 91.2 points in Group A and 92.8 points in Group B at the last follow-up. The most common complication was metatarsophalangeal joint stiffness, which occurred in 13 rays in Group A and in 12 rays in Group B; malalignment of the lengthened metatarsal was observed six times in each group. No significant intergroup differences in the outcomes were found.

The researchers concluded that distraction osteogenesis for first and/or fourth brachymetatarsia provided successful lengthening of a metatarsal with eventual osseous union and was associated with similar outcomes in terms of healing index, function score, and the prevalence of complications between the two groups, though frequent complications were encountered and no improvement in foot function was found.

From the article of the same title
Journal of Bone and Joint Surgery (American) (11/17/10) Vol. 92, No. 16, P. 2709 Lee, Keun-Bae; Park, Hyeong-Won; Chung, Jae-Yoon

Reliability of MRI Findings of Peroneal Tendinopathy in Patients with Lateral Chronic Ankle Instability

Researchers performed a study to see the reliability of MRI findings of peroneal tendinopathy in patients with chronic lateral ankle instability. Images for 82 patients who had chronic lateral ankle instability and had received surgical treatment between March 2006 and November 2009 were compared with impressions from operating rooms.

Of the 82 cases, 26 were true positives, 38 true negatives, 13 false positives and 5 false negatives. Of 39 cases of peroneal tendinopathy diagnosed from MRI, 14 had peroneal tendon partial tears, 15 tenosynovitis, three dislocations, 17 low-lying muscle bellies, and six peroneus quartus muscles. Of 31 cases of peroneal tendinopathy observed in surgery, 11 had peroneal tendon partial tears, four tenosynovitis, five dislocations, 12 low-lying muscle belliess, and one peroneus quartus muscle. Sensitivity and specificity of peroneal tendinopathy were 83.9 percent and 74.5 percent, respectively. Positive predictive value was 66.7 percent. Negative predictive value was 88.4 percent. Accuracy rate was 78 percent.

The researchers concluded that MRI is a useful diagnostic tool for detecting peroneal tendinopathy in patients with chronic lateral ankle instability.

From the article of the same title
Clinics in Orthopedic Surgery (12/01/10) Vol. 2, No. 4, P. 237 Park, Hee Jin; Cha, Seung Doh; Kim, Hyung Soo; et al.

The Effect of Kinesiotape on Function, Pain, and Motoneuronal Excitability in Healthy People and People With Achilles Tendinopathy

Researchers studied the effect of kinesiotape on hop distance, pain, and motoneuronal excitability in healthy people and people with Achilles tendinopathy (AT). Twenty-six healthy people and 29 people with AT were recruited. Seven participants were lost after functional testing, leaving 24 participants in each group. The single-leg hop test and visual analog scale were measured with and without the tape. Using the Hoffman (H) reflex, change in motoneuronal excitability of calf muscles was measured before tape application, with the tape on and after its removal.

There were no changes to hop distance when tape was applied. Additionally, there were no changes to pain. The H reflex amplitude of soleus and gastrocnemius increased in the healthy group after its removal, whereas the H reflex remained unchanged in people with AT.

The researchers concluded that the results do not support the use of kinesiotape for AT.

From the article of the same title
Clinical Journal of Sport Medicine (11/01/10) Vol. 20, No. 6, P. 416 Firth, Bridget L.; Dingley, Paul; Davies, Elizabeth R.; et al.

Practice Management

Health Reform May Endanger Independent Physician Practices

Healthcare reform will dramatically change how physicians conduct business and likely will mean the end of full-time, independent, private practitioners accepting third-party payments, according to a new report by Boston-based The Physicians Foundation. The study predicts that physicians will become employees, part-time workers, or administrators; operate cash-only "concierge" practices; or leave medicine altogether.

From the article of the same title
HealthLeaders Media (11/22/10) Commins, John

How Does Routine Disclosure of Medical Error Affect Patients' Propensity to Sue and Their Assessment of Provider Quality?: Evidence From Survey Data

The disclosure of medical errors to patients remains rare because providers fear that it will trigger lawsuits and jeopardize their reputation. Researchers set out to analyze how patients might respond to their providers' disclosure of a medical error. A representative sample of Illinois residents was surveyed in 2008 about their knowledge about medical errors, their confidence that their providers would disclose medical errors to them, and their propensity to sue and recommend providers that disclose medical errors and offer to remedy them.

Of the 1018 respondents, 27 percent would sue and 38 percent would recommend the hospital after medical error disclosure with an accompanying offer of remediation. Compared with the least confident respondents, those who were more confident in their providers' commitment to disclose were not likely to sue but significantly and substantially more likely to recommend their provider.

The researchers concluded that patients who are confident in their providers' commitment to disclose medical errors are not more litigious and far more forgiving than patients who have no faith in their providers' commitment to disclose mistakes.

From the article of the same title
Medical Care (11/01/10) Vol. 48, No. 11, P. 955 Helmchen, Lorens A.; Richards, Michael R.; McDonald, Timothy B.
Web Link - Publication Homepage: Link to Full Text Unavailable | Return to Headlines

Medical Malpractice Liability and Electronic Health Records

While the adoption of electronic health record (EHR) systems is a top priority among hospitals as a way to improve patient care and safety, experts caution that with the adoption of these programs comes increased risks, particularly in terms of medical malpractice liability. Moreover, as these systems become more connected to external systems, the risks will increase. Hospitals must be aware that during the implementation process, computer-related errors and information gaps can occur between electronic and paper records, and those risks must be minimized. Other areas of risk include the use of secure messaging and EHR systems in relation to breaches of privacy and confidentiality; disputes over the ownership of health data; and increased vulnerability to Medicaid fraud claims. Hospitals must ensure staff is educated about these risks and how to best use the system to prevent liability. At the same time, these systems will ensure more documentation and metadata are available to defend against liability claims.

From "Medical Malpractice Liability in the Age of Electronic Health Records"
New England Journal of Medicine (11/18/10) No. 363, P. 2060 Mangalmurti, Sandeep S.; Murtagh, Lindsey; Mello, Michelle M.

Health Policy and Reimbursement

IOM Takes First Step in Defining Essential Health Benefits

The Institute of Medicine (IOM), an independent advisory group, has begun a study to recommend how to determine and update the minimum benefits that health plans must offer to be sold in the reform law's 2014 health insurance coverage requirement. The Department of Health and Human Services (HHS) requested the study, which is expected to be delivered by September 2011. HHS will develop separate standards for the minimum amount of health insurance individuals must have to meet the health reform law's individual health insurance mandate.

From the article of the same title
American Medical News (11/22/10) Trapp, Doug

New Rules Tell Insurers: Spend More on Care

The Obama administration has issued new federal rules that will require many health insurance companies to spend more on medical care and allocate less to profits, executive compensation, marketing, and overhead expenses. Starting next year, insurers in the individual and small-group markets must spend at least 80 percent of their premium revenues on medical care and activities to improve the quality of care, while insurers in the large-group market must spend at least 85 percent of premium dollars. Insurers that do not meet the standards will have to pay rebates to consumers, starting in 2012.

From the article of the same title
New York Times (11/22/10) Pear, Robert

Some States Weigh Unthinkable Option: Ending Medicaid

Budget shortfalls are prompting some states to consider dropping out of the Medicaid insurance program. Elected and appointed officials in nearly a half-dozen states have publicly proposed the idea. Wyoming and Nevada this year produced detailed studies of what would happen should they withdraw from the program. The idea of abandoning Medicaid is so extreme, however, that even proponents do not expect any state to follow through.

From the article of the same title
Wall Street Journal (11/22/10) Adamy, Janet; King Jr., Neil
Web Link - May Require Paid Subscription | Return to Headlines

Medicine, Drugs and Devices

Amgen's Bone Drug Denosumab Cleared to Treat Fractures in Cancer

Amgen's osteoporosis drug denosumab has been approved by the FDA for reducing fractures in prostate and breast cancer patients. Denosumab will be marketed to reduce fractures and surgery in patients whose breast, prostate, or other solid tumors have spread to their bones. The drug targets a protein called RANK ligand that works with others in a process that routinely breaks down old bone in the body and replaces it with new. It also plays a role in weakening the bones of people with osteoporosis and cancer.

When women’s estrogen levels fall after menopause, or when cancer spreads to the bones from other parts of the body, the change stimulates production of RANK ligand, intensifying bone destruction. Denosumab, a synthetic version of an immune cell, inhibits RANK ligand and reduces bone destruction.

From the article of the same title
Bloomberg (11/19/10) Waters, Rob

Are Online Doctors the Best Medicine?

Online companies are diagnosing and treating common conditions such as allergies and the flu over the Internet or on the phone, forcing state regulators to revisit decade-old rules about what constitutes a doctor/patient relationship. Critics say that assessments of patients sight unseen, or through video cam, could miss signs of underlying conditions.

Most state medical boards permit doctors to diagnose and treat only those patients whom they've seen at least once in person. But the online companies argue that the examination does not need to be in person if technology such as videoconferencing can provide the same information as a face-to-face visit.

From the article of the same title
USA Today (11/19/10) Rubin, Rita

Intra-articular Sodium Hyaluronate Injections in the Osteoarthritic Ankle Joint: Effects, Safety and Dose Dependency

Researchers set out to determine the efficacy, safety, and dose dependency of intra-articular hyaluronic acid injections in the ankle. Patients were randomly allocated to 1, 2, or 3 ml, or 3 weekly injections of 1 ml (3× 1 ml). Twenty-six patients participated.

The 3× 1 ml dose group showed statistically significant decreases in pain during walking and at rest at week 7, and in pain at rest at week 15. There was no significant decrease of VAS-scores in any of the single dose groups. Seven patients experienced temporary local swelling and increased pain in the injected ankle.

The researchers concluded that viscosupplementation in the ankle joint is effective and well tolerated. The 3× 1 ml dose regimen shows the best results.

From the article of the same title
Foot and Ankle Surgery (12/01/10) Vol. 16, No. 4, P. 159 Witteveen, Angelique G.H.; Sierevelt, Inger N.; Blankevoort, Leendert; et al.

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December 1, 2010