News From ACFAS

Make your plans now to explore the brilliant minds, ideas and beaches at the ACFAS 2011 Annual Scientific Conference, March 9–12, in Fort Lauderdale, Fla.

Register today to save $65 or more! Early bird conference registration ends Jan. 4, 2011.

The 2011 Annual Scientific Conference program and registration information will arrive in your mailbox soon. Use it to plan your own personal educational experience — or visit the conference home page at acfas.org/ftlauderdale.

Hospital staff privileges issues are a top priority for ACFAS members. The College is creating a team of expert advisors to counsel ACFAS members on credentialing and privileging matters. To start this initiative, the College will hold a special meeting to educate potential advisors on the privileging challenges that ACFAS members face. This session will be held on March 12, 2011, the last day of the ACFAS Annual Scientific Conference in Fort Lauderdale, Fla.

If you meet many of the criteria below, or know an ACFAS member who does, please contact Kristin Hellquist Cunningham, director of health policy, practice advocacy and research at kristin.hellquist@acfas.org by Jan. 15, 2011.

Criteria for participation include:

• Having been through a privileging battle either defending one's expertise or being a decision-maker on appropriate credentialing and privileging for podiatric surgeons.
• Willingness to serve as a mentor and provide time and expertise to others.
• Active license to practice and full privileges at one or more institutions.
• Leadership roles in a hospital or ASC.
• Prepared to serve ACFAS in this role for the next 3–7 years (either active or retired surgeon).
• Expertise in medical staff and/or hospital bylaws.
• Experience on a state podiatric board desired.
• Passionate and consultative in working with others.
• ACFAS member in good standing.

Foot and Ankle Surgery

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures

Researchers compared the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functional rehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone.

A total of 144 patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. All patients underwent an accelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The primary outcome was the rerupture rate as demonstrated by a positive Thompson squeeze test, the presence of a palpable gap, and loss of plantar flexion strength. Secondary outcomes included isokinetic strength, the Leppilahti score, range of motion, and calf circumference measured at three, six, 12, and 24 months after injury.

Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were 13 complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group.

The researchers conclude that the study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management.



Symptomatic Bunionette Deformity in Adolescents: Surgical Treatment with Metatarsal Sliding Osteotomy

Researchers evaluated the results of a fifth metatarsal sliding osteotomy for the treatment of bunionette deformity in patients under 18 years of age. They retrospectively evaluated 13 feet in 11 consecutive patients with bunionette deformity treated from January 2003 to January 2008 at 2 referral centers.

The average postoperative AOFAS score was 91±4.1 points. Seven patients (8 feet) had an excellent outcome and 4 patients (5 feet) a good outcome according to the Coughlin scoring rate. The IV-V intermetatarsal angle averaged 12.29 degrees±1.5 degrees preoperatively, while postoperatively it was 6.18 degrees±1.4 degrees. The lateral deviation angle improved from 7.74 degrees±1.7 degrees preoperatively to 4.25 degrees±1 degree after surgery. The width of the forefoot decreased from 8.01±1.3 mm to 7.05±1.3 mm. The mean fifth metatarsophalangeal angle decreased from 21.7 degrees±4.1 degrees preoperatively to 7.63 degrees±3.4 degrees at final follow-up. One patient developed a superficial infection around a K-wire.

The researchers concluded that metatarsal sliding osteotomy is a safe and effective method for the correction of symptomatic bunionette in patients below 18 years of age.

Practice Management

Commentary: Violence in the Healthcare Setting

Healthcare workers are at a higher risk of assault than employees in other industries, a study by two physician researchers at Johns Hopkins Hospital in Baltimore has found. Citing government statistics, the study noted that the rate of assaults at healthcare facilities was 8 per 10,000 workers, while the rate for all private-sector industries was 2 per 10,000 workers. The study blamed the higher-than-average assault rate at healthcare facilities on several factors, including the fact that the public no longer views physicians with "reverence," as well as the fact that patients are becoming increasingly frustrated when dealing with the healthcare system.

The researchers advised healthcare facilities to protect their employees by performing ID checks, installing security cameras, conducting regular threat assessments, and training employees on how to recognize and de-escalate a potentially violent situation.



Imaging Self-Referral Associated With Higher Costs and Limited Impact on Duration of Illness

Physicians' practice of self-referring patients for imaging tests with the doctors' own scanners does not reduce the duration of illness or lower costs, according to researchers. From a study of 733,459 episodes of care involving 470,530 unique patients at least 65 years old, the researchers determined that the practice actually supports more testing and greater radiation exposure. The researchers made 20 analyses, and 13 showed substantially higher costs with self-referral while just one "showed a significantly lower cost." When the doctor self-refers a patient, the cost per treatment episode generally averages 4 percent to 10 percent higher.

The researchers also learned that the cost of the imaging test itself was on average 27 percent to 40 percent higher when the test was self-referred, and non-imaging costs were not reduced. They conclude, "Medicare's current exemption for self-referred imaging should be narrowed so that it includes only x-rays, not other forms of imaging. To the extent that state laws or private payers permit self-referral for imaging, they would also do well to follow this policy."



Red Flag Rules Still Matter

The intent of the “Red Flag Rules” still matters despite legislation passed by federal lawmakers that makes doctors exempt from their anti-identity theft requirements. Carriers can request a payment refund from practices that provide care to a patients who turns out not to be the holder of the insurance card. To prevent this, offices should ask for a photo ID and use a scanner to copy the ID to the practice management system.

Health Policy and Reimbursement

Federal Court Strikes at Health-Insurance Law

A federal judge in Virginia has ruled that it is unconstitutional for the federal government to compel Americans to buy health insurance, marking the first time a court has struck down any facet of the healthcare overhaul bill. The opinion by U.S. District Judge Henry Hudson does not invalidate the entire law or force federal and state officials to stop the work of putting it into effect—steps Virginia had asked him to take. Rather the ruling by Hudson, named to the bench by former President George W. Bush, sets up a conflict with opinions by two Democratic-appointed judges who have concluded recently that the law is constitutional. The cases are among two dozen in federal courts across the country that challenge many aspects of the law.



One-Year SGR Fix Now Needs Only Presidential Okay

The House, following the Senate's lead, has passed a $15 billion bill that would keep Medicare physician payment rates steady through 2011, blocking the impending 25 percent cut in the Medicare pay rate. The bill now goes to the president for his signature. The one-year fix is the fifth and longest extension of Medicare physician payment rates passed by Congress this year.

Medicine, Drugs and Devices

Diagnostic Errors: Why They Happen

As many as 80,000 U.S. hospital deaths per year are the result of delayed, erroneous, or missed diagnoses, according to research estimates. Such errors can occur as a consequence of tests that are not ordered, followed up, or correctly interpreted; missed referrals because of a lack of patient follow-through or consultants not reporting back; or patients not keeping their follow-up appointments.

The Maine Medical Center is deploying a system that lets physicians report diagnostic errors anonymously. Doctors can submit a patient's medical record number, the type of error, a description, and whether any harm resulted , and the determination of error is made by an expert physician reviewer without casting blame or identifying patients. The purpose is to identify patterns of diagnostic errors and make improvements.

Another practice to mitigate diagnostic errors is for doctors to open clear communication lines with their patients. Gordon Schiff, MD, of Brigham and Women's Hospital in Boston, advises physicians to notify patients if they are uncertain about a diagnosis and to request that they disclose symptoms that could indicate a misdiagnosis




Kinematic Features of Rear-Foot Motion Using Anterior and Posterior Ankle-Foot Orthoses in Stroke Patients With Hemiplegic Gait

Researchers evaluated the kinematic features of rear-foot motion during gait in hemiplegic stroke patients, using anterior ankle-foot orthoses (AFOs), posterior AFOs, and no orthotic assistance. Patients with hemiplegia due to stroke (n=14) were measured walking under the three conditions with randomized sequences. Control subjects (n=11) were measured walking without an AFO to provide a normative reference.

In the sagittal plane, compared with walking with an anterior AFO or without an AFO, the posterior AFO significantly decreased plantar flexion to neutral at initial heel contact and the swing phase, and increased dorsiflexion at the stance phase. In the coronal plane, the anterior AFO significantly increased maximal eversion to neutral (less inversion) at the stance phase, and decreased the maximal inversion angle at the swing phase when compared with using no AFO. The posterior AFO also decreased the maximal inversion angle at the swing phase as compared with no AFO. In the transverse plane, when compared with walking without an AFO, the anterior AFO and posterior AFO decreased the adduction angle significantly at initial heel contact.

The researchers concluded that for poststroke hemiplegic gait, the posterior AFO is better than the anterior AFO in enhancing rear-foot dorsiflexion during a whole gait cycle. The anterior AFO decreases rear-foot inversion in both the stance and swing phases, and the posterior AFO decreases the rear-foot inversion in the swing phase when compared with using no AFO.



Total Ankle Arthroplasty Outcome Comparison for Post-Traumatic and Primary Osteoarthritis

Researchers compared the clinical and radiographic outcomes of total ankle arthroplasty in patients with posttraumatic and primary osteoarthritis. Total ankle arthroplasty using Hintegra was carried out in 65 patients (67 ankles) with symptomatic ankle osteoarthritis. Group A included 37 patients (37 ankles) with post-traumatic osteoarthritis, and Group B included 28 patients (30 ankles) with primary osteoarthritis. Patients were assessed clinically and radiographically at a mean follow-up of 38 months.

No significant differences were found between the two study groups in terms of AOFAS ankle-hindfoot scales, range of motion, or radiographic values at final follow-up. The incidence of complications (38 percent in Group A, 27 percent in Group B) and additional procedures (54 percent in Group A, 27 percent in Group B) was significantly higher in Group A. One ankle was revised in Group A for a deep
infection.

The researchers conclude that the clinical and radiographic outcomes of total ankle arthroplasty for post-traumatic and primary osteoarthritis were comparable, although the incidence of complications after total ankle arthroplasty was higher in the post-traumatic osteoarthritis group. More preceding or concomitant surgeries were required in order to make the posttraumatic cases suitable for total ankle arthroplasty.



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.