The OFAC team has three recent publications in scholarly, peer-review medical journals. I’ve posted the title, reference and abstract of each below. In addition to our many lectures at local, regional, national and international medical meetings, our focus on scholarly research and publication of our results continues to forge us ahead of any other foot and ankle practice in the country.

Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study

J Foot Ankle Surg. 2009 Nov-Dec;48(6):668-71.

Roukis TS, Hyer CF, Philbin TM, Berlet GC, Lee TH

The purpose of this article is to report the complications associated with autogenous bone marrow aspirate harvested from the lower extremity (ie, tibia and/or calcaneus) for soft tissue and/or osseous healing augmentation. This is a multisite, multisurgeon, observational cohort study involving retrospective review of prospectively collected data of 548 autogenous bone marrow aspirate harvests from the lower extremity of 530 consecutive patients between August 2000 and March 2009. Each patient underwent autogenous bone marrow aspirate harvest from the proximal medial tibial metaphysis, distal medial tibial metaphysis, medial malleolus, lateral calcaneus, medial calcaneus, or a combination of both the proximal tibial metaphysis and lateral calcaneus for application to split-thickness skin graft application sites or for mixture with allogeneic bone graft material for osseous defects or arthrodesis. Patients were kept non-weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 324 female and 206 male patients with a mean age of 54.7 +/- 14.1 years (range: 14 to 84 years). There were 276 left feet/ankles and 272 right feet/ankles undergoing operative interventions with 18 harvests occurring from the proximal medial tibial metaphysis, 183 from the distal medial tibial metaphysis, 11 from the medial malleolus, 325 from the lateral calcaneus, 3 from the medial calcaneus, and 8 from both the proximal tibial metaphysis and lateral calcaneus. All procedures were deemed successful with no nerve-related injury, infection, wound-healing complications, or iatrogenic fracture occurring. When properly performed, autogenous bone marrow aspirate harvest from various locations about the lower extremity as described here represent safe and minimally invasive techniques useful for soft tissue and osseous healing augmentation. Level of Evidence: 4 (Case Series; Therapeutic Study).

Transosseous fixation of the distal tibiofibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases.

J Foot Ankle Surg. 2009 Nov-Dec;48(6):620-30.

Cottom JM, Hyer CF, Philbin TM, Berlet GC

In this prospective cohort study, we compared screw fixation to interosseous suture with endobutton repair of the syndesmosis. Outcomes of interest included preoperative and postoperative modified American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and ankle scores, and Short Form-12 health status scores, as well as radiographic measurements and the time to full weight bearing. Mean averages and ranges were calculated for numeric variables, and outcomes for each fixation group were compared statistically with Student t test. The cohort consisted of 50 patients; 25 in the screw fixation group and 25 in the interosseous wire with endobuttons group. The mean patient age was 34.68 (15 to 55) years in the interosseous suture endobutton group and 36.68 (17 to 74) years in the screw group, and the mean follow-up was 10.78 (range 6 to 12) months in the interosseous suture endobutton group, and 8.20 (range 4 to 24) months in the screw group. No statistically significant differences (P < or = .05) were noted in regard to age, follow-up duration, time to postoperative weight bearing, or subjective outcome scores between the fixation groups; although statistically significant improvements were noted in the subjective scores for each fixation group between the preoperative and postoperative measurements. The results of this study indicate that the interosseous suture with endobuttons is a reasonable option for repair of ankle syndesmotic injuries, and may be as effective as traditional internal screw fixation. Level of Clinical Evidence: 2.

Results of lapidus arthrodesis and locking plating with early weight bearing.

Foot Ankle Spec. 2009 Oct;2(5):227-33

Sorensen MD, Hyer CF, Berlet GC

In the endeavor toward Lapidus fusion, the authors have studied a new application of locked plating for the first tarsometatarsal joint. The goal was to assess the time to fusion, time to ambulation, rate of delayed union/nonunion, rate of revision, and need for hardware removal following the use of locked-plate technology in the fusion of the first tarsometatarsal joint. The findings denoted an average of 6.95 weeks to radiographic fusion, an average of 2 weeks to ambulation, a 9.52% rate of asymptomatic mal-union, a 0% rate of delayed union or nonunion, and a 0% rate of revision. The rate of need for hardware removal was 4.76%.

Check back often for more updates on our mission on improving foot and ankle education and outcomes.

Christopher F. Hyer, DPM, FACFAS

Late last night, the House of Representatives passed HR 3962 by a vote of 220 to 215.  Very close. One Republican jumped ship and a huge debate over federally funded abortion was resolved to carry the vote.

From an orthopedic surgeons point of view, there are a few good things about this bill.  There are provisions which promote a state grant for medical liability alternatives.  There are provisions eliminating the antitrust exemption for health insurance and liability insurance companies.  There are no provisions for a punitive Physician Quality Reporting Initiative.  Finally, there are no provisions for Independent Medicare Advisory Council where Congress would abdicate its reposonsibility for Medicare policy.

These are the good things.  But there are many things of great concern for those of us who remain thoughtful about health care reform.

HR 3962 calls for the formation of a new advisory body, similar to the CMS Innovation Center proposed by the Senate.  This body lacks input from physicians.  There will be no regulatory agency accountability either.

There will be a redistirbution of residency slots with the sole focus on primary care.

There will be restrictions on physician owned hospitals.

There will be the establishment of a public national medical device registry which lacks privacy protection for physician level data.

Finally, there needs to be a permanent repeal and replacement of the Medicare Sustainable Growth Rate formula.

HR 3961, the “companion bill”, takes these major factors into account.  The provisions within this bill will allow health care reform to succeed by creating a stable Medicare program on which our elderly patients can rely.  If we allow these current flaws to continue, health care reform will be in trouble.  We all know our current system is in trouble. But like surgery, we can’t stop after the diseased organ is removed, we still have to finish the operation until the patient is closed up and successfully awake in the recovery room.

Apologies for a very serious blog but major changes are coming and we are all in a position to influence how health care will be delivered to us in the coming generations.