News From ACFAS

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A record-breaking number of foot and ankle surgeons, residents, students and exhibitors from around the globe took over Phoenix at the 73rd Annual Scientific Conference last week, making it the largest-ever conference held by the College!

“The energy and buzz around this year’s conference were amazing,” said Richard Derner, DPM, FACFAS, President of the American College of Foot and Ankle Surgeons. “Each year our Annual Scientific Conference Committee seems to a find way to raise the bar to offer exceptional educational opportunities and exceed expectations for all! Thank you to all attendees and the committee for making this a year to remember,” Dr. Derner added.

See you next year in Austin, Texas, February 11-14, 2016! Congratulations to new ACFAS President Richard Derner, DPM, FACFAS; Sean T. Grambart, DPM, FACFAS, President-Elect; Laurence G. Rubin, DPM, FACFAS, Secretary-Treasurer; and Thomas S. Roukis, DPM, PhD, FACFAS, Immediate Past President. The new officers were installed during the Honors and Awards Ceremony at the Annual Scientific Conference along with the new and returning director members:

• Christopher F. Hyer, DPM, FACFAS
• Byron L. Hutchinson, DPM, FACFAS
• Scott C. Nelson, DPM, FACFAS
• Aksone Nouvong, DPM, FACFAS
• Christopher L. Reeves, DPM, FACFAS
• John S. Steinberg, DPM, FACFAS
• Randal Wraalstad, DPM, FACFAS

A special thank you to retiring Board members Jordan P. Grossman, DPM, FACFAS and Kris A. DiNucci, DPM, FACFAS, for their dedicated service. Congratulations to Lawrence A. DiDomenico, DPM, FACFAS, on being named this year’s recipient of the 2015 ACFAS Distinguished Service Award. This prestigious award, in its twelfth year, is presented each year at the Annual Scientific Conference to recognize those unsung heroes who volunteer their time, expertise and service behind the scenes to advance the College’s mission.

Thank you, Dr. DiDomenico, for your outstanding service to the College and the profession! Publicize to your patients and community you’ve advanced your education by attending ACFAS 2015 in Phoenix with an ACFAS Fill-in-the-Blanks Press Release. This free marketing tool, customized just for ACFAS 2015 attendees, is available online at acfas.org/marketing (login is required). Just open the release template, fill in the blanks with your professional contact information, add your logo and send off to your local media, put in your newsletter or on your website and even share in your social media pages—it’s that easy.

While on the ACFAS Member Marketing Toolbox page, you’ll also find other great practice promotional items available free to members, including more Fill-in-the-Blanks Press Releases, media pitching guidelines, the FootNotes patient newsletter and patient education PowerPoint presentations.

Foot and Ankle Surgery

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A study was conducted to compare short-term functional outcomes in pronation external rotation (PER) IV ankle fractures with and without dislocation. The study involved a review of a database of ankle fractures surgically treated via an anatomic fixation approach from 2003 to 2013. Included for analysis were all PER IV ankle fracture patients older than 18 years with at least 12 months of follow-up, including Foot and Ankle Outcome Score (FAOS). Comparison of patient demographics, injury characteristics, FAOS, ankle range of motion and rate of post-operative complication in PER IV fractures with and without dislocation was conducted. Twenty of the 47 PER IV fractures included for analysis were fracture-dislocations and 27 lacked dislocation. The average age of the study cohort was 49 years. Significantly poorer FAOS was exhibited in the fracture-dislocation cohort compared to the nondislocation cohort. Articular malreduction also occurred with higher frequency in the PER IV dislocation group, while rates of syndesmotic malreduction were similar between PER IV fractures with and without dislocation.


A retrospective study was conducted to analyze long-term follow-up in a group of 29 in situ fused patients with calcaneal fractures. Their single or multiple fusions were performed between 1970 and 1990. In 1998, the patients were examined with plain radiographs and computerized tomography (CT) scan of the affected foot, and assessment of visual analogue score (VAS) for calcaneal fractures, short-form health survey, Olerud Molander score and AOFAS hindfoot score was conducted as well. The plain radiographs and CT scan demonstrated severe remaining deformities in the patients. The outcome parameters were poor overall and were associated with the degree of remaining deformity.


A study was conducted to compare the outcomes of hallux valgus surgery between the sexes via a retrospective review of 60 males and 70 females comprising 66 and 82 feet, respectively. All patients received distal or proximal chevron osteotomy for treatment of hallux valgus deformity between June 2005 and December 2011. Clinical and radiologic results were compared between the sexes. No statistically significant differences in demographics were observed between the sexes. The average AOFAS score, visual analogue scale for pain and patient satisfaction at the final follow-up did not differ significantly between genders. No significant sex-related differences existed between the mean pre-operative hallux valgus angle (HVA) and inter-metatarsal angle (IMA). The average HVA was significantly greater in females than in males at the last follow-up, and average IMA did not differ significantly between the sexes. The average correction of HVA in males was significantly greater than that in females.

Practice Management

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It can be particularly challenging to engage with adolescent patients. Approaches include starting a conversation without the patients realizing it is happening, acquiring a thorough history and physical exam and reviewing necessary age-appropriate health and safety anticipatory guidance. The physician's starting attitude should be one of genuine interest and curiosity when saying hello, and then the physician should ease patients' anxiety by letting them sense that he or she is glad to see them. Before asking sensitive questions, the physician should tell the parent up front that some privacy is required. Adolescents should be made aware that their answers are confidential and will not be shared with their parents unless they consent or unless they are life-threatening to themselves or others. Physicians can also ask patients about life issues, such as hobbies or activities they enjoy, their school situation, friendships/relationships or their future goals, to create opportunities for deeper dialogue.


Young physicians who assume a leadership role earlier in their careers will be better able to plan and ready themselves for more leadership roles as their career progresses. Taking on a leadership role may initially be overwhelming, but by being calm and observant before taking action, a young physician can respond effectively to crises. When a problem crops up in workflow, or even between staff, a physician should identify the viewpoint of each issue or party and explain it to others. Reconciling the various issues and competing interests is important, and key to this is the physician empowering staff to help him or her. Convening people face-to-face can help resolve problems rapidly in such situations. The next step for physicians is to report on outcomes of such encounters and to make plans, set deadlines and follow up to make sure all goals are met. In situations where staff look to the physician for decisions where no concrete solution exists, the physician should do research and due diligence to find the optimal remedy and then decisively stand by his or her decision. The physician then ties these various elements together by following an open-ended strategy involving empowered staff or patients and by being willing to try various solutions. Physician leaders also should consider functioning as a "servant leader" and doing what is required to allow their staff and colleagues to perform to the best of their ability. Finally, physicians afraid of being leaders should ignore their fear and view leadership opportunities as practice that will help them build toward perfection.


Experts offer suggestions to help physicians improve compliance among patients, such as periodic medication reconciliation. This can be done by using semi-structured interviews on the drugs patients are taking in conjunction with brown bag reviews. Experts maintain medication lists generated this way at the point of care have fewer inclusion and omission discrepancies. Another suggestion is to query patients about the obstacles and difficulties they face in achieving compliance. Simplifying the patient's medication regimen with combination drugs whenever possible can also be helpful. It is recommended that physicians familiarize themselves with how much drugs cost for patients, for example, by checking websites that compare retail pharmacy prices for virtually every medication. Physicians educating patients about the drugs they prescribe can also help improve compliance, and clinicians should alert patients to potential adverse drug events as well.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has officially postponed the implementation of a new rule on collecting hundreds of millions in overpayments until Feb. 16, 2016. Providers, however, must still return the money before then. Providers and suppliers who do not return overpayments could face penalties that now include False Claims Act liability carrying fines as high as $10,000 per unreturned overpayment or exclusion from Medicare. Under the proposed rule, Medicare providers and suppliers of services under Parts A and B of title XVIII must return overpayments within 60 days, which CMS says is required by the Affordable Care Act. CMS justified the one-year delay due to “exceptional circumstances” arising from the “complexity of the rule and scope of comments.”


The Centers for Medicare and Medicaid Services (CMS) recently provided financial figures on both meaningful use penalties and incentives. The total sum of electronic health record (EHR) incentive payments increased to $28.1 billion through the end of 2014, with Medicare and Medicaid eligible providers (EPs) receiving $6.8 billion and $3.4 billion, respectively. Meanwhile, eligible hospitals account for $17.8 billion in EHR payments. The number of successful attestations of meaningful use by EPs nearly doubled in 2014 compared to 2013, from 76,730 to 127,815.


Hospitals and doctors’ offices still experience widespread difficulties when trying to exchange patient data among different systems with incompatible technology. Now government and industry initiatives are under way to make the sharing of data easier. The goal is to create networks with the same level of seamless and expansive interoperability as ATMs and cellular phone networks, with the ability to securely exchange patient data among multiple providers for free or for a nominal fee. Carequality, an IT collaborative announced last year, aims to develop common standards and legal agreements for electronic medical records systems. That could help expand regional health information networks that have successfully linked different providers’ systems but cover limited geographic areas. Meanwhile, seven vendor competitors have formed a trade group, CommonWell Health Alliance, to allow their customers to share records. In total, this group represents companies that supply 44% of hospital electronic medical records systems and about 21% of those used in doctors’ offices. After a pilot program in four states last year, CommonWell is rolling out the service nationally.


A Congressional Budget Office (CBO) report states that replacing Medicare's sustainable growth rate (SGR) formula, as proposed in bipartisan legislation last year, would cost $174.5 billion from fiscal year 2015 to fiscal 2025. Two identical pieces of legislation introduced in the U.S. Senate and House in 2014 would implement a permanent replacement to the SGR, a heated topic in the healthcare industry. Congress has passed several pieces of legislation in recent years to delay those Medicare reimbursement reductions to physicians that are scheduled to occur under the SGR. Despite the criticism of SGR, no industry consensus exists on how problems with SGR should be resolved. For example, the American Hospital Association (AHA) believes there should be a permanent fix to the SGR and supports the overall goal of the bipartisan legislation. However, the legislation does not include recommendations on how costs will be covered, and AHA released a statement in January stating it cannot support any proposal to fix the physician payment problem at the expense of funding for services provided by other caregivers. In February, AHA and nine other hospital groups sent a letter to Congress, asking legislators to oppose any bill that includes additional Medicare payment cuts to hospitals to fix the SGR.

Medicine, Drugs and Devices

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The Food and Drug Administration (FDA) is pushing back the public comment period for its proposed change to labeling rules for approved drugs and biological products. In November, the agency suggested updating the labeling rules to permit generic drug makers, who are abbreviated new drug application holders, to revise their product labels to show newly acquired safety-related information, even if the updated label differs from the label on the corresponding brand-name drug. The public comment period for this rule has been extended to April 27, and a public hearing will also be held on March 27.


The Food and Drug Administration (FDA) reports that it is prepared to spend nearly a million dollars to study the quality and effectiveness of long-acting generic drug products, including levonorgestrel-based birth control products. In its funding opportunity notice for Pharmacometric Modeling and Simulation for Long-Acting Injectable Products, FDA's Center for Drug Evaluation and Research explains that the findings from the study will "help establish scientific and regulatory standards for ensuring therapeutic equivalence of generic long acting injectable (LAI) products." FDA says it hopes its research will be able to "assist development of generic LAI products."


A study was conducted to characterize the experience of a U.S. academic level I trauma center with transarticular pinning of selected critical ankle fracture-dislocations followed by delayed definitive fracture fixation once the soft tissues are healed. Median patient follow-up of two years demonstrated that the transarticular pinning technique was performed safely, and there was no association between use of the technique and increased post-operative complication rates. Use of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcome Score (FAOS) questionnaire also led to good subjective outcomes. A total of 1,372 patients were retrieved in the initial database search during the interval of Jan. 1, 2009, to July 1, 2014. Twenty-five of the patients were managed with temporary transarticular ankle pin fixation. Thirteen patients represented the main study cohort of interest, and eight of them were available for subjective follow-up scoring using the FAOS questionnaire. No ankle-related complications occurred in the 13 patients managed with staged ankle pinning and delayed open reduction and internal fixation procedures. The selected study cohort had no wound healing problems, wound breakdown or post-operative surgical site infections.