News From ACFAS

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ACFAS and Elsevier have partnered to bring you a new app – the JFAS iPad® Edition. As a member of the College, you now have free access to the full electronic mobile version of the Journal through this new, easy-to-use app. All you have to do is register yourself through the Elsevier JFAS website, jfas.org, to set up an Elsevier account and then head to iTunes (the Apple App Store) on your iPad to download the new app by searching for JFAS. Once you've downloaded the app and you've opened your Elsevier account, each issue of JFAS will arrive in your Newsstand on your iPad for you to download and read.

The JFAS iPad® Edition allows you to get the content you need, wherever you are, at the moment you think of it. You don’t need to be connected to the internet, and you no longer need to have your print copy handy. With this app, you can:

• Quickly Swipe Through Articles and Issues
• Bookmark Your Favorites
• Save to Your Favorite Reader App
• Take Notes and Highlight Within Articles

Get up-to-the minute alerts on new issues and featured articles by activating the App Alerts. Instructions on how to activate these alerts can be found here in the iTunes store. Listen to the latest ACFAS free podcast Surgical Red Flags, and hear opinions from your peers on what could "raise a red flag" when you meet with a new patient. This brief yet insightful podcast features a discussion on patients with “Type A” personalities and how to predict future issues before they arise. Some situations touched on in this podcast include:

• Which details are important to include in your informed consent forms?
• Looking for “red flags” in a patient’s medical and psychological history – why this is important and how you can handle these red flags?
• Patients who complain about high pain levels – do you prescribe more or stronger medications or do you send them to pain management?
• Dealing with a patient who has healed completely, yet is not happy with the result -- how would your respond?

Check out this and other free podcasts at acfasdistancelearning.com/podcast. ACFAS wants to stay up-to-date on everything our members are doing so we can continue to serve you effectively. If your practice has any websites, addresses, phone or fax numbers that haven’t been added to your profile, we encourage you to add those now so that consumers and referring physicians can find you via the “Find an ACFAS Physician” search tool on FootHealthFacts.org. The information you provide here will also be updated on acfas.org so other members of the College can continue to reach you through the "Find a Colleague" directory. Additionally, you may change your “preferred address” for receiving the Journal of Foot and Ankle Surgery and other ACFAS mailings through your profile.

First, log in and update your contact information. After completing your professional profile to include your website, hours, and up to three office locations, scroll down to “ACFAS Website Listing” and check “Yes” for “Consumer Physician Search” and “Find a Colleague" directory.

Change can be a wonderful thing, but remember to keep ACFAS abreast on how you and your practice are growing so that we can make sure you are available to peers, potential patients and the College! Update your profile today.

Foot and Ankle Surgery

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A study was held to compare and determine the level of correlation of findings at conventional B-mode ultrasonography (US) and sonoelastography of the Achilles tendon with findings at histologic evaluation. Thirteen Achilles tendons in 10 cadavers were studied with B-mode US and sonoelastography. Both modalities verified all 11 tendon thirds of histologically normal tendons as normal. Sonoelastography depicted 14 of 14 tendon thirds exhibiting histologic degeneration, while B-mode US could depict just 12 of 14 lesions. Only moderate agreement between B-mode US and sonoelastography was observed. Sonoelastography might be more potentially sensitive in predicting indicators of histopathologic degeneration of Achilles tendinosis than B-mode US. The study was published in the June issue of the journal Radiology.


A biomechanical study was held to compare the primary stability and stiffness of three-screw fixation and an anterior double plate system used for ankle arthrodesis. The study utilized six matched pairs of human cadaveric lower legs, with one specimen from each pair stabilized with the anterior double plate system and the other with the three-screw method. A mean load of 967 N was required for the anatomically shaped double-plate system to make arthrodesis fail, while the three-screw fixation technique resisted a mean load of 190 N. In terms of stiffness, a mean of 56 N/mm was accomplished for the double-plate system, versus a mean of 10 N/mm for the three-screw fixation method.


A study was held to ascertain the acute talofibular interval changes following lateral ankle sprain, using stress ultrasonography (US). The study involved 25 patients with 27 acute, lateral ankle injuries who underwent bilateral stress US imaging at baseline, and on the affected ankle at three weeks and six weeks from injury in three ankle conditions—neutral, anterior drawer and inversion. Talofibular interval was measured using imaging software and self-reported function by the Foot and Ankle Ability Measure (FAAM). The talofibular interval increased with anterior drawer stress in the involved ankle over the uninvolved ankle at baseline. Inversion stress also led to greater interval changes than uninvolved ankles. A primary impact for time was seen for inversion but not for anterior drawer. Substantial reductions in the talofibular interval occurred between the baseline and third week inversion measurements only. FAAM-activities of daily living and sports results rose significantly from baseline to the third week and from the third week to the sixth week.

Practice Management

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Practices should ensure electronic health record (EHR) data backup is done frequently and properly, even if it is handled by an outside company. Backup plans should take into account both how the data is retrieved and how long it will take to retrieve it. When setting a backup for EHR, practices need to be sure the backup location is located offsite, either at another physical location or in the cloud.

Sophisticated backup methods run parallel servers that backup all data in real time, allowing auditors to look back at a specific date and time to retrieve the data. Less sophisticated methods might only backup data to the previous day, meaning all data from before that point in time would be lost. The three main things to look for when testing a backup are to make sure it works, make sure it works efficiently and identify ways it can be improved and optimized.


Practices can reduce their risk of being sued for malpractice if they have courteous and responsive office staff, as staff perceived by patients as rude or disrespectful may be the deciding factor in cases with negative outcomes, even if the patient likes the physician. On the other hand, there is less chance of a lawsuit if the patient likes both the physician and the staff. However, many physicians who have worked with office staff for years or who may have relatives employed in the office often do not see the way patients are treated.

There also are cases in which the staff are properly trained and responsive, and the physician is the one who is too busy or harried to identify patient dissatisfaction. It is therefore key to learn what is going on outside of the exam rooms, whether patients are acknowledged promptly, courteously and with respect. The staff's response to problems also is important, and a simple survey is often the best way to learn this information, either via emails to patients or a card/suggestion box at the front desk.

Another option worth consideration is the use of a "secret shopper," in which the practice asks friends or relatives unknown to the office staff to act as patients and call in for an appointment, come by the office without an appointment and so on, and collect information on how the staff treated them. Allowing front office staff to voice their concerns and communicate the challenges and issues they are confronted with also is crucial for the practice. The next step is to organize a list of actions and behaviors you expect office staff to exemplify.

It also pays to empower the office staff through information and protocols so they can manage situations when things get difficult, even though they are not at fault, while also maintaining the highest standards of professionalism in all scenarios. Finally, physicians and their colleagues should be aware that they ultimately set the atmosphere and tone of the office. They should thus make it their business to practice friendliness, patience and courtesy as an example to office staff.

Health Policy and Reimbursement

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The Obama administration has released a final version of a rule governing health wellness programs. Among the provisions included in the rule, which will take effect Aug. 1 and is applicable to plan years beginning on or after Jan. 1, is one that will increase the maximum reward of a health-contingent wellness program offered through a group health plan from 20 percent to 30 percent. In addition to increasing the amount of rewards allowed under wellness programs, the rule also includes language that clarifies the reasonable design of health wellness programs as well as the reasonable options they are required to offer in order to avoid discriminatory practices. The final rule can be found here.


The House Energy and Commerce Committee released a draft bill May 28 to restructure physician pay under Medicare. The bill would eliminate the sustainable growth rate formula and provide incentives to pay doctors by their own criteria, instead of on the number of tests they provide. Healthcare providers would receive predictable payments for Medicare until the Department of Health and Human Services (HHS) develops a physician-payment system based on the quality of care provided. Each year since 1997, Congress has used a fiscal patch that maintains physicians' payments even when the Medicare payment formula calls for a cut; they indicate that now they intend to cut the Medicare payment formula. The nonpartisan Congressional Budget Office dropped its estimated cost of repealing the formula while paying doctors the current rate from $245 billion over 10 years to $138 billion. Financial details in the draft bill have yet to be settled; the committee has asked for feedback on the draft bill ahead of a June 5 hearing. Also on May 28, HHS Secretary Kathleen Sebelius published a blog post stating the Affordable Care Act has already reduced the number of patients readmitted to hospitals shortly after being released. Potential healthcare savings could alter the nation's budget debate.


The recent 2013 ICD-10 Survey found that many healthcare providers are not taking steps to prepare for the transition from ICD-9 to ICD-10. The survey, which was performed by the Workgroup for Electronic Data Interchange, found that 40 percent of providers did not know when they would complete their impact assessment, implement business changes and begin external testing of the ICD-10 system. Of those who had made plans to begin external testing, only about a tenth said they planned to do so sometime this year. The results of the survey are essentially the same as they were in the 2012 survey.


The Joint Commission and the Association of periOperative Registered Nurses (AORN) are urging healthcare practitioners and organizations to recognize National Time Out Day to help draw attention to the time out as a tool for the prevention of wrong-site, wrong-side, wrong-procedure or wrong-person surgery. In honor of National Time Out Day, AORN and The Joint Commission ask all immediate members of the surgical team and the organizations where they work to commit to conducting a safe, effective time out for every patient, for every surgical procedure.

National Time Out Day will be celebrated in hospitals and ambulatory surgery centers on June 12. Resources for celebrating National Time Out day are available here.

Medicine, Drugs and Devices

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Researchers have performed a study that examined whether cartilage oligomeric matrix protein (COMP) binds to bone morphogenetic protein-2 (BMP-2) as well as whether it enhances BMP-2's osteogenic activity. The study found that COMP does indeed bind to BMP-2, and that this binding improves BMP-2 induced intracellular signalling through Smad proteins. Researchers also found that COMP binding enhanced BMP-2-dependent osteogenesis in vitro in the C2C12 cell line and in primary human bone mesenchymal stem cells. COMP enhanced BMP-2-dependent ectopic bone formation was also observed in a rat model.


A study published in the New England Journal of Medicine has found that there may be a more effective way to prevent hospital-acquired infections than the method that is commonly used now. Researchers examined nearly 75,000 patients at 74 adult intensive care units at facilities owned by Hospital Corp. of America, and found that using a procedure called universal decolonization--which involves washing all ICU patients with the antimicrobial soap chlorhexidine and giving them a nasal antibiotic ointment mupirocin--reduced bloodstream infections by 44 percent and reduced the incidence of methicillin-resistant Staphylococcus aureus (MSRA)-positive cultures in the ICU by 37 percent. Two other methods--including testing patients for MSRA and isolating and treating those who test positive with a soap-ointment combination, a method which is often used in hospitals--were less effective in reducing infections.