News From ACFAS

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The July issue of the Journal of Foot & Ankle Surgery will be in your mailbox soon, but you can read it online today! Features include a remarkable observational study about the clinical outcomes of ankle arthrodesis titled, “Long-term Follow-up of Tibiocalcaneal Arthrodesis in Diabetic Patients with Early Chronic Charcot Osteoarthropathy,” as well as an alternative procedure for handling the rare Müller-Weiss Disease, titled, “Fusion of Talonavicular and Naviculocuneiform Joints for the Treatment of Müller-Weiss Disease.” Check it out and find what interests you by following these directions:

Use your free member access to read original research, case reports, reviews, and quips, tips and pearls by visiting acfas.org/jfas, clicking “Read current and past issues online” and logging in with your ACFAS member ID. Attend one of four Advances in Forefoot Surgery Workshops & Seminars. These are hands-on opportunities that the College and four ACFAS Divisions partnered to provide for practicing and in-training surgeons. Dates and locations include:

• September 14-15
  ACFAS and Division 4
  Embassy Suites Denver Downtown
  Denver, CO
  Register Here
• September 21-22
  ACFAS and Division 13
  Marriott Louisville East
  Louisville, KY
  Register Here
• October 5-6
  ACFAS and Division 7
  Detroit Marriott Southfield
  Southfield, MI
  Register Here
• October 19-20
  ACFAS and Division 14
  Charlotte Marriott Executive Park
  Charlotte, NC
  Register Here

Each program will begin on Friday evening with a presentation on "Common Forefoot Surgical Complications," followed by case studies. Participants, please bring cases to share. Saturday will provide a full day’s schedule of succinct lectures followed by hands-on workshops. While the U.S. Supreme Court has upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA) under the taxation clause vs. the commerce clause, other challenges will now advance through the courts, including: the constitutionality of the Independent Payment Advisory Board, whether First Amendment rights are violated by the PPACA’s mandate for religiously affiliated hospitals and other organizations to provide contraception and other services they say violate their religious values, and whether the law unconstitutionally prevents the expansion of doctor-owned hospitals.

Watch This Week @ACFAS for further health policy updates.

Foot and Ankle Surgery

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Researchers determine the prognostic value of a standardized hybrid image-based scoring system, the Composite Severity Index (CSI), in diabetic foot infection (DFI). The research involved masked retrospective 99mTc-white blood cell single photon emission computed tomography (CT)/CT image interpretation and independent chart review of 77 patients (101 feet) suspected of DFI-associated osteomyelitis. Correlation was drawn between CSI scores and the likelihood of favorable results during average 342-day follow-up. CSI ranged from zero to 13, and receiver operating characteristic accuracy for anticipating favorable outcome was 0.79. A CSI score of zero had a 92 percent chance of favorable outcome, which declined progressively to 25 percent as indices climbed to greater than or equal to seven. Image-based osteomyelitis compared to no osteomyelitis evaluation was less accurate than CSI at predicting outcome. In patients with intermediate severity, treatment failure fell from 68 percent to 36 percent when antibiotic duration was extended to less than or equal to 42 days.


A prospective study of 100 professional soccer players was performed to identify the intrinsic risk factors for noncontact ankle sprains, with the assessment covering ankle joint asymmetries in isokinetic muscle strength, flexibility, proprioception and stability, along with somatometric asymmetries, past injuries and lateral dominance characteristics. At least one noncontact ankle sprain was sustained by 17 players, and it was determined through logistic regression that players with eccentric isokinetic ankle flexion strength asymmetries, greater body mass index and increased body weight each had a substantially higher risk of a noncontact ankle sprain. Younger players and those with ankle laxity asymmetries also were determined to be at a higher risk for ankle sprain.


A retrospective study of 108 feet in 83 patients who underwent silastic implant arthroplasty of the first metatarsophalangeal joint to treat hallux rigidus was conducted to measure the procedure's long-term effects, with a follow-up period of 8.5 years. The average total AOFAS score was 77.5, while mean active and passive arc of motions were 36.8 degrees and 46.82 degrees, respectively. The average patient satisfaction visual analog scale was 7.73. Persistent pain led to the removal of the prostheses in three feet at three, five and seven years post surgery, respectively. Twenty-three percent (25 feet) were determined to have osteolysis, but they were non-progessive and did not have any correlation with the functional outcome.

Practice Management

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Social media can provide value to physicians and their practices in ways doctors may not have considered. Two reports from large consulting organizations examined ways in which social media can accomplish business objectives beyond basic marketing. The reports, one from the PwC Health Research Institute and one from CSC’s Global Institute for Emerging Healthcare Practices, looked at social media as a valuable business intelligence tool, a customer service tool and an avenue for reporting that could lead to better care and improved outcomes. Karla Anderson, partner in PwC’s Health Industries practice, explained that progressive physicians "are more focused on the customer experience and how they can differentiate themselves from other physicians, not just from a clinical perspective but from the overall engagement perspective." Social media is an easy way to do this, and it does not require constant monitoring or hiring a social media team.

Experts point to four categories of opportunity for doctors looking to use social media in new ways. The first is discovering needed services. Physicians can gain insight into what patients are willing to do to improve their health and what obstacles stand in their way. Social media can provide this information in a conversational way. It also can be used to improve customer service. How a physician practice or hospital responds to negative comments and complaints can carry equal or more weight than positive consumer engagement; and unlike customer service issues brought to a practice’s attention in a survey, complaints made on social media can be addressed and often remedied immediately. This is because social media provides an outlet for dialogue.

Practices can respond in public with an apology and offer to correct the situation so that others can see action being taken. This immediacy helps customers realize that customer service is taken seriously, and it gives the practice a chance to know about situations immediately so they are remedied and not exacerbated by an upset patient. Social media also can be used to gather feedback on medications. For example, monitoring the Twitter buzz surrounding a certain drug could offer great insight into how patients are reacting to it. There may be insight about a therapy the physician has not tried. Patient communities are a great source of information for physicians. Monitoring the social media activities of others also can give practices that are just dipping their toes into the online waters ideas on how best to facilitate those activities.


The current working climate can be stressful, with employees being stressed about job security and employers concerned about the future. Fortunately, there are things employers can do to build a successful practice filled with efficient, friendly and motivated staff members by building trusting relationships with their employees. Competitive organizations understand the importance of trust in their organizations, and they know how to earn and keep the trust of employees.

If employees speak negatively about their organization it creates an environment of distrust. Even if certain employees are not engaged in such behavior, tolerating this behavior can lower overall employee moral. A lack of trust can reduce productivity and cause good employees to leave. Positive motivation and trust is created when employees are treated as if they and their quality of life matter. In the current rapidly changing economy, employees need to feel secure and compensated for their dedication and productivity.

When employees only hear promises and lofty goals, trust can be hard to build. Make predictable and accurate goals when measuring and paying for performance, which will help maintain employee productivity. Be clear about expectations and acknowledge staff members when they meet those expectations. Doing so will create confidence and consistency in management. Praise individuals when responsibilities are fulfilled to provide positive feedback and acknowledge your appreciation of their work. Establish well-defined boundaries that promote connection. Boundaries allow staff members to work within their departments, have clearly defined assignments and know with whom they can interact and look for guidance.

Lastly, honor all agreements with staff members. Employees need to realize that their word is the most simple but important way to develop and maintain trust. If management or the organization views agreements as trivial then there will be no trust within the organization. If you are uncertain about being able to keep a promise, don't make it. Ultimately, increasing trust reduces employee turnover, improves productivity, creates a more positive work environment, and motivates employees to truly care about their employers and organization. Focus on building trust with employees and your organization will reap the rewards.


A research letter published by the Archives of Internal Medicine indicates that the deployment of electronic health record (EHR) systems can lead to a significant reduction of malpractice claims, with a group of Massachusetts physicians reporting a steep drop in such claims, from 49 to two, following EHR implementation. Thirteen of the pre-EHR claims were resolved with payments, while the two post-EHR claims were not. General surgeons constituted 27 percent of the pre-adoption claims, while internists and orthopaedic surgeons each had one of the post-implementation claims. The researchers conceded that "physicians who were early adopters of EHRs may exhibit practice patterns that make them less likely to have malpractice claims, independent of EHR adoption." However, the researchers stressed that the study provides evidence that EHR use does not play a role in a claim increase, and that it "lends support to the push for widespread implementation of health information technology."

Health Policy and Reimbursement

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The U.S. Supreme Court's decision to uphold the Patient Protection and Affordable Care Act was met with a generally favorable—but somewhat guarded—response from physician groups. The American Medical Association released a statement attributed to AMA President Dr. Jeremy Lazarus noting that the organization was pleased with the decision, as it means millions of Americans "can look forward to the coverage they need." The American Academy of Family Physicians issued a statement from its president, Dr. Glen Stream, echoing many of the points raised by the AMA, also noting that among the upheld provisions were those to build the primary-care workforce, advance wider implementation of the patient-centered medical-home model and maintain scholarships and loan repayment programs for medical students who choose a primary care career path.

The ruling received a more lukewarm response from Physicians for a National Health Program, a single-payer advocacy group, which stated that, despite the healthcare reform law's "modest benefits," it will leave gaps in coverage and will not make healthcare affordable for many who have insurance.

The Florida Medical Association, meanwhile, issued a statement that said it "remains concerned that the surviving act weakens the Medicare program, fails to substantively address medical liability reform, and dramatically increases the regulatory burden on physicians and patients."

In an e-mailed statement attributed to association President Dr. Michael Speer, the Texas Medical Association repeated its stance that the country is confronted with the challenge "to find what's missing, keep what works, and fix what's broken in the new law." It criticized the reform law's Independent Payment Advisory Board and restrictions on physician hospital ownership.


The Centers for Medicare and Medicaid Services is starting a third round of its Advanced Payment Model program for accountable care organizations (ACOs) involved in the Medicare Shared Savings Program. The agency will accept applications for advanced payments from August 1 through September 19 for an ACO performance period starting on January 1, 2013. Advanced payments are designed to help offset the costs of expanding an ACO. Notice of the application period was published in the Federal Register on June 26.

Medicine, Drugs and Devices

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The mobile health application store Happtique is planning to launch a two-month trial this summer of its new mRx program. During the trial, the 100 participating physicians will give their patients mHealth apps that are suggested by Happtique, as well as any other apps that they feel are necessary. Apps for Android smartphones and those written in the HTML5 format can be sent by doctors directly to patients' phones, while doctors can send patients e-mails with links to Apple's App Store in order to download iOS apps. Happtique hopes that the pilot will allow it to see how likely it is that patients will download a healthcare app after being told about it by their doctors.


PremierConnect, which is being billed as the largest virtual healthcare community in the world, is being launched online and is expected to be the first of many efforts to put physicians in control of their performance improvement plans and to rely more on data in their day-to-day decision-making. PremierConnect databases are aggregates of several data sources, including claims, lab, billing, purchasing, and operational data that are updated every 30 days. The data can be queried, based on individual needs, or found through pre-generated reports prepared by Premier or other users. The goal of the project is to foster both clinical and financial performance improvements.


The U.S. Food and Drug Administration (FDA) user fee reauthorization bill has been passed by the U.S. Senate. The FDA Safety and Innovation Act renews the FDA's user fee program for another five-year period, beginning next year. The reauthorization directs the FDA to collect approximately $6.4 billion from the drug and medical device industry, and it now includes generic drugs and biologics as well as modifications supported by medical device manufacturers.


Researchers have reported in the journal Molecular Pharmaceutics that surfaces coated with bionanoparticles could greatly accelerate the early phases of bone growth. Their coatings, based in part on genetically modified Tobacco mosaic virus, reduced the amount of time it took to convert stem cells into bone nodules, from two weeks to just two days.