News From ACFAS

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ACFAS sends its condolences to the family and friends of Cecil W. Davis, DPM, FACFAS, the first African-American ACFAS President, who passed away recently at the age of 92.

Dr. Davis served as President of the College from 1978-1979 and based his podiatry practice out of this home and office in Hackensack, NJ until his retirement in 1999. Before starting practice, he served in the U.S. Army in World War II and the Korean War.

Among Dr. Davis’ passions in the College was the ACFAS fellowship qualification and examination process, even prior to becoming president. He also decreased the overlap of residency reviews with ABPS, creating a more streamlined system. ACFAS is grateful for Dr. Davis' service and extends its sympathies to his family. Whether you’re a student, resident, or a practicing foot and ankle surgeon, you should know the many reasons why the American College of Foot and Ankle Surgeons is beneficial to your career, and a pillar in the industry. ACFAS released two quick, high-quality videos designed to summarize the benefits of membership, for both physician members and student members.

Check out these quick clips by visiting acfas.org, then clicking on “Physicians” or “Students” in the menu bar. You will find each video in the featured grey section near the top of your screen. You might recognize some of the students and members highlighted in the video, or even yourself! Attend the Diabetic Foot and Ankle Surgical Symposium in Miami, Oct. 26-28 to learn about core surgical approaches and procedures, including the latest cutting-edge approaches in treating the diabetic patient’s foot and ankle.

The program will offer a vast array of topics to explore and debate. Plus, take advantage of the optional wet lab workshop for an additional fee. Learn from a faculty of dedicated physician experts who lead the discussions to enhance your knowledge on diabetic foot and ankle surgery. These experts will share first-hand their cases and experiences related to how they tackle diabetic controversies.

To view the full agenda, learn more about the symposium or register, visit the Diabetic Foot and Ankle Symposium page. There are still a few openings available for members to participate in a new multi-center retrospective study on performing subtalar joint arthroerisis in adults and children.

To participate, complete the online application today by visiting the ACFAS Subtalar Study Information Page on acfas.org. Here you’ll also find other key information as well as the study criteria. Subjects and sites will be compensated for their time.

Foot and Ankle Surgery

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Surgeons treated residual clubfoot deformities in older children using a percutaneous midfoot Gigli saw osteotomy and the Taylor spatial frame. There were 11 children in the study, and mean frame fixation time was 15.1 weeks. Because the primary problems in these children were midfoot and forefoot deformities, a Butt frame was applied after the midfoot osteotomy. Two patients had partial recurrence of the deformities and were reoperated. One patient with residual supination is planned to be operated close to maturity. Complications included superficial pin-tract infection in five patients and premature consolidation of the osteotomy that needed reosteotomy.


A study was performed to explore the effectiveness and safety of Botulinum toxin A (BoNT-A) for treating patients with chronic plantar fasciitis, in which 40 subjects were randomized to receive 200 units of BoNT-A or saline placebo. The primary outcome measure was the proportion of responders at the sixth week, while global assessments were performed by the patient and physician at each visit up to the 18th week. Twenty-five percent of patients receiving BoNT-A achieved a response at week six compared to five percent of those receiving the placebo. Differences between treatments favored BoNT-A on secondary measures of pain, but did not reach statistical significance. In the BoNT-A group, 52.7 percent of subjects evaluated their condition as slightly/significantly improved at week six, versus 40 percent in the placebo group. At the 18th week, 63.1 percent of the BoNT-A group felt an improvement compared to 55 percent of the placebo group. No difference in global assessment between physician and patient or negative events related to treatment were observed.


The time to onset and persistence of zoledronic acid's antifracture effect in women with osteoporosis were evaluated, using data from 9,355 female subjects randomized in two placebo-controlled pivotal trials. The timing of onset of antifracture effectiveness was determined through Cox proportional hazards regression. At 12 months, the medicine lowered the risk of all clinical fractures, and this effect was persistent over three years, with the reductions in the second and third years slightly larger than in the first year. The study was published in the July issue of the Journal of Bone and Mineral Research.

Practice Management

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The difficulties of physicians are regularly addressed, but the problems encountered by support staff are often overlooked. Many staffers report a tangled web of supervisors who often provide conflicting instructions. The governance structures within most medical groups are often anything but linear, with clinical and clerical staff reporting to their supervisors, but also taking instructions from physicians, who may in turn report to stakeholders. There may also be administrators overseeing nonphysician employees, as well as instructions from a board of directors. Some experts say the most effective governance model is to assign both a clinical and clerical lead who manage the staff in their departments and report to a practice administrator. This is particularly effective in practices where the administrator has no prior clinical experience.

No personnel matters should come to physicians that can be resolved by other department heads. When clinical support staff report to two bosses, the supervisor and physicians should maintain a strict reporting protocol to minimize confusion. Clear lines between professional reporting responsibilities and operations reporting responsibilities should be drawn. For issues related to education and patient care, those employees should deal with the physician, but for operational matters, such as requests for days off, they need to speak to their supervisor.

One of the most effective tools for establishing a hierarchy is to identify in job descriptions the reporting structure for each position. A big hurdle for practices is that physician owners without business management training may not know how to relinquish control to their team. A culture of autonomy should be created so each employee can perform their job confidently. The most progressive practices provide leadership by demonstrating that managers know their jobs, are interested in what’s going on and are paying attention to details.


Until very recently, physicians lacked significant choice when they wanted to connect with a health information exchange (HIE). Last year, however, saw an estimated 40 percent growth in the HIE market, largely from private organizations, according to Chilmark Research. Now, many physicians may have two or three choices in HIEs, allowing them to exchange health information with other doctors and facilities electronically. Different HIEs offer different things and operate under various business models. Public HIEs involve several stakeholders across an established geographic area, but many health organizations are launching their own private HIEs to prepare for integration into an accountable care organization.

When looking to join an HIE, there are several things that physicians should consider. These include the efficiencies the practice wants to gain by joining an HIE, such as time involved with getting lab results, or the staff time spent on referrals. Another consideration is the geographic footprint of patient population. It may be important for a practice to have access to an HIE that connects throughout a state, such as in New Hampshire and Georgia. Physicians should also consider business model and sustainability; physicians that depend on an HIE to meet data exchange objectives may have to wait for a local exchange with a business model that will stay in operation. An October 2011 report by the eHealth Initiative found that there were 255 multistakeholder community initiatives to build HIEs in that year, but only 24 were considered sustainable.

For physicians looking to facilitate exchange without a formal HIE, electronic prescribing networks may be one route. In 2010, the Health and Human Services Dept. Office of the National Coordinator for Health Information Technology launched the Direct Project, a technology that vendors have included in their EHR or personal health record systems and which permits direct and secure communication between two parties, such as a physician's patient-care summary sent to another physician. Until HIEs develop further, physicians may find it challenging to find one that fulfills all their needs.


A proactive policy that helps patients manage their medications can benefit all. Physicians can start by training their intake nursing staff to review any medications patients say they are taking against what is written in their records. The medication reconciliation process is an important part of patient check-in. Additionally, clinical staff can be instructed to pull charts every morning for each patient who is scheduled. In many cases, patients suffering chronic conditions rely on their spouse or adult children to help them manage their illness, making it important to keep caregivers and family members in the loop and make sure they have the required legal documentation to assist in their loved one's care.

Where appropriate, e-mails regarding medication changes, refills and upcoming appointments should be sent to the designated caregiver as well as the patient. Additionally, practices that offer secure patient portals, through which patients can access their records and request refills, should also make a point of educating patients on how to use them. This decreases the number of calls coming into the practice and allows requests to be handled in a more timely manner without all the communication back and forth between patient and pharmacy. This simplification allows the front desk staff to focus on the patient in front of them. Smartphone users should also be encouraged to utilize the latest mobile phone applications, including HealthPrize, MediRemind and Pillboxie, which send text messages to remind patients that it's time to take their pills and in what dosage. A final option is to give eligible patients a full year's prescription.

Health Policy and Reimbursement

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The Centers for Medicare & Medicaid Services (CMS) has proposed increasing payments to hospital outpatient departments and ambulatory surgery centers next year. Under CMS' proposal, payment rates to hospital outpatients departments and ambulatory surgery centers (ASCs) would increase 2.1 percent and 1.3 percent, respectively. In addition, CMS has proposed replacing the system of using median costs for the outpatient prospective payment system and instead using a geometric means of cost of services within an ambulatory payment classification, which are the categories of services in the outpatient prospective payment system. CMS is also proposing new requirements for the ASC Quality Reporting program for the roughly 5,000 ambulatory surgery centers that take part in the Medicare program. Those requirements deal with the reporting of quality data, a policy for updating measures, and data completeness mandates.


Starting on Oct. 1, a new Centers for Medicare & Medicaid Services (CMS) rule created under the Patient Protection and Affordable Care Act will require any Medicare-eligible ambulatory surgery center to submit reports on five quality measures or face a 2 percent payment reduction. CMS has said it will publish surgical center quality scores as reported and risk adjusted on a new website.

The initial five quality metrics are the number of 1) patient burns; 2) falls; 3) surgeries that are wrong site, wrong side, wrong patient, wrong procedure or wrong implant; 4) surgeries requiring a hospital transfer or admission; and 5) the number of patients who did not receive an IV antibiotic within one or two hours before incision.

The following year, the list will include facility volume for some gastrointestinal, eye, nervous system, musculoskeletal, skin and genito-urinary codes. The year after that, the list expands further to the percentage of healthcare personnel who receive influenza vaccination. Another 33 metrics are listed in the CMS rule as "under consideration."


The California Medical Association and 63 physicians have sued Aetna and its California subsidiary for allegedly retaliating against patients, doctors and ambulatory surgery centers that attempt to use out-of-network benefits sold by the insurance company. The complaint alleges that Aetna has warned patients not to use their out-of-network insurance benefits and denied payment for those services while retaliating against physicians who make referrals to out-of-network surgery centers by kicking them out of the health plan's network. In addition to the doctors and the state medical association, the lawsuit includes four ambulatory surgery centers (ASCs). Aetna sued many of the same doctors and ASCs in February, alleging that the doctors were illegally waiving their fees and inducing patients to receive overly expensive procedures at out-of-network facilities owned in part by the physicians themselves.

Medicine, Drugs and Devices

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Researchers have cited recent advances in implantable sensor technology and cartilage scaffolding systems as major developments in the use of engineered cartilage for bone and joint repair. These advances could mean help for the vast number of patients suffering from damaged joints and osteoarthritis. Newer, smaller sensing devices that more accurately measure stress loads on joints are giving researchers testing newly grown engineered cartilage within a joint a better understanding of the healing process. Armed with these data, doctors could advise patients on safer, more beneficial levels of activity following joint surgery. The sensors also transmit their measurements wirelessly, enabling patients undergoing cartilage growth therapy to monitor their own joint stress loads in real time. The advances are discussed in the June issue of the Journal of the American Academy of Orthopaedic Surgeons.


Researchers have published the results of a study that presents new information about the risk of fractures, falls and osteoporosis in people taking anti-epileptic drugs. The study, which was published in the journal Neurology, involved 150 epilepsy outpatients who had been taking anti-epileptic drugs for at least three months, as well as 506 people who were not taking the medications. Researchers found that people who were taking the medication were up to four times more likely than those who were not to suffer spine, collarbone and ankle fractures, and were also four times more likely to have been diagnosed with osteoporosis. The researchers also found that female patients who were taking anti-epileptic drugs were twice as likely to suffer falls as those who were not taking the drugs.


The Food and Drug Administration (FDA) has released its proposed rule on unique device identifiers (UDI), which would be applicable to most medical devices distributed in the United States so that the agency can better track and collect safety data about the devices, particularly information about adverse events. Participating devices will be assigned a device identifier, which is a unique numeric or alphanumeric code for a device model, and a production identifier, which includes data such as lot or batch number, serial number or expiration date. Low-risk devices such as bedpans and other over-the-counter products will be exempted from the rule, which will mandate implementation for high-risk devices first. High-risk devices would have to have a UDI on the label and packaging within 12 months after the final rule, and on the device itself within three years.