News From ACFAS

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The ACFAS Nominating Committee is looking for the best and the brightest to serve on the College's Board of Directors.

If you are an ACFAS Fellow, believe you are qualified, and would like to take an active role in leading the profession, you are encouraged to submit a nomination application by September 15, 2013.

For complete details on the recommended criteria for candidates and the nomination application, visit acfas.org/nominations, email Executive Director Chris Mahaffey, or call him at (773) 693-9300. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Michelle L. Butterworth, DPM, FACFAS (email), or call her at (843) 355-9690.

The Nominating Committee will announce recommended candidates to the membership no later than October 31, 2013. Candidate information and ballots will be e-mailed to all voting members no later than December 15, 2013. Electronic voting will end on January 14, 2014. New officers and directors will take office during the ACFAS 2014 Annual Scientific Conference set for February 27-March 2, 2014 in Orlando, Florida. Liking the new ACFAS Facebook Page paid off! Congratulations to Brent Fuerbringer of Des Moines, Iowa, ACFAS Student Club Member and the winner of a $100 American Express gift card! Brent took a moment to "Like" the new ACFAS Facebook Page and was awarded for his efforts.

August 1 marked the official closing of the old ACFAS Facebook Group, but when one door closes, another one opens! Stay connected to ACFAS and the podiatric arena by "Liking" the new ACFAS Facebook Page. Also, don't forget to also share the new ACFAS Facebook Page with your colleagues so more and more bright-minded people just like you can bounce ideas off each other and be a part of the conversation. Check out the latest ACFAS clinical e-session Hallux Rigidus (1.0 CPME CE Credit), where you’ll be privy to discussions on perspectives, case presentations, and fixation options. You can find this clinical e-session and other valuable e-sessions at acfas.org/e-learning. These online presentations are available to members and non-members at no cost. Continuing education contact hours are available to ACFAS members.

The College commits to the highest standards set by members and peers alike, and our scientific education courses represent that. We have speakers beyond comparison for presentation topics of all sorts, and the tools for you to test your new knowledge by downloading the CME test afterward. Manuscript submissions for the ACFAS 2014 Annual Scientific Conference are due August 15 - that's one week from tomorrow! Now is the time (if you haven't yet done so) to submit your paper so it can be considered for oral presentation at the Annual Scientific Conference. Before submitting, be sure to read the Call for Manuscripts (Information and Policies) (PDF) to know what is required of you, then submit your manuscript in the next eight days. The Manuscript Judging Committee will thoroughly review all manuscript submissions to choose the best ones for presentation at the conference.

For more information on manuscript submissions or the ACFAS 2014 Annual Scientific Conference, visit acfas.org/asc. Have you recently moved into a new home or office? Is your email address different from what it always has been? Do you want to change your “preferred address” for receiving the Journal of Foot & Ankle Surgery and other ACFAS mailings?

Answering "yes" to any of these questions means you need to log in to your ACFAS member profile and make some updates. There's no time like the present! Visit the new "Member Center" page at acfas.org/members, and under the heading "Manage Your Membership," click "Update Your Contact Information."

Your contact information can be listed in the College’s online membership directory so your colleagues can find you, and you can also be listed in the “Find an ACFAS Physician” search tool on ACFAS’ consumer website FootHealthFacts.org. After completing your professional profile with website, hours, and up to three locations, scroll down to “ACFAS Website Listing” and check “Yes” for “Consumer Physician Search” and “Members-Only Directory.”

Keep yourself available to your peers, potential patients and the College! Update your profile today!

Foot and Ankle Surgery

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Researchers at South Korea's Inje University have performed a study that examined the radiographic characteristics and structural configurations of patients with primary degenerative arthritis of the second metatarsophalangeal joint (MTPJ). Patients who had undergone surgery for primary degenerative arthritis of the second MTPJ were compared with a group of individuals without arthritis of the second MTPJ who were selected at random. Researchers discovered that the average second metatarsal length of the 37 feet in the study group was significantly longer than it was in the feet of the control group. In addition, the average length of the first metatarsal compared to the fourth metatarsal was significantly shorter in the study group than it was in the controls. The average length of the second metatarsal compared to the fourth metatarsal was significantly longer in the study group. Finally, researchers classified four feet as grade-zero, nine as grade-one, 17 as grade-two and seven as grade-three. The study concluded that doctors should consider second toe rigidus as a diagnosis in patients with painful limited dorsiflexion of the second MTPJ when there are no signs of Freiberg's infraction or trauma.


A study by researchers in South Korea has found that patients with Morton's neuromas experienced better outcomes when treated with metatarsal shortening osteotomy with deep transverse metatarsal ligament (DTML) release than they did when treated with DTML release alone. The retrospective study examined 86 neuromas in 84 consecutive patients who underwent surgery for a Morton's neuroma between 2008 and 2011. Forty-six of the neuromas were treated with DTML release alone (Group A), while the remaining 40 underwent metatarsal shortening osteotomy with DTML release. Both groups experienced significant improvements in clinical outcomes following surgery, though there were significant differences in the clinical outcomes that were seen in the two groups. Significant correlations were observed between neuroma size and outcomes in Group A, though no such correlations were seen in Group B.


A recent study found that the ToeFit-Plus prosthesis is effective in treating advanced hallux rigidus. Researchers examined 26 toes of 24 patients with metatarsophalangeal (MTP) arthritis of the great toe, all of whom were treated with the ToeFit-Plus implant. They discovered that the mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score improved in these patients from 42.7 before the operation to 88.5 post follow-up after an average of 29.9 months. Average visual analogue scale pain scores improved as well, dropping from 7.4 before the operation to 1.9 at the final follow-up. As for the average MTP joint range of motion, it too improved from 25.9 degrees before the operation to 53.8 degrees at the final follow-up. Radiolucency was seen in two patients who were treated with the implant, though no evidence of radiologic loosening was seen. None of the patients required revision surgery.

Practice Management

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Legal experts say that doctors who provide care to their patients via team-based models could potentially face a number of legal risks in the event a patient suffers an adverse outcome. For instance, physician supervisors who fail to properly monitor lower-level healthcare professionals in their practice could be subjected to failure-to-supervise claims. These and other types of legal liability can arise when communication among members of a practice is inadequate. This is because communications problems within a practice can result in patient injuries. According to a study by The Doctors Company, communication problems contributed to 7 percent of injuries in the 2,466 claims it reviewed from 2007 to 2011. Experts say that there are a number of steps that practices can take to avoid communications problems and thus avoid the legal liabilities that may subsequently arise. For instance, no one within a practice should ever simply assume that patient information has been transferred to another doctor or nurse. Experts also say that practices should avoid having a hierarchical structure, in which lower-level employees are hesitant to speak up about potential problems with patient care. Finally, physicians should lead by example, experts say. This means that doctors must be the first ones to adopt solutions that will help address problems within their teams.


With small physician practices facing a number of regulatory uncertainties, some are choosing to collaborate with other small practices in order to survive. These collaborations can take a number of different forms, including independent practice associations (IPAs) which allow like-minded doctors in small or solo practices to work together while remaining in private practice. Doctors who participate in IPAs say this model has a number of advantages, including the ability to make small practices look bigger. For example, practices that participate in IPAs can hire a social worker and take other steps that make them look larger more easily than they could if they were operating alone. IPAs are also more willing to help practices offset some of the expenses associated with data collection, since they are in a better position to reach financial arrangements with insurance companies that want to improve population health and reduce costs.

Another model that small practices can adopt is that of a Patient-Centered Medical Home, which is less structured than an IPA but allows practices to work together on staffing, billing, purchasing, and other tasks. Practices that make up Patient-Centered Medical Homes generally maintain their independence but can share personnel to minimize staffing costs. Such collaborations offer other benefits as well, including greater flexibility in scheduling for doctors.

Health Policy and Reimbursement

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The Centers for Medicare & Medicaid Services released a final rule on Aug. 2 that governs payments to inpatient acute care and long-term care hospitals. The rule calls for Medicare payments to inpatient hospitals to rise by a total of $1.2 billion during the next fiscal year. Long-term care hospitals will receive a 1.3 percent increase in their FY-'14 payments compared to FY-'13 levels. That represents an increase of roughly $72 million. Operating rates for inpatient stays at the roughly 3,400 general acute care hospitals that are paid under the inpatient prospective payment system will receive a 0.7 percent increase. The rule also implements the healthcare delivery reforms that are mandated by the Affordable Care Act, including an effort to improve hospital safety and improve the Hospital Readmissions Reduction Program. The rule will be effective for discharges that take place on or after Oct. 1.


The House Energy and Commerce Committee voted Wednesday to approve legislation that would repeal Medicare's Sustainable Growth Rate (SGR) formula. The bill, known as the Medicare Patient Access and Quality Improvement Act, would replace SGR with a payment system that would reward doctors for providing high-quality care. A five-year transition period would be created while the new payment system is being developed, during which time providers would be given a 0.5 percent annual increase in payments. Healthcare providers will be eligible for an additional 1 percent payment increase in 2019 if they meet certain quality of care standards. The bill now goes to the full House for its consideration.


A number of issues related to the Affordable Care Act's effects on physicians' practices remain unresolved roughly two months before the statute's heath insurance exchanges are scheduled to launch. For example, there is a possibility that doctors could be forced to collect payments from patients who have not paid premiums for insurance plans purchased on the exchanges. Under the Centers for Medicare and Medicaid Services' rules regarding the three-month grace period for those who have not paid their premiums, insurers must pay claims during the first 30 days of the grace period but will be allowed to hold claims during the subsequent 60 days. If at the end of the 90 days the patient has still failed to pay the premiums and the policy is cancelled, the insurer will not be required to pay claims for services submitted during the last 60 days of the grace period. Doctors will then be required to collect the money they are owed from such patients, said Medical Group Management Association (MGMA) Chief Executive Officer Susan Turney. As a result, it is important for practices to keep their information on patients accurate and up to date so that they can work with patients and plan for any liabilities they may incur as the result of patients losing their coverage, MGMA said. The organization is also calling on CMS to re-evaluate its rules regarding the three-month grace period.


The Institute of Medicine (IOM) has issued a final version of a report that examined the effects of a geographic value index on Medicare spending. The authors of the report examined data from Medicare, Medicaid, and private insurance to answer the question of whether cutting payments to healthcare providers in high-cost areas would save money without having an impact on the care provided to patients or if it would encourage healthcare providers to operate in a more cost-effective manner. The report concluded that because health decisions are made at the physician or organization level, a geographic value index that would peg payments to the health benefits and costs of services in a particular region would be ineffective in encouraging value improvement. The report also noted that a geographic value index likely would not work well because there can be large variations in spending within a particular area, even within individual healthcare providers. In addition, IOM said a geographic value index would "unfairly reward low-value providers in high-value regions" while simultaneously having a negative impact on high-value providers in low-value regions. As a result, IOM said Medicare should not adopt a geographic value index.

Medicine, Drugs and Devices

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A recent 12-week study has found that integra bilayer wound matrix (IBWM), a bilayer skin replacement system made up of a dermal regeneration layer and a temporary epidermal layer, is safe and effective in treating diabetic foot ulcers in an outpatient clinical setting. The study examined 10 diabetic patients with a mean age of 60.6 years, all of whom had a non-infected ulcer on the plantar aspect of the foot. Some of the patients were treated with IBWM, though no epidermal autografting was performed on these patients following silicone release--something that is typically done in an inpatient setting. Patients treated with IBWM experienced gradual healing of their ulcers over the course of the study, with the greatest mean wound reduction being roughly 95 percent in week 12. Researchers also found that 70 percent of patients treated with IBWM experienced complete closure of their ulcers by the end of the study. No patients reported recurrent ulcers at follow-up.


A recent study by researchers at a company that operates wound care centers has found that frequent debridement could help diabetic foot ulcers and other chronic wounds heal faster. Researchers from Healogics reviewed data on roughly 155,000 patients with chronic wounds who were treated at a wound care center between 2008 and 2012. Although the amount of time it took a wound to heal varied depending on the type of wound, researchers found that more frequent debridement usually led to shorter healing times. Diabetic foot ulcers, for example, healed in an average of 21 days when they were debrided at least once per week. Those same wounds healed in an average of 76 days when they were debrided every two weeks or more. But Dr. Robert Kirsner, a wound care researcher from the University of Miami who wrote a commentary on the study, said that the faster healing times may have been the result of other factors. For example, he said that patients who underwent debridement more frequently may have been better at adhering to other recommendations for caring for their wounds. However, Kirsner said that the evidence indicates that more frequent cleaning is beneficial, though he said debridements should only be performed when necessary.


According to a study in Antimicrobial Resistance and Infection Control, an electronic monitoring system can accurately measure hand hygiene compliance. Researchers confirmed a system exists that captures the number of soap and sanitizer dispenser activations. The hand hygiene opportunities were measured by video surveillance of a period of 15 months and by using an algorithm of predicted hand hygiene opportunities. The algorithm and electronic system revealed a hand hygiene compliance rate of 65 percent to 71 percent. The actual compliance rate from video surveillance was 66 percent to 75 percent, which was in line with the prediction. Direct observation measured a compliance rate of 92 percent to 99 percent. "We believe that electronic monitoring using the Five Moments method provides the most accurate and actionable HH compliance data," said the authors of the study. The "Five Moments of Hand Hygiene" was defined by the World Health Organization.