News From ACFAS

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The American College of Foot and Ankle Surgeons invites you to exhibit at our 71st Annual Scientific Conference, February 11-14, 2013 in Las Vegas, Nevada.

The Exhibitor Prospectus is in the mail, but if you just can’t wait to see the options, keep reading! For more information on the overall Annual Scientific Conference and submission details for manuscripts and posters, visit www.acfas.org/lasvegas. To view the sponsorships and exhibit booth offerings specifically, visit the Exhibition Opportunities web page.

Find one-stop shopping (and more) in the Nation’s largest gathering of foot and ankle surgeons and primary care podiatric medicine physicians. We hope you take this opportunity to join us - See you there! If you haven’t yet done so, sign up for 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. Have you recently changed your work, home or e-mail address, or phone or fax number? Does your practice have a website? Do you want to change your “preferred address” for receiving the Journal of Foot & Ankle Surgery and other ACFAS mailings? We want to stay in touch with you! Update your contact information at the member login page on acfas.org (member login required).

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 compared the outcomes of percutaneous distal metatarsal osteotomy and distal chevron osteotomy performed on 31 feet and 33 feet, respectively, to determine how effectively the treatments corrected mild-to-moderate symptomatic hallux valgus. All 53 patients were clinically evaluated with the AOFAS scoring system, while radiographical assessment was carried out using the hallux valgus angle (HVA) and intermetatarsal angle (IMA). The average correction of HVA and IMA achieved in the percutaneous distal metatarsal osteotomy group was 14.4 degrees and 4.8 degrees, respectively. In the distal chevron osteotomy group the average HVA/IMA correction was 13.1 degrees and 3.9 degrees, respectively. The average AOFAS score rose from a pre-operative of 44.6 points to 90.2 points in the group receiving percutaneous distal metatarsal osteotomy, and from 47.5 points to 87.7 points in the group receiving distal chevron osteotomy. In the first group, 89.6 percent of patients were happy with the cosmetic results of the surgery, versus 64.5 percent of the patients in the second group. The results of the study, the researchers concluded, support the idea that percutaneous distal metatarsal osteotomy yields good functional and radiological result and is associated with a high degree of postoperative patient satisfaction.


Researchers assessed the effectiveness of a new method, selective plantar fascia release, as a substitute for Achilles tendon lengthening for managing nonhealing diabetic plantar ulcerations in the forefoot. Sixty diabetic patients were evaluated for an average of 23.5 months following selective plantar fascia release for the treatment of nonhealing diabetic neuropathic forefoot ulcers. Healing was exhibited by 56 percent of the ulcers, including 60 percent of the plantar toe ulcers and 44 percent of the metatarsophalangeal joint ulcers, within six weeks. Average range of motion of the affected metatarsophalangeal joint rose from 15.3 degrees ± 7.8 degrees to 30.6 degrees ± 14.1 degrees postoperatively. Ulcer healing was experienced by all patients in whom the preoperative dorsiflexion of the affected metatarsophalangeal joint was between five degrees and 30 degrees and in whom the range of motion of that joint increased by greater than or equal to 13 degrees. There was no observation of ulcer recurrence in the original location at follow-up, nor did any patients endure complications associated with the selective plantar fascia release.


A study was held to define the disease pattern in recalcitrant plantar fasciopathy for pathological classification, so that current and future therapies can be meaningfully assessed. The study involved 125 consecutive feet exhibiting plantar fasciitis symptoms for longer than six months, where plantar fasciopathy was verified through ultrasound scanning. Two-thirds of the patients evaluated exhibited typical insertional disease, while the remaining 34 percent had atypical distal fascia disease. Mixed insertional and distal disease was observed in 22 percent of patients, while pure distal disease was seen in 12 percent. Either distant thickening or discrete fibromata was found in patients suffering from pure distal disease.

Practice Management

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Some practices are struggling with meeting patient demands, as there is a real shortage of physicians in a number of specialties. This can tax many practices, making it difficult to meet and manage demand. The problem becomes more pressing if there are senior physicians in a practice who plan to reduce their hours or retire in the next year or so. A natural solution is to recruit for young physicians, but there are several things to keep in mind during the recruiting process.

The first is assuring good fit, which is the most challenging aspect of recruiting, because it is hard to determine before the work has started. To bring on a new physician, practices must think about what they want in a new physician. This may be determined by specialty, a need in the community or something else. It is smart for a practice to define what it wants in a physician and what the expectations are in terms of workload, then develop a job description that makes these things clear. Practices should also share their practice philosophy, which begins with discussing the practice's mission and vision for the future, and what drives the physician managers. Some physicians are even reinventing their practice, looking for ways to create a stronger economic position. They may have plans to become bigger and more forceful in the community by buying up ailing practices, expanding into outlying areas or adding a broad line of services that are not typical of their specialty. It would be important to share this information with a physician who is considering joining the practice.

Practices must also manage the transition by allowing plenty of planning time. Making a smooth transition will involve both management and staff. Spreading the word through marketing is another important aspect for practices. Market visibility, practice support and the new physician's own appeal will determine how quickly they fit into the community and grow a healthy patient base. The wise practice will prepare a marketing plan and budget for the finances essential to helping the new physician create a desirable presence. This includes offering community lectures, personal meetings with potential referring sources and actively being involved in the medical community. The new physician will need to have time to pursue these activities, and the practice will need to dedicate time and funds for marketing and promotion, starting with a professional marketing plan. Finally, practices should have a plan that will not only examine the demographics and define the ideal target market, but will provide specific strategies that can be executed and measured.


The federal government is on a mission to reduce wasteful healthcare spending, and the stack of regulations with which physicians are expected to comply continues to grow. In February 2012, the Centers for Medicare & Medicaid Services (CMS) upped the ante when it proposed a new rule regarding Medicare overpayments, which would require healthcare providers to report and return Medicare overpayments within 60 days of their identification. This applies to payments up to 10 years after the date of service. CMS has received comments from more than 100 organizations asking for clarification and relief.

Given the challenges associated with the rule, physicians are wondering what to do. To begin, they should be proactive, precise and thorough, by way of several steps. The first is keeping their billing in the middle of the bell curve, which may prevent auditors' automatic software from detecting any outliers that could suggest an error or foul play. Next, physicians should conduct periodic self-audits, which will enable them to spot potential problems and get training in place before they become systemic. Additionally, physicians should track down root causes of problems and document obsessively. It may be beneficial for physicians to know what triggers an audit. Physicians should also stay up to date on coding requirements and should respond promptly to audit notifications. Finally, physicians may be wise to have a compliance program.


The Centers for Medicare & Medicaid Services has unveiled a compliance map on its website that is geared toward giving providers easier access to the appropriate contact information for such federal groups as fiscal intermediaries, carriers and recovery audit contractors. Providers can click on their state or territory to see a listing of related contacts for Medicare Parts A and B and for other selected provider classifications. The compliance map can be accessed here.

Health Policy and Reimbursement

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Medicare providers who were required to e-prescribe in the first six months of 2012 but did not may avoid penalties under two newly proposed hardship exemptions from the Centers for Medicare & Medicaid Services (CMS). The CMS has proposed exemptions for eligible professionals who were required to e-prescribe at least 10 times during the first six months of 2012 or lose 1.5 percent of their Medicare payments next year. Those penalties increase to 2 percent of Medicare payments by 2014. The proposed exemptions would eliminate penalties for providers and practices that achieved meaningful use of certified electronic health-record (EHR) systems in 2013 and 2014, as well as those that indicate their intent to participate in the EHR incentive program. The specific ways in which providers would demonstrate to either the CMS or their state Medicaid program their intent to participate in the EHR program were not specified.


The Centers for Medicare & Medicaid Services (CMS) has set Aug. 27 as the date for the start of a demonstration program that will allow Medicare recovery audit contractors (RACs) in 11 states to review the medical necessity of claims before the providers are paid. The demonstration program, called recovery audit prepayment review, will focus on certain types of claims that CMS says are prone to high rates of improper payments. The reviews will focus on seven states with providers prone to errors and fraud (California, Florida, Illinois, Louisiana, Michigan, New York and Texas) and four with large volumes of short inpatient hospital stays (Missouri, North Carolina, Ohio and Pennsylvania).



An adjustment or repeal of the sustainable growth-rate (SGR) Medicare payment formula is not included in a budget agreement to keep the federal government running through the first quarter of next year. A new report from the Congressional Budget Office (CBO) says the SGR will require a 27 percent reduction in physician payments in 2013, and the office notes that its estimates are likely to be amended when the Medicare physician fee schedule is released in November. The CBO study examines several short-term options costing $15.3 billion to $376.6 billion in additional spending from 2013 to 2022. The lowest cost estimates issued by the CBO call for short-term Medicare payment increases followed by payment reductions, ranging from 22 percent to 26 percent.


Bi-partisan senior senators are urging stepped-up enforcement by the Obama administration and implementation of new laws after some Medicaid providers were recently found to owe large amounts of unpaid federal taxes. Sen. Carl Levin (D-Mich.), chairman of the Permanent Subcommittee on Investigations, urged both steps after a recent Government Accountability Office (GAO) report that he requested showed that about 7,000 providers were reimbursed $6.6 billion for treating Medicaid patients when the providers owed at least $791 million in federal taxes from 2009 or earlier. Levin urged levies on healthcare providers' Medicaid payments and Medicaid payments to managed-care organizations whose doctors or other principals owe taxes. He also urged new authority for the federal government to bar healthcare providers with unpaid taxes from enrolling in Medicaid. Sen. Tom Coburn (R-Okla.), ranking member of the subcommittee, said the GAO findings are yet another indication of the program's vulnerability to fraud.

Medicine, Drugs and Devices

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Now that a growing number of physicians are equipped with smartphones and tablets that connect to a practice's EHR, patients can get care and relief more quickly. Physicians are warming up to iPads in particular, according to several studies, and because many are eager to use the devices to connect to their EHR systems, some observers are wondering whether the iPad will do more to encourage EHR adoption than any government stimulus or vendor promotion ever could. But before buying a bunch of iPads for your practice, consider:

1. The EHR factor. Think about the mobile-friendliness of your EHR or any you're contemplating buying. If you have an EHR that doesn't offer a mobile app, find out what the vendor's plan is for mobile access, and when it expects to execute on those plans. For practices still shopping for an EHR that want the option of mobile access, it's important to explore how EHRs you are looking at are leveraged on mobile devices.

2. Financial feasibility. Assuming your EHR has a mobile-app companion, hardware and service costs can be significant. Tablets typically run $300 or more apiece. Those with 4G capability cost more and are useless without accompanying cell coverage. Cell plans typically come with data caps that your physicians will face if they're using cell networks routinely to connect on their iPads. Practices that invest in iPads for their physicians might want to purchase Wi-Fi-only devices, giving the doctors the option of cell-enabled devices if they want to pay for the extra cost of the hardware and the cell coverage.

3. Life/work style. While media tablets are great, physicians should be careful not to be seduced by their physical features. Instead, they should look realistically at the device and see if it is something they would use, if it would benefit them, and how it would benefit them.


New anesthesia drugs are being developed faster, with more predictable effects and metabolism and without undesirable side effects, through assessment with molecular-level methods and computer models, according to studies published in the August issue of the International Anesthesia Research Society journal Anesthesia and Analgesia. Massachusetts General Hospital researchers detail development of an improved form of the sedative etomidate that promotes hemodynamic stability without suppressing adrenocortical function. Meanwhile, a research team from the Johns Hopkins University School of Medicine and PAION UK report on the development of remimazolam, a new benzodiazepine-type sedative whose properties include "fast onset, a short, predictable duration of sedative action and a more rapid recovery profile than currently available drugs."